Review Question - QID 217422

The patient is presenting with early-stage Freiberg's disease that has failed an initial course of conservative management. The best next treatment option is 2nd MTP joint debridement and metatarsal osteotomy.

Freiberg's disease is the idiopathic osteonecrosis and fracture of the metatarsal head. Some evidence suggests the relatively long 2nd metatarsal combined with gastrocnemius contractures are predisposing factors. Initial treatment consists of a short period of immobilization followed by shoe modifications in early radiographic disease. Surgical treatment consists of joint debridement and metatarsal osteotomy for stage II and III disease. Partial metatarsal head resection or interpositional arthroplasty is recommended for stage IV and V disease.

Carmont et al. reviewed the pathophysiology, presentation, and treatment of Freiberg's disease. The authors proposed the relatively long second metatarsal and lack of mobility from the keystone effect within the TMT joint leads to increased loads across the 2nd MTP joint. They concluded nonoperative treatment for early disease can result in pain relief and prevent deformity progression.

Seybold and Zide reviewed the treatment of Freiberg disease. The authors stated that first-line conservative treatment consists of oral anti-inflammatories and shoe modifications or metatarsal pads to offload the affected MTP joint. The authors recommended joint debridement with metatarsal osteotomy for Smillie stage II and III disease and interpositional arthroplasty for stage IV and V disease.

Figure A is an AP radiograph of the right foot with Freiberg's disease of the 2nd metatarsal head. Illustration A is a diagram depicting the Smillie classification.

Incorrect answers
Answers 2, 3, and 4: Surgical treatment for stage 2 Freiberg's disease after failing conservative treatment is 2nd MTP joint debridement and metatarsal osteotomy.
Answer 5: Continued conservative management is not likely to benefit the patient at this time.