“Outcomes Following Surgical Intervention for Freiberg’s Infarction – A Systematic Review” (Butler et al., 2023) | Find Your Stride | Edinburgh Podiatrist

Introduction

Freiberg’s infarction (also known as Freiberg's disease), a rare osteonecrosis of the metatarsal head, remains a challenging condition for podiatric surgeons. In Foot & Ankle Orthopaedics (2023), Butler et al. presented a systematic review examining outcomes of various surgical interventions for Freiberg’s disease, aiming to consolidate evidence on clinical and radiological improvements, complications, and failure rates. This review explores the strengths and shortcomings of their findings through a critical lens relevant to podiatric practice.

Freiberg's infarction is often seen at the 2nd or 3rd metatarsal head (the joints in this image appear normal)

Study Overview

The review synthesised data from 18 studies, covering 299 patients (302 feet) with Freiberg’s infarction, followed up for an average of 50 months. Procedures ranged from dorsal closing wedge osteotomies to joint-preserving and joint-reconstructive techniques. The mean AOFAS (American Orthopaedic Foot & Ankle Society) score improved from 60.3 to 84.3, while range of motion increased by roughly 20 degrees. Complications were relatively low (5.2%), with pain being the most frequent issue. The failure rate was minimal (1.6%).

Critical Appraisal

While the review provides a valuable aggregation of existing surgical data, several limitations warrant discussion:

1. Low Quality of Evidence: Butler et al. acknowledge that most included studies were of low-level evidence (case series or retrospective reviews). This significantly limits the strength of the conclusions.

   
   

2. Heterogeneity of Data: The studies varied widely in surgical technique, patient selection, and outcome reporting, making quantitative synthesis difficult and potentially masking true differences in efficacy.

   
   

3. Under-reporting of Complications: Given that “pain” was the most cited complication, the low 5.2% rate may reflect inconsistent reporting rather than genuine surgical success.

   
   

4. Lack of Long-Term Outcomes: Most follow-up periods were short to mid-term, leaving questions about durability, arthritic progression, and functional recovery beyond five years.

   
   

5. Clinical Relevance: Despite demonstrating improvement in pain and motion, no single technique emerged as superior, underscoring the need for prospective, comparative studies with standardised outcome measures.

Implications for Podiatric Practice

For podiatrists managing Freiberg’s disease, this review reinforces that surgery can yield meaningful improvement, particularly when conservative care fails. However, practitioners should interpret these results cautiously — individual patient factors, disease stage, and surgeon expertise remain key determinants of outcome. The findings highlight the ongoing need for multi-centre trials and patient-reported outcomes to refine surgical decision-making in metatarsal osteonecrosis.

Conclusion

Butler et al. (2023) make a noteworthy contribution to the literature on Freiberg’s infarction surgery, summarising current evidence well. Yet, the review ultimately presents a promising set of surgical results constrained by low methodological quality and data inconsistency. Further clarity is needed.

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Citation

Butler, J. J., Omar, V., Konar, K., Azam, M. T., & Kennedy, J. G. (2023). Outcomes following surgical intervention for Freiberg’s infraction: A systematic review. Foot & Ankle Orthopaedics, 8(4). https://doi.org/10.1177/2473011423S00369