Freiberg’s Infarction

FREIBERG’S INFRACTION AS SEEN IN ADOLESCENT ATHLETES AND DANCERS WITH A FOCUS OF OSTEOCHONDRAL AUTOLOGOUS TRANSPLANTA TOOL

Introduction-

Freiberg’s infraction disease is a lesser-known condition of the articular surface of the head of any of the metatarsals (usually the second or third metatarsal) when the head of the involved metatarsal undergoes avascular necrosis (osteonecrosis).

This is thought to occur due to trabecular stress injury caused by disproportionate, repeated pressure on the metatarsal head during movement causing microfractures, loss of blood supply to the subchondral bone, cancellous bone damage, and cartilage deformation ^l.

Elite youth athletes and dancers are particularly vulnerable to injury due to growth-related factors – adolescent growth spurt^{2 3} , susceptibility to growth plate injury^{3 4} , age- and maturity-associated variation,⁴‘⁵ longer recovery and differing physiological response⁵‘⁶, and nonlinearity of growth⁷ ‘ .

Management of the disease may be conservative or surgical. Conservative management allows for the chance of remodelling following spontaneous healing, in the early stages of the disease. Operative options are osteotomies, osteochondral transplant, and resection arthroplasty ⁹.

Dorsiflexion closing wedge metatarsal osteotomy (DCWMO) has long been considered the traditional treatment of Freiberg disease. However, several case reports show that osteochondral autologoustransplantations (OAT) may also show positive outcomes ^l0. The purpose of this article is to examine OAT as a viable new treatment option against the traditional DCWMO.

Pathophysiology-

Freiberg’s infraction is a condition of degeneration of cartilage of the metatarsal heads. Adolescent females are the classical patients but both males and females may present with this condition later in life. Second and third metatarsals are most commonly affected. Incidence is higher in females than in males.

The pathophysiology is unknown, but studies suggest- a combination of vascular compromise (blood flow to the metatarsal heads), repetitive stress and a combination of pressure and altered biomechanics.

Aetiology-

1. Traumatic- repetitive microtrauma over time from early adolescence when the bone and cartilage is undergoing an unusual period of growth.
2. Vascular- Arterial insufficiency is also a prominent proposed aetiology. Avascular necrosis of the lesser metatarsal head may occur due to (a) mechanical compression of the arteries to the metatarsal head, (b) arterial spasm, (c) ischemia, (d) prolonged compression resulting in vessel occlusion, and(e) resulting in bone resorption, remodelling, and collapse”.

3. Mechanical factors- The relative immobility of the second metatarsal, a longer second metatarsal, hallux abducto valgus (angular displacement of the great toe), use of high heels. The theory proposed is that these mechanical factors result in increased stress over MTP joint thus causing osteonecrosis in this area”.
4. Systemic- Systemic abnormalities may contribute to the development, (namely, infection, endocrine disturbance, hormonal changes as the condition affects predominantly young females, steroid use, andosteopenia. ¹¹

An interesting new angle being seen, now that more research is being done upon Freiberg’s- the association of the incidence of Freiberg’s seen more in female ballet dancers and gymnasts. Dancers may be predisposed due to repetitive microtrauma to the ball of the foot during habitual dance movements ^l2.

Overuse alters the biomechanical properties of the bone and its cellular composition, causing an imbalance between overload and recovery. The risk factors are, broadly, intrinsic, and extrinsic ^l‘.

1. Intrinsic- malalignments, muscle imbalance, inflexibility, weakness, and instability ’⁴_Other biomechanical characteristics include external hip rotation greater than 65°, forefoot varus, and poor ankle joint ROM ‘ ⁴‘¹’. Foot architecture in combination with other biomechanical factors plays a crucial role in the development of Freiberg’s in young athletes.
2. Extrinsic factors- include poor technique, improper equipment, hard surfaces of training, and improper changes in training ‘ ⁴‘¹⁵.
3. Nutrition, may be classified as a 3’^d factor affecting predisposition to Freiberg’s because of the implications for bone density ^{16 17} especially concerning the “female triad” ¹⁴‘¹⁶ ‘ ⁷ or RED-S (Reduced Energy Deficiency in Sport): eating disorder, amenorrhea, and osteoporosis.

Diagnosis – is made clinically and imaging is used to confirm.

Clinical signs and symptoms-

Patients with Freiberg’s infraction typically complain of pain with activity, increasing on walking and in high heels. Clinically, tenderness on compression and movement. Swelling is usually present as well. The patient may or may not show decreased joint ROM depending on the stage of the disease process.’⁹ Radiopaedia, Nikoletti)

Radiography-

• Plain X-rays maybe inconclusive in the early stages of the disease. The earliest changes show widening of the joint space. The metatarsal may show decreased bone mineral (osteopenic). Eventually, sclerosis is visible with flattening and depression of the metatarsal head. Severe joint space narrowing and necrosis characterize end-stage Freiberg’s infraction.
• Magnetic resonance imaging (MRI) is a useful tool in evaluation before X-ray changes are visible. Evidence of subchondral fractures and bone marrow edema, and later flattening of the metatarsal head with subchondral sclerosis.¹⁹

Management-

Nonoperative treatment is based on decreasing foot pressure, modulation of activities and NSAIDs, and unloading the affected metatarsal, by modification of footwear, rest.

Conservative treatment in young athletes and dancers has been seen to be disappointing, and surgical options have not produced uniform results. Previously published studies of successful surgical outcomes (DCWMO) would, for a gymnast or dancer, result in an unacceptable loss of range (dorsiflexion) of the MTP joint’².

Surgical Options-

In case of failed conservative methods, Surgical management includes resection of the metatarsal head, and bone grafting the defect, joint debridement, excision of the base of the proximal phalanx, replacement of the metatarsal head, and dorsal closing wedge osteotomy of the metatarsal neck ^l9. The most popular until now has been the Dorsal Closing Wedge Osteotomy or Dorsal Closing Wedge Metatarsal Osteotomy (DCWMO). However, the Osteochondral Autologous Transplantation has in recent times been used with greater positive outcomes, especially concerning athletic populations.

Defining key terms-

• Osteochondral autologous transplantation (OAT) is a treatment strategy for small and medium-sized focal articular cartilage defects in the knee²’

• Dorsal closing-wedge osteotomy is a realignment osteotomy of the metatarsal head and neck to redirect the articular surface, allowing the intact plantar cartilage to articulate with the proximal phalanx”

A study by Georgiannos and colleagues (Georgiannos et a1., 2019), was insightful to show how the traditional gold-standard of treatment, the osteotomy (DCWMO), may now have a strong contender in the Osteochondral Autologous transplantation²².

Methodology-

A randomised control study was done following 27 patients with Freiberg disease [randomly assigned to either the DCWMO group (14 patients) or the OAT group (13 patients)]. The primary outcomes monitored were:

• postoperative complications,
• ROM (range) of the metatarsophalangeal joint,
• length of the metatarsal,
• function of the foot (measured with the American Orthopaedic Foot and Ankle Society—lesser metatarsophalangeal-interphalangeal [AOFAS-LMI] score), and
• pain (with visual analog scale—foot and ankle score).

Regular assessments of the patients were done at- 2 weeks for wound check, at 6 weeks for radiographic assessment, and at 3 and 12 months and 3 years post-operatively.

Surgical Procedures-

The osteotomy (DCWMO) was intra-articular (within the joint), and the entire defect was cut out while the joint hinge was preserved. The metatarsal head was rotated, bringing the healthy plantar into contact with the phalanx.

In the OAT group, the necrotic (dead tissue) defect was scraped to expose the underlying sclerotic bone. An osteochondral plug (to fill the defect) was arthroscopically cored out from either the trochlea of the knee or the talus (Figure 3). The depth of the recipient socket was measured, and the plug was trimmed accordingly to fill in the defect (Figure 4).

Figure 3. (A, B) Arthroscopic harvesting of the graft from the talus (C) X-ray of the ankle shows the donor site (circIe)taIus. (Georgiannos et al., 2019)

Figure 4. OAT for treating the second metatarsal head. (A) Head of the metatarsal (B, C) recipient site is prepared with the OAT system. (D) Final OAT.(Georgiannos et al., 2019)

At the end of both techniques, the joint capsule was roughly sutured and the skin incision closed with absorbable sutures.

Post-operative Management-

No period of immobilization applied postoperatively. Active toe movement exercises started from the first postoperative day for all patients, and were allowed heel weight-bearing for 4 weeks. Full weight- bearing was allowed at 4 weeks and running at 8 weeks.

Results-

1. The mean SD of function AOFAS-LMI score in the DCWMO group was- 63.4 + 14.4 preoperatively, 81.8 6.6 at 1 year postoperatively, and 84.4 + 5.6 at 3 years postoperatively. While in the OAT group, it was 62.8 14, 89.9 7.1, and 92 6.9, respectively. There was a significant difference in favour of the OAT group between the postoperative values at 1 year (P= .001) and 3 years {P<.001).
2. The mean visual analog scale—foot and ankle score improved significantly from 49.9 + 10.9 to 95.4 + 4.4 in the OAT group (P< .001) and from 48.1 + 11.5 to 91.8 + 9.5 in the DCWMO group (clinical significance seen).
3. Bone union was achieved at 6 weeks for both the groups.
4. Decrease in metatarsal length by a mean 1.9 + 0.5 mm in the DCWMO group, as opposed to a metatarsal lengthening of 0.2 + 0.1 mm in the OAT group.
5. ROM- In the DCWMO group, dorsiflexion increased from 35°+ 11° to 38°+ 12.5°, and plantar- flexion decreased slightly from 28°+ 12° to 26°+ 13°. In the OAT group, dorsiflexion increased from 37°+ 12° to 48O+ 14° and plantarflexion increasedfrom 30°+ 11° to 32O+ 12°.
6. Return to sport- seen earlier in the OAT group. In the OAT group, patients started training at 6 + 1 weeks and to return to sport at 10 + 2.5 weeks, while in the DCWMO group, the time was 8
7. 1.5 weeks and 13 + 2.5 weeks, respectively. There was a significant difference in favour of the OAT group in time to return to training (P< .001) and to previous sport level (P< .05).

Figure 5. (A, B) Preoperative right foot radiographs of a 22-year-old soccer player show symptomatic Freiberg infraction of the second metatarsal head. (C, D) Four-month postoperative- show the reconstruction and the osteochondral graft in place. .(Georgiannos et al., 2019)

Conclusions and Effectiveness of the emerging surgical technique-

It may not be easy to decide on a treatment pathway for the disease, due to paucity of literature on the disease itself, as well as the rarity of the disease.

OAT is a recognised treatment for articular cartilage lesions of the knee, ankle, and elbow joints^{22 2}3. In 2002, OAT was introduced as a surgical advance by Hayashi et al²⁵, to treat advanced-stage Freiberg disease. OAT was considered at an advantage since it was non-destructive and could restore the congruity of the MTP joint.

The other positive details include- early return to sport²⁶, lengthening of the metatarsal²², improvement of the ROM. Athletes treated with osteochondral transplantation returned to both training and full sport activities 2 to 3 weeks earlier than the athletes who received metatarsal osteotomy for treatment. The earlier time to return to previous sport level could be due to- (1) the increased ROM and improved congruity of the joint (2) the large contact area of the surfaces (recipient site) both favourable for early bone-to-bone healing. These advantages of the OAT show an edge of this emerging technique, allowing the athletes to accelerate rehabilitation and return to sport earlier. Furthermore, the joint surface restored with hyaline cartilage was durable and capable of being preserved against repetitive mechanical stress and highly demanding sport activity.

A lot of variable factors like the activity levels — pre- and post-operative, age of the patient, previous and current nutritional status and any previous procedures at the joint, will definitely come into consideration while deciding the course of treatment. Treatment for Freiberg’s disease is also highly dependent on the stage of the disease.

However, as studies emerge on Osteochondral Transplantations (OAT), there is fledgeling, but positive data to support an edge over the traditional Osteotomies (DCWMO). Especially, with regard to athletic populations and return to sport.

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