Results of Dorsal Closing Wedge Osteotomy in Freiberg’s Disease

Introduction: Freiberg’s disease, the osteochondrosis of themetatarsal seen in our part of the world, usually at late stages,are refractory to the conservative treatment. Objective:Thepurpose of this study was to evaluate the results of dorsalclosing wedge osteotomy and pin fixation besides debridementand synovectomy.Material and Methods: Twenty patients (14 females,6 Males), mean age 19.3 years; range 14 to 26 years wereevaluated and teated by dorsal closing wedge osteotomy andpin fixation besides debridement and synovectomy, betweenseptember 2016 to 2018 at our institution. The presentingsymptoms were pain on walking or sports, limitation of dailyroutine activities, footwear problems, cosmetic deformitiesof forefoot and failed conservative treatment. Three patientshad a history of trauma. According to Smillies’s classificationtwelve patients were type IV and eight were Type V.Meanfollow-up period was 14.85 months(range 6 months to 24months).Results: Patients were assessed by the lessermetatarsophalangeal interphalangeal (LMPI) scale bykitaokaetal. At the final follow-up, scoring had changed from(44-66) with an average 54.65 to (76-100) with an average85.3. There was no case of infection, avascular necrosis,arthritis or pseudoarthrosis.Conclusion: Treatment of freiberg's disease with dorsalclosing-wedge osteotomy shows satisfactory pain relief andimprovement in quality of life

Outcome of Extraarticular Dorsal Closing Wedge Osteotomy for Freiberg's Disease / 대한족부족관절학회지

PURPOSE: The aim of this study was to evaluate the result of extraarticular dorsal closing wedge osteotomy in Freiberg's disease. MATERIALS AND METHODS: Between February 2012 and July 2014, total 10 patients who underwent dorsal closing wedge osteotomy and followed up more than 1 year were selected for inclusion. Average age was 16.3 years, and average follow-up period was 15.5 months. The diagnosis was made using magnetic resonance imaging of those with a limitation in walking or usual activity due to pain in the metatarsal head. During operation, we removed loose body, and synovectomy was done. Osteotomy at the metatarsal neck and fixation with Kirschner wire were performed. X-ray was taken to check shortening of 2nd metatarsal and bone union. Moreover, we checked the active range of motion of 2nd metatarsophalangeal joint before and after surgery. At the last follow-up, the shortening of metatarsal, American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS), and patient's subjective satisfaction were evaluated. RESULTS: According to the Smillie's stage, there were 3 cases of stage II, 4 cases of stage III, and 3 cases of stage IV. Average bone union time on the osteotomy site was 8 weeks. Average shortening of metatarsal was 2.53 mm. Average AOFAS score improved significantly from 56.9 to 82.8 points at final follow-up (p<0.05), and average VAS score also improved significantly from 6.4 to 1.4 points at final follow-up (p<0.05). Average active range of motion at metatarsophalangeal joint improved from 28.0° preoperatively to 46.5° at the final follow-up. Other complications, such as metatarsalgia and arthritis, were not found; however, there was 1 case of delayed union with no symptom. CONCLUSION: In Freiberg's disease, dorsal closing wedge osteotomy is recommended for the improvement of clinical symptoms and range of motion.

Freiberg's Disease and Metatarsophalangeal Joint Instability / 대한족부족관절학회지

Freiberg's disease is a osteochondrosis of a metatarsal head that is recognized as primarily a disorder of the second metatarsal. It is seen more often in girls. Pain and limitation of motion of the affected joint is the predominant clincal feature. The radiographic appearance demonstrates from osteosclerosis in the early stage to osteolysis with collapse in the later stage. Conservative therapy may take the form of rest, a stiff shoe, and even a cast support to decrease the stress across the joint. Surgical intervention may also be of benefit. Surgery have been attempted either to modify the diseae process or to salvage the situation once the metatarsophalangeal joint develops degenerative changes. Metatarsophalangeal joint instability is common cause of forefoot pain that can develop in association with a traumatic episode and inflamatory tissue disorders as well as neighboring toe deformities. The second ray is by far the most frequently involved. The diagnosis can be made by clinical observation and physical examination including drawer test. Many surgical procedures have beem recommended when conservative treatment has failed. Procedures described range from soft tissue releases and tendon trasfer to the direct plantar plate repair combined with a Weil osteotomy.

Modified Weil Osteotomy for the Treatment of Freiberg's Disease

BACKGROUND: Numerous metatarsal osteotomies have been developed for the treatment of Freiberg's disease. The purpose of this study was to evaluate the clinical outcomes of modified Weil osteotomy in the treatment of Freiberg's disease. METHODS: From November 2001 to July 2008, nineteen patients (twenty feet), treated surgically for Freiberg's disease, were included in this study. The average age of the patients was 33.6 years (range, 17 to 62 years), the mean follow-up period was 71.6 months (range, 41 to 121 months). Clinical outcomes were evaluated according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the patients' subjective satisfaction and range of motion (ROM) of metatarsophalangeal (MTP) joint. In the radiologic evaluation, initial metatarsal shortening by Freiberg's disease compared to opposite site, metatarsal shortening after modified Weil osteotomy compared with preoperative radiography and term for radiologic union were observed. RESULTS: VAS showed improvement from 6.2 +/- 1.4 to 1.4 +/- 1.5 at last follow-up (p < 0.0001). Points of AOFAS score increased from 63.3 +/- 14.9 to 80.4 +/- 5.6 (p < 0.0001). ROM of MTP joints also improved from 31.3 +/- 10.1 to 48.3 +/- 13.0 degrees at last follow-up (p < 0.0001). According to Smillie's classification system, there was no significant improvement of VAS, AOFAS score and ROM between early stages (stage I, II, and III) and late stages (stage IV and V). Out of twenty cases, nineteen (95%) were satisfied, reporting excellent or good results. CONCLUSIONS: Modified Weil osteotomy is believed to be a useful method for the treatment of Freiberg's disease, not only in the early stages but also in the late stages. It relieves pain and improves function via shortening of metatarsals and restoration of MTP joint congruency.

Weil Osteotomy for Freiberg's Disease / 대한족부족관절학회지

PURPOSE: The aim of this study was to evaluate the result of combined Weil and dorsal closing wedge osteotomy for Freiberg's disease. MATERIALS AND METHODS: We performed combined Weil and dorsal closing wedge osteotomy of the second metatarsal under the diagnosis of Freiberg's disease in 7 patients, 7 feet (2 male and 5 female). The mean age at the time of operation was 29 years and the mean follow-up period was 31 months. Patients had no trauma history and no combined deformity of the foot. The surgical results were evaluated by VAS and weight bearing radiographs in antero-posterior and oblique projection. RESULTS: According to Smillie staging system, there were 1 of stage II, 2 of stage III and 4 of stage IV patients. The osteotomy site was united at 8 weeks and the second metatarsal was shortened in length of average 2.8 mm. Remodeling of the metatarsal head was observed at 24 months. The mean VAS was decreased from 8.2 points preoperatively to 2.7 points at follow-up. And average range of motion of second metatarso-phalangeal joint was increased from 30o preoperatively to 45o at follow-up. There was no transfer metatarsalgia or arthritis of the metatarsal head during follow-up. CONCLUSION: Combined Weil and dorsal closing wedge osteotomy of the metatarsal appears to be an effective procedure for the treatment of Freiberg's disease with a view to shortening of metatarsal length and elevation of metatarsal head.

Autogenous Osteochondral Graft for Freiberg's Disease: A Case Report / 대한족부족관절학회지

Freiberg disease is a osteochondrosis of the lesser metatarsal heads. Various surgical treatment have been recommanded including joint debridement and metatarsal head reshaping, metatarsal dorsal wedge osteotomy, metatarsal head excision and joint arthroplasty. Autogenous osteochondral graft for the treatment of Freiberg disease is an effective restorative procedure that provides early range of motion exercise, weight bearing, and reduces other morbidity. We report a case of late stage Freiberg disease treated with arthrotomy, removal of loose body and autogenous osteochondral graft.

Dorsal Wedge Osteotomy Using Bioabsorbable Pins for the Treatment of Freiberg's Disease / 대한족부족관절학회지

PURPOSE: To present the procedure and results of dorsal wedge osteotomy fixated by bioabsorbable polyglycolide pins for the treatment of symptomatic Freiberg's disease. MATERIALS AND METHODS: From January 1997 to December 2002, six patients with Freiberg's disease underwent dorsal wedge osteotomy of the metatarsal neck to bring the healthy plantar part of the metatarsal head into articulation. Bioabsorbable polyglycolide pins were used for the fixation and short-leg walking cast was applied for 4 weeks. RESULTS: All patients returned to full daily activities without pain in three months after the operation. Radiographically, solid healing of the osteotomy was observed at average ten weeks. The active range of motion of the metatarsophalangeal joint increased by a mean gain of 30 degrees, and no complication such as displacement, osteolysis or sinus formation was observed. CONCLUSION: Dorsal wedge osteotomy fixated by bioabsorbable pins for patients with symptomatic Freiberg's disease is effective procedure that provides relatively early range of motion exercise and avoids second procedure for implant removal.

Dorsal Wedge Osteotomy Using Bioabsorbable Pins for the Treatment of Freiberg's Disease / 대한족부족관절학회지

PURPOSE: To present the procedure and results of dorsal wedge osteotomy fixated by bioabsorbable polyglycolide pins for the treatment of symptomatic Freiberg's disease. MATERIALS AND METHODS: From January 1997 to December 2002, six patients with Freiberg's disease underwent dorsal wedge osteotomy of the metatarsal neck to bring the healthy plantar part of the metatarsal head into articulation. Bioabsorbable polyglycolide pins were used for the fixation and short-leg walking cast was applied for 4 weeks. RESULTS: All patients returned to full daily activities without pain in three months after the operation. Radiographically, solid healing of the osteotomy was observed at average ten weeks. The active range of motion of the metatarsophalangeal joint increased by a mean gain of 30 degrees, and no complication such as displacement, osteolysis or sinus formation was observed. CONCLUSION: Dorsal wedge osteotomy fixated by bioabsorbable pins for patients with symptomatic Freiberg's disease is effective procedure that provides relatively early range of motion exercise and avoids second procedure for implant removal.

Operative Treatment of Old Neglected Freiberg's Infraction (Comparison of Three Techniques) / 대한족부족관절학회지

PURPOSE: We compared the results of three surgical procedures of the old neglected Freiberg's disease that was managed with metatarsal head reshaping, metatarsal head resection, and dorsal closing wedge osteotomy. MATERIALS AND METHODS: From march 1996 to July 2002, five cases in six patients whose metatarsal head collapse already progressed underwent operative treatment. We compared the operative results in the view point of the radiographic follow-up and lesser toe metatrasophalangeal joint scale of AOFAS. RESULTS: There were no further joint destruction and loose body formation. Also, lesser toe metatrasophalangeal joint scale of AOFAS improved from average score, 38.5 (range 22~49) of preoperative one to average score, 86.6 (range, 72~100). Especially, the 2 cases that underwent dorsal closing wedge osteotomy showed most favorable result and the 2 cases with metatarsal resection showed next favorable result. The 2 cases with intra-articular loose body removal and metatarsal reshaping showed the least effective result among three operative methods. CONCLUSION: Our Operative experiences of old neglected Freiberg's disease were all satisfactory irrespective of operative options and dorsal closing wedge osteotomy was thought to be most effective method.

A Patient with Piriformis Syndrome Combined Spondylosis Deformans Treated by Acupuncture and Moxibustion / 全日本鍼灸学会雑誌

In the present study, acupuncture treatment has performed in a patient with spondylosis deformans combined piriformis syndrome, and applied to relief the hypertonus of the piriformis in the right buttock. As a result, the mitigation of right buttock pain and subsequent improvement in the range of the hip joint motion were observed from the early stage of treatment. These acupuncture effects are probably due to pain relief that resulted from increased local muscle blood flow following acupuncture stimulation. In addition, the present patient was suspected of double lesion neuropathy consisting of spondylosis deformans complicated by piriformis syndrome. From the present study, acupuncture therapy is thought to be useful method of enhancing the decompression of an entrapped nerve and vessels by increasing blood flow in the affected muscle in entrapment neuropathy such as thoracic outlet syndrome or piriformis syndrome.

Treatment of Freiberg's Disease with Joint Debridement and Reshaping of Metatarsal Head / 대한정형외과학회잡지

Freibergs disease is avascular necrosis of the second or third metatarsal bone. Since 1914, numerous causes and treatments have been proposed but no definite single cause and treatment method were developed. The simple method, joint debridement could not recover the pathophysiologic condition of Freibergs disease and the destructive method, metatarsal head resection and prosthetic replacement arthroplasty had many postoperative problems. Recently, dorsiflexion osteotomy, which was described by Gauthier and Elbaz for the first time, and joint debridement and reshaping of the metatarsal head, which was described by Mann, were very effective method to manage Freibergs disease. This paper was aimed to evaluate the result of joint debridement and reshaping of the metatarsal head which were relatively simple, less destructive and safe method in treatment of the advanced Freibergs disease. We treated 7 cases of Freibergs disease from August 1993 to March 1997. The results were as follows: 1. All the patients of the last follow-up improved pain. 2. The passive range of motion was increased from 39.1 preoperatively to 57.6 postoperatively. 3. Follow-up X-rays showed no loose body and further metatarsal head destruction. The above results suggested that the joint debridement and reshaping of metatarsal head provided good result in the treatment of advanced Freibergs disease.

Dorsal Closing Wedge Osteotomy in Freiberg's Disease / 대한정형외과학회잡지

This etiology of Freiberg's disease, an idiopathic avascular necrosis of the second metatarsal head, has not been clarified. In 1979, Gauthier and Elbaz treated 53 cases of the advanced Freiberg's disease by a new technique, that is, dorsal closing wedge osteotomy, and their result was successful. Recently, in 1989, Zollinger identified that the load per surface area is concentrated at the dorsal rather than plantar surface of the second metatarsal head during walking by an experimental dynamic study, and this theory explained why the lesion of the disease is confined to the dorsal surface of the second metatarsal head, and provided a basic concept on the dorsal closing wedge osteotomy. The authors reviewed 5 cases of Freiberg's disease treated by dorsal closing wedge osteotomy from September 1989 to February 1994, and the average follow-up period was 2 years and 5 months(range, 12 to 50 months). The results were as follows; 1. All were female, and the average age at the time of operation was 29.4 years(range, 22 to 43 years). 2. All were pain-free at the last follow-up. 3. The range of motion(ROM) of the metatarsophalangeal joint was increased postoperatively; average ROM: preoperative, 33°/ postoperative 77°; mean gain of ROM, 44° So, dorsal closing wedge osteotomy is a recommendable procedure for the treatment of advanced Freiberg's disease.