Medium-Long-Term Clinical and Radiographic Outcomes of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Central Primary Metatarsalgia: Do Maestro Criteria Have a Predictive Value in the Preoperative Planning for This Percutaneous Technique?

BACKGROUND: The purpose of this prospective study was first to evaluate the safety and effectiveness of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) in treating central metatarsalgia, identifying possible contraindications. The second objective was to verify the potential of DMMO to restore a harmonious forefoot morphotype according to Maestro criteria. METHODS: A consecutive series of patients with metatarsalgia was consecutively enrolled and treated by DMMO. According to Maestro criteria, preoperative planning was carried out by both clinical and radiological assessment. Patient demographic data, AOFAS scores, 17-FFI, MOXFQ, SF-36, VAS, and complications were recorded. Maestro parameters, relative morphotypes, and bone callus formation were assessed. Statistical analysis was carried out (p < 0.05). RESULTS: Ninety-three patients (93 feet) with a mean age of 62.4 (31-87) years were evaluated. At mean follow-up of 58.7 (36-96) months, all of the clinical scores improved significantly (p < 0.0001). Most of the osteotomies (76.3%) had healed by 3-month follow-up, while ideal harmonious morphotype was restored only in a few feet (3.2%). Clinical and radiological outcomes were not different based on principal demographic parameters. Long-term complications were recorded in 12 cases (12.9%). CONCLUSION: DMMO is a safe and effective method for the treatment of metatarsalgia. Although Maestro criteria were useful to calculate the metatarsal bones to be shortened and a significant clinical improvement of all scores was achieved, the ideal harmonious morphotype was restored only in a few feet. Hence, our data show that Maestro criteria did not have a predictive value in clinical outcomes of DMMO.

Freiberg's infraction: A modified closing wedge osteotomy for an undiagnosed case.

INTRODUCTION: Freiberg's infraction is an osteonecrosis affecting the metatarsal head whose pathogenesis is not fully understood, although stress overloading by multiple microtraumas remains the most widely accepted cause. Operative treatment, by different techniques, is necessary when conservative treatment fails. PRESENTATION OF CASE: A 31-year old woman presented with left foot severe pain, especially at the level of the metatarsophalangeal joint (MTPJ) of the second ray, underestimated upon initial evaluation. She had a history of repetitive microtraumas, a long second metatarsal bone and altered forefoot kinematics. Clinical and radiographic findings were compatible with Freiberg's infraction. A dorsal closing-wedge osteotomy with single screw stabilization was performed. At last follow-up, the patient was completely asymptomatic with a normal MTPJ range of motion. DISCUSSION: Our patient had a history of repetitive microtraumas combined with a long second metatarsal bone and altered forefoot kinematics. Initially, because of the low frequency of the disease and lack of knowledge about it, even among general orthopaedic surgeons, the infraction was not diagnosed. However, the radiological characteristics of the lesion, combined with intra-operative observation and histological exams associated with the medical history and clinical exam of the patient, revealed a disease compatible with Freiberg's syndrome. A closing-wedge osteotomy, performed by using a straight burr, appeared to be the most correct treatment. CONCLUSION: This case shows how Freiberg's infraction can pass unrecognized or underestimated and how dorsal closing-wedge osteotomy can be an efficient surgical treatment.