Freiberg Disease Treatment & Management
- Author: Shayne D Fehr, MD, FAAP; Chief Editor: Jason H Calhoun, MD, FACS more...
Various suggestions regarding conservative therapy for Freiberg disease have been put forth in the literature, depending on the stage and the acuteness of the onset of pain. A period of appropriate nonoperative conservative management is indicated for all patients presenting with Freiberg disease. Regardless of the treatment method chosen, the goal of therapy is to rest the joint to allow inflammation and mechanical irritation to resolve.
In patients presenting with severe pain of an acute nature, a non-weightbearing cast may provide sufficient relief during the acute phase. In other persons, a short leg walking cast or hard-sole shoe may be more appropriate. Typicialy, the initial period of immobilization lasts 4-6 weeks.
In patients with chronic complaints, less restrictive options, such as shoe modifications in the form of inserts with metatarsal bars or pads, rigid shanks, or a rocker bottom, may be helpful. Activity modification during exacerbations may help to prevent the aggravating symptoms of pain and swelling.
Medications may be helpful for pain but should not be used to allow increased activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used commonly for pain, but cautious use is recommended. Although sufficient human studies are lacking, NSAIDs have been shown to delay stress fracture healing in rats.
Hoskinson reported on the long-term results (average, 12 years) of conservative treatment on a series of 16 patients. Eleven of the 16 patients were completely pain free at final follow-up; however, all 16 had some restricted ROM.
The progression of Freiberg disease is variable with regard to time course and severity. Whereas some stage I, stage II, and stage III lesions may resolve spontaneously, patients who do not respond to conservative measures and patients with stage IV and stage V lesions may require surgery. Smillie believed that it was possible to restore joint congruity in early lesions (stages I-III) with surgery.
Several surgical options have been advocated in the past. Simple debridement and loose body removal were originally described by Freiberg. Other described procedures, including various osteotomies, elevation of the depressed metatarsal head with bone grafting, core decompression, metatarsal head excision, shortening of the metatarsal, proximal phalanx hemiphalangectomy, total joint arthroplasty, and various combinations of the above, have been implemented.
No consensus exists as to which surgical procedure is the most appropriate for patients with symptomatic Freiberg disease. Common to all of these procedures is the goal of diminishing pain and restoring joint function. However, most studies have included small numbers of patients and have not been stratified by age or stage of the disease, making it difficult to draw conclusions about the potential effectiveness of these procedures. The relative rarity of the condition makes it difficult to perform prospective analyses.
Helal and Gibb suggested one pattern for management of Freiberg disease. They suggested grafting and elevation of the collapsed articular surface for patients with stage I or stage II disease. For later-stage lesions (stages III-V), they suggested tailoring the treatment to the patient's symptoms. They recommended using an osteotomy to treat patients with pressure metatarsalgia and using replacement arthroplasty to treat patients suffering from arthritic symptoms of pain with joint motion.
Although these recommendations may provide guiding principles, it is important to recognize that at present, there is no consensus as to which procedure works best for all patients. In general, if conservative treatment fails, the least destructive and invasive procedures should be considered first for patients with early-stage disease, with the more invasive, joint-altering procedures reserved for advanced cases or for patients in whom other forms of treatment have failed.
Freiberg's original monograph reported that two of his six patients had good results with debridement. The report only infers that these two patients presented with advanced-stage disease based on the presence of loose bodies. Subsequent authors also have advocated simple debridement as an effective treatment for Freiberg disease. However, staging of the lesions, as well as detailed assessment of results, has not commonly been reported, making it difficult to make recommendations based on the currently available data.
Erdil et al reported on 14 patients with advanced-stage disease of the second metatarsal; they found joint debridement and metatarsal head remodeling to be safe, simple, and effective in alleviating symptoms.
Simple debridement can be combined with other procedures. Hoskinson described 12 patients treated with various surgical procedures, including excision of the metatarsal head (n=4), hemiphalangectomy (n=4), and debridement with loose body excision (n=4). He believed that the best results were seen following simple debridement, but he warned about drawing conclusions from such limited numbers.
In an attempt to restore joint congruity, Smillie described a procedure in which a cancellous bone graft was used to elevate the depressed metatarsal articular surface. The technique involved creating a slot in the metatarsal shaft through which the sclerotic bone could be drilled. The metatarsal articular surface was then elevated and supported by a bone graft. The authors recommended this procedure for stage I, II, or III lesions in which an intact cartilage flap is present.[15, 27]
In 1987, Helal and Gibb reported on 25 patients with Freiberg disease; 11 of these patients were treated with a modification of Smillie's original procedure. The authors reported eight patients to be clinically and radiographically normal at 3-8 years following surgery. Three patients demonstrated expanded metatarsal heads radiographically, and two of the three reported pain with running or wearing high-heeled shoes.
Several different osteotomies have been described. The common goal of all osteotomies is to redirect the loading of the metatarsophalangeal (MTP) joint away from the damaged area of the articular surface. The two basic procedures are dorsal closing wedge osteotomy and shortening osteotomy.
Dorsal closing wedge osteotomy
Gauthier and Elbaz were the first to describe a dorsal closing wedge osteotomy for the treatment of Freiberg disease. They reported results from 53 patients who were treated with a dorsiflexion osteotomy of the neck of the metatarsal. As described, the dorsal closing wedge osteotomy reoriented the intact cartilage on the plantar surface to articulate with the base of the proximal phalanx. The authors reported stable results with no complications. In 35 of the 53 cases, the postoperative arc of motion averaged 80°.
Al-Ashhab et al, in a series of 10 patients, showed that dorsiflexion osteotomy of the metatarsal head was a simple procedure that was capable of good results in stage IV and stage V disease.
Chao et al reported results from 13 patients with all stages of Freiberg disease who were treated with dorsal closing wedge osteotomy combined with synovectomy and debridement. Temporary fixation with Kirschner wires (K-wires) was utilized in all patients. The patients all had follow-up visits at an average of 40 months.
The results, as graded by the American Orthopaedic Foot and Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal scale, were as follows : Four patients reported excellent results, seven good results, and two poor or fair results. Metatarsal shortening averaged 2.1 mm, with passive range of motion (ROM) decreased by an average of 15° of flexion and 8° of extension. One patient, who underwent 3 mm of shortening, experienced transfer metatarsalgia.
Kinnard and Lirette reported on 15 patients who were treated with dorsiflexion osteotomy, including several patients with advanced-stage disease. They reported complete pain relief, with only three patients experiencing mild discomfort with athletic activities. Loss of extension averaged 10°, and flexion loss averaged 15°. Metatarsal shortening averaged 2.5 mm, with no cases of transfer metatarsalgia. No major complications were reported.
Another osteotomy reported for treatment of Freiberg disease is the shortening osteotomy. The basis for the use of a shortening osteotomy is the observation that when involved, the second metatarsal often is the longest of the metatarsals. Several authors believe that this subjects the involved metatarsal to repetitive injury and abnormal loading. With shortening, overloading of the metatarsal is reduced, as are symptoms.
Smith et al described a shortening osteotomy in which the metatarsal was shortened approximately 4 mm. Of the 16 patients treated in their series, 15 had complete pain relief; however, seven of the 16 patients experienced stiffness of the involved ray, with four patients unable to place the toe flat when standing. Five patients graded their result as excellent, nine said that they were very pleased with the outcome, one was satisfied with it, and one was unhappy with the result.
Two minor complications occurred, with one sinus requiring reexploration and one hardware failure occurring despite union. Advantages cited by the authors included the ease of the procedure, avoidance of damage to the metatarsal head, and apparent remodeling of the articular surface, as seen radiographically in most cases.
Resection arthroplasty, though advocated in the past, has fallen out of favor for the initial treatment of Freiberg disease. Open and arthroscopic techniques have been described. Two of the described methods are resection of the base of the proximal phalanx or of the metatarsal head. Resection can be combined with soft-tissue interposition arthroplasty or even syndactylization of the toes, or it can be performed without these other procedures.
Hoskinson reported on eight patients treated with resection arthroplasty, both hemiphalangectomy and resection of the metatarsal head, and found that only three had a satisfactory result, with residual symptoms and deformity limiting the remaining five.
Resection arthroplasty is an inherently destructive procedure. With these procedures, several authors have expressed concerns about the development of transfer lesions as a result of rendering the affected metatarsal incompetent. Additionally, potential complications from any of the resection techniques include progressive hallux valgus and excessive shortening.
Total small joint arthroplasty
Total small joint arthroplasty using a silicone prosthesis has also been described for the treatment of Freiberg disease. Potential complications are similar to those for resection arthroplasty; other potential problems, inherent in the implants themselves, include synovitis, infection, and dislocation.
Several implants are available commercially. Most of these implants originally were developed for use in the hand. Potential advantages over resection arthroplasty include maintenance of length, improved joint motion, and better weight distribution if condyles are preserved. Newer MTP-specific implants may prove to be better than previous implants, but long-term data are lacking.
Other options for replacement arthroplasty, including a titanium hemiarthroplasty and total ceramic arthroplasty, have been explored in recent years for high-stage lesions. Similar to silicone implants, these newer devices present possible complications, including implant loosening, bone erosion, infection, and a stiff, floating toe.[37, 38]
Freiberg and Freiberg described core decompression for the treatment of early-stage lesions. In their procedure, the metatarsal head is drilled multiple times with a .045-in. Kirschner wire (K-wire), with satisfactory results (somewhat analogous to drilling for osteochondritis dissecans).
Maresca et al described arthroscopic drilling in a patient with bilateral stage II disease, with evidence of restoration of the joint surface and satisfactory results at 2 years. Although such results are encouraging, further investigation is warranted into the potential usefulness of such procedures.
Miyamoto et al performed an osteochondral plug transplantation for late-stage Freiberg disease in four female patients (average age, 12 years); the osteochondral plug was harvested from a non-weightbearing site of the upper lateral femoral condyle of the ipsilateral knee.
In this study, the average American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 70.8 points preoperatively to 97.5 points postoperatively. Magnetic resonance imaging (MRI) at 6 months after surgery showed an osteochondral plug–subchondral bone interface, but healing of the plug was confirmed at 12 months after surgery in all patients. At 12 months after surgery, two patients had a normal International Cartilage Repair Society Cartilage Repair Assessment Score, and two had a nearly normal score.
Future and Controversies
Although Freiberg disease was originally described more than a century ago, the etiology and the most appropriate treatment remain controversial. Current recommendations have been based on small series of patients treated by various methods, and there is no clear consensus as to optimal management. A trial of conservative treatment can be implemented for most patients presenting with Freiberg disease. If such treatment fails, multiple surgical options exist. Further investigation through prospective, multicenter analysis would best guide future treatment options.
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