Osteonecrosis/infraction of a lesser metatarsal head · Smillie I–V · plantar cartilage quality drives the operation · advanced
- Freiberg's disease is osteonecrosis/osteochondrosis of a lesser metatarsal head — 2nd MT most common (around 68 percent), then 3rd MT (around 27 percent); classically adolescent females but a large share present in adulthood, and it is a rare condition (population incidence about 1 in 2800 livebirths).
- Smillie Stage I to V determines treatment: I to II early disease (core decompression or cheilectomy), III to IV established disease (dorsal closing wedge osteotomy or Weil osteotomy), V end-stage disease (MTP fusion).
- Plantar cartilage quality is the critical decision point — if good (smooth, white) joint preservation is possible; if damaged (fibrillated, eburnated, exposed bone) fusion is needed. Confirm with preoperative MRI and again intra-operatively.
- The dorsal closing wedge osteotomy (DCWO) removes the collapsed dorsal wedge and rotates the good plantar cartilage dorsally to articulate with the phalanx — the most anatomic option, with only modest shortening (around 2 to 3 mm) so transfer metatarsalgia is uncommon, but technically demanding.
- Failed conservative treatment (activity modification, a stiff-soled shoe, NSAIDs for 3 to 6 months) is a prerequisite for surgery. Bilateral disease occurs in 15 to 20 percent, so always examine the contralateral foot.
When & Why
Indication. Symptomatic Freiberg's disease (avascular necrosis/infraction of a lesser metatarsal head) — activity-related forefoot pain over the affected metatarsal head, often with a stiff, enlarged MTP joint and a positive joint-loading sign — that has failed conservative treatment (activity modification, a stiff-soled shoe, NSAIDs for 3 to 6 months, and where appropriate a corticosteroid injection). The 2nd metatarsal is involved in around 68 percent of cases, the 3rd in around 27 percent, and rarely the 4th; bilateral disease occurs in 15 to 20 percent, so examine the contralateral foot. Two decisions drive the whole operation. Before incising, settle both: 1. The Smillie stage (radiographic, confirmed intra-operatively) — sets which family of procedure applies. 2. The plantar cartilage quality — assess on preoperative MRI, then confirm directly at arthrotomy. This is the single most important determinant of whether the joint can be preserved or must be fused. The stage maps to three procedure families, and the plantar cartilage quality then confirms whether preservation is possible within that family:
Minimal or early collapse. Joint-preserving, low-morbidity: cheilectomy (remove the dorsal 25 to 30 percent) or core decompression in the young. Good plantar cartilage is expected.
Collapse with a free fragment, plantar cartilage still usable. Dorsal closing wedge osteotomy (DCWO) — most anatomic, preserves length — or Weil osteotomy — simpler, predictable, shortens the ray.
Plantar cartilage destroyed, severe arthritis. No joint-preserving option remains: MTP arthrodesis is the salvage, sacrificing motion for reliable pain relief.
The one rule that determines success. Plantar cartilage quality is the pivot between joint-preserving surgery (cheilectomy, core decompression, DCWO, Weil) and fusion. If the plantar cartilage is good, preserve the joint; if it is destroyed, fuse. Choosing to preserve a joint in Stage V — or fusing a joint with excellent plantar cartilage — is the classic cause of failure. Consent specifically for toe numbness or a painful neuroma (dorsal digital nerve), wound problems on thin dorsal skin, stiffness, possible transfer metatarsalgia (after a Weil), non-union (after fusion, higher in AVN bone), and the realistic expectation that Freiberg's is an AVN process that may progress despite surgery. Setup. Supine with the foot at the end of the table (or a small bump under the ipsilateral hip to neutralise rotation), ankle block or general anaesthesia, and an ankle or thigh tourniquet at 250 mmHg. Loupe magnification is strongly recommended — the dorsal digital nerves lie only 3 to 5 mm from the midline and are often adherent in chronically inflamed tissue. Fluoroscopy must be available throughout.
The Operation
The goal is to expose the metatarsophalangeal joint through a dorsal intermetatarsal approach (identical in concept to the Weil osteotomy exposure), confirm the stage and the plantar cartilage quality, remove all loose bodies and necrotic bone, and then perform the stage-appropriate procedure — preserving the joint where the plantar cartilage is good, or fusing when it is destroyed — while protecting the dorsal digital nerves, the plantar neurovascular bundles and the remaining plantar cartilage.
Operative sequence
- Supine, foot at the end of the table or a small bump under the ipsilateral hip; ankle block or general anaesthesia; ankle or thigh tourniquet at 250 mmHg.
- Confirm the affected ray and the planned procedure from the Smillie stage and the preoperative MRI (cartilage quality and extent of necrosis).
- Equipment: small-fragment set with 2.0 to 2.5 mm screws or mini-plates, an oscillating saw with a fine blade, rongeurs and small curettes, K-wires for provisional fixation, and fluoroscopy for every osteotomy and fusion.
- The Smillie stage sets the family of procedure (see the table above): I to II — cheilectomy or core decompression; III to IV — DCWO or Weil osteotomy; V — MTP fusion.
- Re-confirm plantar cartilage quality directly once the joint is open (Step 5) — good cartilage means preserve; destroyed cartilage means fuse. The plan is finalised intra-operatively, not on the skin mark.
- A dorsal longitudinal incision, 3 to 4 cm, centred in the intermetatarsal space directly over the affected metatarsal head, between the extensor digitorum longus (EDL) tendons — the same exposure used for a Weil osteotomy.
- Centring it in the interspace (not directly over the tendon) keeps you between the dorsal digital nerves of the adjacent toes and allows access to both the metatarsal head and the phalanx base.
- Sharp dissection through subcutaneous tissue; identify and protect the dorsal digital nerve branches that run 3 to 5 mm from the midline on the medial and lateral borders of the adjacent toes.
- These nerves are often more adherent than usual because of chronic synovitis — use loupe magnification and vessel loops for gentle retraction, and develop the plane between the EDL tendons.
- The plantar digital neurovascular bundles lie 8 to 10 mm plantar to the metatarsal head; staying dorsal to the plantar plate and avoiding plantar dissection beyond the capsule protects them.
- A longitudinal dorsal capsulotomy over the MTP joint, extended by releasing the medial and lateral collateral ligaments from the metatarsal head for mobility and visualisation.
- Debride the often-impressive synovitis to see the joint, then hyperplantarflex the toe to bring the dorsal metatarsal head fully into view.
- Critical assessment, in order: (1) extent of dorsal collapse/fragmentation; (2) presence and size of loose bodies or free fragments; (3) plantar cartilage quality — examine the plantar surface directly; (4) overall joint congruency; (5) osteophyte formation. This assessment confirms the stage and finalises the procedure choice.
- Remove all loose bodies, free fragments and detached osteochondral pieces with a rongeur or curette — they are the source of mechanical symptoms and reactive synovitis.
- Debride unstable dorsal cartilage back to stable margins and remove dorsal and marginal osteophytes with a rongeur or saw. Copiously irrigate to clear debris.
- Preserve the plantar cartilage — gentle handling only, no aggressive plantar curettage; it is the best remaining surface and its quality governs whether preservation is possible.
- Adjunct — microfracture: after debridement of necrotic bone, multiple small perforations (a 1.0 mm drill or microfracture awl, 3 to 4 mm apart, 2 to 3 mm deep) in exposed subchondral bone stimulate fibrocartilage and may enhance healing. PRP or bone-marrow aspirate can be added; specific evidence in Freiberg's is limited.
- Indicated when collapse is minimal and conservative measures have failed.
- Remove the dorsal 25 to 30 percent of the metatarsal head — including the collapsed/avascular dorsal portion — with the oscillating saw, cutting in the coronal plane to take off the dome of the head; smooth the edges with a rongeur.
- Goal: remove the impinging dorsal bone, decompress the joint, and preserve the plantar 70 percent for weight-bearing. Assess range of motion intra-operatively — aim for a pain-free arc. No fixation is needed.
- An option in young patients with very early disease, attempting to improve vascularity and prevent progression.
- With a 2.0 to 3.0 mm drill, create 3 to 5 drill holes from the dorsal metatarsal head into the neck/diaphysis, perpendicular to the dorsal surface, depth 15 to 20 mm, avoiding plantar cortex perforation.
- Theory: decompression reduces intraosseous pressure and creates channels for revascularisation; may be combined with bone-marrow aspirate and with cheilectomy if dorsal osteophytes are present. No fixation. Evidence is limited and it is not curative — it is inadequate for established disease (Stage III and beyond).
- Indicated when the plantar cartilage is good. The principle: remove the collapsed dorsal wedge and rotate the intact plantar cartilage dorsally and distally so it articulates with the phalanx.
- Wedge planning: apex plantar, at the junction of plantar and dorsal cartilage (this preserves the plantar cartilage — the critical technical point); base dorsal, encompassing all the collapsed avascular bone; typically 3 to 5 mm of dorsal wedge height.
- Execution: dorsal limb is a coronal cut through the collapsed area with the saw; the plantar limb is an oblique cut from dorsal converging toward the plantar apex. Remove the necrotic wedge, then close the wedge, bringing the plantar cartilage dorsal and distal.
- Fixation: provisional K-wire to check position, then a 2.0 to 2.5 mm screw from the distal fragment proximally perpendicular to the osteotomy (most common), or a dorsal mini-plate if comminuted or unstable.
- Most anatomic reconstruction — preserves metatarsal length so transfer metatarsalgia is uncommon — but technically demanding, with a learning curve and longer operative time.
- The simpler, more predictable alternative to DCWO; choose by surgeon familiarity and the specific anatomy.
- An oblique osteotomy through the metatarsal neck, parallel to the weight-bearing surface (the same technique as a Weil for metatarsalgia): start 2 to 3 mm distal to the dorsal cartilage and cut proximal-plantar, then translate the capital fragment proximally 3 to 4 mm.
- This shortens the metatarsal, decompresses the joint and unloads the damaged dorsal portion, leaving healthy plantar cartilage weight-bearing. Fix with a 2.0 to 2.5 mm headless screw perpendicular to the osteotomy.
- Trade-off versus DCWO: simpler, more predictable and familiar, but it shortens the ray (potential transfer metatarsalgia and a floating toe if excessive — limit translation to 3 to 4 mm).
- Indicated when the plantar cartilage is destroyed — no joint-preserving option remains. Counsel that motion is sacrificed for reliable pain relief; lesser MTP motion is less critical than at the hallux.
- Joint preparation: remove all remaining cartilage from the metatarsal head and phalanx base with saw, rongeur and curette down to bleeding bone; fish-scale or create flat surfaces for apposition. Metatarsal-head collapse often leaves significant bone loss — bone graft is frequently needed (local autograft from the metatarsal or calcaneus, or iliac crest for a larger defect).
- Position: slight plantarflexion of 5 to 10 degrees relative to the adjacent lesser toes so the toe just touches the ground, with neutral varus/valgus and neutral rotation checked against the adjacent toes. Hold with a provisional K-wire and confirm alignment clinically and fluoroscopically.
- Fixation (in order of common use): crossed 1.6 mm K-wires from phalanx into metatarsal (simple, effective, low-profile — most common for a lesser MTP); a single 2.5 to 3.0 mm cannulated screw from the phalanx into the metatarsal (more rigid, risk of hardware prominence); or a dorsal/medial mini-plate for bone loss or comminution (most rigid, higher profile).
- Close the dorsal capsule with absorbable sutures (3-0 Vicryl). If the capsule is lax, reef (imbricate) dorsally to provide a dorsal restraint against subluxation, but avoid overtightening — full plantarflexion range should be preserved for lesser-toe function.
- Reposition the EDL tendon anatomically and repair significantly disrupted collateral ligaments. Handle gently — the chronically inflamed capsule of Freiberg's is friable.
- Fluoroscopy (before closure): for DCWO confirm wedge closure, plantar cartilage rotated dorsal, and screw perpendicular to the osteotomy; for Weil confirm a cut parallel to the weight-bearing surface with 3 to 4 mm translation and no dorsiflexion malunion; for fusion confirm apposition and alignment in all planes. AP, lateral and oblique views; document the images.
- Irrigation & haemostasis: copious irrigation (500 mL minimum) to remove debris and bone dust, and a final check for retained loose bodies; meticulous bipolar haemostasis. Deflate the tourniquet to identify bleeding points, then achieve haemostasis before closure.
- Closure: subcutaneous layer with fine absorbable sutures (4-0 Vicryl); skin with a subcuticular absorbable (4-0 Monocryl) or interrupted 5-0 nylon for thin dorsal skin, plus Steri-strips.
- Dressing: soft dressing with gauze between toes for alignment and a compression wrap (not tight). A stiff-soled postoperative shoe for joint-preserving procedures (cheilectomy, DCWO, Weil); a rigid postoperative shoe or CAM boot with toe immobilisation for fusion.
The dorsal digital nerves lie only 3 to 5 mm from the midline incision on the toe borders and are often bound down by chronic synovitis; identify them early under loupe magnification and retract gently on vessel loops — a transected nerve means permanent numbness or a painful neuroma (the commonest litigated complication). The plantar articular cartilage (the plantar 50 to 70 percent of the head) is the best remaining surface in this AVN process: gentle handling only, no aggressive plantar curettage, and never resect it — its quality is what decides whether the joint can be preserved at all.
In the dorsal closing wedge osteotomy the wedge apex must sit exactly at the junction of plantar and dorsal cartilage. Place it too plantar and you notch the good cartilage you are trying to save; place it too dorsal and the damaged cartilage stays in the articulation after you close the wedge. Mark it before any cut, preserve the plantar cartilage at the apex, and check rotation of healthy cartilage dorsal with fluoroscopy.
Trying a joint-preserving procedure when the plantar cartilage is destroyed will fail. Confirm cartilage quality directly at arthrotomy, not only on imaging — and if it is gone, fuse. The reverse error (fusing a joint with excellent plantar cartilage) forfeits motion that could have been saved.
Aftercare & Complications
Rehabilitation — protocol is procedure-specific | Procedure | Immobilisation & weight-bearing | Rehabilitation | Return to shoes | |------------|--------------------------------|----------------|-----------------| | Cheilectomy | Heel weight-bearing immediately in a postoperative shoe; gentle ROM from day 3 to 5 | Progressive forefoot weight-bearing at 2 to 3 weeks | 6 to 8 weeks (earliest return) | | DCWO / Weil | Heel weight-bearing in a postoperative shoe for 3 to 4 weeks; gentle ROM from day 3 to 5; buddy-tape 6 to 8 weeks | X-ray at 4 weeks; progressive forefoot weight-bearing 4 to 6 weeks based on healing | 6 to 8 weeks | | MTP fusion | Non-weight-bearing in a CAM boot or rigid shoe for 6 weeks; no motion at the fusion site | X-ray at 6 weeks; weight-bearing in a shoe at 6 to 8 weeks if uniting; repeat films every 2 to 4 weeks if delayed | 8 to 12 weeks once solid fusion is confirmed | | Core decompression | Weight-bearing as tolerated immediately; activity modification for 6 to 8 weeks while revascularisation occurs | Serial X-rays to monitor progression versus improvement; MRI at 6 months may show revascularisation | As tolerated | Universal for all procedures: suture removal at 10 to 14 days; avoid high heels for 3 to 4 months; long-term activity modification with avoidance of excessive impact or repetitive loading of the affected metatarsal; and counsel the patient that Freiberg's is an AVN process that may progress despite surgery, so realistic expectations are essential. Early gentle range of motion is critical for the joint-preserving procedures (it prevents stiffness); rigid immobilisation until union is critical for fusion (it prevents non-union). Complications
- Recognition
- Persistent forefoot pain, radiographic progression, joint-space narrowing
- Prevention
- Right procedure for the stage; activity-modification counselling; realistic expectations
- Management
- Conservative trial (orthotics, NSAIDs); if it fails, escalate to a more definitive procedure (failed cheilectomy to DCWO/Weil or fusion)
- Recognition
- Limited MTP dorsiflexion and plantarflexion, difficulty with push-off
- Prevention
- Early gentle ROM from day 3 to 5 for non-fusion procedures; avoid prolonged immobilisation
- Management
- Aggressive therapy and passive ROM; manipulation under anaesthesia if severe and within 12 weeks; accept some stiffness as expected
- Recognition
- Pain under adjacent metatarsal heads, plantar calluses, altered gait
- Prevention
- Limit Weil translation to 3 to 4 mm; assess adjacent metatarsals preoperatively
- Management
- Orthotics with a metatarsal pad and offloading; an adjacent Weil osteotomy if severe
- Recognition
- Persistent pain, motion at the site, a radiolucent line, hardware failure
- Prevention
- Adequate fixation; bone graft for any defect; smoking cessation and diabetic control; appropriate immobilisation
- Management
- Observe if asymptomatic; revise with bone graft and improved fixation if symptomatic
- Recognition
- The toe does not contact the ground; may catch on shoes
- Prevention
- Limit shortening to 3 to 4 mm; check toe position intra-operatively; avoid excessive dorsiflexion
- Management
- Observe if asymptomatic (most); taping and exercises; flexor-to-extensor transfer if severe and symptomatic
- Recognition
- Numbness along the toe borders, burning dysaesthesia, a tender Tinel at the scar
- Prevention
- Identify nerves early under loupes; vessel-loop retraction; stay midline in the interspace
- Management
- Most resolve or compensate; desensitisation therapy; excision and burial of a permanent painful neuroma
- Recognition
- Dehiscence, delayed healing, infection, skin necrosis
- Prevention
- Gentle tissue handling (AVN patients have compromised vascularity); meticulous low-tension closure; smoking cessation
- Management
- Local wound care; antibiotics if infected; surgical debridement for necrosis; healing by secondary intention or re-closure
Viva & Exam Focus
SCENTSMILLIE classification — stage to treatment
SPLATDCWO versus Weil — how to choose for Stage III to IV
- Location
- 3 to 5 mm from the midline on the medial and lateral toe borders
- How to protect it
- Identify early under loupes; vessel-loop retraction; stay midline; beware adhesions in chronic synovitis
- Location
- 8 to 10 mm plantar to the metatarsal head
- How to protect it
- Avoid plantar dissection beyond the capsule; stay dorsal to the plantar plate
- Location
- Plantar 50 to 70 percent of the metatarsal head — the best remaining surface
- How to protect it
- Gentle handling only; no aggressive plantar curettage; its quality determines whether preservation is possible
- Location
- Retrograde intramedullary from the diaphyseal nutrient artery — already compromised in AVN
- How to protect it
- Minimise soft-tissue stripping; preserve periosteum; limit dissection to what is necessary (affects healing, especially for fusion)
- Location
- Immediately medial and lateral in the tight intermetatarsal spaces
- How to protect it
- Careful retractor placement; assess for concurrent pathology; monitor for transfer metatarsalgia
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“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 the plantar cartilage appears intact on MRI. What is your diagnosis and management approach?”
“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.”
“A 45-year-old presents with chronic third metatarsal pain from Freiberg's disease. Intra-operatively you find Stage V disease with complete destruction of the plantar cartilage. What is your management and how do you technically perform the MTP arthrodesis?”
Indication & decision
- Freiberg's disease (AVN of a lesser MT head) that has failed conservative care (activity modification, stiff shoe, NSAIDs for 3 to 6 months)
- 2nd MT around 68 percent, 3rd MT around 27 percent; adolescent females typical but any age possible; bilateral in 15 to 20 percent
- Smillie stage AND plantar cartilage quality together drive the procedure choice
Exposure & danger structures
- Dorsal longitudinal 3 to 4 cm incision in the intermetatarsal space between the EDL tendons — the Weil-type exposure
- Dorsal digital nerves 3 to 5 mm from the midline — identify early under loupes, retract on vessel loops
- Plantar neurovascular bundles 8 to 10 mm plantar — stay dorsal to the plantar plate
- Plantar cartilage (plantar 50 to 70 percent) — preserve; its quality governs preservation versus fusion
Procedure by stage
- I to II: cheilectomy (dorsal 25 to 30 percent) or core decompression
- III to IV with good plantar cartilage: DCWO (most anatomic, preserves length) or Weil (simpler, predictable, shortens)
- V with destroyed plantar cartilage: MTP fusion only
- All stages: remove every loose body; microfracture is an adjunct
Closure & fixation
- DCWO: wedge apex at the cartilage junction, fix with a screw perpendicular to the osteotomy or a dorsal mini-plate
- Weil: cut parallel to the weight-bearing surface, translate 3 to 4 mm, headless screw
- Fusion: cartilage to bleeding bone, graft the defect, position 5 to 10 degrees plantarflexion, crossed K-wires or screw/plate
- Fluoroscopy before closure; meticulous haemostasis; stiff shoe (preserve) or CAM boot (fuse)
Postoperative protocol
- Cheilectomy: heel WB immediately, ROM day 3 to 5, shoes at 6 to 8 weeks (earliest return)
- DCWO/Weil: heel WB 3 to 4 weeks, ROM day 3 to 5, forefoot WB 4 to 6 weeks, shoes 6 to 8 weeks
- Fusion: NWB 6 weeks, X-ray at 6 weeks, WB 6 to 8 weeks if uniting, shoes 8 to 12 weeks (longest)
- All: avoid high heels 3 to 4 months; long-term activity modification; AVN may progress
Complications
- Recurrent pain/progression 10 to 20 percent; stiffness 15 to 25 percent
- Transfer metatarsalgia 5 to 10 percent (Weil shortening); floating toe 10 to 15 percent (Weil)
- Non-union: fusion 5 to 10 percent (higher in AVN bone), DCWO rare 2 to 3 percent
- Dorsal digital nerve injury 3 to 5 percent; wound complications 3 to 5 percent (higher in AVN)
Exam tips
- Know Smillie I to V and its matching treatment — it drives all decision-making
- Plantar cartilage quality is the pivot between joint preservation and fusion
- Be able to compare DCWO versus Weil — both work for Stage III to IV; trade-offs are technical complexity versus metatarsal shortening
- Freiberg's is an AVN process — it may progress despite surgery, so set realistic expectations
- Fusion loses motion but lesser MTP motion is less critical than at the hallux — an acceptable salvage for Stage V
Background & Evidence
Epidemiology. Freiberg's disease is an osteochondrosis/avascular necrosis of a lesser metatarsal head. The 2nd metatarsal is affected in around 68 percent of cases, the 3rd in around 27 percent, and rarely the 4th. Although classically described in adolescent females, the largest modern synthesis shows most reported patients are in fact adults (516 over 18 versus 194 under 18 in one review), so the diagnosis should not be excluded on age. It is genuinely rare — the first population-based incidence estimate is approximately 1 in 2833 livebirths — and bilateral disease occurs in 15 to 20 percent. Pathoanatomy. The metatarsal head is supplied by a retrograde intramedullary blood supply from the diaphyseal nutrient artery, which is vulnerable and already compromised once the AVN process begins. Repetitive loading and vascular insult produce subchondral fracture, collapse and fragmentation of the head, with secondary osteoarthritis. Because the plantar cartilage is loaded last and least, it is preserved longest — which is exactly why it can be rotated into the articulation (DCWO) or relied upon to decide preservation versus fusion. Smillie classification. The five-stage system (originally described 1957, formalised 1967) remains the standard for surgical decision-making and ties each stage to a management family.
- Pathology
- Subchondral fissure fracture, minimal changes
- Typical surgical management
- Conservative first; if it fails, core decompression or cheilectomy
- Pathology
- Central collapse, flattening and sclerosis
- Typical surgical management
- Cheilectomy, or core decompression in the young
- Pathology
- Central collapse with a free osteochondral fragment
- Typical surgical management
- Dorsal closing wedge osteotomy (DCWO) or Weil osteotomy
- Pathology
- Further flattening, plantar cartilage damage beginning
- Typical surgical management
- DCWO or Weil osteotomy while plantar cartilage remains usable
- Pathology
- End-stage arthritis, plantar cartilage destroyed
- Typical surgical management
- MTP arthrodesis — the only reliable salvage
Key evidence. The dorsal closing wedge (dorsiflexion) osteotomy is the foundational joint-preserving operation: Kinnard and Lirette (1989) showed excellent results in a small series with mean shortening of only 2.3 mm and no postoperative metatarsalgia, and Chao et al. (1999) reported good or excellent outcomes in 11 of 13 with the necrotic segment rotated away from the joint. The modified Weil osteotomy gives predictable function and union at the cost of around 3 to 4 mm of shortening (Kim et al., 2012), and remains effective even in advanced (Smillie IV to V) disease when usable plantar cartilage remains (Kooner et al., 2022). The comprehensive review by Rehm et al. (2025) confirms that no single operation is clearly superior and that several joint-preserving osteotomies give good results — so the procedure should be selected by stage, cartilage quality and surgeon familiarity.
Dorsiflexion (dorsal closing wedge) osteotomy in Freiberg's disease
- Retrospective series of 10 patients undergoing dorsiflexion (dorsal closing wedge) osteotomy, mean follow-up 36.5 months
- Excellent results in all patients with minimal loss of MTP motion
- Average radiological metatarsal shortening only 2.3 mm with NO postoperative metatarsalgia
- Procedure described as reliable and non-destructive, leaving further options open if needed
Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients
- 13 patients treated with debridement plus extraarticular dorsal closing-wedge osteotomy of the metatarsal neck; lesion in 2nd MT in 10, 3rd MT in 3
- After osteotomy the necrotic segment was rotated away from the joint so healthy metatarsal head cartilage faced the phalangeal cartilage
- Good or excellent subjective outcome in 11 of 13, fair in 1, poor in 1, at mean 40 months
- MRI found useful preoperatively for defining lesion extent and planning the correction
Modified Weil osteotomy for the treatment of Freiberg's disease
- 20 feet treated with single-screw modified Weil (intra-articular dorsal closing wedge) osteotomy, mean follow-up 72 months
- AOFAS lesser MTP score improved from 63.3 to 80.4 and VAS from 6.2 to 1.4 (both p less than 0.0001); MTP ROM improved from 31 to 48 degrees
- No significant difference in outcome between early (Smillie I to III) and late (IV to V) stages; 19 of 20 (95 percent) satisfied
- Mean operative shortening 3.4 mm; transfer metatarsalgia in 1 (5 percent), floating toe 1 (5 percent), radiographic union at mean 8.2 weeks
Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy: 5-year follow-up
- 12 feet with advanced (Smillie IV to V) disease treated with synovectomy and modified Weil osteotomy, mean follow-up 5.2 years
- AOFAS score improved from 48.1 to 88.9 (mean improvement 40.8, p less than 0.001); all achieved radiological union
- 92 percent of patients reported excellent or good results and were satisfied
- Only complication a single superficial infection treated with oral antibiotics
Freiberg's disease: variation of surgeries, outcomes, and first population-based incidence
- Inclusive review of 163 publications (1121 patients, 1169 feet; 939 feet operated) plus a population study of 124,644 livebirths
- First population-based incidence estimate: approximately 1 in 2833 livebirths, confirming Freiberg's disease is rare
- Across the literature most patients were adults (516 over 18 versus 194 under 18), tempering the 'adolescent female' stereotype
- Multiple osteotomy types (intra- and extra-articular DCWO, modified Weil) and osteochondral autograft all achieved high rates of good/excellent outcomes when nonoperative care failed
References
All citations below are verified against PubMed; DOIs are provided as links where indexed. 1. Smillie IS. Treatment of Freiberg's infraction. Proc R Soc Med. 1967;60(1):29-31. PMID: 5335092. DOI. Classic paper from the originator of the five-stage classification that remains standard for surgical decision-making (staging originally described 1957). 2. Kinnard P, Lirette R. Dorsiflexion osteotomy in Freiberg's disease. Foot Ankle. 1989;9(5):226-231. PMID: 2731834. DOI. Original dorsiflexion (dorsal closing wedge) osteotomy series; mean shortening only 2.3 mm with no transfer metatarsalgia. 3. Kinnard P, Lirette R. Freiberg's disease and dorsiflexion osteotomy. J Bone Joint Surg Br. 1991;73(5):864-865. PMID: 1894683. DOI. Follow-up report confirming durability of the dorsiflexion osteotomy. 4. 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. PMID: 10622482. DOI. DCWO for established disease; 11 of 13 good/excellent; MRI useful for planning. 5. Kim J, Choi WJ, Park YJ, Lee JW. Modified Weil osteotomy for the treatment of Freiberg's disease. Clin Orthop Surg. 2012;4(4):300-306. PMID: 23205240. DOI. Single-screw modified Weil; AOFAS 63 to 80, 95 percent satisfied, effective in both early and late stages. 6. Kooner S, Lee JM, Jamal B, David-West K, Daniels TR, Halai M. Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy, 5-year follow up. Foot (Edinb). 2022;57:101952. PMID: 37866283. DOI. Joint-preserving osteotomy effective even in Smillie IV to V disease with usable plantar cartilage. 7. Rehm A, Seah M, Chase HE, et al. Freiberg's disease: variation of surgeries, outcomes, and first population-based incidence. J Pediatr Orthop B. 2025;34(5):488-497. PMID: 40014303. DOI. Largest synthesis to date; first population incidence (about 1 in 2833 livebirths); majority of reported patients are adults. 8. Miyamoto W, Takao M, Miki S, Kawano H. Midterm clinical results of osteochondral autograft transplantation for advanced stage Freiberg disease. Int Orthop. 2015;40(5):959-964. PMID: 26419957. DOI. Osteochondral autograft (from ipsilateral knee) for advanced disease; AOFAS 67 to 93 at minimum 5 years. 9. Brandao B, Fox A, Pillai A. Comparing the efficacy of Cartiva synthetic cartilage implant hemiarthroplasty vs osteotomy for the treatment of conditions affecting the second metatarsal head. Foot (Edinb). 2019;41:30-33. PMID: 31675598. DOI. Osteotomy outperformed synthetic implant; supports osteotomy as mainstay when AVN of the metatarsal head is present.