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.     

Avascular necrosis after first metatarsal head osteotomies

Thirty patients who were surgically treated for hallux valgus by first metatarsal head osteotomies between 1975 and 1980 were reviewed. The average follow-up was 41 months, with the longest being 78 months and the shortest 16 months. Radiographs were obtained to determine if avascular necrosis of the first metatarsal head had occurred. Two cases of avascular necrosis were discovered.     

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.     

Austin bunionectomy: postoperative MRI evaluation for avascular necrosis.

The authors used magnetic resonance imaging (MRI) to evaluate the formation rate of avascular necrosis following performance of 20 modified Austin bunionectomies. Five modified McBride bunionectomies without first metatarsal osteotomy were also performed as an MRI control. Results showed an avascular necrosis formation rate of 50%. The majority of the avascular necrosis areas were found dorsally within the cancellous bone substance of the first metatarsal head. These lesions, in all cases, did not cause any patient disability or result in any decline in the degree of patient satisfaction. The MRI positive avascular necrosis evaluations do suggest potential problem areas with the surgical technique that may be eliminated through further modification of the classic Austin bunionectomy procedure.     

Idiopathic Avascular Necrosis of First Metatarsal Head in a Pediatric Patient

Idiopathic avascular necrosis of the first metatarsal head rarely occurs in pediatrics. The present case of avascular necrosis of the first metatarsal head occurred in a 13-year-old male who came to the clinic with a 9-month history of pain in the first metatarsophalangeal joint. Conservative treatment had been applied for 9 months, but the pain had not been relieved. Therefore, surgical treatment, including decompression and debridement, was performed in the first metatarsal head of the patient. After 6 months of follow-up monitoring, full range of motion of the first metatarsophalangeal joint was observed, and the pain had disappeared. No any other complications had developed during 18 months of follow-up monitoring.     

Clinical results of Keller's arthroplasty

Fifty cases of hallux valgus treated by Keller's arthroplasty were reviewed over an average period of 91 months. This revealed radiographic changes in the first metatarsal head suggestive of avascular necrosis (AVN) in as many as eight feet. The blood supply to the first metatarsal head and probable cause of these AVN changes are discussed.     

The use of surgical core decompression as treatment for avascular necrosis of the second and third metatarsal heads

Freiberg's disease, a type of avascular necrosis, is an idiopathic osteochondrosis disorder affecting epiphyses of developing bones in children, particularly the second metatarsal with respect to the foot. This disorder can be caused by acute trauma and has been documented that exacerbation of it is present in patients with an elongated second metatarsal, thus, making it more vulnerable to repetitive trauma. Here we present a patient with a chief complaint of a painful mass. Radiographic and repetitive MRI findings were used to diagnose the patient with Freiberg's disease. Following the benefit time of conservative care, surgical core decompression was the surgical course of treatment. Core decompression has been routinely used to prevent structural changes in the metatarsal head and to relieve pain by decreasing the increased intraosseous pressure associated with avascular necrosis and allowing for revascularization of the necrotic area. The use of surgical core decompression with respect to the metatarsal head is relatively new; but has been routinely used for the hip and knee. Whether or not this form of surgical treatment will prevent recurrence is uncertain; further long-term studies are needed.     

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.     

Osteochondral Fracture of the Fourth Metatarsal Head Treated by Open Reduction and Internal Fixation

Fracture of the metatarsal head is uncommon, and reports of isolated osteochondral fracture of the metatarsal head are rare. Because of the distal location of the fracture, it is difficult to achieve and maintain reduction, and potential complications include avascular necrosis and subchondral fatigue fracture. The authors present a case of an osteochondral fracture in a 40-year-old man, which was treated by open reduction and internal fixation with a single twist-off screw, with good results 12 months postoperatively.     

Reconstruction of the ulnar head with a vascularized second metatarsal head: case report

A case of a young patient with avascular necrosis of the ulnar head following a severely displaced ulnar head fracture is presented. Treatment included debridement of the entire ulnar head, leaving the ulnar styloid, sigmoid notch, triangular fibrocartilage, and both distal radioulnar ligaments intact. The head of the ulna was reconstructed by transferring a vascularized second metatarsal head. At 4-year follow-up, the patient had a pain-free wrist with 45° active pronation and 65° supination. He resumed working without limitations as a manual laborer. We conclude that ulnar head reconstruction with a vascularized second metatarsal head is worthwhile in the setting of an unreconstructable traumatic defect, particularly when the sigmoid notch and distal radioulnar ligaments are preserved.     

Distal soft tissue procedure in hallux valgus surgery: biomechanical background and technique

The distal soft tissue procedure has evolved into an indispensable additional surgical procedure to increase the corrective effect in hallux valgus surgery. Considering the biomechanical development of hallux valgus deformity, degenerative changes of the soft tissues around the first metatarsophalangeal joint contribute much more to the deformity than changes in the bony structures which can rather be seen as degenerative changes secondary to the deformity. Thus the principles in hallux valgus correction should aim to reverse all pathogenetic steps leading to deformity: release of the contracted lateral soft tissue structures, tightening of the torn-out medial structures and reduction and rebalancing the first metatarsal head onto the sesamoid complex. The scientific discussion over the last decades has clarified the impact of different surgical steps and methods on the efficacy of the lateral release, the risk of creating overcorrection or instability of the joint and the risk of avascular necrosis of the first metatarsal head. According to anatomical and clinical data, a lateral soft tissue release can be combined with a distal metatarsal osteotomy, provided that the osteotomy is performed in a defined safe zone without increasing the risk for avascular necrosis of the first metatarsal head. Transecting the lateral metatarsosesamoid suspensory ligament is the key to a successful lateral release in hallux valgus surgery. Release of the deep transverse metatarsal ligament and the adductor hallucis muscle does not contribute to hallux valgus correction. The lateral short sesamophalangeal ligament and the plantar attachment of the articular capsule should be preserved to avoid possible joint instability. Thus today, the distal soft tissue procedure cannot be seen only as a supplementary surgical procedure in cases where the bony procedure needs additional correction, but rather is an indispensable procedure to restore the physiological situation and function of the first metatarsophalangeal joint.     

Bone marrow edema of the forefoot after chevron osteotomy--a rare cause of metatarsalgia: a case report

Treatment options of bone marrow edema syndrome, which is associated with vascular disturbances, are protracted nonoperative treatment or core decompression which still demands several weeks until complete recovery. We obtained excellent results by the use of the vasoactive drug iloprost, a stable prostacyclin analogue, leading to a complete relief of symptoms in cases of bone marrow edema which had initially suggested early avascular necrosis of the second metatarsal head. The bone marrow edema of the second metatarsal bone was thought to be due to altered biomechanics following a distal first metatarsal chevron osteotomy. During the five days of iloprost infusion, the patient reported relief of rest pain. After therapy, the pedobarogram was normalized. The AOFAS forefoot score improved from 44 to 85 points after one month, and to 95 points after three months. At that time, the marrow showed normal signals. Without additional intervention the patient was able to resume normal activities.     

Tc-SN-pyrophosphate scintigraphy following traumatic posterior dislocation of the hip

Avascular necrosis of the head of the femur is a serious complication of traumatic dislocation of the hip joint; therefore ^99mTc-SN-pyrophosphate scintigraphy was carried out 10 to 14 weeks (average 12 weeks) after the injury on 12 patients to determine whether it was possible to demonstrate reduced or no activity of the head of the femur before development of radio-logical avascular necrosis of the head of the femur.

Increased activity was observed in 9 of 11 hips with fracture-dislocation of the head of the femur, acetabulum or both, and normal activity was demonstrated in the contralateral hip of all patients.

During the follow-up period avascular necrosis of the head of the femur developed in four hips from 6 to 20 months after the accident.

It is concluded that ^99mTc-SN-pyrophosphate scintigraphy 12 weeks after traumatic dislocation of the hip was unable to identify hips at risk of later development of avascular necrosis of the head of the femur.     

Avascular necrosis of the hallux metatarsal head

Avascular necrosis of the first metatarsal head is rare. Although idiopathic cases have been reported, AVN of the first metatarsal head is usually iatrogenic following surgical correction of hallux valgus using a distal metatarsal osteotomy with or without lateral soft tissue release. A thorough understanding of the delicate vascular anatomy of the first metatarsal head is essential when surgery is considered. Careful operative technique permits a safe combination of distal osteotomy and lateral soft tissue release. Because the intraosseous blood supply is completely disrupted with distal metatarsal osteotomy, excessive capsular release and saw blade penetration into the lateral capsular vessels must be avoided. Among the thousands of reported distal metatarsal osteotomies performed using a variety of technique modifications of the original procedure described by Austin, the prevalence of AVN is low. Undoubtedly, the first metatarsal head has an excellent capacity to accommodate to changes in its blood supply. Although radiographic changes are frequently observed in the metatarsal head following a distal metatarsal osteotomy with or without lateral release, rarely do these changes progress to symptomatic AVN. These transient radiographic findings probably represent an adjustment period as the metatarsal head recovers from vascular compromise. Not only is AVN of the first metatarsal rare, but it is rare for it to be symptomatic. Many more cases that are never identified may exist. Management of symptomatic AVN of the first metatarsal head has not been standardized because of the infrequency of this condition. Anecdotal experience suggests that simple activity and shoe modifications may suffice; however, joint debridement and metatarsal head decompression may prove beneficial as they have in the management of other joints more commonly afflicted with AVN. Finally, severe head collapse may be salvaged with MTP joint arthrodesis. In the event that a substantial amount of avascular bone must be removed, consideration can be given to bone block distraction arthrodesis to avoid transfer metatarsalgia.     

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.     

The arterial supply of the lesser metatarsal heads: a vascular injection study in human cadavers

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones. We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals. The metatarsal heads had two arterial sources: 1. The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and 2. The plantar metatarsal arteries, which are branches of the posterior tibial artery. These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone. Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.     

Low-grade Osteomyelitis of the Fifth Metatarsal with Possible Concomitant Freiberg’s Disease of the Metatarsal Head

Freiberg’s disease, metatarsal avascular necrosis, is most often seen in healthy athletic adolescent girls. Presenting symptoms include vague pain, swelling, and loss of motion in the involved metatarsophalangeal joints. Low-grade osteomyelitis often is difficult to identify. In this case report, we present a 14-year-old girl with low-grade osteomyelitis of the fifth metatarsal accompanied by possible Freiberg’s disease in the same metatarsal.     

Sesamoid disorders of the first metatarsophalangeal joint

The sesamoid complex is located centrally and plantar to the first metatarsal head, where they are imbedded within the plantar plate, which transmits 50% of body weight and more than 300% during push-off, is susceptible to numerous pathologies. These pathologies include sesamoiditis, stress fracture, avascular necrosis, osteochondral fractures, and chondromalacia, and are secondary to these large weight-bearing loads. This article discusses sesamoid conditions and their relationship with hallux limitus, and reviews the conditions that predispose the first metatarsophalangeal joint to osteoarthritic changes.     

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     

髓芯减压＋自体外周血干细胞移植治疗早期股骨头缺血性坏死

目的探讨应用髓芯减压＋自体外周血干细胞移植治疗股骨头缺血性坏死（ANFH）的疗效。方法对61例Ⅰ、Ⅱ期的ANFH患者采用髋关节髓芯减压入路＋自体外周血干细胞移植方法治疗。结果所有患者随访6～32个月,疼痛均消失,行走正常,髋关节活动范围正常或接近正常,CT或MRI片示股骨头轮廓清晰,囊性变消失,骨密度均匀,关节间隙正常。结论髋关节髓芯减压＋自体外周血干细胞移植手术治疗早期ANFH具有损伤小、简便、准确、有效的优点。