Avascular Necrosis of the Metatarsal Head / Friedberg’s Disease

Frieberg’s infarction or avascular necrosis of a metatarsal head is a problem that is commonly misdiagnosed and a cause of pain for patients. There are several advances in the treatment of Frieberg’s disease that have helped revolutionize the treatment of this difficult problem. The cause of the problem is not fully understood but seems to be due to chronic micro-trauma and overload of the metatarsal head leading to fracture and collapse of the metatarsal head and decreased or loss of circulation to the collapsed area. Over time, arthritis and pain develop.

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X-ray showing a normal second metatarsal head. X-ray showing an AVN of the second metatarsal head. Notice the collapsed of the bone and the destruction of the joint.
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Picture of an AVN of the second metatarsal head. Notice the missing cartilage on the end of the bone.

Conservative care for Frieberg’s infarction is through offloading of the area. During the active period of pain and early collapse, the patient is often placed in a boot or cast and on crutches to limit or completely remove weight from the metatarsal head. With time, an orthotic is made to decrease the abnormal pressure through the metatarsal head.

If there is collapse and early arthritis noted, three procedures are used to salvage the joint. The first is to remove all loose bone and spurs in the joint. In more advanced cases, the spurs are removed and the metatarsal head is shortened to decrease the abnormal stress going through the area. In cases of more advanced cartilage damage, the cartilage from the bottom of the joint is tilted upwards to resurface the joint and remove the damage cartilage on the top of the joint.

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X-ray showing a damaged 2nd toe joint. Picture showing the bone cut made to decompress the joint.
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X-ray showing the pins that hold the bone cut in the new position with the healed joint. Picture showing the drill holes made into the bone to facilitate new cartilage growth.

In severe cases of arthritis, the metatarsal head is removed and the area is either filled with a tendon graft or an implant is used to resurface the joint. This new resurfacing technique has allowed rapid recovery and dramatic improvement in pain and function.

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X-ray showing damaged joint prior to surgery. X-Ray showing a joint implant in the 2nd toe joint.