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Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
PROCEDURE 5
Proximal Long Oblique (Ludloff ) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure Mark E. Easley and Hans-Jörg Trnka INDICATIONS PITFALLS
• Contraindications to surgical correction of hallux valgus deformity: peripheral vascular disease and peripheral neuropathy • Contraindication to surgical correction of hallux valgus with a metatarsal osteotomy: hallux rigidus (degenerative joint disease of the first metatarsophalangeal [1MTP] joint) • Relative contraindications to the Ludloff osteotomy: narrow first metatarsal (1MT; limited surface area for healing) and osteopenia (risk for poor fixation) CONTROVERSIES
• Hypermobility of the first ray: some surgeons recommend a 1TMT joint arthrodesis (modified Lapidus procedure) in lieu of a metatarsal osteotomy.
TREATMENT OPTIONS
• One of over 130 corrective procedures for symptomatic hallux valgus; with moderate to severe deformity, a proximal osteotomy or modified Lapidus procedure is favored.
INDICATIONS • Symptomatic moderate to severe hallux valgus (first/second intermetatarsal angle [1/2 IMA] >15°) failing nonoperative treatment
EXAMINATION/IMAGING • Relatively wide forefoot with a tender, prominent medial eminence (medial 1MT head). Fig. 5.1 shows a patient in a weight-bearing stance with one foot corrected with a Ludloff osteotomy and distal soft-tissue procedure and the other foot uncorrected. • Hallux valgus deformity (lateral deviation of the hallux) is noted. • Weight-bearing anteroposterior radiograph showing moderate to severe hallux valgus deformity (an increased 1/2 IMA exceeding 15°) is shown in Fig. 5.2A. • Weight-bearing lateral radiograph without plantar gapping at the first tarsometatarsal (1TMT) joint (suggestive of hypermobility) is shown in Fig. 5.2B.
SURGICAL ANATOMY • Dorsomedial sensory cutaneous nerve to the hallux (terminal branch of the superficial peroneal nerve; Fig. 5.3A) • Medial position of the 1MT head relative to the anatomically positioned sesamoid complex (Fig. 5.3B) • Lateral capsule with important blood supply to the 1MT head (Fig. 5.3C) • 1TMT joint
POSITIONING • Supine position on the operating room table
TREATMENT PEARLS
• Unlike many other 1MT osteotomies, periosteal stripping is not required and should be avoided.
TREATMENT PITFALLS
• Making the medial incision too plantar may limit exposure of the 1MT and lead to excessive skin retraction and potential skin necrosis at the dorsal wound margin.
FIG. 5.1
40
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
A
B FIG. 5.2
A
B
C FIG. 5.3
PORTALS/EXPOSURES • Two exposures should be considered: (1) a dorsal first web space incision to perform the lateral release and (2) a longitudinal medial approach to perform the medial capsulotomy and 1MT osteotomy. Alternative to the dorsal first web space incision, the lateral suspensory ligament between the lateral metatarsal head and the lateral sesamoid may be released via the medial approach with a blade passed between the plantar aspect of the 1MT head and the sesamoid complex.
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.4
A
B FIG. 5.5
PORTALS/EXPOSURES PEARLS
• With long-standing hallux valgus deformity, an audible “pop” indicative of a successful release is typically experienced and desirable. However, overrelease of the lateral capsule must be avoided.
PORTALS/EXPOSURES PITFALLS
• If the lateral capsule is tight, then the lateral capsule may be fenestrated. We recommend performing the lateral capsular fenestration distal to the metatarsal head to preserve the metatarsal head’s blood supply, in the event where a distal osteotomy is required in conjunction with the proximal Ludloff osteotomy (risk of 1MT head avascular necrosis). • Avoid overreleasing the lateral capsule to limit the risk of hallux varus (multiple small fenestrations and a varus stress of only 20° typically suffice).
Dorsal First Web Space Incision • A 3- to 4-cm incision is made between the distal first and second metatarsals. The superficial neurovascular structures are protected. • The enveloping fascia (innominate fascia) is split longitudinally, and blunt dissection (with a finger) is performed to access the lateral aspect of the 1MTP joint. A lamina spreader may be placed between the first and second metatarsals to improve access to the first web space (Fig. 5.4).
Medial Midaxial Longitudinal Approach • A longitudinal incision is made from the 1MTP joint to the 1TMT joint, directly over the 1MT (Fig. 5.5A). A tendency to make the incision slightly more dorsal than plantar will facilitate exposure of the 1MT for the osteotomy. • The dorsomedial cutaneous sensory nerve to the hallux and extensor hallucis longus (EHL) tendon must be identified and protected throughout the procedure (Fig. 5.5B). • The medial 1MTP joint capsule should be exposed but not violated during the surgical approach.
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.6
A
B
PROCEDURE Step 1: Lateral Release and Medial Capsulotomy Lateral Release • The ligament between the lateral capsule and the lateral sesamoid is released sharply by introducing the scalpel blade directly into the articulation between the plantar metatarsal head and the lateral sesamoid (Fig. 5.6). This maneuver can be performed from the proximal end to the distal end and, if carefully controlled, may be continued distally and slightly laterally to simultaneously release the adductor hallucis tendon from the base of the first proximal phalanx (Fig. 5.7A). • Next, the adductor hallucis is directly released from the lateral sesamoid (Fig. 5.7B), thereby fully detaching both aspects of the adductor hallucis to the 1MTP joint and sesamoid complex (Fig. 5.7C). • Then, the lateral capsule is weakened distal to the lateral metatarsal head by fenestrating it with multiple scalpel blade stab incisions (Fig. 5.8). • Depending on surgeon preference, the transverse intermetatarsal ligament may be carefully elevated from the underlying common digital artery and nerve and divided while protecting these neurovascular structures; we do not routinely release this ligament. • Alternatively, the lateral release may be performed through a single medial approach, releasing the lateral suspensory ligament between the lateral metatarsal head and lateral sesamoid.
C FIG. 5.7
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
44
FIG. 5.8
A
FIG. 5.9
B FIG. 5.10
STEP 1 PEARLS
• We recommend cooling the microsagittal saw blade with cool saline irrigation to limit heat that may create areas of osteonecrosis along the osteotomy. • Hold the forefoot with the opposite hand while performing the 1MT osteotomy; this will provide greater stability and facilitate orienting the osteotomy properly. STEP 1 PITFALLS
• Do not make the osteotomy too short; a longer osteotomy typically leads to greater stability.
CONTROVERSIES
• Alternatively, the lateral release may be performed through the medial approach, but this may not provide full visualization of the contracted lateral soft tissues.
• Finally, a varus stress is applied to the hallux while applying medially directed counterpressure on the 1MT to complete the lateral release (Fig. 5.9). Provided adequate multiple fenestrations were performed laterally, a varus stress of 20° is sufficient. • Of note, with satisfactory correction of the IMA, our experience is that it is typically not necessary to perform an extensive lateral release. In fact, releasing the suspensory ligament between the lateral metatarsal head and the lateral sesamoid in isolation typically suffices.
Medial Capsulotomy and Medial Eminence Resection • With the medial capsule fully exposed and the EHL tendon and the cutaneous nerve branch to the hallux protected, the medial capsulotomy is performed. • We favor an L-shaped capsulotomy (Fig. 5.10), but any one of a number of described techniques is applicable. It is important that sufficient tissue remains at the time of closure to perform a satisfactory capsulorrhaphy. • The medial eminence may be resected at this point or immediately before capsulorrhaphy. The medial eminence is resected in line with the medial 1MT shaft (Fig. 5.11), immediately medial to the medial sulcus, avoiding overresection (which may promote hallux varus). • In addition, the microsagittal saw must be held in the proper sagittal plane to avoid overresection of the plantar aspect of the 1MT head, which articulates with the medial sesamoid.
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.11
A
B FIG. 5.12
Step 2: Proximal Oblique (Ludloff) First Metatarsal Osteotomy • The 1MT is fully exposed. The sensory cutaneous terminal branch of the superficial peroneal nerve and the EHL tendon are protected. • With minimal periosteal stripping, a small blunt Hohmann retractor is positioned on the lateral side of the 1MT. To define the 1TMT joint, a small-diameter Kirschner wire may be placed in the joint and its position confirmed on intraoperative fluoroscopy. • Dissection plantar to the metatarsal may be kept to a minimum, but some exposure is required to define the exit point of the osteotomy and to create adequate access to place a second screw. • With the 1MT exposed, the planned osteotomy is marked and/or scored (Fig. 5.12). The desired osteotomy should originate at or just distal to the dorsal aspect of the 1TMT joint and extend obliquely and plantarward to a point just proximal to the metatarsal head–sesamoid complex. A long osteotomy provides the greatest surface area for healing and readily permits fixation with two screws. In our experience, a short osteotomy tends to be less stable than a long osteotomy. • The greatest challenge with this osteotomy is achieving its ideal orientation and congruency. • The osteotomy must be performed from the direct medial aspect of the 1MT, avoiding the tendency is to start the osteotomy too dorsally. • Staying in the same plane for the entire length of the osteotomy is facilitated by not allowing the saw blade to completely exit the osteotomy when it is advanced distally and plantarward. • To avoid a tendency to elevate the distal fragment during IMA correction, the saw blade may be inclined 10° in a plantarward direction, to promote slight plantar flexion of the distal fragment.
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.13
FIG. 5.14
• With the ideal osteotomy marked/scored on the medial aspect of the 1MT and a small blunt Hohmann retractor protecting against accidental overpenetration of the saw blade through the lateral cortex, the microsagittal saw is fully seated through the proximal aspect of the planned osteotomy. The distal corner of the saw blade is then retracted, leaving the proximal aspect of the blade within the osteotomy, and the saw blade is then fully seated through both cortices more distally than the initial cut. This process is repeated multiple times to advance the saw along the proximal two-thirds of the planned osteotomy (Fig. 5.13). • After completing the proximal two-thirds of the osteotomy, the saw is removed and a small-fragment lag screw is inserted perpendicular to the completed portion of the osteotomy (Fig. 5.14). • The proximal two-thirds of the osteotomy must be fully completed before inserting this screw because access to the lateral cortex will be limited once the screw is in position. • This position of this screw should not violate the 1TMT joint, not fracture the thinner dorsal fragment, and be proximal enough to allow for insertion of a second screw across the more distal aspect of the osteotomy. • When using a fully threaded solid screw, the proximal (dorsal) cortex will need to be overdrilled to create a lag effect. We routinely use a dual-pitch or partially threaded cannulated screw. • With compression of the proximal osteotomy confirmed, the screw is temporarily released a few turns to allow completion of the osteotomy. • The microsagittal saw is reintroduced into the osteotomy, and in a manner similar to that described earlier, the distal portion of the osteotomy is completed (Fig. 5.15). The plantar soft tissues must be protected as the saw blade exits the plantar cortex. A tendency may be to advance the saw blade too distally, potentially creating an exit point in the metatarsal head or one that violates the sesamoid complex, and therefore it is essential that the target remains the planned exit point of the scored/marked osteotomy. • The IMA is corrected by rotating the distal fragment on the proximal fragment, pivoting about the screw that has been inserted across the proximal aspect of the osteotomy (Fig. 5.16). • Occasionally the soft tissues at the proximal-most and distal-most aspects of the osteotomy need to be carefully released to permit the osteotomy to mobilize. A towel clip attached to the distal aspect of the proximal fragment provides stability as manual pressure is applied to the medial 1MT head. With desired correction, the proximal screw is secured and the towel clip is positioned to temporarily prevent loss of correction (Fig. 5.16). IMA correction is confirmed with intraoperative fluoroscopy (Fig. 5.17).
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.15
A
B FIG. 5.16
A
B FIG. 5.17
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48
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.18
FIG. 5.19
INSTRUMENTATION/IMPLANTATION
• Microsagittal saw • Small-fragment screws (solid or cannulated) • Towel clip • Small fluoroscopy unit
STEP 2 PEARLS
• Even without complete repair of the medial capsule, the hallux position should be nearly anatomic with appropriate correction of the IMA.
STEP 2 PITFALLS
• The operation is not over until the hallux is properly positioned; greater tightening of the medial capsulorrhaphy is rarely the solution. • If the IMA is undercorrected, the proximal osteotomy will need to be repositioned. • If the distal metatarsal articular angle (DMAA) is increased, a supplemental distal, medial closing wedge 1MT osteotomy must be added.
• With overcorrection or undercorrection of the IMA, the proximal screw and towel clip may be readily released, further correction can be made, and the screw and towel clip can again be secured. • A second lag screw is placed over the distal aspect of the metatarsal shaft (Fig. 5.18). • We prefer to direct this screw from plantar to dorsal. With the plantar soft tissues retracted and retraction of the dorsal soft tissues released, the plantar screw can be safely inserted. If the screw is placed obliquely from medial to lateral, its compression may promote loss of correction as the distal fragment is pulled medially. Therefore the distal screw should be directed as much as is possible from plantar to dorsal while remaining perpendicular to the osteotomy. • This screw should be started centrally on the distal aspect of the plantar fragment, avoiding the risk of medial or distal fracture as the screw is compressed. In addition, the screw should not penetrate the dorsal cortex of the distal fragment more than a millimeter or two because this may create symptomatic hardware postoperatively. • We recommend intraoperative fluoroscopy to confirm satisfactory correction of the IMA (Fig. 5.19).
Step 3: Medial Capsulorrhaphy and Closure • Typically, distal and proximal prominences remain on the medial aspect of this osteotomy upon completion of the IMA correction. These should be removed with the microsagittal saw (Fig. 5.20). While protecting the sensory cutaneous nerve to the hallux, the medial capsule is repaired, typically with imbrication (Fig. 5.21). We use a combination of absorbable and nonabsorbable suture to close the capsule. • In order to rebalance the hallux on the 1MT head, slight supination and varus are applied to the hallux during the medial capsulorrhaphy. Intraoperative fluoroscopy confirms that the hallux is balanced in an anatomic position and that the metatarsal head is properly repositioned on the sesamoid complex (Fig. 5.22). • We deem a minimal amount of varus positioning optimal as this tends to correct to an anatomic position; however, a true varus positioning of the hallux should be avoided. • In the event that overcorrection has occurred, either the IMA is overcorrected (necessitating repositioning of the 1MT osteotomy) or the lateral capsule has been overreleased.
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
B
A
FIG. 5.20
FIG. 5.21
• With overrelease of the lateral capsule, one option is to attach the residual adductor hallucis tendon to the distal lateral capsular tissues. • If the metatarsal head, sesamoid, and hallux relationship is not anatomic, then the IMA correction is inadequate, the capsular closure is not appropriate, or the patient has an increased DMAA. The surgeon should not leave the operating room until the hallux is properly positioned. • Rarely is the problem related to an inappropriate medial capsular closure. • If the IMA proves to be undercorrected, then the proximal osteotomy will need to be realigned to achieve appropriate IMA correction. • With an increased DMAA, a supplemental distal 1MT osteotomy is warranted, either a medial closing wedge osteotomy (Reverdin) or a biplanar distal chevron osteotomy, to reestablish the proper alignment of the 1MT’s articular surface on the 1MT shaft. Because of the potential need for a distal osteotomy in addition to a proximal correction, the lateral capsular release must always be performed judiciously in order to prevent compromising the blood supply to the 1MT head.
FIG. 5.22
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
STEP 3 PEARLS
• Edema will persist for a minimum of 6 months. • Routine bunion strapping may not be required; postoperative radiographs determine hallux position and guide the need for bunion strapping. • The metatarsal osteotomy ideally heals by direct bone healing. Radiographic evidence for callus formation at the osteotomy site is suggestive of inadequate or loss of fixation. If correction is maintained, we recommend casting and limited weight bearing until healing is satisfactory.
POSTOPERATIVE PITFALLS
• Postoperative callus formation at the osteotomy site (Fig. 5.25A) indicates inadequate fixation, motion at the osteotomy site, and potential for loss of correction. We recommend casting and protective weightbearing until there is radiographic evidence for healing (typically 8–10 weeks from time of surgery). Note the relatively short osteotomy (lacking stability) in Fig. 5.25B. After casting and delaying weight bearing, callus consolidation is achieved with minimal loss of correction (Fig. 5.25C). On follow-up at 1 year, there is satisfactory maintenance of correction and healing with callus resorption (Fig. 5.25D).
• Occasionally, deeper soft tissues may be repaired over the osteotomy and at the 1TMT joint, but typically the only layers that can be closed are the subcutaneous tissue and the skin. The sensory nerve to the hallux must be protected during this closure. The dorsal first web space incision is closed as well (Fig. 5.23). • A sterile dressing is applied to the wounds.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Bunion strapping and surgical dressing are applied. • Weekly follow-up is scheduled for 1MTP joint manipulation, bunion strapping, and radiographs to assess 1MTP joint position and healing. • Bunion strapping is recommended for 6 weeks and a toe spacer for an additional 4–6 weeks to unload the medial capsulorrhaphy while it heals. • Protective weight-bearing status, with heel weight bearing only and limiting weight bearing on the forefoot, should be maintained until there is radiographic evidence for healing of the osteotomy (typically 6 weeks). • Fig. 5.24 shows the final follow-up of a proximal 1MT osteotomy 7 years postoperatively in a clinical view (Fig. 5.24A) and a weight-bearing lateral radiograph (Fig. 5.24B). In a weight-bearing anteroposterior radiograph (Fig. 5.24C), note the ideal 1MT head position centered over the sesamoid complex. See also Video 5.1, Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft Tissue Procedure.
A
FIG. 5.23
B
C FIG. 5.24
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
A
B
C FIG. 5.25
EVIDENCE Chiodo CP, Schon LC, Myerson MS. Clinical results with the Ludloff osteotomy for correction of adult hallux valgus. Foot Ankle Int 2004;25:532–6. Peer-reviewed article on the clinical results of the Ludloff osteotomy (grade B recommendation; Level IV evidence). Hofstaetter SG, Riedl M, Glisson RR, Trieb K, Easley ME. The influence of patient age and bone mineral density on osteotomy fixation stability after hallux valgus surgery: a biomechanical study. Clin Biomech 2016;32:255–60. Study addressing the patient age and bone density as they pertain to first metatarsal osteotomies in hallux valgus correction. Nyska M, Trnka HJ, Parks BG, et al. The Ludloff metatarsal osteotomy: guidelines for optimal correction based on a geometric analysis conducted on a sawbone model. Foot Ankle Int 2003;23:34–9. Biomechanical study that provides a better understanding of how to perform the Ludloff osteotomy. Robinson AH, Bhatia M, Eaton C, Bishop L. Prospective comparative study of the SCARF and Ludloff osteotomies in the treatment of hallux valgus. Foot Ankle Int 2009;30(10):955–63. This study compared two diaphyseal osteotomies (Scarf and Ludloff) that correct moderate to severe metatarsus primus varus and found that patients who had a Scarf osteotomy had a superior outcome at 6 and 12 months. Trnka HJ, Hofstaetter SG, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. Surgical technique. J Bone Joint Surg Am 2009;91(Suppl 2):156–68. Detailed surgical technique of the Ludloff osteotomy. Trnka HJ, Hofstaetter SG, Hofstaetter JG, Gruber F, Adams Jr SB, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. J Bone Joint Surg Am 2008;90:531–9. Peer-reviewed article on the clinical results of the Ludloff osteotomy (grade B recommendation; Level IV evidence).
D
51
Proximal Long Oblique (Ludloff ) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure Mark E. Easley and Hans-Jörg Trnka INDICATIONS PITFALLS
• Contraindications to surgical correction of hallux valgus deformity: peripheral vascular disease and peripheral neuropathy • Contraindication to surgical correction of hallux valgus with a metatarsal osteotomy: hallux rigidus (degenerative joint disease of the first metatarsophalangeal [1MTP] joint) • Relative contraindications to the Ludloff osteotomy: narrow first metatarsal (1MT; limited surface area for healing) and osteopenia (risk for poor fixation) CONTROVERSIES
• Hypermobility of the first ray: some surgeons recommend a 1TMT joint arthrodesis (modified Lapidus procedure) in lieu of a metatarsal osteotomy.
TREATMENT OPTIONS
• One of over 130 corrective procedures for symptomatic hallux valgus; with moderate to severe deformity, a proximal osteotomy or modified Lapidus procedure is favored.
INDICATIONS • Symptomatic moderate to severe hallux valgus (first/second intermetatarsal angle [1/2 IMA] >15°) failing nonoperative treatment
EXAMINATION/IMAGING • Relatively wide forefoot with a tender, prominent medial eminence (medial 1MT head). Fig. 5.1 shows a patient in a weight-bearing stance with one foot corrected with a Ludloff osteotomy and distal soft-tissue procedure and the other foot uncorrected. • Hallux valgus deformity (lateral deviation of the hallux) is noted. • Weight-bearing anteroposterior radiograph showing moderate to severe hallux valgus deformity (an increased 1/2 IMA exceeding 15°) is shown in Fig. 5.2A. • Weight-bearing lateral radiograph without plantar gapping at the first tarsometatarsal (1TMT) joint (suggestive of hypermobility) is shown in Fig. 5.2B.
SURGICAL ANATOMY • Dorsomedial sensory cutaneous nerve to the hallux (terminal branch of the superficial peroneal nerve; Fig. 5.3A) • Medial position of the 1MT head relative to the anatomically positioned sesamoid complex (Fig. 5.3B) • Lateral capsule with important blood supply to the 1MT head (Fig. 5.3C) • 1TMT joint
POSITIONING • Supine position on the operating room table
TREATMENT PEARLS
• Unlike many other 1MT osteotomies, periosteal stripping is not required and should be avoided.
TREATMENT PITFALLS
• Making the medial incision too plantar may limit exposure of the 1MT and lead to excessive skin retraction and potential skin necrosis at the dorsal wound margin.
FIG. 5.1
40
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
A
B FIG. 5.2
A
B
C FIG. 5.3
PORTALS/EXPOSURES • Two exposures should be considered: (1) a dorsal first web space incision to perform the lateral release and (2) a longitudinal medial approach to perform the medial capsulotomy and 1MT osteotomy. Alternative to the dorsal first web space incision, the lateral suspensory ligament between the lateral metatarsal head and the lateral sesamoid may be released via the medial approach with a blade passed between the plantar aspect of the 1MT head and the sesamoid complex.
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.4
A
B FIG. 5.5
PORTALS/EXPOSURES PEARLS
• With long-standing hallux valgus deformity, an audible “pop” indicative of a successful release is typically experienced and desirable. However, overrelease of the lateral capsule must be avoided.
PORTALS/EXPOSURES PITFALLS
• If the lateral capsule is tight, then the lateral capsule may be fenestrated. We recommend performing the lateral capsular fenestration distal to the metatarsal head to preserve the metatarsal head’s blood supply, in the event where a distal osteotomy is required in conjunction with the proximal Ludloff osteotomy (risk of 1MT head avascular necrosis). • Avoid overreleasing the lateral capsule to limit the risk of hallux varus (multiple small fenestrations and a varus stress of only 20° typically suffice).
Dorsal First Web Space Incision • A 3- to 4-cm incision is made between the distal first and second metatarsals. The superficial neurovascular structures are protected. • The enveloping fascia (innominate fascia) is split longitudinally, and blunt dissection (with a finger) is performed to access the lateral aspect of the 1MTP joint. A lamina spreader may be placed between the first and second metatarsals to improve access to the first web space (Fig. 5.4).
Medial Midaxial Longitudinal Approach • A longitudinal incision is made from the 1MTP joint to the 1TMT joint, directly over the 1MT (Fig. 5.5A). A tendency to make the incision slightly more dorsal than plantar will facilitate exposure of the 1MT for the osteotomy. • The dorsomedial cutaneous sensory nerve to the hallux and extensor hallucis longus (EHL) tendon must be identified and protected throughout the procedure (Fig. 5.5B). • The medial 1MTP joint capsule should be exposed but not violated during the surgical approach.
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.6
A
B
PROCEDURE Step 1: Lateral Release and Medial Capsulotomy Lateral Release • The ligament between the lateral capsule and the lateral sesamoid is released sharply by introducing the scalpel blade directly into the articulation between the plantar metatarsal head and the lateral sesamoid (Fig. 5.6). This maneuver can be performed from the proximal end to the distal end and, if carefully controlled, may be continued distally and slightly laterally to simultaneously release the adductor hallucis tendon from the base of the first proximal phalanx (Fig. 5.7A). • Next, the adductor hallucis is directly released from the lateral sesamoid (Fig. 5.7B), thereby fully detaching both aspects of the adductor hallucis to the 1MTP joint and sesamoid complex (Fig. 5.7C). • Then, the lateral capsule is weakened distal to the lateral metatarsal head by fenestrating it with multiple scalpel blade stab incisions (Fig. 5.8). • Depending on surgeon preference, the transverse intermetatarsal ligament may be carefully elevated from the underlying common digital artery and nerve and divided while protecting these neurovascular structures; we do not routinely release this ligament. • Alternatively, the lateral release may be performed through a single medial approach, releasing the lateral suspensory ligament between the lateral metatarsal head and lateral sesamoid.
C FIG. 5.7
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
44
FIG. 5.8
A
FIG. 5.9
B FIG. 5.10
STEP 1 PEARLS
• We recommend cooling the microsagittal saw blade with cool saline irrigation to limit heat that may create areas of osteonecrosis along the osteotomy. • Hold the forefoot with the opposite hand while performing the 1MT osteotomy; this will provide greater stability and facilitate orienting the osteotomy properly. STEP 1 PITFALLS
• Do not make the osteotomy too short; a longer osteotomy typically leads to greater stability.
CONTROVERSIES
• Alternatively, the lateral release may be performed through the medial approach, but this may not provide full visualization of the contracted lateral soft tissues.
• Finally, a varus stress is applied to the hallux while applying medially directed counterpressure on the 1MT to complete the lateral release (Fig. 5.9). Provided adequate multiple fenestrations were performed laterally, a varus stress of 20° is sufficient. • Of note, with satisfactory correction of the IMA, our experience is that it is typically not necessary to perform an extensive lateral release. In fact, releasing the suspensory ligament between the lateral metatarsal head and the lateral sesamoid in isolation typically suffices.
Medial Capsulotomy and Medial Eminence Resection • With the medial capsule fully exposed and the EHL tendon and the cutaneous nerve branch to the hallux protected, the medial capsulotomy is performed. • We favor an L-shaped capsulotomy (Fig. 5.10), but any one of a number of described techniques is applicable. It is important that sufficient tissue remains at the time of closure to perform a satisfactory capsulorrhaphy. • The medial eminence may be resected at this point or immediately before capsulorrhaphy. The medial eminence is resected in line with the medial 1MT shaft (Fig. 5.11), immediately medial to the medial sulcus, avoiding overresection (which may promote hallux varus). • In addition, the microsagittal saw must be held in the proper sagittal plane to avoid overresection of the plantar aspect of the 1MT head, which articulates with the medial sesamoid.
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.11
A
B FIG. 5.12
Step 2: Proximal Oblique (Ludloff) First Metatarsal Osteotomy • The 1MT is fully exposed. The sensory cutaneous terminal branch of the superficial peroneal nerve and the EHL tendon are protected. • With minimal periosteal stripping, a small blunt Hohmann retractor is positioned on the lateral side of the 1MT. To define the 1TMT joint, a small-diameter Kirschner wire may be placed in the joint and its position confirmed on intraoperative fluoroscopy. • Dissection plantar to the metatarsal may be kept to a minimum, but some exposure is required to define the exit point of the osteotomy and to create adequate access to place a second screw. • With the 1MT exposed, the planned osteotomy is marked and/or scored (Fig. 5.12). The desired osteotomy should originate at or just distal to the dorsal aspect of the 1TMT joint and extend obliquely and plantarward to a point just proximal to the metatarsal head–sesamoid complex. A long osteotomy provides the greatest surface area for healing and readily permits fixation with two screws. In our experience, a short osteotomy tends to be less stable than a long osteotomy. • The greatest challenge with this osteotomy is achieving its ideal orientation and congruency. • The osteotomy must be performed from the direct medial aspect of the 1MT, avoiding the tendency is to start the osteotomy too dorsally. • Staying in the same plane for the entire length of the osteotomy is facilitated by not allowing the saw blade to completely exit the osteotomy when it is advanced distally and plantarward. • To avoid a tendency to elevate the distal fragment during IMA correction, the saw blade may be inclined 10° in a plantarward direction, to promote slight plantar flexion of the distal fragment.
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.13
FIG. 5.14
• With the ideal osteotomy marked/scored on the medial aspect of the 1MT and a small blunt Hohmann retractor protecting against accidental overpenetration of the saw blade through the lateral cortex, the microsagittal saw is fully seated through the proximal aspect of the planned osteotomy. The distal corner of the saw blade is then retracted, leaving the proximal aspect of the blade within the osteotomy, and the saw blade is then fully seated through both cortices more distally than the initial cut. This process is repeated multiple times to advance the saw along the proximal two-thirds of the planned osteotomy (Fig. 5.13). • After completing the proximal two-thirds of the osteotomy, the saw is removed and a small-fragment lag screw is inserted perpendicular to the completed portion of the osteotomy (Fig. 5.14). • The proximal two-thirds of the osteotomy must be fully completed before inserting this screw because access to the lateral cortex will be limited once the screw is in position. • This position of this screw should not violate the 1TMT joint, not fracture the thinner dorsal fragment, and be proximal enough to allow for insertion of a second screw across the more distal aspect of the osteotomy. • When using a fully threaded solid screw, the proximal (dorsal) cortex will need to be overdrilled to create a lag effect. We routinely use a dual-pitch or partially threaded cannulated screw. • With compression of the proximal osteotomy confirmed, the screw is temporarily released a few turns to allow completion of the osteotomy. • The microsagittal saw is reintroduced into the osteotomy, and in a manner similar to that described earlier, the distal portion of the osteotomy is completed (Fig. 5.15). The plantar soft tissues must be protected as the saw blade exits the plantar cortex. A tendency may be to advance the saw blade too distally, potentially creating an exit point in the metatarsal head or one that violates the sesamoid complex, and therefore it is essential that the target remains the planned exit point of the scored/marked osteotomy. • The IMA is corrected by rotating the distal fragment on the proximal fragment, pivoting about the screw that has been inserted across the proximal aspect of the osteotomy (Fig. 5.16). • Occasionally the soft tissues at the proximal-most and distal-most aspects of the osteotomy need to be carefully released to permit the osteotomy to mobilize. A towel clip attached to the distal aspect of the proximal fragment provides stability as manual pressure is applied to the medial 1MT head. With desired correction, the proximal screw is secured and the towel clip is positioned to temporarily prevent loss of correction (Fig. 5.16). IMA correction is confirmed with intraoperative fluoroscopy (Fig. 5.17).
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.15
A
B FIG. 5.16
A
B FIG. 5.17
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
FIG. 5.18
FIG. 5.19
INSTRUMENTATION/IMPLANTATION
• Microsagittal saw • Small-fragment screws (solid or cannulated) • Towel clip • Small fluoroscopy unit
STEP 2 PEARLS
• Even without complete repair of the medial capsule, the hallux position should be nearly anatomic with appropriate correction of the IMA.
STEP 2 PITFALLS
• The operation is not over until the hallux is properly positioned; greater tightening of the medial capsulorrhaphy is rarely the solution. • If the IMA is undercorrected, the proximal osteotomy will need to be repositioned. • If the distal metatarsal articular angle (DMAA) is increased, a supplemental distal, medial closing wedge 1MT osteotomy must be added.
• With overcorrection or undercorrection of the IMA, the proximal screw and towel clip may be readily released, further correction can be made, and the screw and towel clip can again be secured. • A second lag screw is placed over the distal aspect of the metatarsal shaft (Fig. 5.18). • We prefer to direct this screw from plantar to dorsal. With the plantar soft tissues retracted and retraction of the dorsal soft tissues released, the plantar screw can be safely inserted. If the screw is placed obliquely from medial to lateral, its compression may promote loss of correction as the distal fragment is pulled medially. Therefore the distal screw should be directed as much as is possible from plantar to dorsal while remaining perpendicular to the osteotomy. • This screw should be started centrally on the distal aspect of the plantar fragment, avoiding the risk of medial or distal fracture as the screw is compressed. In addition, the screw should not penetrate the dorsal cortex of the distal fragment more than a millimeter or two because this may create symptomatic hardware postoperatively. • We recommend intraoperative fluoroscopy to confirm satisfactory correction of the IMA (Fig. 5.19).
Step 3: Medial Capsulorrhaphy and Closure • Typically, distal and proximal prominences remain on the medial aspect of this osteotomy upon completion of the IMA correction. These should be removed with the microsagittal saw (Fig. 5.20). While protecting the sensory cutaneous nerve to the hallux, the medial capsule is repaired, typically with imbrication (Fig. 5.21). We use a combination of absorbable and nonabsorbable suture to close the capsule. • In order to rebalance the hallux on the 1MT head, slight supination and varus are applied to the hallux during the medial capsulorrhaphy. Intraoperative fluoroscopy confirms that the hallux is balanced in an anatomic position and that the metatarsal head is properly repositioned on the sesamoid complex (Fig. 5.22). • We deem a minimal amount of varus positioning optimal as this tends to correct to an anatomic position; however, a true varus positioning of the hallux should be avoided. • In the event that overcorrection has occurred, either the IMA is overcorrected (necessitating repositioning of the 1MT osteotomy) or the lateral capsule has been overreleased.
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
B
A
FIG. 5.20
FIG. 5.21
• With overrelease of the lateral capsule, one option is to attach the residual adductor hallucis tendon to the distal lateral capsular tissues. • If the metatarsal head, sesamoid, and hallux relationship is not anatomic, then the IMA correction is inadequate, the capsular closure is not appropriate, or the patient has an increased DMAA. The surgeon should not leave the operating room until the hallux is properly positioned. • Rarely is the problem related to an inappropriate medial capsular closure. • If the IMA proves to be undercorrected, then the proximal osteotomy will need to be realigned to achieve appropriate IMA correction. • With an increased DMAA, a supplemental distal 1MT osteotomy is warranted, either a medial closing wedge osteotomy (Reverdin) or a biplanar distal chevron osteotomy, to reestablish the proper alignment of the 1MT’s articular surface on the 1MT shaft. Because of the potential need for a distal osteotomy in addition to a proximal correction, the lateral capsular release must always be performed judiciously in order to prevent compromising the blood supply to the 1MT head.
FIG. 5.22
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PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
STEP 3 PEARLS
• Edema will persist for a minimum of 6 months. • Routine bunion strapping may not be required; postoperative radiographs determine hallux position and guide the need for bunion strapping. • The metatarsal osteotomy ideally heals by direct bone healing. Radiographic evidence for callus formation at the osteotomy site is suggestive of inadequate or loss of fixation. If correction is maintained, we recommend casting and limited weight bearing until healing is satisfactory.
POSTOPERATIVE PITFALLS
• Postoperative callus formation at the osteotomy site (Fig. 5.25A) indicates inadequate fixation, motion at the osteotomy site, and potential for loss of correction. We recommend casting and protective weightbearing until there is radiographic evidence for healing (typically 8–10 weeks from time of surgery). Note the relatively short osteotomy (lacking stability) in Fig. 5.25B. After casting and delaying weight bearing, callus consolidation is achieved with minimal loss of correction (Fig. 5.25C). On follow-up at 1 year, there is satisfactory maintenance of correction and healing with callus resorption (Fig. 5.25D).
• Occasionally, deeper soft tissues may be repaired over the osteotomy and at the 1TMT joint, but typically the only layers that can be closed are the subcutaneous tissue and the skin. The sensory nerve to the hallux must be protected during this closure. The dorsal first web space incision is closed as well (Fig. 5.23). • A sterile dressing is applied to the wounds.
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Bunion strapping and surgical dressing are applied. • Weekly follow-up is scheduled for 1MTP joint manipulation, bunion strapping, and radiographs to assess 1MTP joint position and healing. • Bunion strapping is recommended for 6 weeks and a toe spacer for an additional 4–6 weeks to unload the medial capsulorrhaphy while it heals. • Protective weight-bearing status, with heel weight bearing only and limiting weight bearing on the forefoot, should be maintained until there is radiographic evidence for healing of the osteotomy (typically 6 weeks). • Fig. 5.24 shows the final follow-up of a proximal 1MT osteotomy 7 years postoperatively in a clinical view (Fig. 5.24A) and a weight-bearing lateral radiograph (Fig. 5.24B). In a weight-bearing anteroposterior radiograph (Fig. 5.24C), note the ideal 1MT head position centered over the sesamoid complex. See also Video 5.1, Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft Tissue Procedure.
A
FIG. 5.23
B
C FIG. 5.24
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
A
B
C FIG. 5.25
EVIDENCE Chiodo CP, Schon LC, Myerson MS. Clinical results with the Ludloff osteotomy for correction of adult hallux valgus. Foot Ankle Int 2004;25:532–6. Peer-reviewed article on the clinical results of the Ludloff osteotomy (grade B recommendation; Level IV evidence). Hofstaetter SG, Riedl M, Glisson RR, Trieb K, Easley ME. The influence of patient age and bone mineral density on osteotomy fixation stability after hallux valgus surgery: a biomechanical study. Clin Biomech 2016;32:255–60. Study addressing the patient age and bone density as they pertain to first metatarsal osteotomies in hallux valgus correction. Nyska M, Trnka HJ, Parks BG, et al. The Ludloff metatarsal osteotomy: guidelines for optimal correction based on a geometric analysis conducted on a sawbone model. Foot Ankle Int 2003;23:34–9. Biomechanical study that provides a better understanding of how to perform the Ludloff osteotomy. Robinson AH, Bhatia M, Eaton C, Bishop L. Prospective comparative study of the SCARF and Ludloff osteotomies in the treatment of hallux valgus. Foot Ankle Int 2009;30(10):955–63. This study compared two diaphyseal osteotomies (Scarf and Ludloff) that correct moderate to severe metatarsus primus varus and found that patients who had a Scarf osteotomy had a superior outcome at 6 and 12 months. Trnka HJ, Hofstaetter SG, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. Surgical technique. J Bone Joint Surg Am 2009;91(Suppl 2):156–68. Detailed surgical technique of the Ludloff osteotomy. Trnka HJ, Hofstaetter SG, Hofstaetter JG, Gruber F, Adams Jr SB, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. J Bone Joint Surg Am 2008;90:531–9. Peer-reviewed article on the clinical results of the Ludloff osteotomy (grade B recommendation; Level IV evidence).
D
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