High Yield Overview

FREIBERG'S DISEASE SURGICAL MANAGEMENT (INFRACTION OF LESSER METATARSAL HEAD)

Dorsal longitudinal approach over affected metatarsal head in intermetatarsal space (similar to Weil osteotomy approach) | advanced

Critical Danger Structures

Danger 1: Dorsal Digital Nerves

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

Danger 2: Plantar Digital Neurovascular Bundles

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

Danger 3: Plantar Articular Cartilage

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

Danger 4: Metatarsal Head Blood Supply

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

Danger 5: Adjacent Metatarsal Heads

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

Mnemonic

SCENTSMILLIE Classification

Memory Hook:Plantar cartilage quality determines transition from joint-preserving to fusion - assess intraoperatively

Mnemonic

SPLATDCWO vs Weil Decision Making

Memory Hook:Both procedures work for Stage III-IV - choice based on surgeon experience and patient anatomy

Positioning and Preparation

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

Operative Technique - Comprehensive Steps

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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.

Exam Pearl

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.'

Dangers at this step

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

Complications - Recognition and Management

Complication Management

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 16-year-old female presents with 9 months of second metatarsal pain. X-rays show flattening of the metatarsal head with some sclerosis but plantar cartilage appears intact on MRI. What is your diagnosis and management approach?"

EXCEPTIONAL ANSWER

This is Freiberg's disease, avascular necrosis of the second metatarsal head. Based on description this sounds like Smillie Stage II (central collapse and flattening with sclerosis). At 16 years old with 9 months of symptoms, she has likely failed initial conservative treatment (activity modification, stiff-soled shoes, NSAIDs). For Stage II with good plantar cartilage on MRI, I would offer surgical treatment with either cheilectomy or core decompression. I prefer cheilectomy - removal of dorsal 25-30% of metatarsal head including the collapsed avascular portion. This removes the mechanical impingement, decompresses the joint, while preserving the plantar 70% weight-bearing surface. Similar concept to hallux rigidus cheilectomy. Core decompression is alternative - drilling multiple holes to improve vascularity, but limited evidence. I would counsel regarding prognosis - cheilectomy has good results in appropriate staging but Freiberg's can progress, may need more aggressive surgery in future if AVN continues. Bilateral disease occurs in 15-20% so I examine the contralateral foot.

VIVA SCENARIOStandard

EXAMINER

"You are performing a dorsal closing wedge osteotomy (DCWO) for Freiberg's disease Stage III. Describe your technique and the key technical points that determine success."

EXCEPTIONAL ANSWER

DCWO removes collapsed dorsal wedge and rotates intact plantar cartilage dorsally to articulate with phalanx. After dorsal capsulotomy and joint assessment confirming good plantar cartilage, I mark the wedge carefully. Apex is plantar at the junction of plantar and dorsal cartilage - this is CRITICAL as the apex must preserve plantar cartilage. Base is dorsal encompassing all collapsed avascular bone, typically 3-5mm wedge height dorsally. Using oscillating saw, I make the dorsal limb as a coronal cut through the collapsed area. Then plantar limb is an oblique cut from dorsal converging toward the plantar apex. Remove the necrotic wedge. Close the wedge bringing plantar cartilage dorsal and distal - this rotates healthy cartilage into the weight-bearing articulation with phalanx. Provisional K-wire fixation to check position, then definitive fixation with 2.0-2.5mm screw from distal fragment proximally perpendicular to osteotomy, or dorsal mini plate if unstable. Fluoroscopy confirms wedge closure, plantar cartilage rotated dorsal, hardware position. This is most anatomic reconstruction - preserves MT length so no transfer metatarsalgia risk, maintains joint congruency. Trade-off is technically demanding - requires precise planning and execution.

VIVA SCENARIOStandard

EXAMINER

"A 45-year-old presents with chronic third metatarsal pain from Freiberg's disease. Intraoperatively you find Stage V disease with complete destruction of plantar cartilage. What is your management and how do you technically perform MTP arthrodesis?"

EXCEPTIONAL ANSWER

Stage V Freiberg's with destroyed plantar cartilage has no joint-preserving option - MTP fusion is the treatment. I counsel the patient preoperatively that fusion sacrifices motion but provides reliable pain relief, and lesser MTP motion is less critical than hallux. For the fusion technique, after capsulotomy I remove all remaining cartilage from MT head and phalanx base with saw, rongeur, curette down to bleeding bone. Fish-scale or create flat surfaces for apposition. In Freiberg's there is often significant bone loss from MT head collapse, so I frequently need bone graft - local autograft from metatarsal or calcaneus, or iliac crest if large defect. Positioning is critical: slight plantarflexion 5-10 degrees relative to adjacent lesser toes so toe just touches ground, neutral varus/valgus, neutral rotation checked against adjacent toes. Provisional K-wire fixation and check alignment clinically and fluoroscopically. For fixation I typically use crossed 1.6mm K-wires from phalanx into MT - simple, effective, low-profile for lesser MTP. Alternatives are single screw or dorsal mini plate if comminution. Postoperatively non-weight-bearing 6 weeks in CAM boot, X-ray at 6 weeks, progress to weight-bearing 6-8 weeks if uniting. Nonunion risk 5-10% due to AVN bone with poor healing - bone graft and adequate fixation critical.

Freiberg's Disease Surgical Management - Exam Summary

High-Yield Exam Summary

References

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.
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.
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.
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.
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.
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.
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.
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.
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.
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)