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Updated: Oct 22 2022

Freiberg's Disease

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  • summary
    • Freiberg's Disease is a rare foot condition characterized by infarction and fracture of the metatarsal head.
    • Diagnosis is made radiographically with plain radiographs showing subchondral sclerosis, flattening of the involved MT head and eventual joint destruction in advance disease. MRI studies may be needed to detect early disease.
    • Treatment is activity modification and NSAIDs in early disease. Surgical management is indicated for progressive pain, joint destruction and joint deformity. 
  • Epidemiology
    • Demographics
      • female to male = ~ 4:1
      • most commonly seen in patients 13-18 years
      • more common in female adolescent athletes
    • Anatomic location
      • most often seen in 2nd metatarsal (MT) head, particularly the dorsal aspect
      • 4th and 5th MT rarely affected
    • Risk factors
      • more common in patients with long 2nd metatarsals
  • Etiology
    • Pathophysiology
      • thought to be related to a disruption in the blood supply due to microtrauma or osteonecrosis and stress overloading
        • leads to eventual collapse of 2nd MT head
  • Classification
      • Smillie Classification
      • Stage 1
      • Subchondral fracture visible only on MRI
      • Stage 2
      • Dorsal collapse of articular surface on plain radiographs
      • Stage 3
      • Collapse of dorsal MT head, with plantar articular portion intact
      • Stage 4
      • Collapse of entire MT head, joint space narrowing
      • Stage 5
      • Severe arthritic changes and joint space obliteration
  • Presentation
    • Symptoms
      • forefoot pain, swelling and stiffness localized to head of the second MT
        • worse with weight bearing activities
    • Physical exam
      • inspection
        • peri-articular swelling
      • motion
        • exacerbated by distraction (early stages) and compaction (later stages)
        • limitation of motion in 2nd MTP joint
  • Imaging
    • Radiographs
      • recommended views
        • AP, lateral, obliques of foot
      • findings (see Smillie classification)
        • subchondral sclerosis in early disease
        • flattening of involved MT head
        • joint destruction in late disease
        • defect is usually located in the upper half of the articular surface of the MT head
    • MRI
      • findings
        • can show patchy edema in metatarsal head
  • Treatment
    • Nonoperative
      • activity limitations, NSAIDS, immobilization
        • indications
          • early stage of disease
        • technique
          • short leg walking cast or boot for 4-6 weeks
            • can be used if symptoms are severe and do not improve with orthotics
          • stiff-soled shoe with MT bars or pads
            • typically used after period of casting
    • Operative
      • metatarsophalangeal arthrotomy with removal of loose bodies
        • indications
          • very rarely indicated
          • only if extensive nonoperative management fails
      • dorsal closing-wedge osteotomy
        • indications
          • dorsal disease involvement of bone and cartilage
      • DuVries arthroplasty (partial MT head resection)
        • indications
          • severe stage 4 or 5 disease
          • plantar cartilage is not sufficient to reconstruct joint
          • can consider adding capsular interposition after joint debridement
  • Techniques
    • Metatarsophalangeal arthrotomy with removal of loose bodies
      • approach
        • lesser toe MTP joint approach
      • technique
        • may be combined with drilling of metatarsal head, subchondral bone grafting, and interposition arthroplasty using EDL tendon
        • metatarsal head resection should be avoided due to increased loads on adjacent metatarsal heads
    • Dorsal closing-wedge osteotomy
      • goals
        • shortening offloads stress on metatarsal head
        • resects collapsed dorsal diseased bone and cartilage
      • approach
        • lesser toe MTP joint approach
      • technique
        • bring less affected plantar cartilage into contact with proximal phalanx
  • Complications
    • Degenerative joint disease
      • of 2nd MTP joint in adulthood
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