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

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.

Comparative study of dorsiflexion closing wedge osteotomy of the metatarsal head and osteochondral autologous transplantation for Freiberg disease treatment: A multicenter analysis

Freiberg disease (FD) is a condition characterized by osteochondrosis affecting the metatarsal heads, with the second metatarsal head being the most commonly affected. Dorsiflexion Closing Wedge Osteotomy of the Metatarsal Head (DCWMO) has been conventionally employed, whereas Osteochondral Autologous Transplantation (OAT) represents a more recent technique with restricted comparative research. This study aimed to compare the outcomes of DCWMO and OAT for treating Freiberg disease (FD). Groups were established among two institutions. Institution-1 has made the treatment with OAT (8 patients) and Institution-2 has made the treatment with DCWMO (8 patients). The primary outcomes collected, including complications, range of motion, length of the metatarsal, American-Orthopaedic-Foot-and-Ankle-Society-lesser MTP-interphalangeal (AOFAS-LMI) score, visual-analog-scale (VAS), Foot-and-Ankle-Disability (FADI) score, and Short-Form-12 (SF-12), were all compared. The Sport-FADI and activity-FADI scores at final follow-up were significantly greater in the OAT group than in the DCWMO group (94.04 vs 84.75 and 97 vs 92, P = 0.021 and P = 0.04, respectively), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (43.13 vs 6.88 degrees, P < 0.001). The AOFAS-LMI score at final follow-up was significantly greater in the DCWMO group than in the OAT group (86.75 vs 75.38, P = 0.013). In conclusion, this study highlights the effectiveness of both OAT and DCWMO in treating Freiberg's disease, as evidenced by significant postoperative improvements in various functional scores, including AOFAS-LMI, VAS and FADI. Notably, OAT demonstrated favorable outcomes in SFADI and AFADI and plantarflexion ROM, while DCWMO led to improved the AOFAS-LMI score.

Osteochondral Autograft Transplantation for Subchondral Insufficiency Fracture of the Metatarsal Head in Middle-Aged and Elderly Patients: A Report of Three Cases

Freiberg disease, characterized by osteochondrosis affecting the metatarsal head, typically afflicts adolescent athletes. However, subchondral insufficiency fractures of the metatarsal head, presenting similarly to Freiberg disease, occur in middle-aged and elderly individuals and pose unique challenges in diagnosis and treatment. This study reports three cases of osteochondral autograft transplantation (OAT) for collapsed metatarsal heads resembling Freiberg disease in middle-aged and elderly women with successful outcomes. Case 1 involved a 59-year-old woman with severe metatarsophalangeal joint (MTPJ) pain and restricted range of motion (ROM) in the second toe. Case 2 featured a 66-year-old woman with trauma-induced deformity and cystic changes in the second metatarsal head. Case 3 included a 71-year-old woman with a crushed third metatarsal head and osteophyte formation. Hallux valgus was observed in one patient; the other two had a history of minor trauma. Radiological assessments revealed deformity, with MRI indicating bone marrow edema in the metatarsal head. Histological findings showed no necrosis, differentiating these cases from classical Freiberg disease. Based on these findings, OAT was chosen to restore joint function and minimize complications such as metatarsal shortening. In all cases, metatarsal head reconstruction was performed using an osteochondral column harvested from the femoral condyle. All patients experienced significant pain relief, improved ROM, and favorable imaging findings. No pain recurrence was noted during the three to seven years' follow-up period after surgery. While classical Freiberg disease involves aseptic necrosis often attributed to repetitive stress, insufficiency fractures may arise from shear stress or subtle injury. Our cases demonstrated the effectiveness of OAT in managing advanced subchondral insufficiency fractures, even in elderly patients, by minimizing risks such as metatarsal shortening and compromised joint mobility.

Freiberg's disease: variation of surgeries, outcomes, and first population-based incidence

The objective of this inclusive literature review is to identify surgeries performed for Freiberg's disease (FD) and their outcomes and to perform the first population-based study to establish its incidence. We reviewed all retrievable publications linked to FD listed in PubMed and publications quoted within these publications going back to 1914. Patients with FD and the number of livebirths born in our maternity hospital between 2000 and 2023 were identified from our hospital database. We identified 208 publications of which we managed to review 163 (1121 patients, 1169 feet, of which 939 feet underwent surgery, 116 had no surgery, and for 114, it was unknown if surgery was performed. Patient age: 194 × <18 years, 516 × ≥18 years, 411 × age unknown). The most frequently performed surgeries were intra-articular closing wedge metatarsal osteotomies through the defect (IDCWMO) (284 feet), extra-articular dorsal closing wedge metatarsal osteotomies (EDCWMO) (118 feet), osteochondral autologous transplantation (OAT) (64 feet), and modified Weil osteotomies with intra-articular dorsal closing wedge osteotomies (52 feet). Outcome scores were used in 39 publications, with the American Orthopaedic Foot and Ankle Society score having been used most frequently (28 studies, 462 patients, 482 feet). The mean scores were excellent for OATs and EDCWMOs and good for IDCWMOs and modified Weil osteotomies. We identified 124 644 livebirths and 44 patients with FD. In conclusion, multiple procedures achieved a high rate of excellent and good outcomes where nonoperative management failed. FDis rare, with an extrapolated incidence of 1 in 2833 livebirths.

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.

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.