Abstract
Background
Freiberg’s disease is a rare osteochondrosis of the metatarsal head that can cause progressive pain, deformity, and loss of function. The two most widely used joint-preserving surgical options for advanced disease are dorsiflexion closing wedge metatarsal osteotomy (DCWMO) and autologous osteochondral transplantation (AOT). To date, no meta-analysis has directly compared these procedures. This systematic review and meta-analysis aimed to evaluate functional, radiographic, and complication outcomes of AOT versus DCWMO in Freiberg’s disease.
Methods
A systematic search of PubMed, Embase, and Cochrane Library was conducted in August 2025 according to PRISMA guidelines. Inclusion criteria were clinical studies comparing or reporting outcomes of AOT or DCWMO in Freiberg’s disease. Risk of bias was assessed using JBI Critical Appraisal Tools. Pairwise meta-analyses were performed for comparative studies evaluating American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analogue scale (VAS) pain, range of motion (ROM), and complications. Single-arm pooled analyses were conducted for AOT and DCWMO separately to provide context for within-group improvements and complication rates. Random-effects models were applied throughout.
Results
Sixteen studies involving 259 toes were included: 62 treated with AOT and 197 with DCWMO. Three comparative studies (n = 70) demonstrated significantly greater functional gain with AOT (AOFAS mean difference [MD] 7.15, 95 % CI 4.29–10.02; I²=0 %) and superior dorsiflexion both postoperatively (MD 7.85°, 95 % CI 4.40–11.29; I²=0 %) and in terms of gain from baseline (MD 7.46°, 95 % CI 3.77–11.14; I²=0 %). Absolute postoperative AOFAS and VAS pain scores were similar between groups, as were improvements in plantarflexion. DCWMO consistently shortened the metatarsal head (pooled mean 1.76 mm), whereas AOT preserved or slightly increased length (–0.20 mm). Complications were significantly lower with AOT (risk difference–0.20, 95 % CI–0.35 to–0.04; risk ratio 0.23, 95 % CI 0.05–0.96). Single-arm pooled analyses confirmed large improvements in AOFAS (∼25 points) and VAS (∼5 points) for both groups, with pooled complication rates of 1 % for AOT and 6 % for DCWMO.
Conclusion
Both AOT and DCWMO provide meaningful pain relief and functional improvement in advanced Freiberg’s disease. However, AOT demonstrated superior functional gains, greater preservation of motion and metatarsal length, and fewer complications, suggesting it may represent the preferred joint-preserving option, particularly for Smillie stage III–IV disease. Future prospective comparative trials with standardized outcome reporting and exploration of lower-morbidity donor graft sources are warranted to refine surgical decision-making.
Level of Evidence
Level II, systematic review and meta-analysis.
1
Introduction
Freiberg’s disease, also known as Freiberg infraction, is a rare osteochondrosis of the metatarsal head that leads to pain, restricted motion, and progressive functional limitation in affected patients. First described by Alfred H. Freiberg in 1914 , the condition has since been recognized as an important cause of forefoot morbidity, particularly among adolescents and young adults, with a strong predilection for females . The underlying pathogenesis remains multifactorial, with theories implicating vascular insufficiency , repetitive microtrauma, mechanical overload, and altered forefoot biomechanics . Freiberg’s disease most commonly affects the second MTP joints, with the second and third being most susceptible due to their length and in the context of a hypermobile first ray . Clinically, patients present with pain localized to the metatarsophalangeal (MTP) joint, swelling, stiffness, and difficulty with weight-bearing activities. Without effective intervention, the disease may progress to advanced arthritis with chronic disability , .
Conservative management, including activity modification, orthotics, non-steroidal anti-inflammatory drugs, and physiotherapy, is generally recommended for early-stage disease (Smillie stages I and II) . However, advanced disease (stages III to V), where collapse and articular incongruity predominate, often requires surgical intervention to restore joint congruency and relieve symptoms . A wide variety of operative techniques have been described, reflecting the lack of consensus on optimal treatment. Among these, the two most frequently utilized joint-preserving options for advanced Freiberg’s disease are the dorsiflexion closing wedge metatarsal osteotomy (DCWMO) and the autologous osteochondral transplantation (AOT).
DCWMO, first popularized by Gauthier and Elbaz in 1979 , involves resection of a dorsal wedge from the metatarsal head or neck, allowing rotation of the intact plantar cartilage dorsally into the weight-bearing zone. This procedure effectively transfers load to viable cartilage, relieves dorsal impingement, and has traditionally been considered the “gold standard” treatment . However, the osteotomy shortens the metatarsal and can limit plantarflexion, which can lead to metatarsalgia and altered biomechanics of the forefoot . Additionally, the osteotomy site requires healing which lengthens recovery time and delays return to activity .
AOT is a technique adapted from the treatment of osteochondral lesions of the knee and ankle , . It entails harvesting an osteochondral plug from a non-weight-bearing donor site, commonly the femoral condyle, and implanting it into the necrotic dorsal aspect of the metatarsal head ,,,,,, . By resurfacing the articular surface with viable hyaline cartilage and subchondral bone, AOT aims to restore joint congruency without altering metatarsal alignment or length. This theoretically preserves the range of motion and avoids the biomechanical trade-offs inherent to osteotomy procedures.
Despite decades of clinical experience with DCWMO and the more recent adoption of AOT, the comparative effectiveness of these two procedures in Freiberg’s disease remains unclear. A recent evidence-based treatment algorithm recommended both AOT and DCWMO for Smillie stage III–IV lesions but acknowledged the absence of high-quality comparative data to guide surgical decision-making . To date, no systematic review and meta-analysis has been performed to directly compare outcomes between AOT and DCWMO. Given the rarity of Freiberg’s disease and the consequent limitations in individual study power, pooling data across the existing literature is necessary to better define the relative merits of these procedures. A systematic synthesis of outcomes may help inform treatment selection.
The purpose of this systematic review and meta-analysis was therefore to evaluate the comparative effectiveness of AOT versus DCWMO in the management of Freiberg’s disease. Incorporating both pairwise comparative analyses and single-arm pooled estimates provides a more comprehensive overview, establishing realistic benchmarks for expected improvements while also clarifying procedure-specific advantages. The hypothesis was that AOT would be associated with superior functional outcomes and improved range of motion.
2
Methods
2.1
Search strategy
The present systematic review has been conducted and authored according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline . Our patient, intervention, comparison, and outcome (PICO) were defined as follows: patients: patients with Freiberg’s disease; intervention: AOT; comparison: DCWMO; and outcome: patient rated scores and range of motion (primary outcomes), and complication rates (secondary outcome).
In August 2025, the following search terms were used: (Freiberg OR Freiberg’s disease OR metatarsal head osteonecrosis) AND ((osteochondral autograft OR AOT OR osteochondral transplantation OR mosaicplasty OR osteochondral graft OR osteochondral transfer OR AOT) OR (dorsiflexion osteotomy OR dorsal closing wedge osteotomy OR metatarsal osteotomy OR DCWMO)). Inclusion criteria were as follows: 1) any human clinical studies reporting or comparing AOT to DCWMO for Freiberg’s disease and evaluating outcomes, 2) published in peer-reviewed journals, 3) written in English. Exclusion criteria included 1) case reports, 2) less than 2 months’ follow-up, 3) cadaveric or animal studies, 4) systematic reviews. Two independent reviewers (AT, EL) screened the titles, abstracts, and full text articles to ensure the criteria were applied to all studies searched. This paper’s senior author (JGK) was consulted to arbitrate any disagreements that arose
2.2
Assessment of level of evidence and methodological quality
The level of evidence (LOE) was evaluated using the criteria published by The Journal of Bone & Joint Surgery. The level of evidence (LOE) was evaluated using the criteria published by The Journal of Bone & Joint Surgery . Risk of bias was assessed independently by two reviewers (AT, EL) using the Joanna Briggs Institute (JBI) Critical Appraisal Tools, with study design–specific checklists applied to randomized controlled trials, cohort studies, and case series . Each domain was scored according to the JBI guidance as “yes,” “no,” “unclear,” or “not applicable.” Discrepancies were resolved by the senior author (JGK). Results of the critical appraisal were summarized narratively and tabulated to provide an overview of study quality across designs.
2.3
Data extraction and evaluation
Two independent reviewers (AT, EL) independently extracted and assessed the data from each individual study. The key characteristics of each article were extracted and inserted into spreadsheets in Microsoft Excel to facilitate analysis and presentation. For missing data, attempts were made to contact the original investigators for included studies published less than 10 years ago. Data was collected on patient preoperative demographics, American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, metatarsophalangeal dorsiflexion (DF) and plantarflexion (PF) range of motion, and complication rates.
2.4
Statistical analysis
All continuous variables are expressed as means ± standard deviations (SD). Pooled means were calculated using meta-analysis of single means (MRAW approach), weighting each study by inverse variance with random-effects models were applied to account for heterogeneity across cohorts. Single and pairwise meta-analyses, along with forest plots and heterogeneity assessments (χ² and I² statistics), were performed using Review Manager (RevMan) version 5 software. If only interquartile ranges (IQRs) were provided, SDs were estimated by dividing the IQR by 1.35. When only the median was available, it was assumed to approximate the mean. Pooled means were computed as the weighted average of means, using sample sizes as weights. Pooled SDs including those for differences between pre- and post-operative scores were derived using the following formula :
Direct comparative studies of AOT versus DCWMO were synthesized for the following outcomes: AOFAS, VAS pain score, DF and PF, and complication rates. Continuous outcomes were analyzed using mean difference (MD) with 95 % confidence intervals (CI). When scales were comparable across studies, raw mean differences were used. Dichotomous outcomes (complications) were pooled using risk difference (RD) and risk ratio (RR) with 95 % CI. All analyses were conducted with a random-effects model using the Paule–Mandel estimator for τ², and Hartung–Knapp adjustment for small-study robustness. Between-study heterogeneity was quantified with I².
For AOT and DCWMO separately, single-arm case series were synthesized together with arms from the comparative studies to estimate pooled within-group changes in AOFAS, VAS, DF, PF, metatarsal length, return to sport, osteotomy healing time, and complication rates. This approach provides important clinical context by summarizing the absolute magnitude of benefit expected with each procedure, particularly when comparative evidence is limited to a small number of studies. For pre-post continuous outcomes, the effect size was calculated as the mean change (postoperative– preoperative) with the pooled standard deviation (SD) of the change calculated as shown above. The results were reported as pooled mean changes with 95 % CI. Pooled complication rates were calculated as proportions using the Freeman–Tukey double-arcsine transformation to stabilize variance and accommodate studies with rare or zero events. A random-effects model was used, and results were back-transformed and expressed as pooled percentages with 95 % CI. All the forest plot meta-analyses are in the supplemental materials .
3
Results
The search generated 173 studies, and 16 studies met the inclusion and exclusion criteria ( Fig. 1 ).
– PRISMA Checklist.
3.1
Study characteristics
The study characteristics and patient demographic data are listed in Table 1 . AOT was performed in 62 patients (62 toes) and DCWMO was performed in 193 patients (197 toes). The pooled mean age for the AOT cohort was 30.2 years (95 % CI 23.96–36.35 years, I 2 =98.7 %) and was 32.4 years (95 % CI 24.39–40.49 years, I 2 =98.8 %) for DCWMO. Mean follow-up ranged from 17 to 276 months across studies. The majority of patients affected were female, with 79 % (42/53) of patients being female in the AOT group and 77 % (134/173) of patients being female in DCWMO group. “In the AOT group (n = 62), 11 patients (18 %) had Smillie stage II, 9 (15 %) stage III, 27 (43 %) stage IV, and 15 (24 %) stage V disease. In the DCWMO group (n = 197), 46 patients (23 %) had stage II, 43 (22 %) stage III, 88 (45 %) stage IV, and 20 (10 %) stage V disease.
Table 1
– Summary of study & patient characteristics.
| Study | LOE | Study type | Patients/toes (n) | Age (yr) | M:F | Follow-up (mo) | Smillie Stage |
|---|---|---|---|---|---|---|---|
| Autologous osteochondral transplant (AOT) | |||||||
| Tsuda et al. 2011 | IV | CS | 3/3 | 13.7 ± 0.6 | 2:1 | 25 ± 1.2 |
III- 1
IV– 2 |
| Miyamoto et al. 2016 | IV | CS | 13/13 | 17.9 ± 7.6 | 0:13 | 67 ± 12 |
III– 4
IV- 9 |
| Ishimatsu et al. 2017 | IV | CS | 10/10 | 14.8 ± 1.5 | 1:9 | 24.6 ± 6.8 |
II– 3
III– 5 IV- 2 |
| Georgiannos et al. 2019 | II | RCT | 13/13 | 22 ± 6.5 | 4:9 | 46 ± 6.0 |
III– 5
IV– 5 V– 3 |
| Kim et al. 2020 | III | rCS | 12/12 | 53.2 ± 9.5 | 3:9 | 38.6 ± 10.3 |
III– 1
IV– 8 V– 3 |
| Incesoy et al. 2025 | III | rCS | 8/8 | 31.3 ± 14.4 | 1:7 | 33.8 ± 14.4 |
II– 0
III– 2 IV– 6 |
| Shimokawa et al. 2025 | IV | CS | 3/3 | 65.3 ± 6.0 | 0:3 | 44 ± 36.7 |
III– 2
IV- 1 |
| Dorsal closing wedge osteotomy | |||||||
| Lee et al. 2007 | IV | CS | 12/12 | 36 ± 11 | 0:12 | 45 ± 15.5 |
II- 4
III- 3 IV- 2 V- 3 |
| Lee et al. 2013 | IV | CS | 13/13 | 29.7 ± 15.8 | 1:12 | 44.3 ± 16.5 |
II– 3
III– 3 IV– 6 V– 1 |
| Kilic et al. 2013 | III | rCS | 8/8 | 29.0 ± 11.5 | 1:7 | 22 ± 10.3 |
IV- 3
V- 5 |
| Ikoma et al. 2014 | IV | CS | 13/13 | 31.7 ± 14.8 | 4:9 | 17 ± 2.5 |
III– 3
IV– 5 V– 5 |
| Helix-Giordanino et al. 2015 | IV | CS | 28/30 | 61.2 ± 11.8 | 6:22 | 78 ± 26.4 |
II– 12
III– 11 IV- 7 |
| Pereira et al. 2015 | IV | CS | 20/20 | 15.2 ± 1.6 | 2:18 | 276 ± 55 |
II– 8
III– 9 IV– 3 |
| Ozkul et al. 2016 | III | rCS | 11/11 | 24.5 ± 9 | 5:6 | 30.8 ± 11.8 |
IV– 10
V- 6 |
| Georgiannos et al. 2019 | II | RCT | 14/14 | 22.5 ± 6 | 6:8 | 46 ± 6.0 |
III– 4
IV– 6 V– 4 |
| Dhar et al. 2020 | IV | CS | 20/20 | 22.8 ± 6.0 | n/r | 36 ± 12 |
IV– 11
V- 9 |
| Kim et al. 2020 | III | rCS | 15/15 | 54.7 ± 10.5 | 3:12 | 38.7 ± 9.7 |
III– 2
IV– 5 V– 8 |
| Mutlu et al. 2023 | III | rCS | 31/33 | 34.6 ± 7.5 | 6:25 | 20.7 ± 1.8 |
III- 22
IV- 9 |
| Incesoy et al. 2025 | III | rCS | 8/8 | 27.9 ± 4.4 | 5:3 | 40.8 ± 27.0 |
II– 1
III– 7 |
LOE– level of evidence, N– number, yr– years, M– male, F– female, mo– months, CS– case series, RCT– randomized controlled trial, rCS– retrospective cohort study
Based on the level of evidence (LOE), the AOT group included one randomized controlled trial (LOE II), two retrospective comparative study , (LOE III), and four case series ,,, (LOE IV). The osteotomy group included one randomized controlled trial (LOE II), five retrospective comparative studies ,,, (LOE III), and six case series ,,,,, (LOE IV). The JBI Critical appraisal toolkit was used to assess the risk of bias. Taken together, the evidence base consisted of one RCT at moderate risk of bias, five cohort studies at low risk of bias, and case series at either low or moderate risk of bias due to selection and reporting limitations. Full details of the JBI appraisal for each study are presented in Fig. 2 .
– Risk of Bias Assessment.
3.2
Surgical techniques
The surgical techniques are summarized in Table 2 . Across the included studies, all procedures were performed through a dorsal longitudinal incision over the affected metatarsophalangeal joint, with patients receiving either an osteochondral autograft transfer system (AOT) or a dorsiflexion closing wedge metatarsal osteotomy (DCWMO). AOT techniques consistently involved curettage of the necrotic dorsal articular surface, preparation of a recipient socket, and press-fit implantation of an osteochondral plug harvested from a non–weight-bearing area of the ipsilateral knee (lateral femoral trochlea or femoral condyle) ,,,,,, and in some cases, the talus was also used as a donor site . DCWMO techniques generally involved resection of a dorsal wedge of the metatarsal head or neck, with preservation of a plantar hinge and rotation of intact plantar cartilage dorsally into the weight-bearing zone ,,,,,,,,,,, . Fixation methods for osteotomies varied, including crossed Kirschner wires ,,,,,,, , absorbable pins , metallic staples , figure-of-8 stainless steel wire loops , and polyblend suture fixation . Postoperative rehabilitation protocols were broadly consistent: most osteotomy series reported short-leg cast or splint immobilization with heel weight-bearing, followed by progressive forefoot loading and range-of-motion exercises after 4–6 weeks ,,,,,,,,,,, ; in contrast, AOT studies typically permitted earlier mobilization, with heel weight-bearing within days and return to sports permitted by 3–4 months ,,,,,, ( Table 3 ).
Table 2
– Surgical details of included studies.
| Study |
Patients/
Toes (n) |
Surgery | Details | Fixation | Postop protocol |
|---|---|---|---|---|---|
| Autologous osteochondral transplant (AOT) | |||||
| Tsuda et al. 2011 | 3/3 |
OATS
(Arthrex system) |
Plug (9.0 ± 1.0 mm) harvested from ipsilateral lateral femoral trochlea.
CT used for planning (diameter, depth, angle); trimmed to fit socket |
Press-fit |
No immobilization; heel WB + toe flexion day 1;
full WB with orthosis at 2 wks; running at 6 wks; return to sport 10–12 wks |
| Miyamoto et al. 2016 | 13/13 |
OATS
(Arthrex system) |
Plug (7.4 ± 1.0 mm) harvested from ipsilateral lateral femoral condyle;
donor site via lateral arthrotomy |
Press-fit |
Splint × 3 days; heel WB and ROM after splint removal; full WB with orthosis at 2 wks;
jogging at 4 wks; |
| Ishimatsu et al. 2017 | 10/10 |
AOT
(mosaicplasty system, Smith & Nephew) |
Plug (6.3 ± 0.6 mm) harvested from ipsilateral lateral femoral condyle; | Press-fit | Splint × 1 wk; heel WB day after surgery; extension-block splint × 6 wks; return to sport at ∼3 mos |
| Georgiannos et al. 2019 | 13/13 |
OATS
(Arthrex system) |
Plug (n/r size) harvested from ipsilateral lateral trochlea of femur or talus; plug diameter matched with sizers | Press-fit | No immobilization; heel WB × 4 wks; toe ROM day 1; full WB at 4 wks; running at 8 wks |
| Kim et al. 2020 | 12/12 |
OATS
(Arthrex system) |
Plug (7.3 ± 1 mm) harvested from ipsilateral lateral femoral trochlea | Press-fit | Splint → partial foot cast at 2 days; WB as tolerated; cast off at 6 wks; aggressive ROM |
| Incesoy et al. 2025 | 8/8 | OATS (Arthrex system) | Plug (n/r size) harvested from ipsilateral lateral femoral trochlea; size based on defect | Press-fit | Short leg cast × 2 wks; WB commenced after cast removal |
| Shimokawa et al. 2025 | 3/3 | AOT[unspecified] | Plug (7.0 ± 0.9 mm) harvested from ipsilateral femoral trochlea | Press-fit | Heel WB at 1 wk with brace; full WB at 6 wks |
| Dorsal closing wedge metatarsal osteotomy | |||||
| Lee et al. 2007 | 12/12 |
Intra-articular DCWMO
(Gauthier-modified) |
5–7 mm dorsal wedge excised; apex proximal to minimize shortening | 3–4 absorbable pins (Biofix®) | Cast; heel WB; shoe at 4 wks; ROM at 4 wks |
| Lee et al. 2013 | 13/13 |
Extra-articular DCWMO
(Chao-modified) |
Neck wedge guided by MRI/K-wire angle planning; plantar cortex preserved | Cross-pinning with K-wires | Cast × 4 wks; wires out at 4 wks; progressive WB/ROM |
| Kilic et al. 2013 | 8/8 |
Dorsal crescentic osteotomy
(curved chisel) |
Crescentic cut 5 mm proximal to articular surface; rotated ∼15° dorsally | 2 crossed K-wires | Heel WB; K-wires out ∼4 wks |
| Ikoma et al. 2014 | 13/13 |
Extra-articular DCWMO
w/ polyblend suture |
5–7 mm wedge; distal fragment dorsiflexed |
Polyblend suture
(figure-8) |
Splint × 1 wk; progressive WB; ROM from 2 wks |
| Helix-Giordanino et al. 2015 | 28/30 |
Intra-articular DCWMO
(Gauthier technique) |
Entire necrotic dorsal head excised; plantar hinge preserved | 1–2 metal staples | Off-loading shoe × 3 wks; rehab |
| Pereira et al. 2015 | 20/20 |
DCWMO
(lesion-tailored wedge) |
Wedge size matched to lesion size; head rotated dorsally/proximally | Figure-of-8 wire loop | Splint × 6 wks; then soft shoes × 8 wks |
| Ozkul et al. 2016 | 11/11 |
DCWMO
(comparative resection) |
Distal metaphyseal wedge; head tilted ∼15° dorsally | 2 crossed K-wires | Cast × 6 wks; WB after cast removal; resection WB at 2 wks |
| Georgiannos et al. 2019 | 14/14 | Intra-articular DCWMO | Entire dorsal defect excised; plantar hinge preserved; head rotated dorsally | Nonabsorbable FiberWire sutures | No immobilization; heel WB × 4 wks; toe ROM day 1; full WB at 4 wks; running at 8 wks |
| Dhar et al. 2020 | 20/20 | DCWMO (distal metaphysis, joystick technique) |
Distal wedge ∼2–3 mm proximal to lesion; head rotated dorsally ∼15°
joystick K-wire used for control |
1–2 K-wires | Cast; wires out at 6 wks; WB thereafter |
| Kim et al. 2020 | 15/15 | Intra-articular DCWMO | Intra-articular wedge excision; plantar cartilage rotated into articulation | One mini-screw fixation | Splint → partial cast at 2 days; WB as tolerated; cast off at 6 wks; aggressive ROM exercises |
| Mutlu et al. 2023 | 31/33 |
DCWMO
(unspecified) |
Distal wedge osteotomy w/
synovectomy, osteophyte removal |
2 crossed K-wires | Cast × 6 wks; wires out at 6 wks |
| Incesoy et al. 2025 | 8/8 |
Extra articular DCWMO
(distal metaphysis) |
Distal metaphyseal wedge; ∼15° tilt dorsally | 2 intersecting K-wires | Cast × 6 wks; wires out at 6 wks; WB thereafter |
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