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Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure


Indications

  • Symptomatic moderate to severe hallux valgus (first/second intermetatarsal angle [1/2 IMA] >15°) failing nonoperative treatment

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)

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.

    FIG. 5.1

  • 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 .

    FIG. 5.2

  • 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 )

    FIG. 5.3

  • 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

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.

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.

Positioning

  • Supine position on the operating room table

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