A 50-year-old female patient presents with right forefoot pain. The pain has progressed over the last 1 year. No inciting injury or trauma. Radiographs are provided. There is the loss of plantar cartilage with the collapse of the metatarsal head. The patient has failed conservative management. Which of the following would be the most appropriate surgical treatment?
Freiberg’s disease is avascular necrosis of the second metatarsal head. In the early stages of the disease, fair evidence supports the use of open surgical debridement as well as osteotomy. A dorsiflexion osteotomy has the advantage of rotating healthy plantar cartilage to the center of the joint.
Once the joint has become arthritic, there is fair evidence supporting the use of excisional arthroplasty with the interposition of soft tissue within the joint.
An arthroplasty with silicone implants may produce good results but their long-term function can be compromised by loosening and foreign-body reaction. Problems with silicone implants include inappropriate fit, poor material strength, loosening of the implant, local bony resorption, lack of toe purchase, and the development of transfer lesions.
In this case, there is an advanced disease of the cartilage and collapse of the metatarsal head, which precludes perichondral grafting and metatarsal osteotomy, and excisional and interpositional arthroplasty is the most appropriate due to the advanced nature of this disease
Carmont M. Current Concepts Review: Freiberg’s Disease. Foot Ankle Int. 2009(30):167-176