What is the primary management approach for a patient diagnosed with Osteonecrosis Freiberg's disease?

Management of Freiberg's Disease

For Freiberg's disease, begin with conservative management in early stages (Smillie I-III), including offloading with metatarsal bars, semirigid orthoses, and short leg walking casts; surgical intervention with dorsal closing-wedge osteotomy is recommended for advanced stages (Smillie IV-V) when conservative treatment fails, as it provides superior outcomes compared to resection arthroplasty. 1, 2

Understanding Freiberg's Disease

Freiberg's disease is osteonecrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females, though it can occur at any age. 1, 2 The pathophysiology is multifactorial, involving trauma, altered foot biomechanics, systemic disorders, and arterial insufficiency. 2

Clinical Presentation

• Patients typically present with pain, swelling, and motion restriction in the affected metatarsophalangeal joint. 1
• MRI is the most useful investigation for early diagnosis. 3

Conservative Management (First-Line for Early Disease)

• Nonoperative treatment is best applied in early-stage disease (Smillie stages I-III) and should be attempted first. 2
• Use semirigid orthoses to offload the affected metatarsal head. 1
• Apply metatarsal bars to redistribute pressure away from the diseased area. 1
• Consider short leg walking cast for immobilization during acute phases. 1
• This is a self-limiting disease in many cases, making conservative management the mainstay of initial treatment. 3

Surgical Management (When Conservative Treatment Fails)

For Advanced-Stage Disease (Smillie IV-V)

Dorsal closing-wedge osteotomy is the preferred surgical option for advanced-stage Freiberg's disease, as it preserves metatarsal length and provides better functional outcomes than resection. 1

• Dorsal closing-wedge osteotomy achieves mean postoperative LMPI scores of 86 (range 64-100), significantly better than resection arthroplasty. 1
• This technique results in minimal metatarsal shortening (mean 2.2 mm) compared to resection (mean 9.8 mm), avoiding cosmetic problems. 1
• Mean passive flexion restriction is 18° and extension restriction is 12° following osteotomy. 1

Alternative Surgical Options Based on Disease Stage

• Debridement and cheilectomy can be considered for early-stage disease with failed conservative management. 2, 3
• Microfracture combined with bone grafting and AMIC (Autologous Matrix Induced Chondroplasty) membrane shows reliable functional outcomes, with mean MOxFQ improving from 72.5 to 31.4 at 36 months. 3
• Osteochondral grafting may be used for focal defects with preserved joint architecture. 2
• Resection arthroplasty should be reserved for severely damaged joints where osteotomy is not feasible, though it results in significant shortening (7-14 mm) and lower functional scores (mean LMPI 72.6). 1

Treatment Algorithm

1. Early diagnosis via MRI when clinical suspicion exists. 3
2. Conservative management for 3-6 months in early-stage disease (Smillie I-III). 1, 2
3. Surgical intervention if conservative treatment fails or for advanced-stage disease (Smillie IV-V). 1, 2
4. Choice of surgical procedure should be based on joint damage severity and patient age:
   • Dorsal closing-wedge osteotomy for preserved joint architecture 1
   • Debridement with microfracture and AMIC for focal defects 3
   • Resection arthroplasty only for severely damaged joints 1

Important Caveats

• Inform patients about potential cosmetic issues (metatarsal shortening) when considering resection arthroplasty versus osteotomy. 1
• Corticosteroid use can precipitate acute Freiberg disease, so physicians must remember the risk of osteonecrosis when prescribing steroids. 4
• Significant pain relief is obtained with both osteotomy and resection, but functional outcomes and cosmetic results favor osteotomy. 1
• The decision between osteotomy and resection should be based on the degree of joint injury and patient expectations regarding cosmetic outcomes. 1