Karl Ludloff (1864-1945): An Inventive Orthopedic Surgeon,His Work and His Surgical Technique for the Correction of Hallux Valgus

Introduction

Karl Ludloff (1864-1945) was a prominent orthopedic surgeon of his time with a multilevel contribution to the development of orthopedics in the first half of the 20th century. The purpose of this article is to summarize his work and his pioneering achievements in the field of orthopedic surgery.

Moreover, a special reference will be made to his innovative surgical technique for the treatment of hallux valgus with a mid-shaft osteotomy, which had been neglected for many years, but it was reinvented in the 1990s with improvements in hardware and biomaterials used for osteosynthesis.

Short Biography of Karl Ludloff

Karl Ludloff was born on June 7, 1864, in Gundersleben, Thüringen, and he died in 1945. He studied in Jena, Würzburg, Munich, and Strasburg. He received his doctorate in Jena in 1894 and worked as an assistant at the Physiological Institute in Königsberg and as an Oberarzt at the Surgical Clinic in the same town and in Breslau. He was trained for surgery in Königsberg in 1900, becoming a titular professor in 1906 and an ordinary honorary professor in 1913. In 1914, he became the director of the University Clinic for Orthopedic Surgery in Frankfurt am Main, where he was appointed professor in 1919. He continued working there until his retirement. ¹

The Work of Karl Ludloff and His Achievements

One of the main contributions of Karl Ludloff in the history of surgery was announced on February 10, 1916, in the convention of the German Orthopaedic Society. According to the New York Times of that period, Ludloff made a significant contribution to the technique and knowledge of his era by describing a method for uniting damaged nerves and reestablishing the muscular action of nerveless limbs in severely injured German soldiers of World War I. He claimed that injured nerves were inhibited from healing because of the existence of newly formed flesh between them, hindering their healing although their natural tendency was to reunite. Ludloff’s technique comprised the use of a piece of bovine artery filled with a gelatinous fluid through which nerves readily grew, even bridging gaps of several inches. After several weeks, crippled limbs regained their motor activity. Ludloff claimed that many cases had been successfully treated, thus avoiding permanent lameness, which usually followed after such severe war injuries. ¹

In addition, Ludloff’s name has remained in the history of orthopedics for his description of several entities and signs. Ludloff’s pelvic lesion refers to a vertical fracture through the os sacrum near the sacroiliac articulation. ²

Büdinger-Ludloff-Läwen syndrome is another name for the condition named chondromalacia patellae, which is mainly a fatigue syndrome of the knee commonly observed in children and young adults who train excessively in sport activities. It is a traumatic chondritis of the patella treated with reduction of activity or immobilization most commonly. ³

Furthermore, Ludloff’s name has been associated with an operative technique for the reduction of the congenital dislocation of the hip treated in an advanced stage of deformity. It is another name for what is usually called Chiari’s operation. This technique is a reduction technique of the dislocated hip used successfully on infants and young adults combined with an acetabular osteotomy to increase the joint surface of the acetabulum, and it still remains a popular surgical technique of such neglected cases along with the Dega and Swanz technique.^4-6

Another case where the name of Ludloff is mentioned is that of a sign concerning swelling and ecchymosis appearing at the base of Scarpa’s triangle. It is usually observed in cases of traumatic separation of the epiphysis of the lesser trochanter. Also, there is a reference of his name connected with the Ludloff symptom; in this case, a patient with an isolated fracture of the lesser trochanter of the hip is unable to raise his or her leg or flex the hip joint in the sitting position, which can be done when the patient is in the supine position lying on a bed. Ludloff established the sign in 1909, and the term was suggested by Hannemüller in 1910.^2,3

Also, the epiphyseal triangle, which is a radiologic finding occurring in young adults in the lateral projection of the distal femoral epiphyses, is mentioned as Ludloff’s spot (Ludloff’s Fleck in German). It is described as a semicircle in the epiphysis sometimes misdiagnosed as an epiphyseal fracture, but it is a normal radiologic and anatomic variation of the epiphysis.^1-3

Finally, there is the Ludloff-Hohmann test described, according to which the knee can be completely extended when the hip is in flexion and adduction because the relative shortening of the thigh relaxes the hamstrings, which is impossible in a normal hip joint. If the test is positive, it is a strong evidence of hip dysplasia.^3,7

As far as the innovative surgical techniques invented by Karl Ludloff are concerned, it should be pointed out that he was the first to combine silk and living tissue in order to perform a transtibial augmentation procedure of the anterior cruciate ligament in 1927.^8,9

The Ludloff Surgical Technique for the Correction of Hallux Valgus

One of the most significant contributions of Karl Ludloff in the evolution of orthopedic surgery is his technique for the correction of hallux valgus (Figure 1).

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Figure 1.

A sketch of the Ludloff osteotomy for hallux valgus treatment.

Hallux valgus is defined as a lateral deviation deformity of the great toe with a medial deformity of the first metatarsal. It is caused by numerous factors like genetic predisposition, ligamentous laxity, and predisposing anatomy. Certain types of shoe wear also have been reported as contributing factors. ¹⁰

For the correction of hallux valgus, a plethora of surgical techniques have been described in the literature. Its anatomy and pathology including capsular involvement, muscular contribution, and bone deformity as well as its 3-dimensional complexity make it a complex reconstruction challenge. Nowadays, over 130 surgical techniques have been applied for its correction, all of which report a recurrence ratio that is quite high especially among children and young adults. ¹⁰

The Ludloff osteotomy is a surgical technique for the treatment of a moderate to severe hallux valgus deformity. It comprises an oblique osteotomy of the first metatarsal in the transverse plane extending dorsal-proximal to plantar-distal when viewed in the sagittal plane. It is particularly useful for correcting large intermetatarsal angles. As originally described in 1918, the osteotomy was performed without any fixation, but plaster of Paris was used by Ludloff in order to maintain the corrected bones until they heal. The surgical outcomes reported by Ludloff were excellent with this technique.^3,11

Nevertheless, this techniques presented certain pitfalls and contraindications such as first metatarsocuneiform joint instability, symptomatic first metatarsophalangeal arthritis, severe osteopenia, and an abnormal distal metatarsal articulation angle. In addition, the alignment of the toe could not be maintained with the application of plaster of Paris by other orthopedic surgeons. Therefore, this surgical technique remained less popular for the correction of hallux valgus.^3,11

During the 1990s, a new interest concerning this technique emerged. Several surgeons such as Mark Myerson started applying a modified Ludloff osteotomy for the correction of hallux valgus with the use of the innovative modern orthopedic materials applied for fixation. There are several ways of fixation for the stabilization of the Ludloff osteotomy nowadays; the use of screws (Figure 2), pins, and a low-profile locking plate/screw (Figure 3), specially designed for fixation of the Ludloff osteotomy, are among the most popular. The advantages presented by this modified osteotomy with fixation include more favorable outcomes with a low recurrence rate and the correction of the osteotomy in all 3 dimensions.^11-14

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Figure 2.

X-ray of a Ludloff osteotomy fixed with 2 screws (from the personal record of Dr Karaoglanis).

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Figure 3.

A plate with screws for the fixation of a Ludloff osteotomy (from the personal record of Dr Karaoglanis).

In addition, the Ludloff technique has been reported in the past 15 years as a favorable technique for the correction of a bunionette deformity, which is a similar deformity to the hallux valgus but for the fifth toe. ¹⁵

Conclusion

Karl Ludloff was an innovative surgeon of his time with a multilevel contribution in the discipline of orthopedic surgery. He had an impact in the diagnostics, physical examination, orthopedic imaging, and orthopedic surgical technique of his era. He was a pioneer in the surgical treatment of dysplastic hip, anterior cruciate ligament reconstruction, and hallux valgus. His surgical technique for the correction of hallux valgus, initially stabilized with plaster of Paris, remained unpopular among the orthopedic community for decades.

In the 1990s, the advent and use of improved orthopedic materials for fixation attracted the interest of numerous orthopedic surgeons in the Ludloff osteotomy for its ability to correct the deformity in all 3 dimensions, its anatomic and biomechanical outcomes, and its low recurrence rate and patient satisfaction.