Freiberg's disease: variation of surgeries, outcomes, and first population-based incidence

The objective of this inclusive literature review is to identify surgeries performed for Freiberg's disease (FD) and their outcomes and to perform the first population-based study to establish its incidence. We reviewed all retrievable publications linked to FD listed in PubMed and publications quoted within these publications going back to 1914. Patients with FD and the number of livebirths born in our maternity hospital between 2000 and 2023 were identified from our hospital database. We identified 208 publications of which we managed to review 163 (1121 patients, 1169 feet, of which 939 feet underwent surgery, 116 had no surgery, and for 114, it was unknown if surgery was performed. Patient age: 194 × <18 years, 516 × ≥18 years, 411 × age unknown). The most frequently performed surgeries were intra-articular closing wedge metatarsal osteotomies through the defect (IDCWMO) (284 feet), extra-articular dorsal closing wedge metatarsal osteotomies (EDCWMO) (118 feet), osteochondral autologous transplantation (OAT) (64 feet), and modified Weil osteotomies with intra-articular dorsal closing wedge osteotomies (52 feet). Outcome scores were used in 39 publications, with the American Orthopaedic Foot and Ankle Society score having been used most frequently (28 studies, 462 patients, 482 feet). The mean scores were excellent for OATs and EDCWMOs and good for IDCWMOs and modified Weil osteotomies. We identified 124 644 livebirths and 44 patients with FD. In conclusion, multiple procedures achieved a high rate of excellent and good outcomes where nonoperative management failed. FDis rare, with an extrapolated incidence of 1 in 2833 livebirths.