07/05/2013    Don Peacock, DPM

Freiberg's Infraction in 47 Year Old Male

Based on the x-ray and the clinical history, I
feel comfortable that this condition is
Freiberg’s disease. Obviously, a MRI can provide
information in cases where Freiberg disease is
suspected, but no significant radiographic
alterations are noted. In this case, there is
significant radiographic alteration of the second
metatarsal phalangeal joint. This case appears to
be a stage 4 necrosis of the metatarsalphalangeal
joint.

Approach this deformity through minimally
invasive surgery by performing a percutaneous
dorsiflexion osteotomy of the second metatarsal
at the surgical neck. In addition, make an
additional percutaneous incision lateral to the
metatarsal head to allow removal of the dorsal
exostosis via an Isham Burr.

In most cases of Freiberg disease, the pain is
limited to the second metatarsal. Your patient
has pain in the third metatarsal as well. For
this patient, also perform osteotomies on the
second third and fourth metatarsals. Additional
osteotomies would be performed at the base of the
proximal phalanx in a wedge fashion in toes 2-4
to ensure that toe purchase is maintained.

This patient also has early issues with hallux
rigidus that can be addressed with minimally
invasive surgery utilizing a wedge osteotomy
dorsally at the first metatarsal head and at the
proximal phalanx. I do not recommend removal of
the metatarsal head or a removal of the base of
the proximal phalanx. This will lead to further
complications with your patient. The minimally
invasive surgeries would lead the patient with a
cosmetically pleasing foot and a more functional
foot. I do not see a need for biopsy.

Don Peacock, DPM, Whiteville, NC,
peacockdpm@gmail.com

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