Extra-articular dorsal closing-wedge osteotomy to treat late-stage Freiberg disease using polyblend sutures: technical tips and clinical results

Dorsal Metatarsal Closed Wedge Osteotomy in the Treatment of Freiberg's Disease: A Prospective Observational Study

The aim of this study was to prospectively evaluate the clinical and radiological results of dorsal metatarsal closed wedge osteotomy and headless screw fixation in the surgical treatment of Freiberg's disease.Thirty-four patients who were treated with dorsal metatarsal closed wedge osteotomy (DMCWO) for Freiberg's disease between February 2018 and March 2022 were included in the study. Patients were staged according to the classification system described by Smillie. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society's (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the visual analog scale (VAS), the range of motion (ROM) of the metatarsophalangeal (MTP) joint, and a subjective patient satisfaction questionnaire. For radiological evaluation, the amount of preoperative shortening of the involved metatarsal, the amount of metatarsal shortening developed after osteotomy, and radiological recovery times were recorded.Thirty-two (94.1%) of the patients were female, and two (5.9%) were male. The average postoperative follow-up period for patients was 33.7 months (range: 24 months to 41 months). The mean AOFAS scores increased from 53.24 to 86.26 (p < 0.01). The mean VAS scores decreased from 8.59 to 1.79, and it was observed that the patients' pain improved significantly (p < 0.01). The mean ROM of the MTP joint increased from 48.76 degrees to 70.76 degrees (p < 0.01). An average of 2.5 mm (range 1 mm to 4.1 mm) of shortening of the metatarsal length developed postoperatively (p < 0.01). Arthrosis developed in 1 case (2.9%), and transfer metatarsalgia developed in 2 cases (5.8%).DMCWO is an effective treatment for both the early and advanced stages of symptomatic Freiberg's disease, leading to high patient satisfaction.

Evidence-Based Treatment Algorithm for Freiberg Disease

Freiberg disease is a type of osteonecrosis of the metatarsal head that predominantly occurs in young females and adolescents, although it may occur at any age. The pathophysiology is multifactorial and may involve trauma, altered foot biomechanics, systemic disorders, and arterial insufficiency. The most typical location is the second metatarsal head, but Freiberg disease may also occur in other lesser toes. Nonoperative treatment is best applied in the early stage of the disease; if this is ineffective, surgical treatment is recommended. Currently available surgical procedures include debridement, osteotomy, osteochondral grafting, microfracture, interposition arthroplasty, implant arthroplasty, and metatarsal shortening arthroplasty. In this article, we propose a treatment algorithm for Freiberg disease based on the current literature and expert opinion.

Metatarsal head restoration versus dorsal closing-wedge osteotomy in the treatment of advanced-stage Freiberg's disease

PURPOSE

Freiberg's disease is mostly characterized by osteonecrosis of second metatarsal head and is widely seen in adolescent women. Metatarsal head restoration technique is a novel surgical procedure intended to protect intact articular surface and regenerate avascular bone under cartilage. This study aimed to evaluate and compare the results and clinical outcomes of metatarsal head restoration technique with those of dorsal closing-wedge osteotomy technique in patients with advanced-stage Freiberg's disease.

METHODS

In this retrospective study, 60 patients who were operated for Freiberg's disease were evaluated. Patients were divided into two groups as who underwent metatarsal head restoration and dorsal closing-wedge osteotomy. Groups were compared according to "American Orthopaedic Foot & Ankle Society score" (AOFAS), "visual analog score" (VAS) and passive "range of motion" (ROM) score.

RESULTS

Thirty-two feet of 29 patients underwent metatarsal head restoration, while 33 feet of 31 patients were subject to dorsal closing-wedge osteotomy. Mean AOFAS score increased from 58.72 ± 6.89 to 89.35 ± 7.43 following metatarsal head restoration, while it increased from 54.13 ± 6.12 to 78.24 ± 6.54 after dorsal closing-wedge osteotomy. Mean VAS score decreased from 6.89 ± 1.18 to 1.33 ± 0.64 after metatarsal head restoration, while it decreased from 6.64 ± 0.92 to 2.71 ± 1.91 following dorsal closing-wedge osteotomy. Mean ROM increased from 12.25° ± 1.65 to 56.28° ± 2.77 after metatarsal head restoration, and it increased from 11.18° ± 0.66 to 47.65° ± 2.05 after dorsal closing-wedge osteotomy (all p < 0.05). In addition, postoperative mean AOFAS (p = 0.044), VAS (p = 0.041) and passive ROM (p = 0.034) scores improvement were found to be statistically significantly better in the metatarsal head restoration group.

CONCLUSION

This study revealed that metatarsal head restoration is a safe and successful surgical technique. It leads to better results than dorsal closing-wedge osteotomy in patients with stages 3-4 Freiberg's disease.

LEVEL OF EVIDENCE

III.

Surgical interventions of Freiberg's disease: A systematic review

BACKGROUND

Freiberg's disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic reviews discussing the various options. The study aimed to systematically review the quantity and quality of literatures exploring the surgical interventions.

METHODS

Fifty articles were found to be relevant for assessing the efficacy of common surgical interventions. The articles were assigned a level of evidence (I-V) to assess their quality. Next, the studies were reviewed to provide a grade of recommendation (A-C, I).

RESULTS

Two studies were found at level III that explored osteotomy and autologous transplantation; the other studies were level IV-V. There is poor evidence (grade C) in supporting of joint sparing and joint sacrificing for Freiberg's disease.

CONCLUSION

Poor evidence exists to support the surgical interventions for Freiberg's disease, higher quality trials are needed to support the increasing application of these surgical techniques.

LEVEL OF EVIDENCE

Level IV, Systematic review.

Interpositional Arthroplasty With Extensor Digitorum Brevis Tendon in Freiberg Disease

BACKGROUND

No consensus has been reached in the treatment of Frieberg disease. Our aim was to evaluate medium- to long-term results of patients with advanced Freiberg disease managed with extensor digitorum brevis tendon interpositional arthroplasty.

METHODS

There were 24 patients (19 females, 5 males) managed with interpositional arthroplasty for advanced Freiberg disease between 2003 and 2015. The mean follow-up was 133.8 (range, 60-198) months. According to Smillie classification, there were 4 grade 3, 13 grade 4, and 7 grade 5 patients. Patients were evaluated preoperatively and at the final follow-up with the American Orthopaedic Foot & Ankle Society (AOFAS) score and metatarsophalangeal joint range of motion and postoperatively with visual analog scale (VAS) and subjective satisfaction evaluation. Joint space was evaluated on x-rays.

RESULTS

Mean AOFAS score increased (53.9 to 80.3, P = .001). Eight patients had excellent, 14 had good, and 2 had fair scores. A significant increase was found in dorsiflexion (38.1° [24°-52°] vs 55.3° [34°-65°]; P = .001) and plantarflexion (19.0° [10°-28°] vs 28.6° [19°-39°]; P = .001). Narrowing of the joint space was not seen in any patient, but expansion was determined in all patients (0.39 [0.35-0.47] vs 0.44 [0.41-0.47] cm; P = .002). Of the patients, 9 were very satisfied, 12 were satisfied, 2 were moderately satisfied, and 1 was dissatisfied. The mean postoperative VAS pain score was 1.7 ± 0.9 (0-4).

CONCLUSION

After a minimum 5-year follow-up, most patients with Freiberg disease managed with interpositional arthroplasty using the extensor digitorum brevis tendon had excellent to good functional results with a widening of the joint space.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Comparison of Osteochondral Autologous Transplantation and Dorsiflexion Closing Wedge Metatarsal Osteotomy for Late-Stage Freiberg Disease in Adults

BACKGROUND

This study aimed to compare the clinical results between osteochondral autologous transplantation (OAT) and dorsiflexion closing wedge metatarsal osteotomy (DCWMO) in symptomatic adult patients with late-stage Freiberg disease.

METHODS

Between 2012 and 2017, patients with late-stage Freiberg disease surgically treated with OAT (12 patients) or DCWMO (15 patients) were retrospectively identified. The American Orthopaedic Foot & Ankle Society-lesser metatarsophalangeal-interphalangeal (AOFAS-LMI) score, visual analog scale score for subjective pain, and range of motion (ROM) were determined preoperatively and at final follow-up. Postoperative complications were also recorded.

RESULTS

The AOFAS-LMI score at final follow-up was significantly greater in the OAT group than in the DCWMO group (95.7 vs 87.9, P < .001), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (30.0 vs 24.0 degrees, P = .037). The DCWMO group reported more postoperative complications including postoperative joint stiffness, deformity, and pain recurrence. In the OAT group, one patient complained of mild knee pain.

CONCLUSION

OAT seemed a better procedure for late-stage Freiberg disease compared with DCWMO in adult patients in terms of postoperative functional score and ROM, with lower complication rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Freiberg's Infraction: Surgical Options

Freiberg's infraction is an uncommon condition of the lesser metatarsophalangeal joints. Onset is usually between the 11th and 17th year of age. It is the only osteochondrosis that dominantly affects females with a reported female-to-male ratio of 5.1. The second metatarsal is most frequently involved (68%) followed by the third metatarsal (27%), and the fourth (3%). Surgical treatment options can be categorized in joint destructive and joint preserving procedures. Studies reveal complete resolution of pain and full return to activities in 70% after joint destructive procedure and more than 90% after joint preserving procedures.

Arthroscopic Dorsal Closing-Wedge Osteotomy of Metatarsal Head for Management of Freiberg Infraction

Freiberg infraction is a relatively rare osteochondrosis of the lesser metatarsal head. Operative treatment is indicated if conservative treatment fails to relieve the pain. Dorsal closing-wedge osteotomy is a realignment osteotomy of the metatarsal head and neck to redirect the articular surface, allowing the intact plantar cartilage to articulate with the proximal phalanx. The purpose of this technical note is to describe the details of arthroscopic dorsal closing-wedge osteotomy of the metatarsal head for management of Freiberg infraction. Although dorsal closing-wedge osteotomy has been proposed for the treatment of late-stage Freiberg infraction, we reserve this technique for early stages of the disease.

Osteochondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infraction in Athletes: A Randomized Controlled Study With 3-Year Follow-up

BACKGROUND

Dorsiflexion closing wedge metatarsal osteotomy (DCWMO) has been considered the traditional treatment of Freiberg disease. Several case reports presented osteochondral autologous transplantation (OAT) as an alternative treatment.

PURPOSE/HYPOTHESIS

The purpose was to compare the results of DCWMO versus OAT for the treatment of Freiberg infraction in an athletic population. It was hypothesized that OAT was superior to DCWMO regarding functional outcomes, pain, and the time that the athletes returned to training and to previous sport level.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Between 2008 and 2013, 27 consecutive patients with Freiberg disease were randomly assigned to either the DCWMO group (14 patients) or the OAT group (13 patients). The primary outcomes collected were as follows: postoperative complications, range of motion of the metatarsophalangeal joint, length of the metatarsal, function of the foot (measured with the American Orthopaedic Foot and Ankle Society-lesser metatarsophalangeal-interphalangeal [AOFAS-LMI] score), and pain (assessed with the visual analog scale-foot and ankle score).

RESULTS

Mean follow-up was 46 months (range, 36-60 months). The mean ± SD AOFAS-LMI score in the DCWMO group was 63.4 ± 14.4 preoperatively, 81.8 ± 6.6 at 1 year postoperatively, and 84.4 ± 5.6 at 3 years postoperatively, while in the OAT group, it was 62.8 ± 14, 89.9 ± 7.1, and 92 ± 6.9, respectively (P < .001). The differences in the AOFAS-LMI scores favoring the OAT group at 1 and 3 years reached statistical but not clinical significance. The mean visual analog scale-foot and ankle score was improved significantly from 48.1 ± 11.5 to 91.8 ± 9.5 in the DCWMO group and from 49.9 ± 10.9 to 95.4 ± 4.4 in the OAT group. There was a shortening of the metatarsals by a mean 1.9 ± 0.5 mm in the DCWMO group, as opposed to a metatarsal lengthening of 0.2 ± 0.1 mm in the OAT group. In the OAT group, patients were able to start training at 6 ± 1 weeks (P < .001) and return to full sport action at 10 ± 2.5 weeks (P < .05), while in the DCWMO group, the time was 8 ± 1.5 and 13 ± 2.5 weeks, respectively.

CONCLUSION

The authors concluded that OAT is equal to DCWMO. Acceptable clinical results were reported, as well as very low morbidity and early return to sport activities. That makes the OAT procedure a safe, effective, and optimal treatment for an athletic population experiencing Freiberg infraction.

Overview of Metatarsalgia

Metatarsalgia can be viewed as more of a symptom rather than a distinct diagnosis. Timing of forefoot pain during the gait cycle and evaluation of whether the pain is from anatomic abnormalities, indirect overloading, or iatrogenic causes can suggest a specific metatarsalgia etiology. A thorough physical examination of the lower extremity, especially evaluation of the plantar foot, and weight-bearing radiographs are critical for diagnosis and treatment. Nonoperative treatment consists of physical therapy, orthotics, shoe wear modification, and injections. If conservative treatment fails, surgical options may be considered. [Orthopedics. 2019; 42(1):e138-e143.].

Treatment of Freiberg Disease

Freiberg disease, or osteochondrosis of the lesser metatarsal head, usually involves the second metatarsal and presents during the second or third decades of life. Conservative measures to relieve pressure on the affected metatarsal head are the first-line treatments, with good success for Smillie stage I to III disease. Operative treatments are divided into joint-preserving and joint-reconstructing procedures. Although multiple case series describe success with numerous techniques, there are no established guidelines for treatment. All surgical techniques carry a risk of a stiff or floating toe and transfer metatarsalgia. This article reviews the current surgical treatment options for Freiberg disease.

Neurectomy for Bilateral Morton's Neuroma A Case Report of a Male Patient

Morton's neuroma is a common condition that mainly affects middle-aged women, and many articles have addressed the surgical treatment of this condition. Previous reports have described bilateral neuroma excision in women but not in men. We report a rare case of bilateral neuromas in a male patient treated with simultaneous neurectomy.

Long-term Follow-up of Dorsal Wedge Osteotomy for Pediatric Freiberg Disease

BACKGROUND

Treatment for Freiberg disease has been largely conservative despite availability of various operative options for severe or refractory cases. The aim of this study was to evaluate the long-term results of pediatric patients with symptomatic Freiberg disease treated with intra-articular dorsal wedge osteotomy.

METHODS

Pediatric patients treated for Freiberg disease with surgery between January 1982 and 1999 were identified and selected for long-term clinical evaluation. Patients were evaluated regarding operative satisfaction and clinical outcome, performed according to the American Orthopaedic Foot & Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal scale and range of motion (ROM) of metatarsophalangeal (MTP) joint. Patients had radiographic assessment of degenerative joint status with anteroposterior and oblique foot x-ray. Twenty patients (18 female, 2 male; mean age 15.2 years; range 12-17 years) were identified. The mean follow-up period was 23.4 (range 15-32) years.

RESULTS

The clinical outcomes of our patients were classified as excellent in 16 (80%) and good in 4 (20%). The AOFAS mean score was 96.8 (range 91-100) points at the last clinical appointment. A negative correlation between AOFAS score and time of follow-up (r's = -0.61, P < .001) was found. Also, a strong negative correlation was found between Smillie classification and AOFAS final score (r's = -0.88, P < .001).

CONCLUSION

The patients were very satisfied with pain and quality of life at a mean follow-up time of 23.4 years. To our knowledge, this is the first long-term follow-up report supporting the procedure described by Gauthier and Elbaz as a good option for operative treatment of Freiberg disease.

LEVEL OF EVIDENCE

Level IV, retrospective case series.