A new classification for Freiberg's disease.

INTRODUCTION: Freiberg's osteochondrosis is an uncommon cause of foot pain. Following a national survey circulated by the British Foot and Ankle Society it was found that no classification is used to guide surgical treatment. This study aimed to create a simple, reproducible CT based classification to preoperatively plan whether an osteotomy is required. METHODS: A retrospective review of 24 CT scans of new Freiberg's diseasediagnoses over a 10 year period was conducted. These images were assigned a study number and anonymised. The scans were then reviewed in their entirety by three independent specialists who determined whether an osteotomy would be of benefit. The sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx was identified and divided the articular surface into 2 zones - plantar and dorsal and this formed the basis for our classification. These sagittal slices were then reviewed independently by two surgeons to determine if patients had disease in one or both zones and re-reviewed two weeks later to assess intra-observer reliability. RESULTS: All 24 cases involved the second metatarsal. From reviewing the sagittal CT slices, it was felt that 18 patients were suitable for osteotomy and 6 were suitable for debridement +/- arthroplasty alone. The current classification demonstrated that 18 patients had disease confined to zone 1 only and the remaining patients had disease in both zones. Inter-observer reliability assessment had 95.8% agreement (Krippendorff's Alpha 0.897). Intra-observer reliability was 100%. Correlation of those observed to have isolated zone 1 disease and suitability for osteotomy was absolute (Pearson r = 1). CONCLUSION: Dividing the metatarsal head into two zones on the widest sagittal slice of the CT scan offers an easy reproducible way to preoperatively plan surgical treatment for Freiberg's osteochondrosis. Patients with isolated zone 1 disease should be suitable for an osteotomy.

Description of a Revision Technique for Failed Polyvinyl Alcohol Hydrogel Implant in Patient with Freiberg's Disease.

Polyvinyl alcohol hydrogel synthetic cartilage implants are increasingly used to treat advanced Freiberg disease. We report a case with recurrence of symptoms within 6 weeks and required revision for fracture of the implant. We describe a revision technique with modified osteochondral bone graft to deal with the variables of revision surgery namely: the bone loss, collateral ligament insufficiency, and changes to the proximal phalanx articular surface. We describe a postoperative plan, recovery and a good outcome achieved in 12 month follow-up.

Management of acute lesser toe pain.

Patients with foot pain commonly present to their primary care physicians for their initial management and treatment. These patients and their respective foot or lesser toe pain can present the physician with a complex problem with a long differential list. Depending on the timing of the pain and underlying pathology, these differentials can be divided into acute and acute exacerbation of chronic conditions. This review categorizes the history, physical exam, radiological findings, conservative treatment, and surgical management for each major cause of lesser toe pain, whether acute or chronic. The acute conditions surrounding lesser toe pain in the adult population discussed are toe fractures, toe dislocations, and metatarsal head and neck fractures. The chronic pathologies surrounding lesser toe pain in the adult population evaluated in this review include metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders.

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.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report.

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

Outcomes of Polyvinyl Alcohol Hydrogel Implant of the Lesser Metatarsals.

BACKGROUND: Lesser toe metatarsophalangeal (MTP) joint pathology presents a challenge for surgical treatment. At our institution, arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the second and third MTP joints for advanced arthritis, failed management of Freiberg's infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 13 patients following PVA implantation of the second or third MTP. METHODS: We retrospectively identified 13 patients (14 joints) who underwent PVA hydrogel implantation of the second (n = 12) or third (n = 2) metatarsal between 2017 and 2019. The average age was 49 (range, 20-67) years, with 100% females. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at an average of 21.1 (range, 8.3-29.2) months postoperatively. Clinical outcomes were also evaluated. The average time to clinical follow-up was 24.7 (range, 7-35.8) months. RESULTS: On average, patients demonstrated pre- to postoperative improvement in all PROMIS domains, with significant improvements in Pain Intensity (P = .01) and Pain Interference (P = .01). Five postoperative complications were observed: 1 case of persistent avascular necrosis, 1 revision with implant removal and bone grafting, 1 periprosthetic fracture, and 2 recurrences of pain requiring ultrasound-guided injection. CONCLUSION: This study represents the largest case series to date evaluating the use of PVA implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg's infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered. LEVEL OF EVIDENCE: Level IV, 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.

Conservative treatment of Freiberg's infraction using foot orthoses: A tale of two prescriptions presented as a case study to open debate.

'Freiberg's infraction or disease' is an osteonecrotic process primarily affecting the 2nd & 3rd metatarsal heads. Early diagnosis is difficult, and the underlying pathogenesis remains unclear. Surgical options for late disease have been widely reported in the literature, yet details on conservative management for the early stages of Freiberg's are largely absent. Pathology should be treated where possible using an evidence-based approach, yet evidence for conservative management in acute stages of Freiberg's is lacking. A case study is presented that outlines two different prescription interventions using foot orthoses; one that attempted to 'offload' the metatarsal head by creating space beneath it; and one that attempted to 'offloaded' by increasing controlled loading of the metatarsals proximal to the head. These resulted in very different outcomes for the patient. The authors will attempt to give a 'pathomechanical rationale' for the treatment outcomes based on mechanical stress principles, and a consequential explanation as to why one type of insole prescription seemed more successful in reducing symptoms and raising activity levels, while another was not.

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.

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.

Freiberg Disease and Avascular Necrosis of the Metatarsal Heads.

Freiberg disease is characterized as osteochondrosis of the second metatarsal head. It is the fourth most common form of primary osteochondrosis with a significant predilection to the adolescent athletic female population, although it has been seen over a wide age range. If treated early, osteochondroses such as Freiberg disease are essentially self-limiting, often resolving with nonoperative management. When surgery is warranted, it is imperative the patient's age, activity level, and degree of articular deformity be taken into account.

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.].

Joint debridement and microfracture for treatment late-stage Freiberg-Kohler's disease: Long-term follow-up study.

BACKGROUND: Freiberg-Kohler's disease is not a common disease and although various reports have been described since 1914, treatment methods are not completely established. The purpose of the present retrospective study was to evaluate the long-term outcomes following joint debridement and microfracture procedures for the treatment of Freiberg-Kohler's disease. METHODS: Fifteen consecutive patients (16 feet) with Freiberg-Kohler's disease (Smillie's classification grade III-V) were operated between May 1996 to December 2011. All patients followed the same post-operative protocol. The objective and subjective evaluations were taken at the initial examination and at final follow-up. RESULTS: Mean follow-up was 11 years ±5.5 (range 4.2-19.7 years). The AOFAS score, VAS score and ROM of the MTP joint improved significantly after surgery (p value <0.05). The AOFAS score improved from a preoperative value of 46.7±15.5 points to 83.2±9.4 points postoperative (p<0.05). The mean preoperative joint ROM was 28°±8° and 49°±13° postoperative (p<0.05). VAS score improved from a preoperative value of 5.5±1.2 points to 1.2±1 points at last follow-up (p<0.05). At the end of follow-up 13 patients (81%) declared they were very satisfied, 3 patients (19%) satisfied and nobody unsatisfied. CONCLUSIONS: Our results suggest that joint debridement and microfracture procedure is an effective surgical treatment for late-stage Freiberg-Kohler's disease with decrease of daily pain, improved ROM, and high patient satisfaction.

Functional Outcomes of Local Pedicle Graft Interpositional Arthroplasty in Adults With Severe Freiberg's Disease.

BACKGROUND: Conservative treatment or debridement is generally sufficient for Freiberg's disease grades I and II but operative intervention for the late stages of the disease process (III-V) is more challenging. Debridement alone is not sufficient and various forms of arthroplasty have been put forward. We have evaluated the outcomes of patients treated with an interpositional arthroplasty technique using a pedicle graft of periosteum and fat made into a "Rollmop" spacer for severe Freiberg's disease. No results have previously been reported for this technique. METHODS: Twenty-five consecutive cases (23 patients) were performed from February 2009 to September 2016 (20 females, 5 males). Mean age at surgery was 52.6 years (range 19-70.5 years) with 92% affecting the second metatarsal. Twenty-three were primary cases and 2 were revision cases. Five cases were stage III, 12 were stage IV, and 8 were stage V. All patients underwent interpositional arthroplasty using a periosteum and fat pedicle graft from the affected metatarsal shaft as described by Myerson. Patients were evaluated using Manchester-Oxford Foot Questionnaire (MOXFQ) and American Orthopaedic Foot & Ankle Society Questionnaire (AOFAS). Mean follow-up was 3.5 years (0.6-7.6 years). Paired 2-tailed Student t tests were used to assess clinical significance. RESULTS: Surgery allowed 8 patients to return to normal footwear, 10 patients returned to fashion footwear/heels, and 5 returned to sports. Nineteen cases (17 patients) were assessed with patient-reported outcome measures and all showed a clinically and statistically significant improvement in their scores. Mean pre- and postoperative VAS pain scores were 6.2 (range 4-9) and 1.8 (range 0-6) ( P < .05). Mean perioperative AOFAS scores were 45.6 (range 15-73) and 82.7 (range 57-100) ( P < .05). Mean perioperative MOXFQ scores were 60.0 (range 23-89) and 18.1 (range 0-80) ( P < .05). CONCLUSION: This novel interpositional arthroplasty technique using a "rollmop" of periosteum and fat for severe Freiberg's disease produced significant improvements in pain, functional outcome, and patient satisfaction without donor site morbidity. Furthermore, it allowed patients to return to desired footwear and sporting activities. The functional outcome and joint range of motion was superior after a K-wire was no longer placed across the joint, and we believe it is essential to avoid this to permit early range-of-motion exercises. LEVEL OF EVIDENCE: Level IV, retrospective case series.

[Gauthier's osteotomy and fixation using osteosuture in the treatment of Freiberg's disease]. / Ostéotomie de Gauthier et fixation par ostéo-sutures dans le traitement de la maladie de Freiberg.

Freiberg's disease is an osteochondrosis of the metatarsal heads mainly affecting the second metatarsal head. This study was conducted over a 3 year period. It reports 6 cases of patients, whose average age was 19.8 years, who had undergone Gauthier's dorsal subtraction osteotomy with fixation using osteosutures. The outcome of this technique was satisfactory. Indeed, the majority of patients had no pain and recovered normal daily activity. This study highlights that fixation using osteosutures is a reliable and inexpensive method.

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.

Return to sporting activity after osteochondral autograft transplantation for Freiberg disease in young athletes.

INTRODUCTION: Freiberg disease is defined as osteochondrosis of the metatarsal head and typically occurs in adolescents with sporting activity. This study aimed to evaluate the sporting activity of young athletes after osteochondral autograft transplantation (OAT) for Freiberg disease. MATERIALS AND METHODS: OAT for Freiberg disease was conducted in 12 consecutive patients between August 2008 and November 2014. The present study evaluated 10 of these patients who both undertook sporting activity preoperatively and were teenagers at the time of surgery. Clinical evaluations were performed based on the Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale (JSSF scale) and range of motion (ROM) of the operated metatarsophalangeal joint preoperatively and at the final follow-up (mean 24.6 months). Whether patients were able to return to sporting activity and time until return to sporting activity were evaluated, including the Halasi score to reflect the level of sporting activity. Regarding symptoms at the donor knee, the Lysholm knee scale score was evaluated at the final follow-up. RESULTS: The mean JSSF scale showed a significant improvement at the final follow-up (p < 0.01). The mean ROM in extension and flexion improved at the final follow-up (p < 0.01, and p < 0.05, respectively). All patients were able to return to sporting activity at a mean time of 3.5 months postoperatively and the Halasi score showed no significant change. The mean Lysholm knee scale score was 97.9 (range 89-100) points at the final follow-up. CONCLUSIONS: All young athletes who underwent OAT for Freiberg disease achieved early return to almost equal sporting activity postoperatively and exhibited a significant improvement of the ROM of the metatarsophalangeal joint with almost no knee pain.

The Nature of Foot Ray Deficiency in Congenital Fibular Deficiency.

BACKGROUND: Absent lateral osseous structures in congenital fibular deficiency, including the distal femur and fibula, have led some authors to refer to the nature of foot ray deficiency as "lateral" as well. Others have suggested that the ray deficiency is in the central portion of the midfoot and forefoot.We sought to determine whether cuboid preservation and/or cuneiform deficiency in the feet of patients with congenital fibular deficiency implied that the ray deficiency is central rather than lateral in patients with congenital fibular deficiency. METHODS: We identified all patients with a clinical morphologic diagnosis of congenital fibular deficiency at our institution over a 15-year period. We reviewed the records and radiographs of patients who had radiographs of the feet to allow determination of the number of metatarsals, the presence or absence of a cuboid or calcaneocuboid fusion, the number of cuneiforms present (if possible), and any other osseous abnormalities of the foot. We excluded patients with 5-rayed feet, those who had not had radiographs of the feet, or whose radiographs were not adequate to allow accurate assessment of these radiographic features. We defined the characteristic "lateral (fifth) ray present" if there was a well-developed cuboid or calcaneocuboid coalition with which the lateral-most preserved metatarsal articulated. RESULTS: Twenty-six patients with 28 affected feet met radiographic criteria for inclusion in the study. All affected feet had a well-developed cuboid or calcaneocuboid coalition. The lateral-most ray of 25 patients with 26 affected feet articulated with the cuboid or calcaneocuboid coalition. One patient with bilateral fibular deficiency had bilateral partially deficient cuboids, and the lateral-most metatarsal articulated with the medial remnant of the deformed cuboids. Twenty-one of 28 feet with visible cuneiforms had 2 or 1 cuneiform. CONCLUSIONS: Although the embryology and pathogenesis of congenital fibular deficiency remain unknown, based on the radiographic features of the feet in this study, congenital fibular deficiency should not be viewed as a global "lateral lower-limb deficiency" nor the foot ray deficiency as "lateral." LEVEL OF EVIDENCE: Level IV-prognostic study.