Classification of freiberg's disease: a guide for management

IntroductionThe current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space.MethodsWe retrospectively reviewed 32 CT scans of new Freiberg's diagnoses in Sheffield over a 10 year period using the PACS system. We identified the sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx and measured the diseased segment of the corresponding metatarsal head as an arc (in degrees). This arc segment was divided by 360°. This gave a ratio of the affected arc in the sagittal plane.Results28 out of 32 cases involved the 2nd metatarsal with the remaining 4 involving the 3rd metatarsal head. Of 32 cases, 18 had fragmentation. Surgically, 20 had debridement only, 5 also had an osteotomy and 1 had a fusion. 6 of the 32 cases were managed non-operatively. 11 cases out of 32 had an arc ratio of < 0.3. Of these, only 3 had an osteotomy, 3 had no procedure and 5 had a simple debridement. Of those that had osteotomies (5/32), 3 of the 5 cases had an arc ratio of < 0.3 with the other 2 being 0.42 and 0.38.DiscussionWe hypothesise that those cases with an arc ratio of less 0.3 would be amenable to a dorsal closing wedge osteotomy and those with a ratio of more than 0.4 would be better suited to a simple debridement. For those cases between 0.3–0.4, we feel either option is viable. Further work to prove or disprove outcomes related to our classification is required.