Supplementary medial locking plate fixation of Ludloff osteotomy versus sole lag screw fixation: A biomechanical evaluation


      • A modified fixation for Ludloff osteotomy is proposed utilizing a mini locking plate.
      • Fourth generation composite 1st metatarsals underwent quasi-static monotonic load up to failure or fatigue (cyclic) tests.
      • The specimens were tracked using an optical system for 3D Digital Image Correlation.
      • The developed osteotomy gap was significantly lower in the modified fixation group.
      • The lateral angle change was significantly lower in the modified fixation group.



      The Ludloff oblique osteotomy is inherently unstable, which might lead to delayed union and loss of correction. Supplementary fixation to two lag screw fixation has been proposed. The hypothesis is that the osteotomy fixation constructs supplemented by a mini locking plate provide greater resistance to osteotomy gaping and loss of angular correction in response to cyclic loading.


      Twenty fourth generation composite 1st metatarsals were used and underwent a Ludloff osteotomy. They were divided in two fixation groups: two lag screws (Group A), and with a supplementary mini locking plate (Group B). Specimens were subjected to either monotonic loading up to failure or to fatigue (cyclic) tests and tracked using an optical system for 3D Digital Image Correlation.


      The osteotomy gap increased in size under maximum loading and was significantly greater in Group A throughout the test. This increase was observed very early in the loading process (within the first 1000 cycles). The most important finding though, was that with the specimens completely unloaded the residual gap increase was significantly greater in Group A after only 5000 cycles of loading up to the completion of the test. The lateral angle change under maximum loading was also significantly greater in Group A throughout the test, with that increase observed early in the loading process (5000 cycles). With the specimens completely unloaded the residual lateral angle change was also significantly greater in Group A at the completion of the test.


      Supplementary fixation with a mini locking plate of the Ludloff osteotomy provided greater resistance to osteotomy gaping and loss of angular correction compared to sole lag screws, in response to cyclic loading.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Acevedo J.I.
        • Sammarco V.J.
        • Boucher H.
        • Parks B.G.
        • Schon L.C.
        • Myerson M.S.
        Mechanical comparison of cyclic loading in five different first metatarsal shaft osteotomies.
        Foot Ankle Int. 2002; 23: 711-716
        • Chiang C.
        • Lin C.F.
        • Tzeng Y.
        • Huang C.
        • Chen W.
        • Liu W.
        Distal linear osteotomy compared to oblique diaphyseal osteotomy in moderate to severe hallux valgus.
        Foot Ankle Int. 2012; 33: 479-486
        • Chiodo C.
        • Schon L.
        • Myerson M.
        Clinical results with the Ludloff osteotomy for correction of adult hallux valgus.
        Foot Ankle Int. 2004; 25: 532-536
        • Choi W.
        • Yoon H.
        • Yoon H.S.
        • Kim B.
        • Lee J.
        Comparison of the proximal Chevron and Ludloff osteotomies for the correction of hallux valgus.
        Foot Ankle Int. 2009; 30: 1154-1160
        • Choi G.W.
        • Choi W.J.
        • Yoon H.S.
        • Lee J.W.
        Additional surgical factors affecting the recurrence of hallux valgus after Ludloff osteotomy.
        Bone Joint J. 2013; 95-B: 803-808
        • Chow F.
        • Lui T.
        • Kwok K.
        • Chow Y.
        Plate fixation for crescentic metatarsal osteotomy in the treatment of hallux valgus: an eight year follow up study.
        Foot Ankle Int. 2008; 29: 29-33
        • Easley M.
        • Kiebzak G.
        • Davis H.
        • Anderson R.
        Prospective, randomized comparison of proximal crescentic and proximal chevron osteotomies for correction of hallux valgus deformity.
        Foot Ankle Int. 1996; 17: 307-316
        • Gallentine J.
        • DeOrio J.
        • DeOrio M.
        Bunion surgery using locking-plate fixation of proximal metatarsal Chevron osteotomies.
        Foot Ankle Int. 2007; 28: 361-368
        • Gardner M.P.
        • Chong A.C.
        • Pollock A.G.
        • Wooley P.H.
        Mechanical evaluation of large size fourth generation composite femur and tibia models.
        Ann. Biomed. Eng. 2010; 38: 613-620
        • Heiner A.D.
        Structural properties of fourth-generation composite femurs and tibias.
        J. Biomech. 2008; 41: 3282-3284
        • Hofstaetter S.G.
        • Glisson R.R.
        • Alitz C.J.
        • Trkna H.J.
        • Easley M.E.
        Biomechanical comparison of screws and plates for hallux valgus opening-wedge and Ludloff osteotomies.
        Clin. Biomech. 2008; 23: 101-108
        • Hofstaetter S.G.
        • Riedl M.
        • Glisson R.R.
        • Trieb K.
        • Easley M.E.
        The influence of patient age and bone mineral density on osteotomy fixation stability after hallux valgus surgery: a biomechanical study.
        Clin. Biomech. 2016; 32: 255-260
        • Hungerer. S.
        • Wipf F.
        • von Oldenburg G.
        • Augat P.
        • Penzkofer R.
        Complex distal humerus fractures-comparison of polyaxial locking and nonlocking screw configurations - a preliminary biomechanical study.
        J. Orthop. Trauma. 2014; 28: 130-136
        • Jones T.B.
        • Karenz A.R.
        • Weinhold P.S.
        • Dahners L.E.
        Transcortical screw fixation of the olecranon shows equivalent strength and improved stability compared with tension band fixation.
        J. Orthop. Trauma. 2014; 28: 137-142
        • Jung H.G.
        • Guyton G.
        • Parks B.
        • Title G.
        • Dom K.
        • Nguyen A.
        • et al.
        Supplementary axial Kirschner wire fixation for crescentic and Ludloff proximal metatarsal osteotomies: a biomechanical study.
        Foot Ankle Int. 2005; 26: 620-626
        • Lasanianos N.G.
        • Garnavos C.
        • Magnisalis E.
        • Kourkoulis S.
        • Babis G.C.
        A comparative biomechanical study for complex tibial plateau fractures: nailing and compression bolts versus modern and traditional plating.
        Injury. 2013; 44: 1333-1339
        • Lian G.J.
        • Markolf K.
        • Cracchiolo III., A.
        Strength of fixation constructs for basilar osteotomies of the first metatarsal.
        Foot Ankle. 1992; 13: 509-514
        • Lienau J.
        • Schell H.
        • Duda G.N.
        • Seebeck P.
        • Muchow S.
        • Bail. H.J.
        Initial vascularization and tissue differentiation are influenced by fixation stability.
        J. Orthop. Res. 2005; 23: 639-645
        • Pinney S.
        • Song K.
        • Chou L.
        Surgical treatment of severe hallux valgus deformity: the state of practice among academic foot and ankle surgeons.
        Foot Ankle Int. 2006; 27: 1024-1029
        • Robinson A.
        • 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: 955-963
        • Sammarco V.
        Surgical correction of moderate and severe hallux valgus: proximal metatarsal osteotomy with distal soft tissue correction and arthrodesis of the metatarsophalangeal joint.
        Instr. Course Lect. 2008; 57: 415-428
        • Saxena A.
        • McCammon D.
        The Ludloff osteotomy: a critical analysis.
        J. Foot Ankle Surg. 1997; 36: 100-105
        • Schon L.
        • Dom K.
        • Jung H.G.
        Clinical tip: stabilization of the proximal Ludloff osteotomy.
        Foot Ankle Int. 2005; 26: 579-581
        • Scott A.
        • DeOrio J.
        • Montijo H.
        • Glisson R.
        Biomechanical comparison of hallux valgus correction using the proximal chevron osteotomy fixed with a medial locking plate and the Ludloff osteotomy fixed with two screws.
        Clin. Biomech. 2010; 25: 271-276
        • Smith W.
        • Ziran B.
        • Anglen J.
        • Stahel P.
        Locking plates: tips and tricks.
        J. Bone Joint Surg. Am. 2007; 89: 2298-2307
        • Stamatis E.
        • Chatzikomninos I.
        • Karaoglanis G.
        Mini locking plate as “Medial Buttress” for oblique osteotomy for hallux valgus.
        Foot Ankle Int. 2010; 31: 920-922
        • Stokes. I.A.
        • Hutton. W.C.
        • Stoff. J.R.
        Forces acting on the metatarsals during normal gait.
        J. Anat. 1979; 129: 579-590
        • Trnka H.
        • Muhlbauer M.
        • Zembsch A.
        • Hungerford M.
        • Ritschl P.
        • Salzer M.
        Basal closing wedge osteotomy for correction of metatarsus primus varus: 10- to 22-year follow-up.
        Foot Ankle Int. 1999; 20: 171-177
        • Trnka H.-J.
        • Parks B.G.
        • Ivanic G.
        • Chu I.-T.
        • Easley M.E.
        • Schon L.
        • et al.
        Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons.
        Clin. Orthop. 2000; 381: 256-265
        • Trnka H.
        • Hofstaetter J.
        • Hofstaetter F.
        • Gruber F.
        • Adams Jr., S.
        • Easley M.
        Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet.
        J. Bone Joint Surg. Am. 2008; 90: 531-539
        • Tsilikas S.P.
        • Stamatis E.D.
        • Kourkoulis S.K.
        • Mitousoudis A.S.
        • Chatzistergos P.E.
        • Papagelopoulos P.J.
        Mechanical comparison of two types of fixation for Ludloff oblique first metatarsal osteotomy.
        J. Foot Ankle Surg. 2011; 50: 699-702
        • Unal A.M.
        • Baran O.
        • Uzun B.
        • Turan A.C.
        Comparison of screw-fixation stabilities of first metatarsal shaft osteotomies: a biomechanical study.
        Acta Orthop. Traumatol. Turc. 2010; 44: 70-75