Freiberg Disease (Infraction) Treatment & Management

There remains controversy as to what represents the most appropriate approach to treatment of Freiberg disease. Current recommendations have been based on small series of patients treated by various methods, and there is no clear therapeutic consensus. 

A trial of conservative treatment can be implemented for most patients presenting with Freiberg disease. Whereas some stage I, stage II, and stage III lesions (see Staging) may resolve spontaneously, patients who do not respond to conservative measures may require surgery, as may patients with stage IV and stage V lesions. Aside from the recommendation of conservative management in the pediatric population and in patients with early-stage lesions, no true contraindications for treatment of Freiberg disease exist.

Further investigation through prospective, multicenter analysis would best guide future treatment options.

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. ^[29]

In patients presenting with severe pain of an acute nature, a nonweightbearing 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. Typically, 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 (MT) 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. ^[6]

Medications may be helpful for pain but should not be used to allow increased activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly administered for pain, but cautious use is recommended. Although sufficient human studies are lacking, NSAIDs have been shown to delay stress fracture healing in rats. ^[30]

Hoskinson reported on the long-term results (average, 12 y) of conservative treatment on a series of 16 patients. ^[17] Eleven of the 16 patients were completely pain free at final follow-up; however, all 16 had some restriction in range of motion (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 MT head with bone grafting, core decompression, MT head excision, shortening of the MT, proximal phalanx hemiphalangectomy, total small-joint arthroplasty, and various combinations of the above, have been implemented. MT head restoration is a newer development. ^[31]

No consensus exists as to which surgical procedure is the most appropriate for patients with symptomatic Freiberg disease. ^[32] 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. ^[15]

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.

Debridement

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 on the basis of the presence of loose bodies. Subsequent authors also advocated simple debridement as an effective treatment for Freiberg disease. ^[33] 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 MT; they found joint debridement and MT head remodeling to be safe, simple, and effective in alleviating symptoms. ^[33]

Simple debridement can be combined with other procedures. Hoskinson described 12 patients treated with various surgical procedures, including excision of the MT 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. ^[17]

Bone grafting

In an attempt to restore joint congruity, Smillie described a procedure in which a cancellous bone graft was used to elevate the depressed MT articular surface. The technique involved creating a slot in the MT shaft through which the sclerotic bone could be drilled. The MT 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. ^{[13, 28]}

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 MT heads radiographically, and two of the three reported pain with running or wearing high-heeled shoes. ^[15]

Osteotomy

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. ^[34]

Dorsal closing wedge osteotomy

Gauthier and Elbaz were the first to describe a dorsal closing wedge osteotomy for the treatment of Freiberg disease. ^[20] They reported results from 53 patients who were treated with a dorsiflexion osteotomy of the neck of the MT. 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 MT head was a simple procedure that was capable of good results in stage IV and stage V disease. ^[35]

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. ^[36] 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 MTP-interphalangeal (IP) scale, were as follows ^[36] : Four patients reported excellent results, seven good results, and two poor or fair results. MT shortening averaged 2.1 mm, with passive 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. ^[37] 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°. MT shortening averaged 2.5 mm, with no cases of transfer metatarsalgia. No major complications were reported.

Dhar et al reported on 20 patients with Freiburg infraction who were treated with a dorsal closing wedge osteotomy of the MT. ^[38] They documented a mean Leeds Movement Performance Index (LMPI) score of 84 (range, 70-86), a mean MT shortening of 2 mm, a passive flexion restriction of 16°, and an extension restriction of 10°. They also found a strong negative correlation between the Smillie classification and the final AOFAS score.

Shortening osteotomy

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 MT often is the longest of the MTs. Several authors believe that this subjects the involved MT to repetitive injury and abnormal loading. With shortening, overloading of the MT is reduced, as are symptoms.

Smith et al described a shortening osteotomy in which the MT was shortened approximately 4 mm. ^[39] Of the 16 patients treated in their series, 15 had complete pain relief; however, seven of the 16 experienced stiffness of the involved ray, with four unable to place the toe flat when standing. Five patients graded their result as excellent, nine said that they were very pleased with it, one was satisfied, and one was unhappy.

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 MT head, and apparent remodeling of the articular surface, as seen radiographically in most cases. ^[39]

Arthroplasty

Resection arthroplasty

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. ^[40] Two of the described methods are resection of the base of the proximal phalanx and resection of the MT 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 MT head, and found that only three had a satisfactory result, with residual symptoms and deformity limiting the remaining five. ^[17]

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 MT 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 there remains a need for long-term data. ^[41]

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. ^{[42, 43]}

Interposition arthroplasty

As a consequence of the lack of consistent results with both resection and small-joint arthroplasty, there has been some interest in interposition arthroplasty. Unfortunately, this procedure too has yielded mixed, unreliable results. ^{[44, 40, 45]}

Other procedures

Freiberg and Freiberg described core decompression for the treatment of early-stage lesions. ^[25] In their procedure, the MT 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. ^[46] Although such results are encouraging, further investigation is warranted into the potential usefulness of such procedures.

Miyamoto et al performed osteochondral plug transplantation for late-stage Freiberg disease in four female patients (average age, 12 y); the plug was harvested from a nonweightbearing site of the upper lateral femoral condyle of the ipsilateral knee. ^[47]  The average 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 in all patients. At 12 months, two patients had a normal International Cartilage Repair Society Cartilage Repair Assessment score, and two had a nearly normal score.

Several investigators have found osteochondral autologous transplantation to be equal or possibly superior to dorsal closing wedge osteotomy for the treatment of Freiberg disease. ^{[48, 49]}

A retospective study by Mutlu et al (N = 60) found that metatarsal head restoration (n = 29; 32 feet) led to better results than dorsal closing wedge osteotomy (n = 31; 33 feet) in patients with stage III-IV Freiberg disease. ^[31]

A case report by Soldado et al described the use of a reverse pedicled MT bone flap from the first MT to treat Freiberg disease in a 13-year-old female. ^[50]