SLR - March 2019 - Gireesh Reddy

Immediate Weightbearing After Hallux Valgus Correction Using Locking Plate Fixation of the Ludloff Osteotomy: A Retrospective Review

Reference: Neufeld SK, Marcel JJ,, Campbell M, Immediate Weightbearing After Hallux Valgus Correction Using Locking Plate Fixation of the Ludloff Osteotomy: A Retrospective Review, Foot Ankle Spec. 2018 Apr;11(2):148–155. doi: 10.1177/1938640017750250. Epub 2018 Jan 12.

Scientific Literature Review

Reviewed By: Gireesh Reddy, DPM                 
Residency Program: Detroit Medical Center

Podiatric Relevance: Ludloff oblique first metatarsal osteotomy is a commonly used procedure for bunion correction. The postoperative protocol generally involves nonweightbearing for two weeks and then either transition to heel weightbearing or continued nonweightbearing for up to six weeks. Poor compliance to nonweightbearing protocols is often related to complications, including malunion (1–5 percent), nonunion (1–2 percent) and loss of correction. The authors hypothesized that anatomical locking plates offer robust fixation and stability at the osteotomy site, as the locking plate transfers the weightbearing stresses from the osteotomy site to the plate construct, making postoperative weightbearing safer for patients.

Methods: A retrospective cohort study was performed between 2010 and 2015 resulting in analysis of 326 feet in 288 patients. Main objectives were to determine the effect of immediate weightbearing on radiographic outcomes, pain and function outcomes, and complication rates. At an average of 44 months after initial surgery, a Foot Function Index (FFI) was administered. All patients followed the same postoperative protocol regardless of the 316 concomitant procedures performed.
                
Results: When comparing initial preoperative with final postoperative weightbearing images, an average correction of HVA by 21.6° and IMA by 7.6° was noted. A total of 103 patients completed the FFI an average of 44 months postoperatively. The average score was 10.4, indicating relatively low pain and disability. Superficial incision site infection (n=16, 4.9 percent) was the most common complication, however, none resulted in hardware removal. No cases of deep infection were noted. Fifteen (4.6 percent) feet, notably in older women, had symptomatic and prominent hardware, requiring hardware removal. Other complications included symptomatic hallux varus (n = 5, 1.5 percent), symptomatic recurrent hallux valgus (n = 3, 0.9 percent), nonunion (n = 1, 0.3 percent), wound dehiscence (n = 2, 0.6 percent), extensor hallucis longus (EHL) rupture (n = 1, 0.3 percent), deep-vein thrombosis (DVT)/pulmonary embolism (n = 1, 0.3 percent) and second metatarsal stress fracture (n = 1, 0.3 percent).

Conclusion: Ludloff osteotomy with anatomical locking plate fixation and an immediate weightbearing postoperative protocol resulted in good long-term pain and function outcome scores, a low rate of symptomatic malunion (2.5 percent), a low rate of superficial infection (4.9 percent) and a relatively low rate of hardware removal (4.6 percent). Tsilikas et al demonstrated that the group augmented with a locking plate required significantly more energy to fail than did the group fixed with screws alone, supporting the notion that locking plates provide more stability than screws alone. Noncompliance with postoperative weightbearing restriction has been implicated as the leading cause of complications. However, with a robust anatomical locking plate fixation, this study shows low complications rates and provides many potential benefits, including but not limited to earlier normalization of gait, earlier return to work and daily activities, reduced DVT rate and reduced operative extremity atrophy. In conclusion, the data support the use of an immediate weightbearing protocol for Ludloff osteotomies fixated with anatomical locking plates.

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