import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 3-5mm from midline incision on medial and lateral toe borders **Protection**: Identify early in dissection, use vessel loops for gentle retraction, loupe magnification helpful in inflamed tissues, often more adherent due to chronic synovitis **Location**: 8-10mm plantar to MT head, run along plantar aspect of metatarsal **Protection**: Avoid plantar dissection beyond joint capsule, gentle debridement of plantar structures, stay dorsal to plantar plate **Location**: Plantar 50-70% of metatarsal head surface - best remaining cartilage in AVN process **Protection**: Gentle handling, no aggressive plantar curettage, preserve for joint-preserving procedures, quality assessment determines treatment **Location**: Retrograde intramedullary from diaphyseal nutrient artery - already compromised in AVN **Protection**: Minimize soft tissue stripping, preserve periosteum, limit dissection to necessary exposure, affects healing potential especially for fusion **Location**: Immediately medial and lateral to surgical site in tight intermetatarsal spaces **Protection**: Careful retractor placement, avoid aggressive lateral dissection, assess preoperatively for concurrent pathology, monitor for transfer metatarsalgia **Patient Position**: Supine with foot at end of table or with small bump under ipsilateral hip, ankle block or general anesthesia preferred, ankle or thigh tourniquet (250mmHg) **Surgical Approach**: Dorsal longitudinal approach over affected metatarsal head in intermetatarsal space (similar to Weil osteotomy approach) **Incision**: Dorsal longitudinal 3-4cm in intermetatarsal space over affected MT head **Equipment Needed**: - Small fragment set with 2.0-2.5mm screws or mini plates - Oscillating saw with fine blade - Rongeurs and small curettes - K-wires for provisional fixation - Fluoroscopy essential for osteotomies and fusion ## Core Decompression Technique **Indications**: Very early disease (Stage I-II) in young patients attempting to improve vascularity and prevent progression **Technique**: - Using 2.0-3.0mm drill, create multiple drill holes (3-5) from dorsal MT head into neck/diaphysis - Drill perpendicular to dorsal surface, depth 15-20mm - Avoid plantar cortex perforation - Creates channels for revascularization - Can combine with bone marrow aspirate injection (emerging technique) - May combine with cheilectomy if dorsal osteophytes present **Evidence**: Limited evidence, anecdotal success in very early stages. Theory: decompression reduces intraosseous pressure, improves vascularity **Outcomes**: Consider in young patients Stage I-II, low morbidity, may prevent progression but not curative --- ## Cheilectomy Technique **Indications**: Early disease (Stage I-II) when minimal collapse, failed conservative treatment **Technique**: - Remove dorsal 25-30% of metatarsal head including collapsed/avascular dorsal portion with oscillating saw - Cut in coronal plane removing dome of head - Smooth edges with rongeur - Goals: remove impinging dorsal bone, decompress joint, preserve plantar weight-bearing surface - Similar concept to hallux rigidus cheilectomy but lesser MT - Assess ROM improvement intraoperatively - should achieve pain-free arc - No fixation needed **Advantages**: - Simple procedure with low morbidity - Preserves plantar 70% for weight-bearing - Early return to function (6-8 weeks) - Can progress to more aggressive procedure if fails **Outcomes**: Good results if appropriate staging - removes mechanical block, allows pain-free motion. Failure rate 15-20% if advanced stage or progression of AVN ## Dorsal Closing Wedge Osteotomy (DCWO) **Indications**: Stage III-IV with good plantar cartilage quality **Technique - Wedge Planning**: - Mark wedge: apex plantar at junction of plantar and dorsal cartilage, base dorsal encompassing all collapsed avascular bone - Typically 3-5mm wedge height dorsally - Critical to preserve plantar cartilage at apex **Technique - Osteotomy Execution**: 1. Dorsal limb: coronal cut through collapsed area using oscillating saw 2. Plantar limb: oblique cut from dorsal toward plantar apex, converging with first cut 3. Remove wedge of necrotic bone 4. Close wedge bringing plantar cartilage dorsal and distal - articulates with phalanx 5. Provisional K-wire fixation to assess position **Fixation Options**: - 2.0-2.5mm screw from distal fragment proximally (perpendicular to osteotomy) - most common - Mini plate dorsal - if comminution or instability - Buried K-wire if poor bone quality **Advantages**: - Most anatomic reconstruction - Preserves MT length (no transfer metatarsalgia) - Maintains joint congruency - Rotates healthy cartilage to weight-bearing position **Disadvantages**: - Technically demanding - Precise wedge planning required - Higher learning curve - Longer operative time **Outcomes**: 75-85% good/excellent results in appropriately selected Stage III-IV cases. Better joint mechanics than Weil theoretically --- ## Weil Osteotomy **Indications**: Stage III-IV alternative to DCWO, surgeon preference **Technique**: - Same technique as Weil for metatarsalgia - Oblique osteotomy through metatarsal neck parallel to weight-bearing surface - Start 2-3mm distal to cartilage dorsally, cut proximal-plantar - Translate capital fragment proximally 3-4mm - This shortens MT, decompresses joint, unloads damaged dorsal portion - Healthy plantar cartilage remains weight-bearing - Fix with 2.0-2.5mm headless screw perpendicular to osteotomy **Advantages**: - More predictable than DCWO - Simpler technique - Less technically demanding - Familiar to most surgeons - Reliable outcomes **Disadvantages**: - MT shortening (may transfer load to adjacent MTs) - Potential floating toe if excessive shortening - Same technical risks as standard Weil (dorsiflexion malunion, stiffness) **Outcomes**: 70-80% good/excellent results. Transfer metatarsalgia 5-10% from shortening. Floating toe 10-15% if excessive shortening **DCWO vs Weil Summary**: Both work for Stage III-IV. Choose based on surgeon comfort level and specific case anatomy. DCWO theoretically superior but Weil more predictable ## MTP Arthrodesis **Indications**: Stage V end-stage with destroyed plantar cartilage and severe arthritis - no joint-preserving option **Joint Preparation**: - Remove remaining cartilage from MT head and phalanx base with saw, rongeur, curette to bleeding bone - Fish-scale or create flat surfaces for apposition - Due to MT head collapse, often significant bone loss - Bone graft frequently needed (local autograft from MT or iliac crest) **Positioning**: - Slight plantarflexion (5-10 degrees relative to adjacent lesser toes) so toe just touches ground - Neutral varus/valgus alignment - Neutral rotation - check against adjacent toes - Hold with K-wire provisionally - Check alignment clinically and fluoroscopically **Fixation Options**: *Crossed K-wires* (most common for lesser MTP): - Two 1.6mm K-wires crossed from phalanx into MT - Simple, effective, low-profile - Leave buried or protruding for removal - 6-8 weeks immobilization *Single screw*: - 2.5-3.0mm cannulated screw - From phalanx tip into MT - Compression across fusion site - More rigid than K-wires - Risk of hardware prominence *Mini plate*: - Dorsal or medial mini plate - If bone loss or comminution - Most rigid fixation - Higher profile, may require removal **Bone Grafting**: - Often needed due to AVN bone loss - Local autograft from metatarsal or calcaneus - Structural graft if large defect - Avoid collapse **Outcomes**: Reliable pain relief in 85-90%. Salvage procedure. Loses motion but lesser MTP motion less critical than hallux. Nonunion higher risk 5-10% due to AVN bone with poor healing potential ## Microfracture of Subchondral Bone **Indications**: Adjunct to any joint-preserving procedure after debridement of necrotic bone **Technique**: - Using small (1.0mm) drill or microfracture awl - Create multiple perforations 3-4mm apart in exposed subchondral bone - Depth 2-3mm only - Creates channels allowing marrow elements (stem cells, growth factors) to access defect - Stimulates fibrocartilage formation **Evidence**: Limited specific evidence in Freiberg's but widely used in cartilage lesions. Theoretical benefit from marrow access **Adjuncts**: Can add PRP or bone marrow aspirate but limited evidence **Cautions**: - Excessive depth causes subchondral insufficiency fracture - Too aggressive removes structural bone - Doesn't replace definitive procedure but may enhance healing --- ## Loose Body Removal **Always Required**: Remove ALL loose bodies, free fragments, and detached osteochondral pieces **Technique**: - Often multiple small fragments from fragmentation - Use rongeur or curette systematically - Check all recesses of joint - Copious irrigation to remove debris **Importance**: - Source of mechanical symptoms - Causes reactive synovitis - Prevents healing - Missing loose bodies causes persistent symptoms --- ## Synovectomy **Indications**: Significant synovitis common in chronic Freiberg's disease **Technique**: - Debride inflamed synovium to visualize joint - Remove hypertrophic tissue - Improves visualization for assessment - May improve symptoms independently **Benefits**: - Better exposure - Removes inflammatory tissue - Theoretical symptom improvement - Always perform if present ## Cheilectomy Protocol **Immediate (0-2 weeks)**: - Heel weight-bearing immediately in postop shoe - Soft dressing - Elevation and ice - Gentle ROM starting day 3-5 **Early (2-6 weeks)**: - Progressive forefoot weight-bearing 2-3 weeks - Continue ROM exercises - Transition to supportive shoe 6 weeks - No high heels **Return to Activity (6-12 weeks)**: - Regular shoes 6-8 weeks - Progressive activity - Activity modification long-term - Avoid excessive impact --- ## DCWO/Weil Protocol **Immediate (0-4 weeks)**: - Heel weight-bearing in postop shoe 3-4 weeks - Gentle ROM starts day 3-5 (prevents stiffness) - Elevation and ice - Buddy taping helpful **Early (4-8 weeks)**: - X-ray at 4 weeks to assess healing - Progressive forefoot weight-bearing 4-6 weeks based on X-ray - Continue buddy taping 6-8 weeks - Transition to supportive shoe 6-8 weeks **Return to Activity (8-12 weeks)**: - Regular shoes 8-10 weeks once healed - Progressive activity - Activity modification long-term - Avoid high heels 3-4 months --- ## MTP Fusion Protocol **Immediate (0-6 weeks)**: - Non-weight-bearing in CAM boot or rigid postop shoe - Strict immobilization - Elevation and ice - No motion at fusion site **Early (6-12 weeks)**: - X-ray at 6 weeks to assess union - If uniting: transition to weight-bearing in protective shoe 6-8 weeks - Continue CAM boot if delayed union - Repeat X-rays every 2-4 weeks **Return to Activity (12+ weeks)**: - Regular shoes 8-12 weeks once solid fusion confirmed - Progressive activity - Permanent loss of MTP motion (expected outcome) - Activity modification long-term --- ## Core Decompression Protocol **Immediate**: - Weight-bearing as tolerated immediately - Activity modification 6-8 weeks while revascularization occurs - Supportive shoe - Avoid high impact **Follow-up**: - Serial X-rays to monitor progression vs improvement - MRI at 6 months may show revascularization - If progression: convert to definitive procedure --- ## Universal Postoperative Care **All Procedures**: - Suture removal 10-14 days - Avoid high heels 3-4 months minimum - Long-term activity modification - Avoid excessive impact/repetitive loading of affected MT - Counsel: Freiberg's is AVN process, may progress despite surgery - Realistic expectations critical ### Step 1: Classification & Procedure Selection - CRITICAL Classification & Procedure Selection - CRITICAL: SMILLIE CLASSIFICATION determines treatment. Stage I (Fissure fracture, minimal changes) - Conservative Rx 3-6mo (activity modification, stiff shoe, NSAIDs), if fails: core decompression or cheilectomy. Stage II (Central collapse, flattening) - Cheilectomy, core decompression. Stage III (Central collapse with free fragment) - Dorsal closing wedge osteotomy (DCWO) OR Weil osteotomy. Stage IV (Flattening, plantar cartilage damage starting) - DCWO or Weil osteotomy. Stage V (End-stage, severe arthritis, plantar cartilage destroyed) - MTP joint fusion. Key: PLANTAR CARTILAGE quality determines success - if good, joint-preserving (cheilectomy, DCWO, Weil). If destroyed, fusion. MRI helpful assess cartilage quality and extent of AVN. **Technical Tip**: EXAM KEY: 'Freiberg's classification SMILLIE Stage I-V. Key decision: PLANTAR CARTILAGE quality. Stages I-II early: cheilectomy or core decompression. Stages III-IV established: DCWO (dorsal closing wedge) or Weil osteotomy - both work, DCWO more anatomic but technically demanding, Weil more predictable. Stage V end-stage: fusion only option. 2nd MT 68% cases, 3rd MT 27%. Adolescent females typical but any age possible.' - Wrong procedure for stage (trying to preserve joint in Stage V equals failure) - Not assessing plantar cartilage quality preoperatively with MRI - Missing bilateral disease (15-20% bilateral) - always examine contralateral foot ### Step 2: Incision & Superficial Dissection Incision & Superficial Dissection: Dorsal longitudinal incision 3-4cm over affected metatarsal head, centered in intermetatarsal space between EDL tendons. Sharp dissection through subcutaneous tissue. Identify and PROTECT dorsal digital nerve branches on medial and lateral borders of adjacent toes (3-5mm from midline). Nerves often more adherent due to chronic inflammation. Use vessel loops for gentle retraction. Develop plane between EDL tendons. **Technical Tip**: EXAM KEY: 'Dorsal approach identical to Weil osteotomy - between EDL tendons in interspace. I protect dorsal digital nerves 3-5mm from midline on toe borders. In Freiberg's patients, tissues often inflamed, adherent from chronic synovitis - extra care with dissection. Loupe magnification helpful for nerve identification.' - Dorsal digital nerve injury - permanent numbness, neuroma formation - Aggressive dissection through inflamed tissues - bleeding, difficulty visualizing anatomy - Inadequate exposure - cannot assess joint pathology properly ### Step 3: Capsulotomy & Joint Assessment Capsulotomy & Joint Assessment: Longitudinal dorsal capsulotomy over MTP joint. Extend with release of medial and lateral collateral ligaments from metatarsal head for mobility and visualization. Often significant synovitis - debride inflamed synovium. Hyperplantarflex toe to fully expose dorsal metatarsal head. CRITICAL ASSESSMENT: (1) Extent of dorsal collapse/fragmentation, (2) Presence and size of loose bodies or free fragments, (3) PLANTAR CARTILAGE QUALITY - examine plantarly, (4) Overall joint congruency, (5) Osteophyte formation. This assessment confirms stage and finalizes procedure choice. **Technical Tip**: EXAM KEY: 'After capsulotomy I assess: dorsal collapse extent, loose bodies common (remove), and CRITICAL: plantar cartilage quality. If plantar cartilage good (smooth, white, no fibrillation) - can preserve joint with cheilectomy, DCWO, or Weil. If plantar cartilage damaged (fibrillated, exposed bone) - fusion needed. Synovitis often impressive - debride to visualize.' - Inadequate assessment leading to wrong procedure choice and failure - Iatrogenic damage to remaining good plantar cartilage during retraction - Missing loose bodies - recurrent synovitis, persistent pain ### Step 4: Debridement & Loose Body Removal Debridement & Loose Body Removal: Remove ALL loose bodies, free fragments, and detached osteochondral pieces. Often multiple small fragments from fragmentation. Use rongeur or curette. Debride unstable cartilage from dorsal MT head to stable margins. Remove dorsal and marginal osteophytes with rongeur or saw. Copious irrigation to remove debris. Preserve plantar cartilage - gentle handling, no aggressive curettage plantarly. **Technical Tip**: EXAM KEY: 'I remove all loose bodies and free fragments - source of mechanical symptoms and synovitis. Debride unstable dorsal cartilage to stable edges. Remove dorsal osteophytes causing impingement. CRITICAL: PRESERVE plantar cartilage - it's the best remaining surface. No aggressive plantar curettage. Irrigation removes all debris preventing further inflammation.' - Damage to plantar cartilage - eliminates joint preservation option - Missing loose bodies - persistent symptoms and treatment failure - Excessive debridement - removes too much bone, destabilizes joint ### Step 5: Procedure-Specific Technique (Cheilectomy) Procedure-Specific Technique: CHEILECTOMY for early disease (Stages I-II) when minimal collapse. Remove dorsal 25-30% of metatarsal head including collapsed/avascular dorsal portion with oscillating saw. Cut in coronal plane removing dome of head. Smooth edges with rongeur. Goals: remove impinging dorsal bone, decompress joint, preserve plantar weight-bearing surface. Similar concept to hallux rigidus cheilectomy. Assess ROM improvement intraoperatively - should achieve pain-free arc. No fixation needed. **Technical Tip**: EXAM KEY: 'Cheilectomy for Stage I-II: remove dorsal 25-30% MT head including avascular portion. Removes impingement, decompresses joint. Preserves plantar 70% for weight-bearing. No fixation needed. Results good if appropriate staging - removes mechanical block, allows pain-free motion. Similar to hallux rigidus cheilectomy concept but lesser MT.' - Under-resection less than 25% - inadequate decompression, persistent symptoms - Over-resection greater than 40% - insufficient plantar surface, instability - Wrong stage selection (trying cheilectomy for Stage IV equals failure) ### Step 6: Procedure-Specific (DCWO) Procedure-Specific: DCWO (Dorsal Closing Wedge Osteotomy) - removes dorsal collapsed wedge of MT head, rotates intact plantar cartilage dorsally to articulate with phalanx. Mark wedge: apex plantar at junction of plantar and dorsal cartilage, base dorsal encompassing all collapsed avascular bone. Dorsal limb: coronal cut through collapsed area. Plantar limb: oblique cut from dorsal toward plantar apex, converging with first cut. Typically 3-5mm wedge height dorsally. Close wedge bringing plantar cartilage dorsal and distal - articulates with phalanx. Fix with 2.0-2.5mm screw from distal fragment proximally (perpendicular to osteotomy) or mini plate dorsal. **Technical Tip**: EXAM KEY: 'DCWO for Stage III-IV: remove dorsal collapsed wedge, rotate good plantar cartilage dorsally to articulate with phalanx. This is MOST ANATOMIC reconstruction - preserves MT length, maintains joint congruency. Technically demanding - need precise wedge planning. Wedge apex plantar at cartilage junction, base dorsal 3-5mm. Close wedge, fix with screw or plate. More complex than Weil but theoretically superior joint mechanics.' - Wedge too large - excessive shortening, changes biomechanics - Wedge too small - inadequate rotation, damaged cartilage still dorsal - Apex not at correct location - damages plantar cartilage - Instability if inadequate fixation - Nonunion (rare with good bone contact) ### Step 7: Procedure-Specific (Weil Osteotomy) Procedure-Specific: WEIL OSTEOTOMY alternative to DCWO for Stages III-IV. Oblique osteotomy through metatarsal neck parallel to weight-bearing surface (same technique as Weil for metatarsalgia). Start 2-3mm distal to cartilage dorsally, cut proximal-plantar. Translate capital fragment proximally 3-4mm. This shortens MT, decompresses joint, unloads damaged dorsal portion. Healthy plantar cartilage remains weight-bearing. Fix with 2.0-2.5mm headless screw perpendicular to osteotomy. ADVANTAGE over DCWO: more predictable, simpler technique, less technically demanding. DISADVANTAGE: shortening vs DCWO length preservation. **Technical Tip**: EXAM KEY: 'Weil for Freiberg Stage III-IV is ALTERNATIVE to DCWO. Same technique as Weil for metatarsalgia: parallel to weight-bearing surface, start 2-3mm distal to cartilage, proximal translation 3-4mm. Decompresses joint, unloads damaged dorsal portion. SIMPLER than DCWO, more predictable, familiar technique. Trade-off: MT shortening (may transfer load to adjacent MTs) vs DCWO length preservation. Both work - choose based on comfort level and specific case.' - Excessive shortening greater than 6mm - floating toe, transfer metatarsalgia - Same technical risks as Weil: dorsiflexion malunion, stiffness - Starting too proximal - damages remaining cartilage ### Step 8: Procedure-Specific (Core Decompression) Procedure-Specific: CORE DECOMPRESSION for very early disease (Stage I-II) attempting to improve vascularity and prevent progression. Using 2.0-3.0mm drill, create multiple drill holes (3-5) from dorsal MT head into neck/diaphysis. Drill perpendicular to dorsal surface, depth 15-20mm. Avoid plantar cortex perforation. Creates channels for revascularization. Can combine with bone marrow aspirate injection (emerging technique). May combine with cheilectomy if dorsal osteophytes present. NO fixation needed. THEORY: Decompression reduces intraosseous pressure, improves vascularity. EVIDENCE: Limited, anecdotal success in very early stages. Consider in young patients Stage I-II. **Technical Tip**: EXAM KEY: 'Core decompression for EARLY Freiberg Stage I-II in young patients attempting to improve vascularity and prevent progression. Multiple drill holes (3-5) dorsal MT head into diaphysis, 2.0-3.0mm drill, depth 15-20mm. Creates revascularization channels, reduces intraosseous pressure. Can add bone marrow aspirate. LIMITED evidence but low morbidity. Some success in very early stages. More definitive procedures (cheilectomy, DCWO, Weil) for later stages.' - Inadequate for established disease (Stage III and beyond) - will fail - Plantar cortex perforation - plantar pain - False expectations - not curative, may still progress - Drill too far - exits bone unintentionally, neurovascular risk ### Step 9: Procedure-Specific (MTP Fusion) Procedure-Specific: MTP FUSION for Stage V end-stage with destroyed plantar cartilage and severe arthritis. Prepare joint: remove remaining cartilage from MT head and phalanx base with saw, rongeur, curette to bleeding bone. Due to MT head collapse, may have significant bone loss - may need bone graft (local autograft from MT or iliac crest). Position: slight plantarflexion (5-10 degrees relative to adjacent lesser toes), neutral varus/valgus, neutral rotation. Hold with K-wire provisionally. Fix: options include (1) crossed K-wires, (2) single screw, (3) mini plate. Crossed K-wires most common for lesser MTP - simple, effective. Immobilize postoperatively. **Technical Tip**: EXAM KEY: 'MTP fusion for Freiberg Stage V end-stage - plantar cartilage destroyed, severe arthritis, no joint-preserving option. Remove all cartilage to bleeding bone. Often bone loss from collapse - bone graft frequently needed. Position slight plantarflexion 5-10 degrees so toe just touches ground, neutral otherwise. Fix with crossed K-wires (most common lesser MTP), screw, or mini plate. Salvage procedure but reliable pain relief. Loses motion but lesser MTP motion less critical than hallux.' - Malposition - toe does not touch ground (excessive plantarflexion or dorsiflexion) - Nonunion - higher risk in AVN bone, inadequate fixation - Bone graft collapse if large defect - Hardware prominence requiring removal - Stiffness (intended outcome but counsel patient) ### Step 10: Microfracture of Subchondral Bone (Adjunct) Microfracture of Subchondral Bone (Adjunct): After debridement of necrotic bone, MICROFRACTURE of exposed subchondral bone may enhance healing. Using small (1.0mm) drill or microfracture awl, create multiple perforations 3-4mm apart in exposed subchondral bone. Depth 2-3mm. This creates channels allowing marrow elements (stem cells, growth factors) to access defect, stimulating fibrocartilage formation. Adjunct to cheilectomy, DCWO, or Weil. Biologics (PRP, bone marrow aspirate) can be added but limited evidence in Freiberg's. **Technical Tip**: EXAM KEY: 'Microfracture adjunct after debridement: small perforations (1.0mm drill or awl) in exposed subchondral bone, 3-4mm spacing, depth 2-3mm. Stimulates fibrocartilage formation by allowing marrow elements access. Simple adjunct, low morbidity, theoretical benefit. Can add PRP or bone marrow aspirate. Limited specific evidence in Freiberg's but widely used in cartilage lesions. Doesn't replace definitive procedure but may enhance healing.' - Excessive depth - subchondral insufficiency fracture - Too aggressive - removes structural bone, weakens subchondral plate - Over-reliance on microfracture without addressing mechanical pathology ### Step 11: Capsular Closure Capsular Closure: Close dorsal capsule with absorbable sutures (3-0 Vicryl). If dorsal capsule lax, can reef (imbricate) to provide dorsal restraint preventing dorsal subluxation. Avoid overtightening limiting plantarflexion. EDL tendon repositioned anatomically. Repair collateral ligaments if significantly disrupted. Gentle closure - inflamed tissues from chronic Freiberg's can be friable. **Technical Tip**: EXAM KEY: 'Capsular closure with balanced tension. Can reef dorsally if lax but avoid overtightening - want full plantarflexion ROM for lesser toes. Tissues often inflamed, thickened from chronic disease - handle gently. If fusion performed, capsule provides additional stability around construct.' - Overtight closure - stiffness, limited plantarflexion - Inadequate closure - instability (rare in lesser MTP) - Tissue tear from friable inflamed capsule ### Step 12: Wound Closure & Dressing Wound Closure & Dressing: Subcutaneous layer with fine absorbable sutures (4-0 Vicryl). Skin: subcuticular absorbable (4-0 Monocryl) or interrupted non-absorbable (5-0 nylon) for thin dorsal skin. Steri-strips for support. Soft dressing with gauze between toes if needed for alignment. Compression wrap (not tight). Postop shoe - stiff-soled for DCWO/Weil/cheilectomy. If fusion: rigid postop shoe or CAM boot with toe immobilization. **Technical Tip**: EXAM KEY: 'Meticulous closure - dorsal MTP skin thin and prone to complications. Subcuticular for cosmesis. Soft dressing for joint-preserving procedures (DCWO, Weil, cheilectomy) allowing early gentle motion. If fusion: rigid immobilization in postop shoe or CAM boot until union confirmed (6-8 weeks). Toe protection critical for fusion healing.' - Wound dehiscence (3-5% risk) - Skin necrosis from tension or AVN-compromised vascularity - Inadequate immobilization if fusion - nonunion risk ### Step 13: Fluoroscopic Confirmation Perform intraoperative imaging/fluoroscopy to confirm adequate position and alignment: For osteotomies (DCWO, Weil), confirm cut position, fragment translation, fixation placement. For fusion, confirm joint apposition, alignment, fixation position. AP and lateral views of foot. Oblique may help visualize screw trajectory. Document images. **Technical Tip**: EXAM KEY: 'Fluoroscopy essential for osteotomies and fusion. For DCWO: confirm wedge closure, plantar cartilage rotated dorsal, screw perpendicular to osteotomy. For Weil: parallel cut to weight-bearing surface, 3-4mm translation, no dorsiflexion malunion. For fusion: check alignment in all planes, adequate apposition. Documentation of intraoperative findings crucial for Freiberg's Disease.' - Radiation exposure - minimize with proper technique - Inadequate imaging - miss malposition - Not recognizing malposition intraoperatively - difficult revision ### Step 14: Irrigation and Hemostasis Irrigate wound thoroughly and achieve meticulous hemostasis: Copious irrigation (500mL minimum) removes debris, loose fragments, bone dust. Check for any remaining loose bodies. Achieve hemostasis with bipolar cautery. Inflate tourniquet before closure to identify bleeding. Deflate tourniquet, check for bleeding points. Reinflate for closure. **Technical Tip**: EXAM KEY: 'Copious irrigation reduces infection risk. Check systematically for any missed loose bodies causing persistent symptoms. Bipolar for hemostasis near neurovascular structures. Tourniquet technique: inflate during closure for clean field, but check with deflated to identify arterial bleeders. Meticulous hemostasis prevents hematoma.' - Hematoma formation - delays healing, infection risk - Wound complications from inadequate hemostasis - Retained loose bodies - persistent symptoms ### Step 15: Postoperative Protocol Implementation Postoperative Protocol - PROCEDURE-SPECIFIC: CHEILECTOMY: Heel WB immediately in postop shoe. Gentle ROM starting 3-5 days. Progressive forefoot WB 2-3 weeks. Regular shoes 6-8 weeks. DCWO/WEIL: Heel WB in postop shoe 3-4 weeks. Gentle ROM starts 3-5 days. Progressive forefoot WB 4-6 weeks based on X-ray healing. Regular shoes 6-8 weeks. Buddy taping 6-8 weeks helpful. FUSION: NWB in CAM boot or rigid shoe 6 weeks. X-ray at 6 weeks - if uniting, transition to WB in shoe 6-8 weeks. Regular shoes 8-12 weeks once solid fusion. CORE DECOMPRESSION: WB as tolerated immediately, activity modification 6-8 weeks while revascularization occurs. All: Sutures 10-14 days. Avoid high heels 3-4 months. Long-term: Activity modification, avoid excessive impact/repetitive loading of affected MT. **Technical Tip**: EXAM KEY: 'Protocol varies by procedure: CHEILECTOMY earliest return (6-8 weeks shoes, early ROM). DCWO/WEIL intermediate (6-8 weeks shoes, protected initially). FUSION longest (8-12 weeks shoes, NWB 6 weeks). Early gentle ROM for joint-preserving procedures prevents stiffness. Fusion requires rigid immobilization. All need activity modification long-term - Freiberg's is AVN process, avoid excessive loading.' - Early excessive WB - hardware failure, loss of correction - Immobilizing joint-preserving procedures - stiffness - Inadequate immobilization of fusion - nonunion - Return to high-impact sports too early - recurrence ## References 1. Smillie IS. Treatment of Freiberg's infraction. Proc R Soc Med. 1967;60(1):29-31. Classic description of classification system that remains standard for surgical decision-making. 2. Kinnard P, Lirette R. Freiberg's disease and dorsiflexion osteotomy. J Bone Joint Surg Br. 1991;73(6):864-865. Describes dorsal closing wedge osteotomy technique and outcomes. 3. Chao KH, Lee CH, Lin LC. Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years. Acta Orthop Scand. 1999;70(5):483-486. Demonstrates DCWO effectiveness for Stage III-IV disease. 4. Capar B, Kutluay E, Mujde S, Bulut M. Weil osteotomy for the treatment of Freiberg's disease. J Orthop Surg (Hong Kong). 2007;15(3):267-271. Supports Weil as effective alternative to DCWO with simpler technique. 5. Ikoma K, Maki M, Kido M, et al. Stage assessment and treatment of Freiberg disease by multimodal imaging and arthroscopy. J Foot Ankle Surg. 2014;53(5):591-595. Modern imaging assessment including MRI for plantar cartilage quality. 6. Lui TH. Arthroscopic debridement of Freiberg's disease. Knee Surg Sports Traumatol Arthrosc. 2012;20(7):1379-1382. Describes arthroscopic technique as minimally invasive option. 7. Miyamoto W, Takao M, Uchio Y, Kono T, Ochi M. Late stage Freiberg disease treated by osteochondral autograft transplantation: a case series. Foot Ankle Int. 2008;29(9):950-955. Describes osteochondral grafting for advanced disease. 8. Hayashi K, Ochi M, Uchio Y, et al. Long-term results of surgical treatment for Freiberg disease. J Orthop Sci. 2002;7(5):490-494. Long-term outcomes data for various surgical procedures. 9. Blitz NM, Yu JH. Freiberg's infraction in identical twins: a case report. J Foot Ankle Surg. 2005;44(3):218-221. Supports genetic component and bilateral occurrence patterns. 10. Smith TW, Stanley D, Rowley DI. Treatment of Freiberg's disease. A new operative technique. J Bone Joint Surg Br. 1991;73(1):129-130. Alternative surgical techniques and comparative outcomes for Stage III-IV disease.

Freiberg's Disease Surgical Management (Infraction of Lesser Metatarsal Head)

Freiberg's Disease Surgical Management (Infraction of Lesser Metatarsal Head)