between november 2001 and july 2008 , nineteen patients ( twenty feet ) underwent modified weil osteotomy for freiberg 's disease . we included patients who complained of persistent pain in spite of more than 6 months of conservative treatment at any stage according to smillie 's classification system . diagnosis was based upon clinical history , physical examination , and plain radiographs for all patients . informed consent was waived because of the retrospective nature of the study . under spinal anesthesia a pneumatic tourniquet was applied to the ipsilateral thigh and inflated to a pressure of 320 mmhg . via the dorsal longitudinal approach , the extensor digitorum longus tendon of the affected toe was retracted laterally , exposing the mtp joint . in the beginning , the joint was debrided and a synovectomy was carried out before osteotomy . if a loose body , peripheral osteophyte , periarticular spur or synovitis were observed , they were removed or a synovectomy was performed . afterwards , modified weil osteotomy was done via the distal metaphysis . in the dorsal aspect , most of the damaged area of the metatarsal head and neck area was removed in the bone wedge . healthy plantar cartilage was rotated to the center of the joint for forming a new articular surface . finally , the osteotomy was stabilized using a single screw ( spin screw ; integra lifescience co. , plainsboro , nj , usa ) with a low profile head and non threaded lag to the dorsal aspect of metatarsal neck ( fig . postoperatively , patients were allowed to bear weight as tolerated on their heel in an open , hard - soled surgical shoe . upon radiographic evidence of healing at the osteotomy site , transfer of weight to the forefoot in a regular shoe the patients underwent periodic clinical and radiographic follow - up at 4 weeks , 3 , 6 , 12 months , and then annually . relief of pain was evaluated using visual analogue scale ( vas)19 ) rating from 0 to 10 . the patients were examined using a standardized questionnaire based on the american orthopaedic foot and ankle society ( aofas ) lesser metatarsophalangeal - interphalangeal scale.20 ) this score includes clinical variables such as pain , restriction of footwear , painful callus , functional restriction of the mtp joint , rom of mtp joint and alignment of the toes . in all cases , passive mobility of mtp joint the patient seated , the examiner stabilized the metatarsal with one hand while grasping proximal phalanx with the other hand . the examiner moved the toe cephalad and caudally in range of maximal area to assess dorsiflexion and plantarflexion . the patients ' subjective satisfaction was also evaluated after surgery at last follow - up . patients were asked to rate their result as excellent , good , fair or dissatisfied.21 ) although the smillie 's classification system is based upon inspection of the metatarsal head , several features may be interpreted from plain radiographs.2,17 ) we reviewed preoperative weight - bearing radiographs and intraoperative finding to classify the stage of freiberg 's disease according to the smillie 's classification system ( fig . we divided the patients again into early stage and late stage based on smillie 's classification system.11,12,17,22 ) the early stage included smillie stage i to iii and the late stage included the rest , stage iv and v. in this study , dorsal closing wedge osteotomy was performed in both early and late stage of freiberg 's disease . in preoperative radiograph , radiograph , metatarsal shortening due to surgery was analyzed by the modification of jones et al.23 ) in periodic radiographic follow - up , if bridging trabeculae across the osteotomy site emerged , it was considered as radiographic union . other complications were also reviewed preoperatively and postoperatively such as callus , floating toe , stiff toe , transfer metatarsalgia , fixation failure , fracture of metatarsal , subluxation of the mtp joint , soft tissue irritation , nerve injury and nonunion or delayed union . wilcoxon signed - rank test and mann - whitney u - test were performed to test the hypotheses regarding effectiveness of the procedure . null hypotheses of no difference were rejected if p - values were less than 0.05 . between november 2001 and july 2008 , nineteen patients ( twenty feet ) underwent modified weil osteotomy for freiberg 's disease . we included patients who complained of persistent pain in spite of more than 6 months of conservative treatment at any stage according to smillie 's classification system . diagnosis was based upon clinical history , physical examination , and plain radiographs for all patients . a pneumatic tourniquet was applied to the ipsilateral thigh and inflated to a pressure of 320 mmhg . via the dorsal longitudinal approach , the extensor digitorum longus tendon of the affected toe was retracted laterally , exposing the mtp joint . in the beginning , the joint was debrided and a synovectomy was carried out before osteotomy . if a loose body , peripheral osteophyte , periarticular spur or synovitis were observed , they were removed or a synovectomy was performed . afterwards , modified weil osteotomy was done via the distal metaphysis . in the dorsal aspect , most of the damaged area of the metatarsal head and neck area was removed in the bone wedge . healthy plantar cartilage was rotated to the center of the joint for forming a new articular surface . finally , the osteotomy was stabilized using a single screw ( spin screw ; integra lifescience co. , plainsboro , nj , usa ) with a low profile head and non threaded lag to the dorsal aspect of metatarsal neck ( fig . postoperatively , patients were allowed to bear weight as tolerated on their heel in an open , hard - soled surgical shoe . upon radiographic evidence of healing at the osteotomy site , transfer of weight to the forefoot in a regular shoe the patients underwent periodic clinical and radiographic follow - up at 4 weeks , 3 , 6 , 12 months , and then annually . relief of pain was evaluated using visual analogue scale ( vas)19 ) rating from 0 to 10 . the patients were examined using a standardized questionnaire based on the american orthopaedic foot and ankle society ( aofas ) lesser metatarsophalangeal - interphalangeal scale.20 ) this score includes clinical variables such as pain , restriction of footwear , painful callus , functional restriction of the mtp joint , rom of mtp joint and alignment of the toes . in all cases , passive mobility of mtp joint the patient seated , the examiner stabilized the metatarsal with one hand while grasping proximal phalanx with the other hand . the examiner moved the toe cephalad and caudally in range of maximal area to assess dorsiflexion and plantarflexion . the patients ' subjective satisfaction was also evaluated after surgery at last follow - up . patients were asked to rate their result as excellent , good , fair or dissatisfied.21 ) although the smillie 's classification system is based upon inspection of the metatarsal head , several features may be interpreted from plain radiographs.2,17 ) we reviewed preoperative weight - bearing radiographs and intraoperative finding to classify the stage of freiberg 's disease according to the smillie 's classification system ( fig . we divided the patients again into early stage and late stage based on smillie 's classification system.11,12,17,22 ) the early stage included smillie stage i to iii and the late stage included the rest , stage iv and v. in this study , dorsal closing wedge osteotomy was performed in both early and late stage of freiberg 's disease . in preoperative radiograph , radiograph , metatarsal shortening due to surgery was analyzed by the modification of jones et al.23 ) in periodic radiographic follow - up , if bridging trabeculae across the osteotomy site emerged , it was considered as radiographic union . other complications were also reviewed preoperatively and postoperatively such as callus , floating toe , stiff toe , transfer metatarsalgia , fixation failure , fracture of metatarsal , subluxation of the mtp joint , soft tissue irritation , nerve injury and nonunion or delayed union . wilcoxon signed - rank test and mann - whitney u - test were performed to test the hypotheses regarding effectiveness of the procedure . null hypotheses of no difference were rejected if p - values were less than 0.05 . the average age of the patients was 33.6 years ( range , 17 to 62 years ) , and the mean follow - up period was 72.6 months ( range , 41 to 121 months ) ( table 1 ) . the aofas score increased significantly after surgery from 63.3  14.9 to 80.4  5.6 ( p < 0.0001 ) . vas improved from 6.2  1.4 to 1.4  1.5 at last follow - up ( p < 0.0001 ) , and rom of the mtp joint increased from 31.3  10.1 to 48.3  13.0 degrees at last follow - up ( p < 0.0001 ) . all patients were satisfied , reporting excellent or good results except one patient who had joint stiffness . the patient had rom limitation of 2nd mtp joint preoperatively and complained about no improvement of rom after surgery , not being satisfied with the surgery . on plain radiographs , joint space widening and degeneration of the mtp joint four cases were classified as smillie stage i , eleven cases as stage ii , one case as stage iii , two cases as stage iv , and two cases as stage v. there was no significant difference in variables such as improvement of vas , aofas score and rom of mtp joint after modified weil osteotomy comparing early stages with late stages ( fig . 3 ) . initially , 14 cases had a shorter metatarsal compared to opposite side and the average of initial metatarsal shortening was 1.0  1.0 mm ( range , 0 to 3.3 mm ) . postoperatively , the mean metatarsal shortening due to operation was 3.4  1.7 mm ( range , 0.9 to 5.8 mm ) without including initial shortening . radiographic union was achieved at 8.2  2.5 weeks ( range , 4 to 12 weeks ) after the osteotomy . postoperative complications included callus on the plantar area of the third metatarsal head in three cases ( 15% ) , floating toe in one case ( 5% ) and stiff toe in one case ( 5% ) . one patient complained about transfer metatarsalgia with callus on the plantar area of the third metatarsal head ( 5% ) . there was no evidence of fixation failure , fracture of metatarsal , subluxation of the mtp joint , soft tissue irritation , nerve injury and nonunion or delayed union at final follow - up . although various reports have described freiberg 's disease since 1914 , classification and treatment methods thereof are not completely established.17 ) smillie2 ) classified the appearance of the metatarsal head in freiberg 's disease into five stages in 1957 . in the early stages of the disease ( smillie stage i to iii ) , fair evidence supports the use of the closing wedge osteotomy of the metatarsal head and neck.14,17 ) on the other hand , kinnard and lirette11,12 ) reported even with advanced cases there was sufficient plantar cartilage to perform the procedure . we divided our patients into early and late stages to compare the effectiveness of modified weil osteotomy among the stages.11,12,17,22 ) upon investigation , improvement of vas , aofas score and rom of the mtp joint did not significantly differ between early stages and late stages . modified weil osteotomy can be a good treatment option in both early stages and late stages of freiberg 's disease . modified weil osteotomy involves open joint debridement and intra - articular dorsal closing wedge osteotomy . open joint debridement allows removal of intraarticular pathology such as thickened synovium , loose bodies , delaminated articular cartilage and peripheral osteophytes and spurs.17 ) closing wedge osteotomy is a realignment osteotomy of metatarsal head and neck.18 ) the aim of closing wedge osteotomy is to redirect the articular surface and theoretically , dorsal closing wedge osteotomy can restore the blood supply to the metatarsal head , preventing further deformity and collaps.8,17,21 ) intra - articular dorsal closing wedge osteotomy enables less metatarsalgia than that of extra - articular osteotomy which often leads to excessive elevation of the metatarsal head.13 ) dorsal closing wedge osteotomy redirects articular surface allowing the intact plantar cartilage to articulate with the proximal phalanx . also , dorsal closing wedge osteotomy offers similar results to extra - articular osteotomy in rom of the mtp joint . kinnard and lirette11 ) reported that dorsiflexion osteotomy gave excellent results with minimal loss of mtp joint motion and with an average of 2 to 5 mm metatarsal shortening . various fixation methods can be applied after completion of dorsiflexion osteotomy of the metatarsal , including cerclage wire,10 ) temporary pins,10 - 12 ) transosseous sutures,12 ) metal screw,18 ) dorsal t plate,9 ) polyglycolide pins.14 ) gauthier and elbaz10 ) suggested intra - articular dorsal wedge osteotomy fixed with cerclage wire in 1979 . the cerclage wire may cause tendinitis and temporary pins have to be removed before motion exercise . because the remaining intact portion of the metatarsal head was too small for wire fixation , kinnard and lirette11 ) modified the intra - articular dorsal closing wedge osteotomy fixated with absorbable suture . transosseous sutures can bring about loss of reduction , whereas metal screw or plate fixation after extra - articular osteotomy is more rigid . however , the metal screw or plate may be bulky and can reduce the rom of the mtp joint . recently , absorbable polyglycolide pins have been used that do not decrease the rom of the mtp joint . after performing dorsal closing wedge osteotomy with absorbable pin fixation , lee et al.14 ) reported no loss and some gain in motion . unfortunately , they are relatively weak and require multiple pinning . in this study , we fixed metatarsal head with a single screw after dorsal closing wedge osteotomy . compared to other fixation devices such as temporary crossed kirschner wires , patients were allowed to start motion exercise and bear weight relatively early . also , the spin screw ( integra lifescience co. ) with its low profile head , may reduce soft tissue irritation and has non - threaded lag for more compression . by placing the apex of the wedge as proximal as possible , a less shortened metatarsal and an enlarged distal fragment can be achieved.14 ) kinnard and lirette11,12 ) underwent an intra - articular dorsal closing wedge osteotomy in fifteen patients with predominantly late stage freiberg 's disease . they reported a minimal loss of joint motion and an average metatarsal shortening of 2.5 mm . in this study , we experienced favorable improvement of rom after operation and even a floating toe occurred in 1 case . after screw fixation , foreign body reaction , fixation failure , perioperative fracture and displacement of osteotomy may occur . in our study , we could not find any complication of the sort ; however , confirmation of such would require a more cases and longer follow - up . limitations of this study include being a retrospective study , as well as no control group for being compared with dorsal closing wedge osteotomy . some prospective and long term follow - up study with more patients and control group can prove the efficacy of dorsal closing wedge osteotomy in frieberg 's disease . through the modified weil osteotomy , we can expect offloading of the metatarsal head and restoration of mtp joint congruency . this study provides great improvement in pain and function after the procedure with a screw fixation for freiberg 's disease . modified weil osteotomy is believed to be a useful method for the treatment of freiberg 's disease in both early stages and late stages .
backgroundnumerous metatarsal osteotomies have been developed for the treatment of freiberg 's disease . 
 the purpose of this study was to evaluate the clinical outcomes of modified weil osteotomy in the treatment of freiberg 's disease.methodsfrom november 2001 to july 2008 , nineteen patients ( twenty feet ) , treated surgically for freiberg 's disease , were included in this study . 
 the average age of the patients was 33.6 years ( range , 17 to 62 years ) , the mean follow - up period was 71.6 months ( range , 41 to 121 months ) . 
 clinical outcomes were evaluated according to visual analogue scale ( vas ) , american orthopaedic foot and ankle society ( aofas ) lesser metatarsophalangeal - interphalangeal scale , the patients ' subjective satisfaction and range of motion ( rom ) of metatarsophalangeal ( mtp ) joint . in the radiologic evaluation , 
 initial metatarsal shortening by freiberg 's disease compared to opposite site , metatarsal shortening after modified weil osteotomy compared with preoperative radiography and term for radiologic union were observed.resultsvas showed improvement from 6.2  1.4 to 1.4  1.5 at last follow - up ( p < 0.0001 ) . 
 points of aofas score increased from 63.3  14.9 to 80.4  5.6 ( p < 0.0001 ) . 
 rom of mtp joints also improved from 31.3  10.1 to 48.3  13.0 degrees at last follow - up ( p < 0.0001 ) . according to smillie 's classification system 
 , there was no significant improvement of vas , aofas score and rom between early stages ( stage i , ii , and iii ) and late stages ( stage iv and v ) . 
 out of twenty cases , nineteen ( 95% ) were satisfied , reporting excellent or good results.conclusionsmodified weil osteotomy is believed to be a useful method for the treatment of freiberg 's disease , not only in the early stages but also in the late stages . 
 it relieves pain and improves function via shortening of metatarsals and restoration of mtp joint congruency .