freibergs disease infraction cover

Freiberg infraction

case presentation

A healthy, 21-year-old man presented with a 1-year history of persistent right mid to forefoot pain. His pain was worse with activity.  Swelling, tenderness and restricted motion of the second metatarsophalangeal (MTP) joint were evident, especially during dorsiflexion; a positive Lachman test suggested MTP joint instability. A right foot X-ray showed that one of his metatarsal heads was flattened and sclerotic and had joint surface irregularity.  Which of the following is the most likely diagnosis metatarsal involved?

A. Kohler’s disease, navicular
B. Kohler’s disease, second metatarsal
C. Freiberg infraction, second metatarsal
D. Freiberg infraction, cuboid

introduction

Freiberg infraction, or Freiberg’s disease, is an osteonecrosis of the metatarsal head bone, which was firstly described in 1914 [1].  It was initially named “infraction” because of the initial association with minor trauma to the foot.  Freiberg disease most often affects the second MTP joints and is less frequently observed at the third, fourth, and fifth MTP joints.  Sports medicine providers must be aware of this condition and it should be in the differential with individuals with midfoot pain.

Freiberg infraction pattern results in flattening and collapse of the head of the second metatarsophalangeal joint, leading to degenerative changes and progressing to arthritis. It is the fourth most common form of primary osteochondrosis with a significant predilection to the adolescent athletic female population, although it has been seen over a wide age range.

It is generally accepted that the condition is of multifactorial cause, including trauma, foot mechanics, and arterial insufficiency.  There are several identified systemic risk factors for Freiberg disease, including hypercoagulability, systemic lupus erythematosus, and diabetes mellitus, but research surrounding these is sparse [2,3].

Freiberg infraction x-ray

Image 1: Freiberg infraction x-ray showing flattening of the second metatarsal head.  Adopted from [21].

The patient will most likely present with insidious onset or progressive onset pain.  Rarely will a patient present with acute onset of pain secondary to a specific inciting injury. This is likely to be related to microtrauma in the form of minor repeat assault and  abnormal weight bearing and gradual overload to dorsal aspect of the joint, causing undue trabecular stress at the epiphysis [4].

Vascular flow to the lesser metatarsal heads is supplied by the dorsal metatarsal arteries and the plantar metatarsal arteries, which are a branch of the posterior tibial artery. It can be surmised that anatomic variants lacking a source of arterial flow are predisposed to ischemia, as shown by Wiley and Thurston in their cadaveric injection studies, whereby second metatarsals lacking normal arterial flow were instead supplied by collateral vessels from the first and third metatarsals [5].

The disease is most commonly observed overlying the second MTP joint with an estimated 68% of cases. It has been known to affect the third MTP (27%),  fourth MTP (3%), and the fifth MTP (<2%) [6]. Less than 10% of patients with Freiberg disease present with bilateral symptoms.

physical examination

Patients predominantly complain of pain overlying the plantar forefoot at the level of the second MTP joint (or other lesser MTP), exacerbated by walking barefoot or while wearing shoes with poor forefoot rigidity and/or elevated heel. Physical examination likely reveals a joint effusion and exquisite plantar/dorsal tenderness directly overlying the affected joint. There may be loss of MTP motion, palpable crepitus, increased anterior laxity or a claw or crossover toe deformity. 

imaging

Most providers will begin imaging with plain radiographs.  Anteroposterior, lateral, and oblique weight-bearing radiographs of the affected foot are most common. It is worth noting that early radiographic evaluation of osteochondroses such as Freiberg disease is often unremarkable [7].  The earliest radiographic manifestation of Freiberg disease is observed approximately 3 to 6 weeks following initial onset of symptoms and is characterized as subtle joint space widening.   As the condition progresses, gradual collapse of the affected metatarsal head may be observed dorsally [8]. 

Magnetic resonance imaging (MRI) is frequently performed if Freiberg infraction is suspected or confirmed.  It  is important both from a staging standpoint as well as for preoperative planning. Before plain radiographic findings, early stage Freiberg disease may be apparent on MR images demonstrating increased marrow signal. Important factors include location of articular compromise, location of articular preservation, osseous defects, presence of intra articular loose fragments and bone marrow edema. Preservation of more plantar articular cartilage is best assessed on the sagittal images, which is necessary if a rotational osteotomy is to be considered as a treatment option [9]. 

Freiberg infraction staging

Figure 2.  Classification system for Freiberg infraction.  Adopted from [14].

Smillie was the first to describe a system of staging based largely on surgical findings but is also applicable to radiographic appearance.  It is the most widely used classification system currently [10].  The first stage represents the development of a chondral fissure overlying the epiphysis of a mildly osteopenic metatarsal head secondary to ischemia.  The second stage is the earliest to be observed radiographically, demonstrating a mildly sunken appearance of the central aspect of the dorsum of the metatarsal head.  The third stage shows a further sunken appearance overlying the metatarsal head due to gradual resorption. These findings are accompanied by subsequent development of bony projections both medially and laterally. The plantar articular cartilage remains intact.  During the fourth stage, the bony projections fracture, forming intra articular loose bodies, and the plantar articular cartilage isthmus give way. Evolution at this point is incapable of anatomic restoration.  Finally, the fifth stage is composed of joint arthrosis. 

treatment

Nonoperative management is usually attempted with the goal to alleviate symptoms and minimize epiphyseal deformity to limit the progression to arthritis.   Activity modification, protected weight-bearing (stiff-soled shoe, fracture boot, or cast), shoe wear modifications, and oral anti-inflammatory medications are utilized in this early treatment.   Shoe wear modifications may include orthoses with metatarsal bars designed to offload the painful metatarsal head have been shown to help patients respond without long-term disability. There are also many “rocker bottom” shoes available for purchase at many stores.  Most patients with Smillie stage 1 through 3 respond to conservative treatment and obtain long-term success [11].

Rocker bottom shoes

Figure 3.  Types of “rocker bottom” shoes .  Adopted form [22].

Corticosteroid  injections may be considered as a means of improving an acutely inflamed joint or for symptomatic management in some cases.    Corticosteroid injections may also be used as a diagnostic tool to differentiate a Freiberg infraction or Morton’s neuroma in some cases.  As with most chronic degenerative conditions, this is unlikely to provide lasting relief but may be a temporary measure. Regenerative medicine injections including platelet-rich plasma, stem cell, amniotic tissue, and exosomes may have a role in reparation of the cartilage deficiency.  There have been minimal published reports on either corticosteroids or PRP in the treatment of Frieberg infraction. 

Operative management of Freiberg infraction should be reserved for patients whose pain and functional limitations are unacceptable with nonsurgical management.  To date, numerous surgical procedures have been described for the treatment of Freiberg’s disease, including osteotomies, debridement, core decompression and microfracture. Additionally, other surgical procedures such as autographs, allographs, and arthroplasties have also been used to manage patients with Freiberg’s disease.

Surgical treatment many times can be grouped into “joint preserving” and “joint sacrificing.” When planning surgical options, consideration into joint deformity, length and mobility of the first ray, second metatarsal length, and other factors such as gastrocnemius contracture need to be factored into decision-making [19].

Options for joint preservation include debridement, osteotomy, and cartilage replacement. These may be performed separately or in combination.   Both open and arthroscopic techniques can be utilized. Open debridement is performed through a standard dorsal approach to the MTP joint. Although this may provide pain relief, it may be a temporary measure because the cartilage deficit persists. Freiberg and others have reported debridement of the joint with overall favorable results using both open and arthroscopic techniques [12-14].

Osteotomies for Freiberg disease include rotational and shortening options. If the cartilage on the plantar aspect of the metatarsal head is relatively free of wear, rotation of the head via a dorsal closing wedge osteotomy can be performed. In cases where the second metatarsal is long leading to further overload at the second MTP joint, shortening the metatarsal at the same osteotomy site or proximally is recommended.

The dorsiflexion osteotomy has been described as intraarticular or extraarticular osteotomy.  Using a dorsal approach, an oblique dorsal closing wedge osteotomy directed in a dorsal distal to plantar proximal direction is used to orient the plantar cartilage into a position that articulates with the proximal phalanx. Various fixation methods have been proposed, but rigid screw fixation is preferable resulting in a stable construct that allows for immediate weight bearing and early joint mobilization. Pereira and colleagues  showed very favorable long-term follow-up at a mean of 23.4 years using this approach in 2016 [15]. 

Dorsiflexion osteotomy

Image 4: Images from a dorsiflexion osteotomy  Adopted from [19].

Cartilage replacement can consist of autogenous osteochondral grafting, osteochondral allograft, or chondral allograft.  Much like in other joint surfaces with osteochondral deficiencies, osteochondral transplantation from the “less essential” portion of the distal femur can be used both to fill the osseous void associated with late-stage Freiberg disease and to replace the deficient joint cartilage.  Osteochondral allograft reconstruction can be used in a similar manner to autogenous grafting or as a joint salvage via a bulk allograft.  Studies are very limited with allografts.

For interpositional arthroplasties, the use of autogenous or allograft soft tissue grafts as a biological spacer have been described with favorable outcomes as a means of providing a “new” joint space to the diseased second MTP joint [16-18].  Using a standard dorsal approach, various tissues including the dorsal capsule, extensor digitorum longus, or extensor digitorum brevis have been used to create a space between the metatarsal head and the proximal phalanx. 

Autograft vs. Allograft Freiberg

Figure 5.  Studies comparing autografts and allografts in the treatment of Freiberg infraction.  Adopted from [20].

Summary

In conclusion, Freiberg infraction is an uncommon disease with variable presentations over a wide age range. Treatment options must take into consideration the patient’s age, symptoms, stage of pathology, and overall foot mechanics. Although radiographic or MRI findings appear significant, patients are often asymptomatic and require nonsurgical management. When symptoms warrant, and surgery is proposed, there is no clear consensus based on a limited amount of studies which option is best. Poor evidence exists overall, though many case studies and reports that show positive results.  An individualized approach taking into consideration the degree of articular deformity is recommended.

CASE CONCLUSION

Freiberg infraction results in flattening and collapse of the head of the second metatarsophalangeal joint most commonly, leading to degenerative changes and progressing to arthritis. It is the fourth most common form of primary osteochondrosis with a significant predilection to the adolescent athletic female population, although it has been seen over a wide age range.  The disease is most commonly observed overlying the second MTP joint with an estimated 68% of cases. It has been known to affect the third MTP (27%),  fourth MTP (3%), and the fifth MTP (<2%). Less than 10% of patients with Freiberg disease present with bilateral symptoms. 

Kohler’s disease is another term for avascular necrosis of the navicular bone and is seen almost exclusively in pediatric patients.  It would also present with pain over the midfoot most likely.

– Read More @ Wiki Sports Medicine: https://wikism.org/Freibergs_Disease

References

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  22. https://lermagazine.com/article/rocker-bottom-footwear-effects-on-balance-gait