Freiberg's disease and dislocation of the second metatarsophalangeal joint: etiology and treatment

Surgical and conservative treatments, based on historic and current concepts, are presented for management of Freiberg's disease and dislocation of the second metatarsophalangeal joint. A preliminary review of the interpositional arthroplasty used at the University of Texas Health Science Center is presented.     

Problems of the second metatarsophalangeal joint

Diagnosis and treatment of second metatarsophalangeal joint problems are discussed. A new staging for Freiberg's disease is presented with differential treatment for each stage. Subluxation of the second metatarsophalangeal joint occurs commonly but is often unrecognized. A simple test in physical examination, the "positive Lachman" of the metatarsophalangeal joint is illustrated and explained. Although controversial, the etiology of synovitis of the second metatarsophalangeal joint is probably diverse; it can occur idiopathically or because of mechanical instabilities relating to malalignment of the first ray or disproportionate length of the second ray. When conservative treatment fails, surgical debridement of the joint is indicated. The second metatarsophalangeal is the most common chronically dislocated joint in the foot. The surgical goal is a reduced metatarsophalangeal joint and a stable toe. Surgical correction detailed by the authors involves a stepwise approach depending on the severity of the contracture, bony overlap, and deformity.     

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.     

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.     

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.     

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 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.     

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.     

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.     

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.     

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 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.     

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.     

Disorders of the Lesser Metatarsophalangeal Joints

Pain in the region of the lesser metatarsophalangeal joints (often termed metatarsalgia) is a common complaint. It can be due to a variety of causes, and accurate diagnosis is essential for effective treatment. Understanding the anatomy and functions of the extrinsic and intrinsic musculature and the plantar plate, ligaments, and fat pad is important in evaluating metatarsophalangeal joint disorders. Claw toe is a hyperextension deformity of the metatarsophalangeal joint in combination with a hammer toe. Pathologic changes involving an isolated metatarsophalangeal joint may be due to monarticular synovitis. Systemic inflammatory disorders can cause variable degrees of instability, resulting in sub-luxation or dislocation. Other specific disorders at the lesser metatarsophalangeal joints include discrete and diffuse intractable plantar keratoses, Freiberg's infraction, and cock-up fifth toe. Once the specific pathologic entity has been determined, the appropriate course of nonsurgical or, if necessary, operative treatment can be instituted.     

Legg-Calvé-Perthes disease in hemophilia: incidence and etiologic considerations

A review of hip radiographs of patients with severe hemophilia showed Legg-Calvé-Perthes disease in four of 63 patients examined before the era of specific treatment. In another series of 44 patients receiving prophylactic treatment, there was no evidence of Legg-Calvé-Perthes disease. A case report of a boy with severe hemophilia with hip joint bleeding that caused joint capsule distention and greatly increased intracapsular pressure is presented. Based on our findings, and previously published results, we suggest that Legg-Calvé-Perthes disease in hemophilia is caused by increased intracapsular pressure secondary to hemarthrosis.     

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.     

Synovial fistula of the knee: a complication of arthroscopy.

The occurrence of a synovial fistula after knee arthroscopy is uncommon. In a retrospective review of 976 arthroscopies of the knee over 3 years, six patients developed synovial fistulae (incidence 6.1/1,000). All patients were treated with short-term immobilization and oral prophylactic antibiotics. All fistulae closed after an average of 9 days of immobilization, and none required further treatment. Risk factors that may predispose a patient to fistula formation are posterior compartment portals and the presence of significant degenerative joint disease. A treatment protocol is presented.     

Symphalangism associated with constriction rings: syndactyly and brachytelophalangy in a black patient

A 7-year-old girl presented with symptoms of constriction ring syndrome, syndactyly, and brachytelophalangy in the presence of proximal unilateral symphalangism. Physical findings revealed previous surgical correction of constriction rings of the right index and long fingers, a short right thumb with a hypoplastic distal phalanx, a shortened long finger with a stiff proximal interphalangeal joint and characteristic absence of skin creases, and incomplete syndactyly of the right first, second, and third web spaces. A brief review of symphalangism and a surgical treatment plan are presented. This is believed to be the first case report of symphalangism in a black patient with multiple congenital anomalies.     

Syringomyelia and associated bone and joint diseases

Syringomyelia can occur in patients presenting bone and joint diseases of various origins. When joint destruction of the shoulder or elbow produces little pain, a neurological cause might be involved. In this case, the disease history can be of utmost importance because an initial diagnosis of rheumatoid polyarthritis, polyosteoarthritis, or destructive joint disease can be misleading before the syringomyelic origin of the bone and joint disease becomes patent. We report two cases illustrating this association and the diagnostic pitfalls which can delay recognition of the syringomyelia. Better awareness of the prevalence of this condition should be helpful in establishing the diagnosis and in selecting patients who can benefit from neurosurgical treatment. The two cases presented here suggest that syringomyelia could be underdiagnosed in certain patients with an initially atypical presentation. A review of the current knowledge of syringomyelia suggests that arthroplasty is generally not advisable for destroyed dislocated syringomyelic joints.     

Elective free vascularized double transfer of toe joint from second toe to proximal interphalangeal joint of index finger: a case report

Alternatives to the treatment of major injuries to the proximal interphalangeal (PIP) joint include fusion, implant arthroplasty, perichondrial grafting, single autogenous free vascularized transfer, and double autogenous free vascularized transfer. A patient presented a gunshot wound to the index finger with loss of skin and extensor tendon and PIP joint disruption. The finger was reconstructed with a composite free flap of skin and extensor tendon and PIP and distal interphalangeal joints of the second toe. A follow-up of 10 months is presented, which demonstrates PIP joint motion and finger function.