Foot Ankle Clin N Am

10 (2005) 15 – 33

Osteotomies for Hallux Valgus Correction

Hans-Jfrg Trnka, MD, PhD
Foot and Ankle Center at the Wiener Privatklinik, Mariannengasse 14/1/2, 1090 Vienna, Austria

The earliest reports of surgical hallux valgus correction date back to Gernet in
1836. Most popular were the resection of parts of the first metatarsophalangeal
(MTP) joint by Mayo [1], Keller [2], and Brandes [3]. Despite the fact that some
of these techniques are still in use, they should be abandoned for most patients.
Correctional metatarsal osteotomies are the treatment of choice of the twenty-
first century. Our ancestors in the nineteenth century already had this thought.
The first reports date back to Reverdin [4], who described a subcapital closing
wedge osteotomy for the correction of hallux valgus deformity in 1881. It became
popular as the Hohmann [5] osteotomy.
From the beginning of the use of osteotomies for the treatment of hallux
valgus deformities, surgeons distinguished between distal and proximal osteo-
tomies. The Hohmann [5], Wilson [6], Mitchell [7], and chevron [8] osteotomies
were representatives of the distal osteotomies, whereas the Loison [9], Balacescu
[10], Ludloff [11], Trott [12] and crescentic Mann osteotomy [13] were repre-
sentatives of the proximal osteotomies. One may think that after more than
160 years of hallux valgus surgery, a perfect treatment should have been found.
In 1931, Peabody [14] thought that he had found it. He stated that all of his
patients were happy and there was no complication; he was wrong. In 1981, Helal
[15] counted more than 150 different techniques; the number has increased since
that time.
A minimum consensus among surgeons has been established. Minor and
moderate deformities (rated by intermetatarsal and hallux valgus angles) may be
treated by distal osteotomies. More severe deformities are treated best by
proximal metatarsal osteotomies; these have been proven mathematically to give
the best corrections.

E-mail address: [email protected]

1083-7515/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.fcl.2004.10.002 foot.theclinics.com
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This article should shed some light on the numerous metatarsal osteotomies.
The author reviewed the results of different metatarsal osteotomies that were
performed from 1975 to 1997 and established an algorithm to treat the different
forms of hallux valgus deformity.

Distal metatarsal osteotomies

In 1884, Barker [16] was the first person to describe a distal metatarsal closing
wedge osteotomy for the correction of hallux valgus deformity. This kind of
technique became popular after the description of Hohmann [5] in the German
literature in 1921. The downside of the original technique was the necessity of a
cast and the resulting shortening of the metatarsal. Therefore, it was modified by
Kramer and colleagues [17,18] who replaced the closing wedge osteotomy with a
lateral translation osteotomy and added a Kirschner wire fixation. Bfsch et al [19]
simplified this procedure further by developing a special lever to perform the
osteotomy subcutaneously. The advantage of this osteotomy—especially the
subcutaneous Bfsch osteotomy—is offset by the disadvantage of the inherently
unstable osteotomy that is not stable enough to maintain correction without
fixation. In 1997, Trnka et al [20] compared the results of the Kramer and the
Austin osteotomies. Similar corrections of the hallux valgus angle and
intermetatarsal angles were observed in both groups. A statistically better
correction of the sesamoid position was seen after the Austin procedure. After the
Kramer osteotomy, more malalignment and recurrent severe hallux valgus
deformity were seen. Bfsch et al [19] reported much better results in a 7- to
10-year follow-up study. Of the 98 feet, the average hallux valgus angle was
corrected from 368 preoperatively (range, 148 to 548) to 198 postoperatively
(range, 78 to 408). The average intermetatarsal angle was corrected from 138
preoperatively (range, 68 to 188) to 108 postoperatively (range, 38 to 188). Com-
plications included four deep infections and four cases of delayed bone healing.
Bretschneider and Wanivenhaus [21] presented a short-term follow-up after the
open Kramer technique. They noted a 12% pin tract infection rate with the
percutaneous wire fixation. Patients missed an average of 10 weeks of work.
Wilson, certainly influenced by the Hohmann osteotomy, presented an oblique
distal metatarsal osteotomy in 1963 that remains in use in several parts of Europe
(eg, England, Greece) [22]. This osteotomy is performed at the distal diaphyseal
shaft of the first metatarsal. The osteotomy is angled 458 to the long axis of the
metatarsal in the anteroposterior plane and 908 to the long axis of the osteotomy
in the sagittal plane. Because of its geometry, the lateral displacement automati-
cally shortens the first metatarsal. The osteotomy also provides no inherent sta-
bility. Because shortening of the first metatarsal incurs the risk of metatarsalgia,
this osteotomy is not recommended. Schemitsch and Horne [23] presented a
follow-up study of the Wilson osteotomy 5 years after surgery. The likelihood of
second metatarsal metatarsalgia as in the case of short first metatarsals, was 50%
and greater.
 osteotomies for hallux valgus correction 17

In 1920, Roux [24] presented a step cut osteotomy of the distal metatarsal. In
1931, Peabody [14] described outstanding 100% patient satisfaction, no recur-
rence, and no complications. Influenced by these results, this technique was
popularized later by Mitchell et al [7], in 1958. The osteotomy cuts are per-
pendicular to the long axis of the metatarsal shaft. After performing the step cut
osteotomy, which causes shortening of the first metatarsal, the distal fragment is
translated laterally. Since the first descriptions, many modifications—including
the removal of a larger plantar base, change of the inclination of the spike, and
various fixation methods—have been proposed. Despite the modifications,
shortening and dorsiflexion that lead to recurrence make the Mitchell osteotomy a
technically demanding procedure [25].
In 1983, Merkel et al [26] presented a follow-up study of the Mitchell
osteotomy. Only 59% of the patients was available for follow-up. Despite
the overall satisfaction of 86%, the shortening was more than 5 mm in 39 of
56 patients. Generally, the osteotomy is inherently unstable [27] and most inves-
tigators advocate cast immobilization for 4 to 6 weeks [25,28].
The chevron osteotomy has become accepted widely for the correction of mild
and moderate hallux valgus deformities. In the initial reports by Austin and
Leventen [29] and Miller and Croce [30], no fixation was mentioned. They
suggested that the shape of the osteotomy and impaction of the cancellous capital
fragment upon the shaft of the first metatarsal provided sufficient stability to
forego fixation.
Generally, the procedure is performed under peripheral nerve blockade with or
without Esmarch tourniquet. A midside incision is made over the first MTP joint
from midshaft of the proximal phalanx to approximately midshaft of the
metatarsal. An inverted L or lenticular medial capsulotomy is used to expose the
medial eminence (Fig. 1). The medial eminence is excised with a power saw. At
this point, the V-osteotomy is planned and performed with care taken to ensure that
each cut is made precisely to give stability, which is the essence of the procedure.
A Kirschner wire is drilled medial to lateral through the first metatarsal head,
aiming at the head of the fourth metatarsal and inclined 208 plantarly (Fig. 2).
Two cuts are made with an oscillating power saw, such that they form an angle of
608 proximal to the drill hole. After the capital fragment is freely mobile, it is

Fig. 1. Inverted L-type medial capsulotomy.

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Fig. 2. Guide wire for the chevron osteotomy. 208 plantar inclination, aimed at the head of the
fourth metatarsal.

transposed laterally (Fig. 3). When the joint surfaces are in correct alignment and
the metatarsal head is in place, the capital fragment is impacted firmly onto the
metatarsal shaft. The remaining medial ‘‘step defect’’ is removed. The medial
capsule is closed by excising a triangle. Postoperatively, immediate weight
bearing is allowed in a postoperative bunion shoe. Patients must wear this shoe
for 6 weeks.
At the Orthopaedic Hospital Gersthof, we performed the original technique
from 1991 to 1992 [31]. Comparing the 2-year and 5-year follow-ups, 43 patients
(57 feet) were available for all three assessment periods—preoperative, 2-year
and 5-year follow-ups [32]. Between 2 and 5 years of follow-up, there was only a
minimal change in overall patient satisfaction (23 very satisfied at 2 years and

Fig. 3. Lateral transposition of the metatarsal head. (A) Drawing. (B) Intraoperative photograph.
 osteotomies for hallux valgus correction 19

24 very satisfied at 5 years) and the average hallux–MTP–interphalangeal scale

score (91 points each). Range of motion of the first MTP joint decreased from 728
preoperatively to 618 at the 2-year follow-up; it was maintained at 628 at the
5-year follow-up Radiographic evaluation revealed a preoperative average hallux
valgus angle of 298 (range, 168 to 508) and a preoperative average intermetatarsal

Fig. 4. Chevron osteotomy in a 32-year-old woman. (A) Incongruent MTP joint, sesamoid position 3,
intermetatarsal angle 148, hallux valgus angle 328. (B) 2-year follow-up. (C) 5-year follow-up.
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angle of 138 (range, 108 to 208). At the 2-year follow-up, the hallux valgus and
intermetatarsal angles averaged 158 (range, 08 to 408) and 88 (range, 08 to 208),
respectively. At the 5-year follow-up, the hallux valgus and intermetatarsal
angles averaged 168 (range, 08 to 408) and 98 (range, 28 to 208), respectively. An
increase of MTP joint arthrosis was noted in 8 feet at the 2-year follow-up and in
11 feet between the 2- and 5-year follow-ups (Fig. 4).
In light of publications by Kitaoka et al [33] and Mann and Pfeiffinger [34] in
1991, a more radical lateral soft tissue procedure was added to the original
procedure. Starting with an incision on the dorsal aspect of the foot in the first
intermetatarsal space, a lateral soft tissue release was added to the chevron
osteotomy. A longitudinal incision is made in the lateral joint capsule, just su-
perior to the lateral sesamoid; the metatarsosesamoidal ligament is incised. The
adductor tendon is identified and carefully dissected from the lateral capsule and
then released from its insertion into the base of the proximal phalanx. The
transverse metatarsal ligament is stretched and carefully incised to release the
tethering effect on the sesamoid complex. The lateral capsulotomy is perforated at
the joint line and the toe is forced manually into 208 varus position. Sutures
through the adductor tendon and the lateral aspect of the first metatarsal lift the
insertion of the adductor muscle; two stabilizing sutures are placed.
When comparing the results of this series with a series of patients who was
operated on according to the original Austin technique [31], a much better cor-
rection of the hallux valgus angle, intermetatarsal angle, and, most importantly,
the sesamoid position, were observed (Fig. 5) [35]. Earlier reports expressed
concern about increased avascular necrosis (AVN) if a lateral release is performed

Fig. 5. Chevron osteotomy with lateral soft tissue release in a 77-year-old woman. (A) In-
congruent MTP joint, sesamoid position 3, intermetatarsal angle 188, hallux valgus angle 428.
(B) 14-month follow-up.
 osteotomies for hallux valgus correction 21

in addition to a chevron osteotomy [36–38]. Jahss, Mann, and Kenzora suggested

that AVN frequently accompanies lateral soft tissue release, with an incidence of
up to 40% [36–38]. Analysis of Meier and Kenzora’s [38] results, however,
reveals a small percentage of patient follow-up and small groups of patients.
Jones et al [39] investigated the blood supply to the metatarsal head. Using a
modified Spalteholz technique in cadaveric specimens, they found an extensive
network of extraosseous vasculature to the metatarsal head proximal and distal to
the site of the osteotomy. Both of these vascular networks were preserved when
the osteotomy was done properly. Neither Trnka et al [35], Pochatko et al [40],
Thomas et al [41], nor Peterson et al [42] found an increased incidence of AVN of
the metatarsal head.
One concern was the loss of correction by performing the chevron osteotomy
without fixation. With the addition of a lateral soft tissue release, this concern
gained importance. Jahss et al [43] noted a 12.5% loss of correction. Hattrup and
Johnson [44] noted displacement in 4 of 225 chevron osteotomies. Multiple
variations of chevron fixations have been described [45–56].
At the Orthopaedic Hospital Gersthof, we performed a prospective study of
the chevron osteotomy with lateral soft tissue release and Kirschner wire fixation
on 45 patients (55 feet). After an average follow-up of 34 months, there was no
case of metatarsal head displacement or loss of correction [57]. The postoperative
regimen included a postoperative bunion shoe for 6 weeks (Fig. 6).
Bettenhausen and Cragel [58], Goforth et al [46], and Klein et al [47]
used screw fixation and limited the period of bunion shoe use to between 2 and
4 weeks. Starting in 1999, we used screw fixation using a oblique from medial to
lateral 2.7-mm cortical screw (New Deal SA, Vienne, France) in patients who had
good bone stock and a 1.6-mm Kirschner wire in elderly patients (N70 years of
age) in patients who had poor bone stock (Fig. 7).

Fig. 6. Chevron osteotomy with lateral soft tissue release and pin fixation in a 49-year-old woman.
(A) Incongruent MTP joint, sesamoid position 2, intermetatarsal angle 138, hallux valgus angle 308.
(B) 6-week follow-up.
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Fig. 7. Chevron osteotomy with lateral soft tissue release and BOLD screw in a 63-year-old woman.
(A) Incongruent MTP joint, sesamoid position 2, intermetatarsal angle 158, hallux valgus angle 348.
(B) 6-week follow-up.

According to papers by Harper [59] and Sarrafian [60], lateral displacement is

limited to up to 50% of metatarsal width. Using our modified technique, we were
able to extend the indication up to 75% of the metatarsal width (Fig. 8).

Midshaft osteotomy

The scarf osteotomy has gained popularity with the presentations of Weil [62],
and especially, Barouk [61]. The word ‘‘scarf’’ is an architectural and carpentry
term that is defined as ‘‘joint made by notching, grooving, or otherwise cutting
the ends of two pieces and fastening together so that they lap over and join firmly
onto one continuous piece’’ [62]. Various modifications of the scarf osteotomy
have been described, including the short scarf [63], the long scarf [61,64,65], and
the inverted scarf [53,66].
The scarf osteotomy—a midshaft osteotomy—should be more stable than
other proximal metatarsal osteotomies, as shown by Trnka et al [67]. Mechanical
testing of the classic scarf osteotomy failed to show improved stability over
other osteotomies, such as the Mau and the proximal closing wedge, however.
Barouk’s modifications should decrease the rate of proximal metatarsal fractures
[64]. In 2000, Weil [62] presented his results of 889 of 2120 patients who were
operated on from 1984 to 1998. Although at a follow-up rate of only 42%, the
results are not 100% reliable but the preoperative intermetatarsal angle was
corrected from 158 to 9.88. In 2002, Kristen et al [65] reported a retrospective
study of 89 patients (11 feet) with a mean follow-up of 36 months (range, 24 to
48 months). The preoperative intermetatarsal angle was corrected from 14.58 to
7.98. Postoperative complications included two cases of superficial wound
infection and one case of traumatic dislocation of the osteosynthesis.
 osteotomies for hallux valgus correction 23

Fig. 8. Chevron osteotomy with lateral soft tissue release and pin fixation and Akin osteotomy in a
82-year-old woman. (A) Incongruent MTP joint, sesamoid position 3, intermetatarsal angle 158, hallux
valgus angle 488. (B) Preoperative photograph. 1-year follow-up radiograph (C) and photograph (D).

There is still controversy about up to what level of deformity a scarf osteo-

tomy is indicated. The author’s personal opinion is that the chevron osteotomy
with the authors’ modifications (lateral soft tissue release) has similar indications
as the scarf osteotomy, but may be less demanding technically.

Proximal metatarsal osteotomies

From a mechanical standpoint, a proximal metatarsal osteotomy can achieve a

greater degree of correction, and therefore, is recommended for more severe
hallux valgus deformities. Various techniques have been described over the last
century. Early reports date back to Loison in 1901 [9] and Balacescu in 1903 [10]
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who used a proximal closing wedge osteotomy. Opening wedge osteotomies were
presented by Trethowan in 1923 [68] and Trott in 1972 [12].
Wedges have the advantage of addressing the deformity on one plane at or
near the deformity [69]. A closing wedge osteotomy always is combined with
a lateral soft tissue release. The osteotomy is performed with a microsaggital
saw blade from the lateral side, 10 mm distal to the metatarsocuneiform. By
preserving the medial cortex, a biplanar wedge with approximately 3-mm to
5-mm bases, laterally and plantarly, is removed and the osteotomy is closed
(Fig. 9). Screw fixations are the most popular, but multiple Kirschner wire
fixations were presented. Clinical studies confirmed the inherent instability and
the high incidence of dorsal elevation and subsequent metatarsalgia. Trnka et al
[70] presented the study with the longest follow-up (10 to 22 years). Of the
81 feet, patients rated outcome as excellent or good in 89% and cosmesis as
excellent or good in 83%. Seventy-four feet (91%) were pain free at the final
follow-up. Radiographically at final follow-up, hallux valgus and intermetatarsal
angles averaged 18.68 (range, 0 to 408) and 7.18 (range, 0 to 228), respectively
(Fig. 10). Excellent correction of sesamoid position was achieved; the average
shortening was 5 mm. Wanivenhaus and Felder-Busztin [71] noted a 60% inci-
dence of dorsal displacement.
The opening wedge is performed at the same level of the metatarsal bone;
however, the osteotomy is performed from the medial side to preserve the lateral
cortex. The opening wedge added the advantage of no shortening of the
metatarsal, even some lengthening. The disadvantages are the question of donor
site and the fixation. Originally, a fragment of the pseudoexostosis was used to
fill the gap; however, the quality of this fragment is not sufficient, and, if the

Fig. 9. (A–D) Closing wedge osteotomy.

 osteotomies for hallux valgus correction 25

Fig. 10. Closing wedge osteotomy in a 30-year-old woman. (A) Incongruent MTP joint, sesamoid
position 3, intermetatarsal angle 198, hallux valgus angle 408. (B) 21-year follow-up.

resected fragment is thicker, there is a potential risk of joint incongruency and

hallux varus. Other options are allografts or autografts from the calcaneus. Stable
fixation without prolonged cast immobilization has not been presented.
The proximal crescentic osteotomy is one of the most popular proximal
osteotomies. Mann and colleagues [13,72,73] popularized this procedure over the
last decades. Always in combination with a lateral soft tissue release, either a
third skin incision is made at the longitudinal dorsomedial skin incision at the
osteotomy site or the incision over the medial eminence is extended proximally to
the metatarsocuneiform joint in a slightly curved manner. Using a oscillating Hall
Zimmer saw with curved blade, the osteotomy is cut halfway between the planes
perpendicular to the metatarsal shaft and perpendicular to the ground, 1.5 cm to
2 cm distal to the tarsometatarsal joint.. After manual displacement of the
fragments, the obtained correction is checked and the osteotomy is fixed with a
4.0-mm cancellous screw. Additional Kirschner wires or crossed Kirschner wires
as the only modes of fixation are used only when screw placement is unstable or
impossible (Fig. 11).
In 1992, Mann et al [74] published a retrospective review of 75 patients
(109 feet) who underwent proximal crescentic osteotomy and distal soft tissue
realignment. At a mean follow-up of 34 months, all osteotomies had healed;
average hallux valgus angle correction was 218 (range, 98 to 318) and average
intermetatarsal angle correction was 88 (range, 68 to 148). Patient satisfaction was
high (93%) and shortening of metatarsals averaged 2 mm. In 28% of patients,
elevation of the first metatarsal without clinical significance was noted. With an
average preoperative intermetatarsal angle of 13.58 (range, 88 to 208), most of
these deformities were moderate. In 2000, Zettl et al [75] presented a retrospective
study of 96 patients (117 feet) who had an average preoperative intermetatarsal
angle of 17.88 (range, 108 to 268) (Fig. 12). Dorsal malalignment was seen in
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Fig. 11. The proximal crescentic metatarsal osteotomy.

95% of patients. These favorable results were confirmed in a long-term follow-up

study by Dreeben and Mann [76]. After a mean period of 5.5 years, loss of
correction averaged 1.48 for the intermetatarsal angle and 3.88 for the hallux
valgus angle. Incidence of varus and recurrent valgus deformity had not increased
from the initial follow-up study and patient satisfaction remained high (85%).
Recent reports by Sammarco et al [77–79], Easley et al [80], and Borton
and Stephens [81] popularized the proximal chevron osteotomy for more severe
deformities. This osteotomy is performed on the medial aspect of the first
metatarsal, 15 mm distal to the metatarsocuneiform joint. The apex of the osteo-
tomy is directed distally; a 0.045 Kirschner wire is inserted to mark the apex. The

Fig. 12. Proximal crescentic osteotomy in a 64-year-old woman. (A) Incongruent MTP joint, sesamoid
position 2, intermetatarsal angle 178, hallux valgus angle 308. (B) 49-month follow-up.
 osteotomies for hallux valgus correction 27

microsagittal saw is used to complete the osteotomy. The distal fragment is

shifted laterally and fixation is completed with a 3.5-mm cortical screw.
Sammarco et al [77] reported excellent correction, quick healing, ease of
performance, and high patient satisfaction. Easley et al [80] noted a shorter
healing time and avoidance of dorsiflexion, compared with the crescentic osteo-
tomy, in a prospective study.
In a biomechanical study on 60 fresh frozen, human, lower extremity
cadaveric specimens (10 for each osteotomy), the sagittal stability of six different
metatarsal shaft osteotomies—the proximal crescentic, proximal Chevron
osteotomy, Mau, Scarf, Ludloff osteotomy, and biplanar closing wedge osteo-
tomy with plantar plate fixation—was investigated [67]. The various osteotomies
were performed according to the originally described techniques, the specimens
were potted within a PVC tube with polyester resin, and clamped to a MTS Mini
Bionex load frame with the metatarsal in 158 of inclination. Cantilever-bend load
was applied at a rate of 5 mm/min until failure. Failure was defined as bony
fracture, screw pull out, or a fracture gap that was greater than 2 mm as measured
by the extensometer. Statistical analysis revealed significant differences ( P = .05)
between the Ludloff, Mau, scarf, and biplanar closing wedge osteotomies
compared with the chevron and crescentic osteotomies. There were no statisti-
cally significant differences between the Mau, biplanar closing wedge, scarf, and
Ludloff osteotomies.
Using the same osteotomies, Nyska et al [82] performed a saw bone three-
dimensional digitizer study to evaluate the three-dimensional geometric changes
in the relative positions of the proximal and distal segments in each osteotomy
(eg, lateral displacement, angular rotation, elevation, shortening). Scarf and
proximal chevron osteotomies, being displacement osteotomies, provided less
angular correction. The Ludloff osteotomy provided lateral and angular cor-
rection similar to those of the crescentic and closing wedge osteotomies with less
elevation and shortening. Taking the results of these two papers in account, the
Ludloff osteotomy seems to be the most favorable osteotomy for correction of
more severe hallux valgus deformity.
In 1918, Ludloff [11] described an oblique osteotomy of the first metatarsal
from dorso-proximal to distal-plantar. He originally shortened the metatarsal
without internal fixation. The Ludloff osteotomy was abandoned for many years
because of its lack of stable fixation. In 1983, Cisar et al [83] presented the Ludloff
osteotomy with internal fixation. They still performed the osteotomy first and then
fixed it by two Schweizerische Arbeitsgemeinschaft für Osteosynthesefragen
(AO) screws. Because of the unstable situation during the correction, shortening of
the first metatarsal was likely. Mark Myerson, unaware of Cisar’s German
publication, also was fascinated by the geometry and the rotational correction of the
osteotomy. He modified the old technique with a modern osteosynthesis and pre-
sented his first experience in 1997 at the joint meeting of the American Foot and
Ankle Society and the Japanese Society for Surgery of the Foot in Hawaii [84].
The surgery starts with a dorsal incision over the first web space. The lateral
joint capsule is incised longitudinally, just superior to the lateral sesamoid. The
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adductor tendon is identified and carefully dissected from the lateral joint capsule
and the lateral sesamoid and is released from its insertion into the base of
the proximal phalanx. The lateral capsule is perforated at the joint line and the
great toe is forced manually into approximately a 208 varus position. One suture
is placed through the adductor tendon and the lateral aspect of the first metatarsal
and on the other side through the periosteum of the 2nd metatarsal to lift the
insertion of the adductor muscle and to stabilize between metatarsal 1 and 2.
A second skin incision is made at the medial aspect of the first MTP joint. This
incision is extended proximally in a slightly curved manner to the first
metatarsocuneiform joint. The medial MTP joint capsule is opened with an
inverted L-type incision. The joint is inspected for degenerative changes. The
metatarsal shaft is now exposed and a Hohmann retractor is placed dorso-
proximal and distal-plantar. The distal-plantar Hohmann retractor protects the
plantar artery to the metatarsal head, whereas the dorso-proximal retractor
protects the extensor hallucis longus tendon and the interosseous branch of the
dorsal pedis artery. An oblique osteotomy is made at the first metatarsal from
dorsal—at the level of the metatarsocuneiform joint—to distal and ending
proximal to the sesamoid apparatus. The dorsal two thirds of the osteotomy is
performed first. A guide-wire for the 3.0-mm cannulated Synthes (Oberdorf,
Switzerland) screw is inserted at the proximal end of the dorsal fragment,
perpendicular to the osteotomy. A 3.0-mm cortical screw is inserted without total
closing of the osteotomy. The osteotomy is finished distally. Using a towel clip,
the plantar fragment is pulled medially and the dorsal fragment is rotated laterally
with the push of the thumb. After the desired correction is achieved, the dorsal
screw is tightened and a BOLD screw (New Deal SA) is inserted from plantar to
dorsal at the distal aspect of the osteotomy. The medial eminence is excised in
line with the metatarsal shaft with care taken not to excise too much bone off the
metatarsal head (Fig. 13).
Attention is now directed toward the medial capsule; a wedge of approxi-
mately 5 mm is removed from the short arm of the L-type capsular incision.
While an assistant holds the great toe in a slightly overcorrected position, the
medial joint capsule is repaired and the first web space sutures are tightened.
After skin closure, the foot is wrapped in compression dressing which protects
the soft tissue repair and holds the great toe in its corrected position. The
osteotomy is checked by radiography. Depending on the intraoperative stability
and tolerance, the patient can walk without restriction in a postoperative shoe
with a stiff sole or is placed in a walking cast. The dressing is changed after 2 days
and then on a weekly basis. Full weight bearing without the postoperative shoe is
allowed after 6 weeks.
Our first preliminary results of 75 patients with an average follow-up of
33 months revealed excellent correction of the hallux valgus and intermetatarsal
angles. The mean correction of the hallux valgus angle was 26.58, from 368
preoperatively to 148 at final follow-up. The intermetatarsal angle was corrected
an average of 98, from 178 preoperatively to 88 at final follow-up (Fig. 14). Thus,
according to our deformity grading, 80% of cases showed normal values for the
 osteotomies for hallux valgus correction 29

Fig. 13. (A–D) The Ludloff osteotomy.

hallux valgus and intermetatarsal angles or presented with a mild residual

deformity after the procedure. Care should be taken in elderly patients. In 15 feet
we found increased callus formation around the osteotomy site; 6 of those were
considered to be a delayed bony healing. The average age of the patient who had
increased callus formation was 67 years, whereas the average age of the other
patients was 53 years. Radiographic analysis also revealed a more osteopenic
bone situation preoperatively in the patients who had callus formation.

Fig. 14. Ludloff osteotomy in a 49-year-old man. (A) Incongruent MTP joint, sesamoid position 3,
intermetatarsal angle 188, hallux valgus angle 398. (B) 2-year follow-up.
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Summary

A variety of metatarsal osteotomies has been described since the first report
by Gernet in 1836. Many of these osteotomies were abandoned throughout the
years. Because one procedure is not capable of correcting all types of hallux
valgus deformities, an algorithm, as a guideline, is preferable.

References

[1] Mayo CH. The surgical treatment of bunion. Ann Surg 1908;48:300–2.
[2] Keller WL. The surgical treatment of bunions and hallux valgus. NY Med J 1904;80:741 – 2.
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