freiberg 's disease is an osteochondrosis most commonly seen in adolescent women and characterized by pain , swelling and motion restriction in the second metatarsal .
it is less common in the third and fourth metatarsals.12 while the etiology of the freiberg 's disease remains obscure , repeated microtrauma is considered to be the cause for development of this disease.23 since the second metatarsal is the longest and the least mobile , excessive pressure on the metatarsal head can lead to impaired blood supply to the subchondral site , as well as chondral collapse and necrosis accompanied by synovitis .
if the synovitis is severe , it may lead to swelling and motion restriction , especially in extension .
subsequently , osteochondral fragmentation may occur at the metatarsal head.456 the early stages of this disease can be managed with semirigid orthoses , metatarsal bars and short leg walking cast.3 if the pain is not relieved by these methods , a number of operative methods are suggested which can be used depending on the pathophysiology of the disease , including abnormal biomechanics , joint congruence and degenerative process.1578 we evaluated the clinical outcomes of the cases of advanced - stage freiberg 's disease who were managed with dorsal closing wedge osteotomy or resection of the metatarsal head .
16 patients ( 11 female , 5 male ) with a mean age of 24.5 years ( range 1349 years ) who underwent dorsal closing wedge osteotomy or resection of the metatarsal head due to advanced stage freiberg 's disease between 2007 and 2012 were included in this retrospective study .
the main presenting symptom was pain on daily activities such as standing , walking and running .
6 had mild , 6 had moderate and 4 had severe pain in daily activities .
all of the patients had a history of trivial trauma and four patients had previously undertaken joint debridement .
the initial treatment was based on conservative methods including rest to the part analgesic and anti - inflammatory medications along with metatarsal bar or splint .
since the patients remained unresponsive to conservative treatment for more than three months , the patients underwent dorsal closing wedge osteotomy or resection of the metatarsal head .
the decision of surgical method was based on the preoperative radiological studies and the cartilage damage during surgery .
osteotomy was performed in the patients with good joint congruency and the ones who had sufficient plantar cartilage to perform the procedure .
resection was done in the patients with impaired joint congruency and severe cartilage damage [ figure 1 ] .
x - ray of a 24-year - old female patient anteroposterior view showing ( a ) freiberg 's disease advanced stage in 2 metatarsal head ( b ) resection of 2 metatarsal head clinical and radiological staging of the cases was based on the smillie 's classification system 1 [ table 1 ] and the lesser metatarsophalangeal - interphalangeal ( lmpi ) scale modified by kitoaka et al .
[ table 2].7 according to the smillie 's classification , 6 of our patients were type v , and 10 of them were type iv .
based on the lmpi scale , the preoperative scores for the osteotomy and excision groups were 58 ( range 4480 ) and 50.8 ( range 4058 ) , respectively .
smillie clasification system for freiberg 's disease lesser metatarsophalangeal  interphalangeal scale all the operations were performed under spinal anesthesia and in the supine position with tourniquet control .
one hour prior to surgery , single dose of 1 g first generation cephalosporin was used for prophylaxis .
the metatarsal head was approached by a 3-cm dorsal incision through the metatarsophalangeal joint . using the dorsal longitudinal method ,
the extensor digitorum longus and brevis muscles of the affected toe were moved laterally following the medial excision of the extensor tendons .
all the osteophytes were removed and synovectomy was done . the metatarsal head was positioned medially and dorsal closing - wedge osteotomy was performed on the distal metaphysis .
the metatarsal head was tilted approximately 15 to the dorsal aspect , and when the joint congruency was achieved between the metatarsal head and proximal phalanx , the osteotomy was stabilized using two crossed kirschner wires ( k - wires ) under fluoroscopic control . in the resection group ,
following a 5 mm resection of the articular surface of the metatarsal head , the capsule was sutured and the soft tissues were closed in layers .
the foot was immobilized in a short leg walking cast in all the patients . in the osteotomy group ,
the cast and pins were removed at 6 weeks and tolerable weight bearing was commenced . in the patients who received debridement and excision of
the metatarsal heads the cast and pins were removed at 2 weeks and weight bearing was started .
all the patients underwent clinical and radiographic followup at 2 and 4 weeks , 2 and 6 months and then every 12 months .
the osteotomy site healing and metatarsal shortening were evaluated by means of anteroposterior and oblique x - ray images .
statistical evaluations were based on descriptive statistics methods ( average , standard deviation , frequency ) and functional improvement was assessed using the wilcoxon test with spss 18.0 for windows 7 ( spss version 18 statistical software , spss inc , chicago , illinois , usa ) .
all the operations were performed under spinal anesthesia and in the supine position with tourniquet control .
one hour prior to surgery , single dose of 1 g first generation cephalosporin was used for prophylaxis .
the metatarsal head was approached by a 3-cm dorsal incision through the metatarsophalangeal joint . using the dorsal longitudinal method ,
the extensor digitorum longus and brevis muscles of the affected toe were moved laterally following the medial excision of the extensor tendons .
all the osteophytes were removed and synovectomy was done . the metatarsal head was positioned medially and dorsal closing - wedge osteotomy was performed on the distal metaphysis .
the metatarsal head was tilted approximately 15 to the dorsal aspect , and when the joint congruency was achieved between the metatarsal head and proximal phalanx , the osteotomy was stabilized using two crossed kirschner wires ( k - wires ) under fluoroscopic control . in the resection group ,
following a 5 mm resection of the articular surface of the metatarsal head , the capsule was sutured and the soft tissues were closed in layers . the foot was immobilized in a short leg walking cast in all the patients . in the osteotomy group ,
the cast and pins were removed at 6 weeks and tolerable weight bearing was commenced . in the patients who received debridement and excision of
the metatarsal heads the cast and pins were removed at 2 weeks and weight bearing was started .
all the patients underwent clinical and radiographic followup at 2 and 4 weeks , 2 and 6 months and then every 12 months .
the osteotomy site healing and metatarsal shortening were evaluated by means of anteroposterior and oblique x - ray images .
statistical evaluations were based on descriptive statistics methods ( average , standard deviation , frequency ) and functional improvement was assessed using the wilcoxon test with spss 18.0 for windows 7 ( spss version 18 statistical software , spss inc , chicago , illinois , usa ) .
osteotomy was performed in 11 and resection of the metatarsal head was performed in five patients . in the resection group ,
solid healing was achieved in a mean period of 6 weeks ( range 48 weeks ) [ figure 2 ] .
no superficial or deep wound infection was observed in any patient . according to the lmpi scale ,
the postoperative scores for the osteotomy and excision groups were 86 ( range 64100 ) and 72.6 ( range 6085 ) , respectively and the elevation in these scores was found significant ( osteotomy group , p = 0.003 ; resection group , p = 0.042 ) . in the osteotomy group ,
mean passive flexion restriction was 18 ( range 035 ) and mean passive extension restriction was 12 ( range 025 ) .
mean metatarsal shortening was 1.8 mm ( range 24 mm ) in the osteotomy group as opposed to 9.8 mm ( range 714 mm ) in the resection group .
no infection was observed in any patient and no nonunion was detected in the osteotomy group . in the patients
managed with osteotomy , significant pain relief was obtained and all the patients started daily life activities , which they could not do before . in the resection group , four patients had significant pain relief in their daily life activities and only one patient had pain which was mimicking metatarsalgia . in this group
x - ray of a 22 year old patient anteroposterior views showing ( a ) freiberg 's disease of 3rd metatarsal head ( b ) postoperative x - ray treated with osteotomy
the primary aim of surgery is to restore the joint in order to eliminate the pain and recover the range of motion .
a number of surgical methods have been defined in the literature : resection of the metatarsal head ( giannestras ) , metatarsal head remodeling and joint debridement ( freiberg and mann ) , resection of the base of the proximal phalanx and syndactylization of the second and third toes ( trott ) , elevation of the depressed fragment of the metatarsal head and bone grafting of the defect ( smilie ) , resection of the base of the proximal phalanx , resection of the metatarsophalangeal joint with cylastic prosthesis , and dorsal closing - wedge osteotomy of the metatarsal head.16891011121314 of these , joint debridement and metatarsal head remodeling are the most common ones , which have yielded successful results in the literature.6 dorsal closing - wedge osteotomy was initially performed by gauthier ve elbaz and has become a conventional method ever since .
this method has been performed many times and has yielded successful results.1415 the primary goal with this method is to restore the articular surface .
dorsal closing - wedge osteotomy is also considered useful in restoring blood supply at the metatarsal head and preventing potential collapses.16 by modifying the method developed by gauthier ve elbaz , which involves the use of cerclage fixation following osteotomy , chao et al .
defined an extra - articular osteotomy , in which the articular surface is rotated to the proximal phalanx after the removal of defective articular surface.1112 using the k - wires for the fixation of osteotomy line , the study reported the average shortening as 2.1 mm , joint flexion as 15 and loss of joint extension as 8. moreover , despite these rates , the authors reported no restriction in daily activities of the patients such as walking and running . in our study , the eleven patients who were managed with closing wedge osteotomy had a mean passive flexion restriction of 18 ( range 035 ) and a mean passive extension restriction of 12 ( range 025 ) .
mean preoperative score was 58 ( range 4480 ) and mean postoperative score was 86 ( range 64100 ) .
in this group , the patients had satisfactory outcomes in terms of pain relief and improvement of range of motion .
resection arthroplasty is another method suggested for the patients with stage iv or v. however , this technique is the least popular one since it causes metatarsal shortening.4 in our series , four of the patients who were managed by this method had previously been performed with joint debridement due to freiberg 's disease . although the pain relief was obtained in all of them , after a certain period of time ( range 318 months ) , the pain relapsed in all the patients .
all four patients had severe cartilage damage and thus underwent excision of the metatarsal head .
metatarsalgia is a common complication arising from the excision of the metatarsal head,4 and it developed in one of our patients . by wearing appropriate footwear and obtaining supportive treatments ,
the most common complaints in the resection group were metatarsal shortening and relevant cosmetic problems.4 in our study , mean metatarsal shortening in the resection group was 9.8 and in this group , the most common complaints were metatarsal shortening and relevant cosmetic problems . since
therefore , the patients to be managed with resection arthroplasty should be informed about the cosmetic problems like shortening and relevant cosmetic problems .
we conclude that the dorsal closing - wedge osteotomy and the resection arthroplasty are effective methods in the treatment of freiberg 's disease
the resection arthroplasty should be used in severe cartilage damage and the dorsal closing - wedge osteotomy should be preferred if there is sufficient healthy plantar cartilage .
 background : freiberg 's disease is an osteochondrosis most commonly seen in adolescent women and characterized by pain , swelling and motion restriction in the second metatarsal . 
 the early stages of this disease can be managed with semirigid orthoses , metatarsal bars and short leg walking cast . 
 number of operative methods are suggested which can be used depending on the pathophysiology of the disease , including abnormal biomechanics , joint congruence and degenerative process . 
 we evaluated the outcomes of the patients with freiberg 's disease who were treated with dorsal closing - wedge osteotomy and resection of the metatarsal head.patients and methods:16 patients ( 11 female , 5 male ) with a mean age of 24.5 ( range 1349 years ) years who underwent dorsal closing wedge osteotomy or resection of the metatarsal head were included in this retrospective study . 
 second metatarsal was affected in 13 and third metatarsal in three patients . according to the smillie 's classification system , 
 ten patients had type iv osteonecrosis and six patients had type v. the results of the patients were evaluated using the lesser metatarsophalangeal - interphalangeal ( lmpi ) scale.results:according to the lmpi scale , the postoperative scores for the osteotomy and excision groups were 86 ( range 64100 ) and 72.6 ( range 6085 ) , respectively . in the osteotomy group , mean passive flexion restriction was 18 ( range 035 ) and mean passive extension restriction was 12 ( range 025 ) . 
 mean metatarsal shortening was 2.2 mm ( range 24 mm ) in the osteotomy group as opposed to 9.8 mm ( range 714 mm ) in the excision group . 
 significant pain relief was obtained in both groups following the surgery.conclusions:the decision of performing osteotomy or resection arthroplasty in the patients with advanced - stage freiberg 's disease should be based on the joint injury and the patients should be informed about the cosmetic problems like shortening which may arise from resection . 
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