Freiberg's disease in diabetes mellitus

A Novel Method for Treating Bilateral Freiberg's Disease of the Second Metatarsal: A Case Report

Freiberg's infraction is osteonecrosis of the lesser metatarsal heads, most commonly affecting adolescent females. Bilateral Freiberg's disease is rare, with only a few cases reported. Conservative management is the mainstay of treatment. Surgical management includes the excision of osteophytes and loose chondral flaps, microfracture, corrective osteotomy, and debridement of the metatarsal head, often with unpredictable outcomes. We report a rare case of a 17-year-old girl with bilateral Freiberg's disease who was treated with Autologous Matrix-Induced Chondrogenesis (AMIC), achieving excellent radiological and functional outcomes.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases

BACKGROUND

Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success.

METHODS

A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores.

RESULTS

The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively.

CONCLUSIONS

Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

Freiberg’s Disease of Bilateral and Adjacent Metatarsals

Freiberg’s disease is a rare condition characterized by avascular necrosis of the lesser metatarsal heads. The incidence is highest in females, and the disease is usually unilateral, affecting just a single metatarsal. In this report, we describe the first male case of Freiberg’s disease involving the second and third metatarsals in both feet, with the aim of highlighting the condition as a potential cause of such forefoot pain. One year of follow-up is provided.

Conservative treatment of Freiberg's infraction using foot orthoses: A tale of two prescriptions presented as a case study to open debate

'Freiberg's infraction or disease' is an osteonecrotic process primarily affecting the 2^nd & 3^rd metatarsal heads. Early diagnosis is difficult, and the underlying pathogenesis remains unclear. Surgical options for late disease have been widely reported in the literature, yet details on conservative management for the early stages of Freiberg's are largely absent. Pathology should be treated where possible using an evidence-based approach, yet evidence for conservative management in acute stages of Freiberg's is lacking. A case study is presented that outlines two different prescription interventions using foot orthoses; one that attempted to 'offload' the metatarsal head by creating space beneath it; and one that attempted to 'offloaded' by increasing controlled loading of the metatarsals proximal to the head. These resulted in very different outcomes for the patient. The authors will attempt to give a 'pathomechanical rationale' for the treatment outcomes based on mechanical stress principles, and a consequential explanation as to why one type of insole prescription seemed more successful in reducing symptoms and raising activity levels, while another was not.

Freiberg Disease and Avascular Necrosis of the Metatarsal Heads

Freiberg disease is characterized as osteochondrosis of the second metatarsal head. 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. If treated early, osteochondroses such as Freiberg disease are essentially self-limiting, often resolving with nonoperative management. When surgery is warranted, it is imperative the patient's age, activity level, and degree of articular deformity be taken into account.

Imaging of the spectrum of bony injuries in the diabetic foot: a case series with emphasis on non-Charcot fractures

Diabetes mellitus is associated with an increased risk of lower limb injuries. Peripheral neuropathy, often associated with diabetes, has been demonstrated to increase the risk of fracture almost two-fold and is associated with complications related to fracture healing. Detection of neuropathy-related foot injury is frequently delayed owing to the paucity of symptoms and low degree of suspicion by the clinician. Early recognition of fracture or bone injury and appropriate treatment are critical in preventing debilitating foot deformity and disability. Therefore, the astute radiologist cognizant of these potential injuries plays an essential role in early diagnosis of bony injuries in the diabetic foot. We present a series of radiological images that depict a range of osseous injuries in the diabetic foot and emphasize the role of the radiologist in early recognition of these abnormalities.

Atypical Presentation of Acute Freiberg Disease

Freiberg disease is a chronic progressive condition that results in pain and loss of normal function of the metatarsophalangeal joint (MTPJ). We describe a case of acute Freiberg disease secondary to a short course of oral steroids. The patient presented with an acute metatarsal head fracture that was managed successfully with open reduction and internal fixation. Although a rare complication of corticosteroid use, physicians having patients start taking steroids must remember the risk of osteonecrosis.

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Surgical Management of Freiberg's Infraction: A Systematic Review

Avascular necrosis of the second metatarsal head was first described by Freiberg in 1913. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. Should conservative treatment fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown. This systematic review was undertaken to determine which surgical procedure allows for the best resolution of symptoms and return to activity. Included studies were restricted to articles published in English language peer-reviewed journals that consecutively enrolled patients of all ages, with Freiberg's infraction of any stage, who underwent operative treatment, and had a mean follow-up of greater than or equal to 12 months duration. Eighty-five publications were identified, of which 38 (44.7%) met all the inclusion criteria. Surgical techniques and outcomes were grouped into joint sparing and joint destructive procedures. A total of 70 joint destructive procedures were performed with a combined mean follow-up time of 15.0 months. A greater than 70% resolution of pain and full return to activity was reported. A total of 257 joint sparing procedures were performed with a combined mean follow-up of 30.4 months. A greater than 90% resolution of pain and full return to activity was reported. Results of this systematic review reveal that the results of joint sparing procedures are reported more often and appear to have a better prognosis for symptom resolution and return to activity. Smillie stage was not consistently reported, making it difficult to determine its effect on procedure selection.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Systematic review of Level IV studies.

Lower limb complications of diabetes mellitus: a comprehensive review with clinicopathological insights from a dedicated high-risk diabetic foot multidisciplinary team

Diabetic complications in the lower extremity are associated with significant morbidity and mortality, and impact heavily upon the public health system. Early and accurate recognition of these abnormalities is crucial, enabling the early initiation of treatments and thus avoiding or minimizing deformity, dysfunction and amputation. Following careful clinical assessment, radiological imaging is central to the diagnostic and follow-up process. We aim to provide a comprehensive review of diabetic lower limb complications designed to assist radiologists and to contribute to better outcomes for these patients.

Freiberg's disease

Freiberg’s disease is a relatively uncommon disorder of the metatarsal head. Although trauma and circulatory disturbances likely contribute major roles in its development, it is widely accepted that Freiberg’s etiology is multifactorial. Conservative treatment, focused on offloading and relieving stress, is uniformly accepted as the appropriate initial management. Surgical management can broadly be categorized as procedures which attempt to correct the pathophysiology and halt its progression, and procedures which address the sequelae of later stage disease. Newer strategies, including osteochondral transplantation, attempt to restore the damage metatarsal cartilage with a viable osteochondral plug.

MRI of metatarsal head subchondral fractures in patients with forefoot pain

OBJECTIVE

The purpose of our study was to determine the MRI features of metatarsal head subchondral fractures in symptomatic adults.

MATERIALS AND METHODS

A retrospective review of foot MRI procedures was performed to detect cases of metatarsal head subchondral fractures over a 6-year period. MR images of selected cases were analyzed by two reviewers for the presence of subchondral fracture, marrow edema-like pattern, metatarsal head flattening, and subchondral sclerosis. Patients with a history of foot surgery, infection, or inflammatory arthritis were excluded. Assessment for coexisting osseous and soft-tissue abnormalities was also performed.

RESULTS

Subchondral fractures of the metatarsal heads were seen in 14 patients. All patients were women. The metatarsal head most commonly affected was the second (71%, 10/14) and the dorsal third of the metatarsal articular surface was involved in 79% (11/14). MRI findings of subchondral fracture of the metatarsal head with severe marrow edema-like pattern were seen in 71% (10/14), suggesting early stage changes. Metatarsal head collapse with subchondral sclerosis and mild or absent marrow edema-like pattern were seen in 29% (4/14) indicating late-stage changes. Concurrent abnormalities included three patients (21%) with metatarsal shaft fractures and one patient (7%) with an interdigital neuroma. One subject was treated surgically.

CONCLUSION

Subchondral fractures of the metatarsal heads can be detected on MR examinations of adults with forefoot pain. A subchondral fracture with associated marrow edema-like pattern is the most common presentation and likely reflects early stages of metatarsal head infraction.

Freiberg's disease in the Emergency Department

Freiberg's disease is an avascular necrosis affecting the second, third, or, rarely, the fourth metatarsal head. It is typically a chronic, progressive process, eventually causing pain and loss of normal function of the metatarsophalangeal joint. Normally, patients present to the Emergency Department with atraumatic foot pain, however, as we illustrate with this case, an acute fracture may occur, requiring recognition and appropriate treatment. Our patient presented with acute pain, swelling, and point tenderness of the forefoot after a minor fall. Radiographs revealed a fracture through the head of the second metatarsal and underlying avascular necrosis consistent with Freiberg's disease. Identifying the underlying chronic process was important in understanding how minor trauma resulted in a fracture in this patient.

Neuropathic osteoarthropathy: diagnostic dilemmas and differential diagnosis

The purpose of this pictorial essay is to illustrate the radiologic spectrum of imaging findings of neuropathic osteoarthropathy. Typical findings include joint destruction, disorganization, and effusion with osseous debris. A variety of other imaging findings related to neuropathic osteoarthropathy such as resorption of the ends of tubular bones and neuropathic fracture are shown. The two prevailing theories for the pathophysiology of neuropathic bone and joint disease, the neurovascular and neurotraumatic theories, are briefly described. Examples of osteoarthropathy from diverse causes are presented including syringomyelia, spinal cord injury, meningomyelocele, diabetes mellitus, congenital insensitivity to pain, steroid injections, syphilis, leprosy, and others. The discussion focuses on key imaging features with emphasis on disease patterns and differential diagnosis, which vary by skeletal location.

Fractures and dislocations of the foot

The incidence and severity of fractures and dislocations vary depending on their location and on the direction of the forces responsible for the injury. The radiologist's role in evaluation of the injured foot is to recognize the types of injuries produced by particular forces. Because there is considerable overlap of fractures and dislocations of the foot and ankle, evaluation of one area to the neglect of the other can lead to significant oversights and failure to recognize additional injury patterns. For example, fractures of the talus, calcaneus, base of the fifth metatarsal, and to a lesser extent, the cuboid and navicular bones may masquerade as ankle sprains or malleolar injuries. The most important aspects to correct interpretation of traumatized foot radiographs are (1) pertinent clinical history, (2) a complete radiographic series, and (3) detection of soft-tissue swelling or injury.