Treatment of Freiberg’s Disease

Dorsal Metatarsal Closed Wedge Osteotomy in the Treatment of Freiberg's Disease: A Prospective Observational Study

The aim of this study was to prospectively evaluate the clinical and radiological results of dorsal metatarsal closed wedge osteotomy and headless screw fixation in the surgical treatment of Freiberg's disease.Thirty-four patients who were treated with dorsal metatarsal closed wedge osteotomy (DMCWO) for Freiberg's disease between February 2018 and March 2022 were included in the study. Patients were staged according to the classification system described by Smillie. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society's (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the visual analog scale (VAS), the range of motion (ROM) of the metatarsophalangeal (MTP) joint, and a subjective patient satisfaction questionnaire. For radiological evaluation, the amount of preoperative shortening of the involved metatarsal, the amount of metatarsal shortening developed after osteotomy, and radiological recovery times were recorded.Thirty-two (94.1%) of the patients were female, and two (5.9%) were male. The average postoperative follow-up period for patients was 33.7 months (range: 24 months to 41 months). The mean AOFAS scores increased from 53.24 to 86.26 (p < 0.01). The mean VAS scores decreased from 8.59 to 1.79, and it was observed that the patients' pain improved significantly (p < 0.01). The mean ROM of the MTP joint increased from 48.76 degrees to 70.76 degrees (p < 0.01). An average of 2.5 mm (range 1 mm to 4.1 mm) of shortening of the metatarsal length developed postoperatively (p < 0.01). Arthrosis developed in 1 case (2.9%), and transfer metatarsalgia developed in 2 cases (5.8%).DMCWO is an effective treatment for both the early and advanced stages of symptomatic Freiberg's disease, leading to high patient satisfaction.

A Novel Method for Treating Bilateral Freiberg's Disease of the Second Metatarsal: A Case Report

Freiberg's infraction is osteonecrosis of the lesser metatarsal heads, most commonly affecting adolescent females. Bilateral Freiberg's disease is rare, with only a few cases reported. Conservative management is the mainstay of treatment. Surgical management includes the excision of osteophytes and loose chondral flaps, microfracture, corrective osteotomy, and debridement of the metatarsal head, often with unpredictable outcomes. We report a rare case of a 17-year-old girl with bilateral Freiberg's disease who was treated with Autologous Matrix-Induced Chondrogenesis (AMIC), achieving excellent radiological and functional outcomes.

Evidence-Based Treatment Algorithm for Freiberg Disease

Freiberg disease is a type of osteonecrosis of the metatarsal head that predominantly occurs in young females and adolescents, although it may occur at any age. The pathophysiology is multifactorial and may involve trauma, altered foot biomechanics, systemic disorders, and arterial insufficiency. The most typical location is the second metatarsal head, but Freiberg disease may also occur in other lesser toes. Nonoperative treatment is best applied in the early stage of the disease; if this is ineffective, surgical treatment is recommended. Currently available surgical procedures include debridement, osteotomy, osteochondral grafting, microfracture, interposition arthroplasty, implant arthroplasty, and metatarsal shortening arthroplasty. In this article, we propose a treatment algorithm for Freiberg disease based on the current literature and expert opinion.

CT-based five-segment classification in Freiberg's infarction: Evaluation of its intraobserver and interobserver reliability

BACKGROUND

According to the location and frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn for Freiberg's infarction. The objective of the current study is to develop a new computed tomography-based Five-Segment classification system for Freiberg's infarction and testify if it has good intra- and interobserver reliability or not.

METHODS

According to the location and its frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn. According to the distribution of osteonecrosis zones of metatarsal heads, we proposed the Five-Segment classification system. Four evaluators evaluated each radiography and computed tomography (CT) twice at 8-week intervals. To test the reproducibility of the Five-Segment classification system, the interobserver and intraobserver reliability of this classification system comparing with that of the Smillie classification by four observers using the kappa statistic.

RESULTS

The 80 cases were classified into five reproducible types by using Five-Segment classification system: type Ⅰ, two (2.5%) cases; type Ⅱ, ten (12.5%) cases; type Ⅲ, 42 (52.5) cases; type Ⅳ, 24 (30.0%) cases; type Ⅴ, two (2.5%) cases. The mean kappa value for interobserver reliability using Smillie classification systems was 0.562 (95% CI: 0.531-0.585), whereas the mean kappa value was 0.828 (95% CI: 0.801-0.852), by using Five-Segment classification; the mean kappa values for intraobserver reliability by using Smillie classification and Five-Segment classification were 0.777 (95% CI: 0.762-0.792) and 0.860 (95% CI: 0.843-0.895), respectively.

CONCLUSIONS

The new Five-Segment classification system demonstrated perfect interobserver and intraobserver agreement between evaluators in the management of Freiberg's infarction. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice.

LEVEL OF EVIDENCE

Level IV, retrospective.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases

BACKGROUND

Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success.

METHODS

A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores.

RESULTS

The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively.

CONCLUSIONS

Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

A new classification for Freiberg's disease

INTRODUCTION

Freiberg's osteochondrosis is an uncommon cause of foot pain. Following a national survey circulated by the British Foot and Ankle Society it was found that no classification is used to guide surgical treatment. This study aimed to create a simple, reproducible CT based classification to preoperatively plan whether an osteotomy is required.

METHODS

A retrospective review of 24 CT scans of new Freiberg's diseasediagnoses over a 10 year period was conducted. These images were assigned a study number and anonymised. The scans were then reviewed in their entirety by three independent specialists who determined whether an osteotomy would be of benefit. The sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx was identified and divided the articular surface into 2 zones - plantar and dorsal and this formed the basis for our classification. These sagittal slices were then reviewed independently by two surgeons to determine if patients had disease in one or both zones and re-reviewed two weeks later to assess intra-observer reliability.

RESULTS

All 24 cases involved the second metatarsal. From reviewing the sagittal CT slices, it was felt that 18 patients were suitable for osteotomy and 6 were suitable for debridement +/- arthroplasty alone. The current classification demonstrated that 18 patients had disease confined to zone 1 only and the remaining patients had disease in both zones. Inter-observer reliability assessment had 95.8% agreement (Krippendorff's Alpha 0.897). Intra-observer reliability was 100%. Correlation of those observed to have isolated zone 1 disease and suitability for osteotomy was absolute (Pearson r = 1).

CONCLUSION

Dividing the metatarsal head into two zones on the widest sagittal slice of the CT scan offers an easy reproducible way to preoperatively plan surgical treatment for Freiberg's osteochondrosis. Patients with isolated zone 1 disease should be suitable for an osteotomy.

Description of a Revision Technique for Failed Polyvinyl Alcohol Hydrogel Implant in Patient with Freiberg's Disease

Polyvinyl alcohol hydrogel synthetic cartilage implants are increasingly used to treat advanced Freiberg disease. We report a case with recurrence of symptoms within 6 weeks and required revision for fracture of the implant. We describe a revision technique with modified osteochondral bone graft to deal with the variables of revision surgery namely: the bone loss, collateral ligament insufficiency, and changes to the proximal phalanx articular surface. We describe a postoperative plan, recovery and a good outcome achieved in 12 month follow-up.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Compression Wrapping for Acute Closed Extremity Joint Injuries: A Systematic Review

OBJECTIVE

Current prehospital recommendations for an acute closed extremity joint injury (ACEJI) are to apply compression in some manner. However, the effectiveness of compression is unclear. We performed a systematic review to summarize and synthesize the evidence for the use of a compression bandage for ACEJI in the prehospital setting.

DATA SOURCES

Cochrane Library, PubMed, and Embase were searched for relevant literature in November 2019.

STUDY SELECTION

Controlled trials involving adults in the prehospital setting with a recent ACEJI were included when compressive, nonimmobilizing interventions, feasible in a first aid setting, were applied and compared with no compression or any noncompressive intervention, such as braces, splints, or noncompressive stockings. Articles in all languages were included if an English abstract was available.

DATA EXTRACTION

Data on study design, study population, intervention, outcome measures, and methodologic quality were extracted from each included article.

DATA SYNTHESIS

Eight studies out of 1193 possibly relevant articles were included. All authors examined compression in the treatment of acute ankle sprains; no studies involved compression for the treatment of other ACEJIs. No difference in the major outcomes of pain reduction or swelling, ankle-joint function, or range of motion could be demonstrated. For the outcome of recovery time, no benefit was shown when comparing compression with no compression. Evidence was insufficient to inform a conclusion about the outcomes of time to return to work or sport. All evidence was of low to very low certainty.

CONCLUSIONS

The evidence for the use of a compression wrap was limited to patients with closed ankle injuries. In this systematic review, we could not demonstrate either a beneficial or harmful effect from the application of a compression or elastic bandage compared with no compression or a noncompressive stocking, splint, or brace as a first aid treatment in the prehospital environment.

Conservative treatment of Freiberg's infraction using foot orthoses: A tale of two prescriptions presented as a case study to open debate

'Freiberg's infraction or disease' is an osteonecrotic process primarily affecting the 2^nd & 3^rd metatarsal heads. Early diagnosis is difficult, and the underlying pathogenesis remains unclear. Surgical options for late disease have been widely reported in the literature, yet details on conservative management for the early stages of Freiberg's are largely absent. Pathology should be treated where possible using an evidence-based approach, yet evidence for conservative management in acute stages of Freiberg's is lacking. A case study is presented that outlines two different prescription interventions using foot orthoses; one that attempted to 'offload' the metatarsal head by creating space beneath it; and one that attempted to 'offloaded' by increasing controlled loading of the metatarsals proximal to the head. These resulted in very different outcomes for the patient. The authors will attempt to give a 'pathomechanical rationale' for the treatment outcomes based on mechanical stress principles, and a consequential explanation as to why one type of insole prescription seemed more successful in reducing symptoms and raising activity levels, while another was not.

Properties and Function of the Flexor Hallucis Capsularis Interphalangeus Tendon

INTRODUCTION

The fibrocartilagenous plantar plates of the forefoot are biomechanically important, forming the primary distal attachment for the plantar aponeurosis. They are integral to the function of the windlass mechanism in supporting the arches of the foot in gait. Dissection of the cadaveric hallux revealed an organised sagittal thickening of the dorsal side of the flexor hallucis longus (FHL) sheath, which attached the interphalangeal plantar plate to the metatarsophalangeal (MTP) plantar plate. A description of a similar structure was made in 1984 when it was termed the flexor hallucis capsularis interphalangeus (FHCI) - however, it has not been researched since, and we aim to study it further and identify its characteristics.

METHOD

Eight specimens were dissected from four cadavers. Two were stained and examined under magnification in both polarized and non polarized light. The remaining 6 were subjected to micrometer testing of their tensile properties.

RESULTS

Both the histological features and mechanical properties were consistent with tendon; with cross sectional area, ultimate tensile strength and stiffness varying between specimens.

CONCLUSIONS

Based on its location and properties, the FHCI tendon may be involved in limiting dorsiflexion of the first MTP joint and could have clinical relevance in pathological processes around both the first and second MTP joints. Clin. Anat., 33:689-695, 2020. © 2019 Wiley Periodicals, Inc.

Subchondroplasty of the Foot: Two Case Reports

Early avascular necrosis of metatarsal heads and cuboid injuries are uncommon conditions encountered by foot and ankle specialists. Treatment options are limited and typically include long periods of offloading or non-weightbearing. There is limited published information on alternative treatment approaches for such pathologies when conservative therapies fail. Presented are 2 patient cases treated with a percutaneous calcium phosphate injection after failure of standard therapy, persistent pain, and bone marrow edema in the foot.

Imaging Features of Avascular Necrosis of the Foot and Ankle

Avascular necrosis of the foot and ankle is a rare but important cause of pain and functional abnormality. This process may occur in any bone in the foot and ankle; however, it presents most often in characteristic locations. Understanding of key radiographic findings is important in management of these lesions. MRI is the most sensitive and specific method for detection and characterization of this abnormality.

Freiberg Disease and Avascular Necrosis of the Metatarsal Heads

Freiberg disease is characterized as osteochondrosis of the second metatarsal head. It is the fourth most common form of primary osteochondrosis with a significant predilection to the adolescent athletic female population, although it has been seen over a wide age range. If treated early, osteochondroses such as Freiberg disease are essentially self-limiting, often resolving with nonoperative management. When surgery is warranted, it is imperative the patient's age, activity level, and degree of articular deformity be taken into account.

Functional Outcomes of Local Pedicle Graft Interpositional Arthroplasty in Adults With Severe Freiberg's Disease

BACKGROUND

Conservative treatment or debridement is generally sufficient for Freiberg's disease grades I and II but operative intervention for the late stages of the disease process (III-V) is more challenging. Debridement alone is not sufficient and various forms of arthroplasty have been put forward. We have evaluated the outcomes of patients treated with an interpositional arthroplasty technique using a pedicle graft of periosteum and fat made into a "Rollmop" spacer for severe Freiberg's disease. No results have previously been reported for this technique.

METHODS

Twenty-five consecutive cases (23 patients) were performed from February 2009 to September 2016 (20 females, 5 males). Mean age at surgery was 52.6 years (range 19-70.5 years) with 92% affecting the second metatarsal. Twenty-three were primary cases and 2 were revision cases. Five cases were stage III, 12 were stage IV, and 8 were stage V. All patients underwent interpositional arthroplasty using a periosteum and fat pedicle graft from the affected metatarsal shaft as described by Myerson. Patients were evaluated using Manchester-Oxford Foot Questionnaire (MOXFQ) and American Orthopaedic Foot & Ankle Society Questionnaire (AOFAS). Mean follow-up was 3.5 years (0.6-7.6 years). Paired 2-tailed Student t tests were used to assess clinical significance.

RESULTS

Surgery allowed 8 patients to return to normal footwear, 10 patients returned to fashion footwear/heels, and 5 returned to sports. Nineteen cases (17 patients) were assessed with patient-reported outcome measures and all showed a clinically and statistically significant improvement in their scores. Mean pre- and postoperative VAS pain scores were 6.2 (range 4-9) and 1.8 (range 0-6) ( P < .05). Mean perioperative AOFAS scores were 45.6 (range 15-73) and 82.7 (range 57-100) ( P < .05). Mean perioperative MOXFQ scores were 60.0 (range 23-89) and 18.1 (range 0-80) ( P < .05).

CONCLUSION

This novel interpositional arthroplasty technique using a "rollmop" of periosteum and fat for severe Freiberg's disease produced significant improvements in pain, functional outcome, and patient satisfaction without donor site morbidity. Furthermore, it allowed patients to return to desired footwear and sporting activities. The functional outcome and joint range of motion was superior after a K-wire was no longer placed across the joint, and we believe it is essential to avoid this to permit early range-of-motion exercises.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Treatment of Freiberg Disease

Freiberg disease, or osteochondrosis of the lesser metatarsal head, usually involves the second metatarsal and presents during the second or third decades of life. Conservative measures to relieve pressure on the affected metatarsal head are the first-line treatments, with good success for Smillie stage I to III disease. Operative treatments are divided into joint-preserving and joint-reconstructing procedures. Although multiple case series describe success with numerous techniques, there are no established guidelines for treatment. All surgical techniques carry a risk of a stiff or floating toe and transfer metatarsalgia. This article reviews the current surgical treatment options for Freiberg disease.

Long-term Follow-up of Dorsal Wedge Osteotomy for Pediatric Freiberg Disease

BACKGROUND

Treatment for Freiberg disease has been largely conservative despite availability of various operative options for severe or refractory cases. The aim of this study was to evaluate the long-term results of pediatric patients with symptomatic Freiberg disease treated with intra-articular dorsal wedge osteotomy.

METHODS

Pediatric patients treated for Freiberg disease with surgery between January 1982 and 1999 were identified and selected for long-term clinical evaluation. Patients were evaluated regarding operative satisfaction and clinical outcome, performed according to the American Orthopaedic Foot & Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal scale and range of motion (ROM) of metatarsophalangeal (MTP) joint. Patients had radiographic assessment of degenerative joint status with anteroposterior and oblique foot x-ray. Twenty patients (18 female, 2 male; mean age 15.2 years; range 12-17 years) were identified. The mean follow-up period was 23.4 (range 15-32) years.

RESULTS

The clinical outcomes of our patients were classified as excellent in 16 (80%) and good in 4 (20%). The AOFAS mean score was 96.8 (range 91-100) points at the last clinical appointment. A negative correlation between AOFAS score and time of follow-up (r's = -0.61, P < .001) was found. Also, a strong negative correlation was found between Smillie classification and AOFAS final score (r's = -0.88, P < .001).

CONCLUSION

The patients were very satisfied with pain and quality of life at a mean follow-up time of 23.4 years. To our knowledge, this is the first long-term follow-up report supporting the procedure described by Gauthier and Elbaz as a good option for operative treatment of Freiberg disease.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Surgical Management of Freiberg's Infraction: A Systematic Review

Avascular necrosis of the second metatarsal head was first described by Freiberg in 1913. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. Should conservative treatment fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown. This systematic review was undertaken to determine which surgical procedure allows for the best resolution of symptoms and return to activity. Included studies were restricted to articles published in English language peer-reviewed journals that consecutively enrolled patients of all ages, with Freiberg's infraction of any stage, who underwent operative treatment, and had a mean follow-up of greater than or equal to 12 months duration. Eighty-five publications were identified, of which 38 (44.7%) met all the inclusion criteria. Surgical techniques and outcomes were grouped into joint sparing and joint destructive procedures. A total of 70 joint destructive procedures were performed with a combined mean follow-up time of 15.0 months. A greater than 70% resolution of pain and full return to activity was reported. A total of 257 joint sparing procedures were performed with a combined mean follow-up of 30.4 months. A greater than 90% resolution of pain and full return to activity was reported. Results of this systematic review reveal that the results of joint sparing procedures are reported more often and appear to have a better prognosis for symptom resolution and return to activity. Smillie stage was not consistently reported, making it difficult to determine its effect on procedure selection.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Systematic review of Level IV studies.

Interpositional arthroplasty with palmaris longus tendon graft for osteonecrosis of the second metatarsal head: a case report

Osteonecrosis of the second metatarsal head is often attributed to Freiberg's disease. We describe the case of a 27-year-old Taiwanese male soldier with persistent painful disability of the right forefoot of 9 months' duration, but no history of trauma. A series of radiographs suggested the diagnosis of late-stage Freiberg's disease. The lesion was treated with interpositional arthroplasty using a palmaris longus tendon graft, in a modification of the traditional interpositional arthroplastic technique for treating Freiberg's disease. After 2 years of follow-up examinations, the patient was satisfied with the clinical outcome, despite having a limited range of motion of the right second metatarsophalangeal joint relative to the adjacent toes. The patient returned to his army group with functional activity that was better than he had experienced before surgery. We believe this modified interpositional arthroplastic treatment strategy will provide more symptom relief and satisfactory functionality for the treatment of late-stage Freiberg's disease.

Single-photon Emission Tomography/Computed Tomography Delineation of Freiberg Infraction

The role of nuclear medicine diagnostic bone scanning is well established and the influence of coregistration between single-photon emission computed tomography and computed tomography well documented. This case provides an insight into a less frequently encountered pathology in which the combination of single-photon emission computed tomography and computed tomography permitted the differentiation of potential pathology.

Freiberg's infraction: diagnosis and treatment

Freiberg's infraction is a condition of cartilage degeneration of the lesser metatarsal heads. Adolescent females are the "textbook" patients but both males and females may present with this condition later in life. The second and third metatarsals are the most commonly affected, while involvement of the fourth and fifth is rare. The incidence is higher in females than in males. The pathophysiology is unknown, but studies suggest a combination of vascular compromise, genetic predisposition, and altered biomechanics. Diagnosis is made clinically and imaging is used to confirm. Early in the process, radiographs are normal however bone scans may demonstrate a photopenic center with a hyperactive collar and magnetic resonance imaging can reveal hypointensity of the metatarsal head. As Freiberg's infraction progresses, radiographs show a flattened and fragmented metatarsal head. Nonoperative treatment is based on decreasing foot pressure and unloading the affected metatarsal. Spontaneous healing with remodeling may occur in early stages of the disease. Operative options are dorsal closing wedge osteotomies, osteochondral transplant, and resection arthroplasty. Currently, we do not understand this disease sufficiently to prevent its occurrence. Outcomes of nonoperative and operative management are good to excellent and most patients are able to return to previous activity.

Osteochondral distal metatarsal allograft reconstruction: a case series and surgical technique

BACKGROUND

Painful degenerative diseases of the metatarsophalangeal joints (MTPJs) are frequently progressive and difficult to treat. Traditional operative treatments such as debridement, distal metatarsal osteotomies, and arthroplasty present a unique set of complications, and pain and deformity may still occur. Osteochondral distal metatarsal allograft reconstruction (ODMAR) is presented as a salvage procedure, reserved for patients with significant bone loss or avascular necrosis in whom traditional interventions have failed or are inadequate to address the underlying joint deformity.

METHODS

A retrospective review identified all ODMAR cases performed by the senior author over the past 10 years. Patient symptoms, satisfaction, and MTPJ range of motion were measured at each postoperative evaluation. Graft healing and subsequent degenerative changes at the MTPJ were observed at each visit with foot radiographs. The surgical techniques for both first and lesser metatarsal reconstructions are described.

RESULTS

Six patients were identified with average follow-up interval of 36 months (range, 6-66). Preoperative diagnoses included infection (1), fracture (1), and avascular necrosis (4). Mean total arc of motion was 40 degrees (range, 30-50). All patients maintained viability of the allograft metatarsal head and joint space was normal or Kellgren-Lawrence grade 1 in 5 of 6 patients at final follow-up. All patients demonstrated osseous union of the metatarsal osteotomy site. No patients have undergone revision surgery to date.

CONCLUSIONS

ODMAR is a safe and effective procedure for treatment of painful, degenerative conditions of the MTPJs. Further studies are required to determine the definitive indications and long-term outcomes for this procedure.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A simple surgical technique for treatment of Freiberg's disease

BACKGROUND

Of all the osteochondrosis, Freiberg's disease is reported to be the fourth most common, exceeded by Köhler's disease, Panner's disease, and Sever's disease. This disease usually occurs in the 2nd metatarsal head and relatively in the 3rd and 4th metatarsal heads.

OBJECTIVE

The purpose of this study was to evaluate the outcome of debridement, synovectomy, dorsal closing wedge osteotomy and pin fixation for Freiberg's disease treatment.

METHODS

Ten female patients, mean age 18.3 years; (ranged 14-24 years) were treated by the above mentioned technique. The main presenting symptom was pain on walking or sport; affected their daily life and activities and was not improved by non-surgical treatment. The second metatarsal head was affected in all patients. Halve of patients had a history of trauma. According to Smillie's classification, four patients were type V and six patients were type IV. Mean follow-up period was 19.2 months (range 6-36 months).

RESULTS

Were assessed by the Lesser Metatarsophalangeal-Interphalangeal (LMPI)Scale by Kitaoka et al. At the final follow up, scoring was changed from (44-76) with an average 57 to (66-100) with an average 80. There was no case of infection, avascular necrosis, arthritis or pseudoarthrosis.

CONCLUSION

We founded that dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

Freiberg's disease: quantitative assessment of osteonecrosis on three-dimensional CT

BACKGROUND

The extent of necrosis is the main determining factor in the outcome of osteonecrosis. There is no method for measuring the extent of osteonecrosis of the metatarsal head in Freiberg's disease. The purpose of this study was to determine the reliability and prognostic ability of a new method for measurement of the extent of osteonecrosis in Freiberg's disease on three-dimensional computed tomography.

METHODS

A retrospective review of 11 cases with symptomatic Freiberg's disease in ten patients (5 males and 5 females; mean age, 27 years) undergoing computed tomography between July 2005 and September 2007 was performed. Two investigators (K.A.C. and H.K.O.) used a new method to measure the necrotic extent of the metatarsal head: the necrotic angle ratio of necrotic arc angle to normal arc angle of the articular surface on the sagittal reconstruction image of computed tomography. The interobserver reliability was determined for computed tomography measurement. Correlation between the Smillie staging using radiographs and the necrotic angle ratio on computed tomography was also evaluated.

RESULTS

One patient presented with stage I disease (Smillie staging), one with stage II, two with stage III, five with stage IV, and two with stage V, respectively. The necrotic angle ratio of the metatarsal head was 14% in stage I, 21% in stage II, 34% in stage III, 43% in stage IV, and 53% in stage V. The interobserver reliability for computed tomography measurement was high (Cronbach α=0.96). We found the increase of the necrotic extent in proportion to the Smillie stage. The Smillie staging using radiographs and the necrotic angle ratio on computed tomography were significantly correlated. (P<0.05)

CONCLUSIONS

Three-dimensional computed tomography measurement of the necrotic extent of the metatarsal head is a reliable and useful method in evaluating the staging of Freiberg's disease and may eventually help to optimize treatment.

Freiberg's disease

Freiberg’s disease is a relatively uncommon disorder of the metatarsal head. Although trauma and circulatory disturbances likely contribute major roles in its development, it is widely accepted that Freiberg’s etiology is multifactorial. Conservative treatment, focused on offloading and relieving stress, is uniformly accepted as the appropriate initial management. Surgical management can broadly be categorized as procedures which attempt to correct the pathophysiology and halt its progression, and procedures which address the sequelae of later stage disease. Newer strategies, including osteochondral transplantation, attempt to restore the damage metatarsal cartilage with a viable osteochondral plug.

Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head

BACKGROUND

The second metatarsal head is commonly involved in cases of metatarsalgia. As part of the conservative treatment, metatarsal bars and metatarsal pads are often prescribed.

OBJECTIVE

To compare the effectiveness of metatarsal bars and metatarsal pads in reducing impulse on the second metatarsal head.

METHOD

Thirty-five healthy subjects were monitored with an insole scanning system during walking in four different conditions: (a) wearing shoes only, (b) shoes plus metatarsal pads and shoes plus metatarsal bars, placed either (c) perpendicular to the foot axis or (d) oblique to the foot axis. The impulse under the second metatarsal head was measured using the first condition as a control. Both feet were examined in each subject resulting in a total of 840 measurements.

RESULTS

Both metatarsal bars and metatarsal pads were effective in reducing impulse when compared with the control (P<0.01). Metatarsal bars were found to be more effective in reducing impulse as compared to the metatarsal pads (P<0.01), and the oblique position of the bars was more effective than the perpendicular one (P<0.01).

CONCLUSIONS

The greatest reduction of impulse on the second metatarsal head in healthy subjects is achieved with the use of metatarsal bars in an oblique position.

Autologous osteochondral plug transplantation for osteochondrosis of the second metatarsal head: a case report

Introduction

Osteochondrosis of the second or third metatarsal head is a rare condition called Freiberg's disease. To relieve foot pain, conservative treatment with a foot orthosis to reduce weight-bearing and immobilize the foot are recommended. In cases in which such treatments have proved to be ineffective, several surgical treatments have been performed. The appropriate surgical treatment for Freiberg's disease remains controversial.

Case presentation

We describe the case of a 20-year-old Japanese woman with a three-year history of right forefoot pain and no history of trauma. Two years after treatment by autologous osteochondral plug transplantation, she has neither complaints nor symptoms.

Conclusion

Autologous osteochondral plug transplantation represents a potentially successful surgical arthroplastic option in preserving the metatarsophalangeal joint in patients with Freiberg's disease.

Case series of 17 modified Weil's osteotomies for Freiberg's and Köhler's II AVN, with AOFAS scoring pre- and post-operatively

BACKGROUND

Treatment for metatarsal head avascular necrosis is largely conservative. For severe or refractory cases there are various surgical options.

METHODS

We have performed a 'modified Weil's osteotomy' of the distal metatarsal in order to manage this problem. We present the largest case series, to our knowledge, with 17 such cases. The patients were scored pre- and post-operatively using the AOFAS Forefoot scoring system.

RESULTS

We found that this procedure provided a mean score improvement of 36 points, with a complication rate of 5.9%.

CONCLUSION

We would advocate this modified osteotomy as an effective, reliable and safe treatment option.

Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence

To summarize the best available evidence in the last decade for managing ankle sprains in the community, data were collected using MEDLINE database from January 2000 to December 2009. Terms utilized: 'ankle injury primary care' (102 articles were found), 'ankle sprain primary care' (34 articles), 'ankle guidelines primary care' (25 articles), 'ankle pathways primary care' (2 articles), 'ankle sprain community' (18 articles), 'ankle sprain general practice' (22 articles), 'Cochrane review ankle' (58 articles). Of these, only 33 satisfied the inclusion criteria. The search terms identified many of the same studies. Two independent reviewers reviewed the articles. The study results and generated conclusions were extracted, discussed and finally agreed on. Ankle sprains occur commonly but their management is not always readily agreed. The Ottawa Ankle Rules are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited.

Treatment of late-stage Freiburg's disease using a temporary metal interpositional device

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.

Late-stage Freiberg disease treated by osteochondral plug transplantation: a case series

BACKGROUND

The purpose of this study was to investigate the clinical, radiological and arthroscopic results of osteochondral plug transplantation for late-stage Freiberg disease.

MATERIALS AND METHODS

We examined 4 consecutive cases of late-stage Freiberg disease of the second metatarsal head. All 4 patients were female with an average age of 12. Osteochondral plug transplantation was performed, harvesting from a nonweightbearing site of the upper lateral femoral condyle of the ipsilateral knee. Clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal Scale was performed before surgery and at the final followup. Magnetic resonance imaging (MRI) was performed before surgery and at 6 and 12 months after surgery. Furthermore, arthroscopic evaluation was performed at 12 months after surgery. The mean follow up was 52 (range 36 to 72) months.

RESULTS

At the final follow up, the average AOFAS score improved from 70.8 points preoperatively to 97.5 points. Although MRI at 6 months after surgery showed an obvious but slight osteochondral plug-subchondral bone interface, healing of the osteochondral plug was confirmed at 12 months after surgery in all patients. With respect to the patients' arthroscopic findings at 12 months after surgery, two of our patients had an International Cartilage Repair Society Cartilage Repair Assessment Score of normal and 2 had a score of nearly normal.

CONCLUSION

Osteochondral plug transplantation for late-stage Freiberg disease yielded satisfactory results upon arthroscopic and radiological evaluations at 12 months after surgery and clinical evaluation for all four cases.

Freiberg's disease in the Emergency Department

Freiberg's disease is an avascular necrosis affecting the second, third, or, rarely, the fourth metatarsal head. It is typically a chronic, progressive process, eventually causing pain and loss of normal function of the metatarsophalangeal joint. Normally, patients present to the Emergency Department with atraumatic foot pain, however, as we illustrate with this case, an acute fracture may occur, requiring recognition and appropriate treatment. Our patient presented with acute pain, swelling, and point tenderness of the forefoot after a minor fall. Radiographs revealed a fracture through the head of the second metatarsal and underlying avascular necrosis consistent with Freiberg's disease. Identifying the underlying chronic process was important in understanding how minor trauma resulted in a fracture in this patient.

Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.

Treatment of Freiberg disease with intra-articular dorsal wedge osteotomy and absorbable pin fixation

BACKGROUND

The purpose of this study was to evaluate the outcome of intra-articular dorsal wedge osteotomy and absorbable pin fixation for the treatment of Freiberg disease.

METHODS

From January of 1997, to July of 2003, 12 patients with symptomatic Freiberg disease had intra-articular dorsal wedge osteotomy through the affected metatarsal head fixed with absorbable polyglycolide pins. All 12 patients were women with an average age of 36 (range 16 to 59) years. The Smillie stage of necrosis ranged from II to V. Active range-of-motion exercise was allowed after 4 weeks of short-leg walking cast wear, and weightbearing on the forefoot was allowed after radiographic union was achieved. The mean followup was 45 (range 22 to 84) months.

RESULTS

Radiographically, solid healing of all osteotomies was observed at an average of 10 (range 8 to 16) weeks. There was no evidence of displacement, osteolysis, sinus formation, or progression of osteonecrosis at final followup. Pain measurement on a visual analog scale had improved significantly from an average of 8.0 to 2.3 (p<0.05). The range of motion of the metatarsophalangeal joint increased by a mean of 26 (range 5 to 60) degrees. All patients were satisfied with the results and would have the surgery again.

CONCLUSIONS

In patients with Freiberg disease, intra-articular dorsal wedge osteotomy restores congruity of the metatarsophalangeal joint, and fixation with absorbable pins provides adequate fixation and avoids a second procedure for implant removal.

Freiberg's infraction in identical twins: a case report

Freiberg's infraction is an ostechondrosis of a lesser metatarsal head resulting in degeneration of the metatarsophalangeal joint. Several mechanisms have been suggested in its pathenogenesis. Freiberg first described the entity and believed single impact trauma was the underlying cause. Repetitive biomechanical microtrauma is the most widely accepted etiologic theory. Other factors contributing to its development include aseptic necrosis, ischemia, and a congenital predisposition. We present a case report of Freiberg's infraction occurring in identical twins involving multiple metatarsals in various stages of degeneration. One of the twins was affected unilaterally whereas the other twin was affected bilaterally. Both twins had involvement of the second metatarsal on the same side extremity. The occurrence of Freiberg's infraction in identical twins suggests that an underlying congenital predisposition to the condition may play more of a role than previously considered.

Freiberg's Infraction in an Adolescent Dancer: Condition Often Mistaken for a Stress Fracture

Freiberg's infraction is not widely seen but can occur among young athletes. Its symptoms and radiographic signs may mimic stress fractures, as in the 12-year-old female dancer described here. This condition, an osteochondrosis that most commonly affects the second metatarsal, is diagnosed with plain radiography. Treatment typically involves immobilization or off-loading to eliminate pain, use of orthoses, and a gradual return to weight-bearing activity.

Regional musculoskeletal conditions: foot and ankle disorders

Foot pain is very common, especially in women, owing to inappropriate footwear. Overuse, repetitive strain and minor, easily forgettable injuries may result in chronic foot and ankle pain. Rheumatoid arthritis, spondyloarthropathies and gout frequently affect the foot, often as a first presentation. Charcot's joints and foot infections are not rare in diabetes. The rheumatologist should be familiar with foot disorders, either localized or as manifestations of generalized disease. History taking, physical examination, identification of the source of pain by intra-articularly given local anaesthetics and imaging methods should be used to reveal the underlying disorder. Correct diagnosis and efficient therapy-including local steroid injections, physiotherapy, orthoses, surgery-are necessary not only for treatment but also for preventing biomechanical chain reactions. This chapter gives an overview of the epidemiology, diagnosis and treatment of foot pain and foot disorders caused by both local and generalized diseases.

A new surgical technique for treating bilateral Freiberg disease

Freiberg disease is relatively rare and difficult to treat satisfactorily. We describe a new surgical technique of osteochondral plug transplantation for late-stage Freiberg disease that may restore normal function to the metatarsophalangeal joint. In the present series, we performed osteochondral plug transplantation to treat a stage IV lesion, according to Smillie's classification, by harvesting an osteochondral plug from the non-weight-bearing site on the upper lateral femoral condyle of the ipsilateral knee. We also treated a stage II lesion using retrograde drilling. One year after surgery, the patient had no pain when running and returned to full athletic activity. The clinical and morphologic results were excellent. Arthroscopic intervention produced good results in the early stages and osteochondral plug transplantation may be an excellent surgical procedure to restore normal function to the metatarsophalangeal joint in the later stages of Freiberg disease.

Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging

Many disorders produce discomfort in the metatarsal region of the forefoot. These disorders include traumatic lesions of the soft tissues and bones (eg, turf toe, plantar plate disruption, sesamoiditis, stress fracture, stress response), Freiberg infraction, infection, arthritis, tendon disorders (eg, tendinosis, tenosynovitis, tendon rupture), nonneoplastic soft-tissue masses (eg, ganglia, bursitis, granuloma, Morton neuroma), and, less frequently, soft-tissue and bone neoplasms. Prior to the advent of magnetic resonance (MR) imaging, many of these disorders were not diagnosed noninvasively, and radiologic involvement in the evaluation of affected patients was limited. However, MR imaging has proved useful in detecting the numerous soft-tissue and early bone and joint processes that occur in this portion of the foot but are not depicted or as well characterized with other imaging modalities. Frequently, MR imaging allows a specific diagnosis based on the location, signal intensity characteristics, and morphologic features of the abnormality. Consequently, MR imaging is increasingly being used to evaluate patients with forefoot complaints. Radiologists should be familiar with the differential diagnosis and MR imaging features of disorders that can produce discomfort in this region.

Anterior lateral ankle ligament damage and anterior talocrural-joint laxity: an overview of the in vitro reports in literature

OBJECTIVE

To provide a clear overview of the literature on the relationship between increased lateral ankle ligament damage and anterior talocrural-joint laxity.

DESIGN

A systematic review of the literature.

BACKGROUND

Diagnostic methods for inversion injuries of the ankle have remained controversial throughout the years. An instrumented test for anterior talocrural-joint laxity could be a diagnostic tool for evaluation of anterior lateral ankle ligament function.

METHODS

An advanced electronic database search using MEDLINE and EMBASE was performed to find studies describing the correlation between lateral ankle ligament damage and talocrural-joint laxity. Two reviewers assessed the methodological quality for each study and agreement was noted. Two reviewers extracted all relevant data with respect to methodology, motion constraints and laxity measurement.

RESULTS

The quality assessment resulted in 5 studies being scored as high quality and 5 as low quality. Different test devices were used to apply the load and measure the displacement. All in vitro tests applied a load to the calcaneus and subsequently measured the translation of the talus and/or calcaneus relative to the tibial dome. Rotation in the transversal and frontal plane was restricted in 8 tests. After analysis of the results presented by nine different studies, the mean value of anterior talocrural-joint laxity with intact ligaments is 4.2 mm. After sectioning of the anterior talofibular ligament, the mean anterior laxity value is 6.5 mm. The mean anterior laxity value after sectioning of the calcaneofibular ligament increases to 8.4 mm. The mean anterior laxity value with the foot in dorsal flexion (3.1 mm) is less than the mean value with the foot in neutral position (4.5 mm) or in plantar flexion (4.7 mm). The applied load and the anterior laxity values between the different studies vary greatly.

CONCLUSIONS

Each ligament section results in significantly increased talocrural-joint laxity. Talocrural-joint laxity can be used as a measure for damage to the anterior talofibular ligament and/or the calcaneofibular ligament. From this review, it is neither possible to give universal recommendations about the optimal flexion angle for testing talocrural-joint laxity as a measure for lateral ankle ligament function, nor to recommend the ideal load for performing the test.

RELEVANCE

The development of an instrumented test as a diagnostic tool for anterior talocrural-joint laxity in the clinical setting is near at hand and practicable.

Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage. The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.

Forefoot problems in athletes

Athletes who participate in high-impact sports involving running, jumping, or contact are at risk for forefoot injury. These injuries occur as a result of acute trauma or chronic overuse. Some athletes may be predisposed to injury because of preexisting foot deformity, such as cavus, hallux valgus, or Achilles contracture. This article reviews the common causes of forefoot pain in the athlete. The most common causes of forefoot pain in the athlete are metatarsal stress fracture, interdigital neuroma, sesamoid pathology, metatarsalgia, hallux rigidus, hallux valgus, and turf toe. The pathophysiology, clinical presentation, and treatment of these conditions are discussed.