SLR - October 2019 - Brittany R. Staples

Osteochondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infraction in Athletes

Reference: Georgiannos, D., Tsikopoulos, K., Kitridis, D., Givisis, P., & Bisbinas, I. (2019). Osteochaondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infarction in Athletes. The American Journal of Sports Medicine, 47(10), 2367–2373. doi: 10.1177/0363546519859549

Scientific Literature Review

Reviewed By: Brittany R. Staples, DPM
Residency Program: SSM Health DePaul Hospital – St. Louis, MO

Podiatric Relevance: Freiberg’s infraction is a form of osteochondrosis found within the lesser metatarsal heads, and most commonly found in the second. The cause has been difficult to pinpoint, however, literature has attributed this disease to trauma, ischemia, and multifactorial causes such as hormonal abnormality and family history. The aim of this article is to determine which method of surgical treatment, between a dorsal closing wedge osteotomy (DCWMO) and the osteochondral autologous transplantation (OATs)  would most benefit an athletic patient with Freibergs infarction.

Methods:
Over the course of five years, twenty-seven patients with Freiberg’s infraction were assigned to two groups: the dorsal closing wedge metatarsal osteotomy group which consisted of 14 patients and the osteochondral autologous transplantation group which consisted of thirteen patients. As a prospective study, the design is a sound measurement for data collection. Given the design of the study and random selection of patients into the two groups, the hypothesis was explored and answered in a subjective manner. This ensures that the data is reliable and can create reproducible results.

Results: The measure of success of the procedures were based on a set of criteria consisting of the following: post-operative complications, length of the metatarsal, range of motion of the MTPJ, function of the foot as measured by AOFAS and pain as measured by the VAS foot and ankle scale. The results of the study were measured over the course of 46 months. The difference in AOFAS scores favors the OAT group reaching statistical but not clinical significance. The VAS scores improved significantly in both surgical groups; from 48.1 to 91.8 in the DCWMO group and from 49.9 to 95.4 in the OAT group. There was shortening of metatarsals by 1.9 in the DCWMO group as opposed to a metatarsal shortening of 0.2 in the OAT group. In the OAT group, patients were able to return to full post action at 10 weeks in the OAT group and eight weeks in the DCWMO.

Conclusions:
The authors concluded that both procedures were equal with regards to treatment of Freiberg’s infraction. This was determined based upon the favorable results as demonstrated by return to activity and pain. The OAT group however, did not suffer the post-operative shorter metatarsal which I feel is beneficial to maintenance of parabolic length. The OATS procedure allowed earlier return to activity which can be extremely beneficial in an athletic patient population. There were also no instances reported of donor site mobility following removal of the plugs. Additionally, two complications were reported in the DCWMO group but were limited to ache and stiffness of the second MTPJ which did not end up requiring further surgical treatment. A second patient required subsequent surgical intervention consisting of Weil osteotomies of the third and fourth metatarsal. Although the authors concluded that the procedures were equally beneficial, I would venture on the side of the OATS procedure due to the reduction in complication rates as well as the quick return to activity. 

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