Freiberg’s Disease

First reported by Freiberg 1914

• 6 cases
• used term ‘infraction’ due to history of associated minor trauma to foot

Kohler 1915

• described osteonecrosis of 2nd metatarsal

Also Known as

• ‘egg shell’ disease
• peculiar characterisitc metatarsal disease
• metatarsal epiphysitis
• osteochondritis deformans metatarsojuvenilis
• malakopathie

Epidemiology

• 4th most common osteocondrosis of the body
• Location
  • 2nd metatarsal head 68%
  • 3rd 27%
  • 4th 3%
  • 5th very rare
• Bilateral and multiple have been reported
• Teenage females
• 5 F : 1 M
• Dominant foot 36%

Aetiology

Theories

• trauma
  • second metatarsal is longest
    • sustains greatest stresses during normal activity
    • keystone at TMTJ
    • least mobile
    • ? reason for being most affected Metatarsal
  • metatarsus primus varus
    • instability of first ray
    • increases load on second metatarsal
  • shoewear
    • higher female incidence
    • high heels hoes caise repetitive forced dorsiflexsion and dorsal impingement on MTPJ
  • skeletal immaturity
    • adolescence is typical time of onset
    • weakness of metatarsal epiphysis at certain stage of epiphyseal maturation
    • centre of ossification
      • lesser metatarsals
        • 5-8 years old
        • fusion 18-20 years old
• impaired vascularity
  • supply
    • branches of medial deep plantar artery and dorsal metatarsal artery
  • ? aberrant anatomy
  • ? vessels injured when joint compressed or swollen after injury
• systemic disorders
  • SLE
  • Hypercoaguability
  • increased intraosseous pressure
  • Little evidence

Anatomy

second metatarsal is longest

• sustains greatest stresses during normal activity
• keystone at TMTJ
• least mobile
• ? reason for being most affected Metatarsal

skeletal immaturity

• adolescence is typical time of onset
• weakness of metatarsal epiphysis at certain stage of epiphyseal maturation
• centre of ossification
  • lesser metatarsals
    • 5-8 years old
    • fusion 18-20 years old

blood supply

• branches of medial deep plantar artery and dorsal metatarsal artery

Pathogenesis / Pathology

Osteonecrosis phases in general

• ischaemia
• infarction
• necrosis
• subchondral fracture with collapse of articular surface
• resorption
• remodelling

Stage	Macroscopic description
I	fissure develops in the ischemic epiphysis. opposing cancellous bone on either side of the fissure appears sclerotic.
II	Collapse. central resorption of bone within the metatarsal head causes the subchondral bone to subside.
III	peripheral irregularities. continued resorption allows the subchondal bone to sink further centrally into the head, creating peripheral irregularities of the intact joint surface. an isthmus of the articular cartilage on the plantar aspect of the metatarsal head remains intact.
IV	Osteochondral Loose body.
V	Flattening deformity and arthrosis. Only the plantar aspect of the metatarsal head where the final isthmus of cartilage fractured retains its original contour.

Classification

Stage	Macroscopic description
I	fissure develops in the ischemic epiphysis. opposing cancellous bone on either side of the fissure appears sclerotic.
II	Collapse. central resorption of bone within the metatarsal head causes the subchondral bone to subside.
III	peripheral irregularities. continued resorption allows the subchondal bone to sink further centrally into the head, creating peripheral irregularities of the intact joint surface. an isthmus of the articular cartilage on the plantar aspect of the metatarsal head remains intact.
IV	Osteochondral Loose body.
V	Flattening deformity and arthrosis. Only the plantar aspect of the metatarsal head where the final isthmus of cartilage fractured retains its original contour.

Stage	Description
0
I	consolidation may occur without sequelae
II	Head flattened
III	Damage is irreparable
IV	Arthrosis

Type	Features	Treatment
I	No degenerative joint disease intact articular cartilage	NWB with metatarsal pad Low heel
II	periarticular spurs articular cartilage intact	Stop sports Cheilectomy Debridement
III	severe degenerative joint disease loss of articular cartilage	Du Vries arthroplasty +/- debridement +/- volar soft tissue interposition
IV	epiphyseal dysplasia multiple head involvement	as indicated for types I, II, III

History

• Typical presentation
  • female adolescent
    • growth spurt
    • pain
      • 2nd metatarsal head
      • worse with weight bearing
      • may wake patient from sleep

Examination

Look

• swollen
• hyperkeratosis
• associated hallux valgus deformity
  • 50%

Feel

• palpable effusion or synovitis
• loose bodies

Move

• range of movement
  • reduced
• crepitance

Special Tests

• Lachman
  • MTP joint instability
  • grading
    • amount of proximal phalanx that can be uncovered vertically
  • technique
    • head of metatarsal between finger and thumb
    • other hand firmly grasping the base of proximal phalanx
    • dorsal pressure applied
  • positive test
    • displaces dorsally
    • reproduces patient’s symptoms

Investigations

Xray

Stage	Description
I	joint space widening due to inflammation and synovitis * appears 3-6 weeks following onset of symptoms
II	flattening of metatarsal head on AP xray
III	progressive central joint depression (due to subchondral bone collapse at the dorsum while the medial and lateral plantar aspects remain intact) * main need oblique lateral xray
IV	loose bodies
V	complete degeneration of joint

MRI and Bone Scan

Theoretically useful, but only case studies in literature of being used to diagnose early disease

Differential Diagnosis

• stress fractures
• joint sepsis
• tumour
• metatarsalgia
• arthritis

Treatment

Nonoperative

• Aim
  • improve symptoms
  • prevent deformity
• Indications
  • early disease
• Options
  • Analgesia
  • activity modification
  • protected weight bearing
    • crutches
  • shoewear modification
    • hard-soled shoe | boot | cast | rocker bottom sole
  • orthotics
    • metatarsal bar
  • traction
    • continuous skelelal traction for 30 days
    • metal arch extending beyond toes supported from a below knee cast
    • level IV evidence
  • alendronate
    • has been shown to prevent collapse of femoral head (Level 1 evidence)
    • nothing to support use in Freiberg’s

Operative

• Core Decompression
  • only case reports (level 4 evidence)
  • 1.1 mm K wire used to drill mulitple holes in metatarsal head
• Open Joint Debridement (level 4 evidence)
  • excision of thickened synovium
  • removal of loose bodies
  • delaminated articular cartilage
  • resection of osteophytes
  • preserve intact plantar aspect
  • +/- K wire across joint
  • +/- short leg walking cast
  • results
    • level 4 evidence
    • all patients experience improvement
    • 80% return to normal ROM
• Arthoscopic Joint Debridement
  • only case studies
• Perichondral grafting
  • Aim
    • Stage I -III
    • elevate depressed articular fragment with bone grafting
  • Technique
    • cut slot in dorsum of MT shaft
    • subchondral sclerotic bone drilled
    • cancellous bone graft
• Autogenous epiphysiodess
  • rectangular portion of bone (2 x 0.75 cm) removed, rotated and re-inserted
• Metatarsal Osteotomies
  • Shortening Osteotomies
    • 4mm shortening
    • dorsal T plate
    • beware dorsiflexion contracture and stiffness
  • Dorsal wedge osteotomy
    • wires used to fix bone
• Excisional and Interpositional Arthroplasty
  • Excision
    • alone may bread alignment of metatarsal arch
    • lead to deformity of toes
    • transfer metatarsalgia
    • gait disturbance
  • Interposition
    • may help with the above problems
    • Soft tissue used
      • flexor and extensor tendons
      • joint capsule
• Joint replacement

Prognosis

Depends on stage of diseaes

References

Jaaos

Author Contribution