CT-based five-segment classification in Freiberg's infarction: Evaluation of its intraobserver and interobserver reliability.

BACKGROUND: According to the location and frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn for Freiberg's infarction. The objective of the current study is to develop a new computed tomography-based Five-Segment classification system for Freiberg's infarction and testify if it has good intra- and interobserver reliability or not. METHODS: According to the location and its frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn. According to the distribution of osteonecrosis zones of metatarsal heads, we proposed the Five-Segment classification system. Four evaluators evaluated each radiography and computed tomography (CT) twice at 8-week intervals. To test the reproducibility of the Five-Segment classification system, the interobserver and intraobserver reliability of this classification system comparing with that of the Smillie classification by four observers using the kappa statistic. RESULTS: The 80 cases were classified into five reproducible types by using Five-Segment classification system: type Ⅰ, two (2.5%) cases; type Ⅱ, ten (12.5%) cases; type Ⅲ, 42 (52.5) cases; type Ⅳ, 24 (30.0%) cases; type Ⅴ, two (2.5%) cases. The mean kappa value for interobserver reliability using Smillie classification systems was 0.562 (95% CI: 0.531-0.585), whereas the mean kappa value was 0.828 (95% CI: 0.801-0.852), by using Five-Segment classification; the mean kappa values for intraobserver reliability by using Smillie classification and Five-Segment classification were 0.777 (95% CI: 0.762-0.792) and 0.860 (95% CI: 0.843-0.895), respectively. CONCLUSIONS: The new Five-Segment classification system demonstrated perfect interobserver and intraobserver agreement between evaluators in the management of Freiberg's infarction. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice. LEVEL OF EVIDENCE: Level IV, retrospective.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases.

BACKGROUND: Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success. METHODS: A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores. RESULTS: The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively. CONCLUSIONS: Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

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.

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.

A new lesser metatarsophalangeal joint replacement arthroplasty design - in vitro and cadaver studies.

BACKGROUND: Isolated degenerative joint disease and/or Freiberg's infraction of the lesser metatarsophalangeal joint, although not frequent may become debilitating in the younger individual. Currently, once conservative management fails, the mainstay of treatment is debridement and excision-interposition arthroplasty. Replacement arthroplasty has been ineffective in the long term as the joints are subject to severe repetitive fatigue loading over small articulating surfaces through a wide range of motion. This is an in vitro and cadaver study of a new design replacement arthroplasty developed by the senior author. The aim of this study is to evaluate this novel replacement arthroplasty of the lesser metatarsophalangeal joint in a laboratory setting and cadaver implantation. METHODS: This three-component mobile bearing device is made of titanium and high density polyethylene which evolved over 4 years. It was subjected to 5,000,000 cycles in a laboratory under physiological and excessive forces to assess resistance to fatigue failure and wear pattern of the polyethylene liner. Following these tests, it was implanted in 15 fresh frozen cadavers at various stages of its development, during which the surgical technique was perfected. Range of motion and stability was tested using custom made instrumentation in four cadavers. The implant was inserted in a further two cadavers by an independent foot and ankle surgeon to check reproducibility. RESULTS: The device showed almost no signs of wear or surface deformation under physiological forces. The surgical technique was found to be simple and reproducible in the cadaver trial. The average dorsiflexion was 28.5° and 28.9° pre- and post-implant respectively. The average plantar flexion was 33.8° and 20.8° pre- and post- implant respectively. The joints were stable both pre- and post-operatively. Post-operative stability was objectively assessed for dorsal displacement and dorsiflexion using a 5 kgf (49 N) and was found to be excellent. CONCLUSION: This novel lesser metatarsophalangeal joint replacement arthroplasty has been developed as an option in the surgical treatment of symptomatic degenerative joint disease and/or Freiberg's infraction resistant to conservative treatment. The implant was found to be durable and resistant to wear in the laboratory testing. The cadaver studies have shown it to require minimal specialized instrumentation with good surgical reproducibility. This proof of concept study is the basis for clinical trials.

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.

Synthetic Cartilage Implant Hemiarthroplasty for Second MTP Joint Osteoarthrosis.

Synthetic cartilage hemiarthroplasty has been used successfully in the first metatarsophalangeal (MTP) joint and might also provide an alternative surgical intervention for second MTP joint osteoarthritis and Freiberg disease. Synthetic cartilage implant hemiarthroplasty was performed on 23 consecutive patients for the treatment of painful second MTP joint disease. Joint damage ranged from mild to severe. Mean follow-up period was 43 months ± 17.6 (range, 28-79 months). Mean age at the time of surgery was 55 years ± 16 (range, 20-73 years). Each participant attended for clinical assessment and an interview which included completion of 2 patient-reported outcome measures: the Manchester-Oxford Foot Questionnaire (MOXFQ) and the Foot and Ankle Ability Measure (FAAM). The implant failed in 2 participants (9%) and required removal and revision. Four participants (17%) reported dissatisfaction with the surgery because of continued pain. Nine participants (43%) reported second MTP joint stiffness; however, this was symptomatic in just 5 cases. Sixteen participants (70%) were pain free and totally satisfied with their outcome. Eleven of 21 participants (52%) reported an improvement in all 3 categories of the MOXFQ. FAAM scores demonstrated good overall function and activity, with a mean score of 91 ± 16 (range, 44-100). There were no postoperative infections, transfer metatarsalgia, or floating toe deformity. In preserving metatarsal and phalanx length as well as the collateral ligaments of the joint, synthetic cartilage implant hemiarthroplasty avoids some of the important risks of metatarsal osteotomy and basal phalangectomy. A range of alternative surgical options are still available if the synthetic cartilage implant fails to resolve symptoms.

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.

Subchondroplasty of the Foot: Two Case Reports.

Early avascular necrosis of metatarsal heads and cuboid injuries are uncommon conditions encountered by foot and ankle specialists. Treatment options are limited and typically include long periods of offloading or non-weightbearing. There is limited published information on alternative treatment approaches for such pathologies when conservative therapies fail. Presented are 2 patient cases treated with a percutaneous calcium phosphate injection after failure of standard therapy, persistent pain, and bone marrow edema in the foot.

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.