There are few reports of the surgical treatment for late stage Freiburg’s disease with flattening of the metatarsal head and osteoarthritis. We describe the results of the surgical treatment of ten consecutive patients with advanced stage Freiburg’s disease (Smillie’s stage V), using a technique that has not been published previously.

Vancomycin-supplemented allografts provide biological restoration of bone stock and sound fixation with a low incidence of re-infection. Experimental incorporation of these grafts is similar to allografts without vancomycin. However, the underlying biology remains unknown.

We report the first histological observations of vancomycin-supplemented impacted bone allografts in two reconstructions performed 14 and 20 months after revision surgery because of a periprosthetic fracture.

Areas of active bone remodelling (creeping substitution), as well as calcified bone trabeculae and graft particles embedded in dense fibrous tissue, were observed with osteoid and fibroconnective tissue surrounding polymethylmethacrylate particles.

These pathological findings are similar to those reported in allografts without vancomycin and support the hypothesis that high levels of vancomycin do not affect the incorporation of bone graft.