Subchondral insufficiency fracture of the second metatatarsal head in an eldery woman treated with autologous osteochondral transplantation

Freiberg's infraction is a rare disorder that arises mostly in adolescent athletes. We describe a 77-year-old woman with the collapse of second metatarsal head with similar clinical appearance to Freiberg's infraction. Radiological findings at initial visit of our hospital were normal. Her condition was obscure and magnetic resonance imaging showed the subchondral insufficiency fracture with bone marrow edema to the second metatarsal head. Despite the conservative treatment, the second metatarsal head collapsed. She was surgically treated with an osteochondral autograft without complications relating surgery. Furthermore, the histological findings showed that the site of collapse was considered to be secondary lesions resulting from the subchondral insufficiency fracture.     

Freiberg disease complicating unrelated trauma

Freiberg's infraction is an avascular necrosis of the metatarsal head characterized by the development of disorderliness of chondrogenesis and osteogenesis in previously normal bone. Radiographic findings follow the pathological progression of bony changes. The presented cases document the development of avascular necrosis in a previously normal metatarsal that occurred after trauma or surgery elsewhere in the foot. It is suggested that infraction of the metatarsal head resulted from microfracture caused by abnormal stress.     

Freiberg's infraction: a subchondral bone fatigue fracture. A new surgical treatment.

Observations on plantar pressure points suggest that Freiberg's infraction is osteonecrosis of the second or third metatarsal head resulting from a subchrondral bone fatique fracture. A series of 53 cases were successfully treated by deflexion osteotomy of the involved metatarsal head.     

Freiberg's infraction: a case from medieval Kent

A. M. Freiberg described a condition in which a collapse of the juvenile second metatarsal head gave rise to localized pain and swelling.¹ This eponymous disease is traditionally classed as one of the osteochondroses: a group of disparate lesions which typically manifest as destruction of an immature epiphysis. A medieval second metatarsal is presented, which by osteological and radiological examination is diagnostic of Freiberg's infraction. Apparently, this is the first evidence that the condition is not confined to modern day populations.²     

Freiberg's infraction of the second metatarsal head with formation of multiple loose bodies

Freiberg's infraction is an osteonecrotic disease process that most often involves the head of the second metatarsal. Establishing a diagnosis can be difficult early in the disease course, mimicking such pathologic processes as stress fracture, septic joint infection, tumors, metatarsalgia, various arthritic diseases, etc. A review of the literature reveals many treatment options and many theories of its etiology. The clinical signs and symptoms, review of the etiologies, radiographic presentation, and conservative and surgical treatments of this disease are presented. A case history and treatment summary of a patient afflicted with Freiberg's infarction involving the second metatarsophalangeal joint of the right foot is presented. Treatment consisted of evacuation of multiple loose bodies from the joint, resection arthroplasty of the diseased joint, and insertion of a total joint prosthesis.     

A case of Freiberg's disease in an adult patient

Freiberg's disease is an osteochondrosis of the IInd metatarsal head that prevalently develops during the second decade of life and that is the cause of important painful symptoms that resist conservative treatment. The disease is quite rare and must be treated surgically during its early phase in order to prevent progression that may result in permanent changes in the metatarsal head. It is the purpose of this study to describe the clinical case of a patient aged 30 years affected with Freiberg's disease, diagnosed at the age of 15 years, and never submitted to either conservative treatment or surgery.     

Interpositional arthroplasty with extensor digitorum brevis tendon in Freiberg's disease: a new surgical technique

BACKGROUND: Freiberg's infraction is an osteochondrosis of a lesser metatarsal head resulting in joint degeneration. There is no consensus regarding the management of these lesions. Here, we describe an interpositional arthroplasty using extensor digitorum brevis tendon as a solution for Freiberg's disease. MATERIALS AND METHODS: Between 2003 and 2006, 6 women and 4 men with Freiberg's disease unresponsive to conservative treatment were operated with interpositional arthroplasty with extensor digitorum brevis tendon. Mean age was 34 (range, 20 to 48) years and followup time 24.6 (range, 12 to 36) months. The transferred tendon was passed through a tunnel, centered, stabilized and rolled into a ball following the debridement of joint. According to the Smillie classification, there were 3 grade II, 5 grade III, and 2 grade IV. The AOFAS scoring system was used for clinical assesment. RESULTS: The mean preoperative and postoperative AOFAS scores were 58.3 (range, 44 to 77) and 80.4 (range, 67 to 100), respectively. The complaint of pain with joint motion was decreased in all patients except one. The postoperative passive range of motion of joints did not differ significantly. We found 4 excellent (40%), 5 good (50%) and 1 poor (10%) result. CONCLUSION: We recommend our technique of interpositional arthroplasty with the extensor digitorum brevis tendon because it is free of additional donor site morbidity. It can be performed easily without specialized instruments. Also, the use of natural tissue eliminates potential foreign body reactions and risk of infection.     

Identical twins with subretinal neovascularization complicating senile macular degeneration

This is the first report, to our knowledge, of proliferative macular degeneration developing in the same eye of identical twins. The concept of a familial predisposition in age related macular degeneration is consistent with other known risk factors including race, iris pigmentation, hyperopia and macular drusen which are known to be genetically determined. Monozygotic twins provide ophthalmology with an excellent opportunity to study the hereditary aspects of ocular disease.     

Assessment of etiologic factors in the development of Freiberg's disease

The etiologic factors in the development of Freiberg's disease are assessed in a consecutive series of 31 patients (33 feet). No evidence was found for the commonly held view that the condition is precipitated by trauma (in only 5 feet (15%), was there a history of injury to the foot). Similarly, pedobarographic studies failed to show high pressure at the affected metatarsal head. However, in 28 feet (85%), the affected metatarsal was the longest in the foot. The importance of this and other possible etiologic factors is discussed.     

Treatment of Freiberg's disease. A new operative technique

A method of treating Freiberg's disease of the metatarsal head by shortening the metatarsal bone is described. This operation has been performed in 15 patients (16 feet). Excellent relief of pain was obtained, although most patients had persistent stiffness of the metatarsophalangeal joint.     

Mirror-image trigger thumb in dichorionic identical twins

The congenital vs acquired etiology of pediatric trigger thumb is the subject of considerable debate. Existing case reports of bilateral presentation in identical twins and first-degree familial association support the congenital hypothesis. However, prospective studies have yet to report a neonate presenting with this anomaly at birth. This article describes the first known set of dichorionic, monozygotic identical twins with unilateral trigger thumbs, affecting contralateral (mirror-image) hands and with asynchronous age at presentation (11 months and 18 months, respectively).Pediatric trigger thumb is caused by a mismatch between the flexor pollicis longus tendon and its A1 synovial pulley. Four sets of twins have been previously reported in the literature with trigger thumb. Of these, 3 sets were monozygotic twins who had bilaterally affected thumbs. Together with the absence of trauma, a congenital etiology was suggested. The fact that pediatric trigger thumb is generally seen several months after birth was felt to be due to infants holding their thumbs clutched in their palms until 6 months. However, no confirmed cases of trigger thumb have been diagnosed at birth in several large prospective studies of newborns.In the current case, the asynchronous presentation of unilateral trigger thumbs in identical twins does not support a solely congenital cause. Furthermore, the mirror-image presentation contradicts current embryological understanding of the temporal course of twinning and the determination of laterality. Thus, a multifactorial etiology is supported with both a genetic and acquired component affecting the development of this condition.     

Etiology of Freiberg's disease: ? trauma

Freiberg's disease is osteochondritis of the metatarsal head(s) commonly occurring in adolescent girls. The true etiology is unknown. The authors present a case precipitated by a form of folk dancing popular among British schoolgirls.     

Joint occurrence of aseptic necrosis of the head of the third metacarpal and Freiberg's disease

Freiberg's disease of the second metatarsal was found together with the aseptic necrosis of the head of the third metacarpal in a 54-year-old female patient. No similar case was found in the available literature. The deformity of the second metatarsophalangeal joint was corrected with an operation, the alteration of the third metacarpal did not need operative correction.     

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.     

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.     

Freiberg’s infraction: A modified closing wedge osteotomy for an undiagnosed case

IntroductionFreiberg’s infraction is an osteonecrosis affecting the metatarsal head whose pathogenesis is not fully understood, although stress overloading by multiple microtraumas remains the most widely accepted cause. Operative treatment, by different techniques, is necessary when conservative treatment fails.Presentation of caseA 31-year old woman presented with left foot severe pain, especially at the level of the metatarsophalangeal joint (MTPJ) of the second ray, underestimated upon initial evaluation. She had a history of repetitive microtraumas, a long second metatarsal bone and altered forefoot kinematics. Clinical and radiographic findings were compatible with Freiberg’s infraction. A dorsal closing-wedge osteotomy with single screw stabilization was performed. At last follow-up, the patient was completely asymptomatic with a normal MTPJ range of motion.DiscussionOur patient had a history of repetitive microtraumas combined with a long second metatarsal bone and altered forefoot kinematics. Initially, because of the low frequency of the disease and lack of knowledge about it, even among general orthopaedic surgeons, the infraction was not diagnosed. However, the radiological characteristics of the lesion, combined with intra-operative observation and histological exams associated with the medical history and clinical exam of the patient, revealed a disease compatible with Freiberg’s syndrome. A closing-wedge osteotomy, performed by using a straight burr, appeared to be the most correct treatment.ConclusionThis case shows how Freiberg’s infraction can pass unrecognized or underestimated and how dorsal closing-wedge osteotomy can be an efficient surgical treatment.     

Hemivertebra in monozygotic twins.

STUDY DESIGN: A case report. OBJECTIVES: To report and discuss a case of thoracic hemivertebra in monozygotic twins. SUMMARY OF BACKGROUND DATA: The etiology of congenital scoliosis remains unclear. Both a genetic basis and environmental influences have been postulated. A few isolated reports of discordant spinal anomalies in twins exist. METHODS: Clinical examination and plain radiograph evaluation were performed on female monozygotic twins with congenital scoliosis secondary to thoracic hemivertebra. RESULTS: Congenital thoracic scoliosis was documented in both of a set of monozygotic twins. CONCLUSIONS: To the authors' knowledge, this is the first report of similar congenital vertebral abnormalities in identical twins in the English literature.     

A PULSATILE GLUTEAL MASS DUE TO SCIATIC ARTERY ANEURYSM

A persistent sciatic artery is a rare congenital anomaly where the internal iliac artery and the original axial artery of the embry continue to provide the major blood supply to the lower limb after birth. Its predisposition to atherosclerosis, aneurysmal degeneration of its gluteal segment and association with other congenital anomalies are important for its management. W report a patient who highlights these aspects and we provide a brief review of this unusual condition.     

Posterior urethral valves in siblings

The etiology and incidence of posterior urethral valves is unknown. We report on a pair of non-twin siblings with identical pathology stemming from type I posterior urethral valves as well as discordance in a pair of monozygotic twins. Familial posterior urethral valves have been reported before in both twin and non-twin siblings. The occurrence of identical pathology in non-twin siblings suggests the possibility of an inherited trait as does its occurrence in identical twins. However, non-identical clinical manifestation is as common as is identical presentation in both groups. There are also instances of discordance in monozygotic twins suggesting the possibility of a random mutation. As such, we recommend urologic evaluation of the male siblings of affected patients with posterior urethral valves. Further prospective and retrospective analyses are needed to define the genetic etiology of valves.