Surgical Management of Freiberg's Infraction: A Systematic Review.

UNLABELLED: 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.

Thompson and Hamilton type IV Freiberg's disease with involvement of multiple epiphyses of both feet.

A 17-year-old boy reported left second and third toe pain after axial loading injury to his left foot. Radiographs showed collapse of the second metatarsal heads and epiphysial irregularities of the fifth metatarsal heads and the condyle of the proximal phalanx of the hallux of both feet. The patient was diagnosed to have Thompson and Hamilton type IV Freiberg's disease. He was screened for epiphysial dysplasia of the other sites. He had on and off bilateral hip and knee pain. Radiographs showed bilateral symmetrical epiphysial abnormalities with morphological change as focal concavity in bilateral femoral heads and fragmentation of the patellar articular surface with preservation of the patellofemoral joint space.

Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle.

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Arthroscopic interpositional arthroplasty for Freiberg's disease.

Freiberg's disease is a relatively rare condition and can be difficult to manage, especially in those with late stages. Surgical treatment should be considered if conservative treatment cannot relieve the symptoms. We describe an arthroscopic interpositional arthroplasty for extensive late stages (stage IV or V) Freiberg's disease. Metatarsophalangeal arthroscopy is performed with dorsolateral and dorsomedial portals. Loose body is removed and joint surfaces are debrided. Extensor digitorum brevis tendon graft is harvested and rolled and brought into the joint. The technique is easy and can be performed on outpatient basis.

Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain.

BACKGROUND: After ankle sprain, there can be many causes of disability, the origins of which cannot be determined using standard diagnostic tools. HYPOTHESIS: Ankle arthroscopy is a useful tool in identifying intra-articular disorders of the talocrural joint in cases of residual ankle disability after sprain. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: The authors gathered the independent diagnostic results of physical examination, standard mortise and lateral radiography, stress radiography of the talocrural joint, and magnetic resonance imaging for 72 patients with residual ankle disability lasting more than 2 months after injury (mean, 7 months after injury). They performed arthroscopic procedures and compared the double-blind results. RESULTS: In all cases, the arthroscopic results matched those of other means of diagnosis. In 14 cases, the arthroscopic approach exceeded the capabilities of the other methods. Including duplications, 39 patients (54.2%) had anterior talofibular ligament injuries, 17 patients (23.6%) had distal tibiofibular ligament injuries, 29 patients (40.3%) had osteochondral lesions, 13 patients (18%) had symptomatic os subfibulare, 3 patients (4.2%) had anterior impingement exostosis, and 3 patients (4.2%) had impingement due to abnormally fibrous bands. There were only 2 cases in which the cause of symptoms could not be detected by ankle arthroscopy, compared with 16 cases in which the cause of disability could not be detected using standard methods. In 3 cases (17.6%) of distal tibiofibular ligament injuries, 8 cases (27.6%) of osteochondral lesions, and all 3 cases (100%) of impingement of an abnormal fibrous band, ankle arthroscopy was the only method capable of diagnosing the cause of residual ankle pain after a sprain. CONCLUSION: The present results suggest that arthroscopy can be used to diagnose the cause of residual pain after an ankle sprain in most cases that are otherwise undiagnosable by clinical examination and imaging study.

A case of Freiberg's disease in an adult patient.

Freiberg's disease is an osteochondrosis of the IInd metatarsal head that prevalently develops during the second decade of life and that is the cause of important painful symptoms that resist conservative treatment. The disease is quite rare and must be treated surgically during its early phase in order to prevent progression that may result in permanent changes in the metatarsal head. It is the purpose of this study to describe the clinical case of a patient aged 30 years affected with Freiberg's disease, diagnosed at the age of 15 years, and never submitted to either conservative treatment or surgery.

Arthroscopically assisted meniscal allograft transplantation with and without combined anterior cruciate ligament reconstruction.

The menisci provide a vital role in load transmission across the knee joint as well as contribute to knee stability, particularly in the ACL-deficient knee. Loss of the meniscus, in part or in total, significantly alters joint function and predisposes the articular cartilage to degenerative changes, which has been well documented both clinically and radiographically. This study examined clinical and patient-reported outcomes following meniscal allograft transplantation with and without combined ACL reconstruction in a select group of 31 patients with complaints of pain and/or instability (34 meniscal allografts); 11 underwent isolated meniscal transplantation and 20 meniscal transplantation combined with ACL reconstruction. Bony fixation was performed with bone plugs for medial transplants and using a bone bridge for lateral transplants. All patients completed several knee-specific and general measures of health-related quality of life and underwent a comprehensive physical examination. Flexion weightbearing PA radiographs at latest follow-up were compared to those obtained preoperatively. Mean follow-up was 2.9 years (range 2-5.5 years). The Activities of Daily Living and Sports Activities Scale scores were 86+/-11 and 78+/-16, respectively, and the average Lysholm score was 84+/-14. There were no significant differences in these scores based upon which meniscus (medial or lateral) was transplanted, concurrent ACL reconstruction, or the degree of chondrosis at arthroscopy. SF-36 scores indicated that patients were functioning at a level similar to the age- and sex-matched population. Twenty-two patients stated they were greatly improved, 8 were somewhat improved, 1 was without change. All but one patient reported that knee function and level of activity were normal or nearly normal. The average loss of motion compared to the noninvolved side was 3 degrees for extension and 9 degrees for flexion. All but one patient had a negative or 1+ Lachman's test. The remaining patient had a 2+ Lachman's test. Assessment with the KT-1000 arthrometer revealed a side-to-side difference of 2 mm (range -2 mm to 7 mm). Average hop and vertical jump indices were both 85% of the contralateral extremity. No statistically significant joint space narrowing was observed by radiography over time. Meniscal allograft transplantation with and without combined ACL reconstruction in carefully selected patients with complaints of compartmental joint line pain and/or instability appears able to provide relief of symptoms and restore relatively high levels of function, particularly during activities of daily living.

[Radiologic diagnosis of lunate necrosis]. / Radiologische Diagnostik der Lunatumnekrose.

In the literature little is to be found concerning diagnosis and differential diagnosis of Kienböck's disease. Because of technical development in radiological imaging, we now possess very detailed pictures. However, there are many radiological findings within the lunate bone, which can be misinterpreted as Kienböck's disease. Pathological findings of the lunate bone are demonstrated, which are not Kienböck's disease. These findings were compared to different stages of Kienböck's disease and identified. The early stages of Kienböck's disease show changes especially in the MRI, which are very similar to acute bone bruise, ulnar impaction syndrome, synovialitis or gout. Vessel tubes or an intraosseous ganglion can be mistaken for Kienböck's disease. In the late stages of Kienböck's disease, it can be difficult to differentiate this from pseudarthrosis of the lunate bone. The differentiation between Kienböck's disease and other pathological findings is at times very difficult--even with MRI. However, sometimes diagnosis can only be verified by MRI. We therefore suggest that Kienböck's disease must be correctly diagnosed with help of the MRI before commencing with any therapeutic steps.

Force distribution through the wrist joint in patients with different stages of Kienböck's disease: using computed tomography osteoabsorptiometry.

The pattern of subchondral bone density has been considered to reflect the stress distribution that occurs under physiologic loading conditions. To determine the force distribution through the wrist joint with Kienböck's disease in living subjects, we applied a computed tomography osteoabsorptiometry and investigated the subchondral bone density pattern across the radio-carpal joint of 6 normal subjects and 10 patients suffering from Kienböck's disease (Lichtman's stage IIIA, 5 patients; stage IIIB, 5 patients). A single density maximum was found in each scaphoid and lunate fossa in all normal subjects. Among the subjects with Kienböck's disease, the current analysis demonstrated that the density maximum area significantly increased in the scaphoid fossa and decreased in the lunate fossa from stage IIIA to IIIB group. These findings indicate that the load is shifted away from the lunate to the scaphoid with the progression of Kienböck's disease in living subjects.

Kienböck's disease: conservative management versus radial shortening.

Avascular necrosis of the lunate, first described by Kienbock, can be treated either conservatively or by various surgical procedures. We compared the results of 18 conservatively treated patients, all of whom had stage-2 or stage-3 disease, with those of 15 who underwent a radial shortening procedure. We evaluated pain, range of movement, grip strength and functional disability, and determined the progression of the disease by assessing radiologically carpal height, the width and flattening of the lunate, the radioscaphoid angle, the pattern of the fracture and sclerosis and cysts. The mean follow-up was for 3.6 years (1.5 to 9). Patients treated by radial shortening had less pain and better grip strength than those managed conservatively. In some patients with stage-3 disease treated conservatively there was rapid deterioration to carpal collapse. Although radial shortening did not reverse or prevent carpal collapse, it slowed down the process in patients with stage-3 disease. We recommend a radial shortening procedure for patients with severe pain and radiological signs of progressive carpal collapse.

Results of arthroscopic joint debridement in different stages of chondromalacia of the knee joint.

A retrospective study was performed of 161 patients who had undergone arthroscopic operation for chondromalacia of the knee joint. After an average follow-up period of 40 (range 10-72) months, patients with severe articular cartilage lesions who had undergone articular lavage alone showed significantly poorer results (P < 0.001). With the same stage of chondromalacia and having undergone the same surgical procedure, younger patients showed better results than older patients. The more effective interruption of the circulus vitiosus during the development of degenerative joint diseases is the primary cause for better results achieved by mechanical debridement of the joint for patients suffering from grade 2 or higher. According to the literature, aggressive subchondral abrasion in severely degenerated knees does not show any benefits. Apparently, the success of the therapy depends to a great extent on the inferiority of the potential degenerative regenerate (lack of capacity of intrinsic regeneration of the hyaline cartilage) as well as on the grade and the progression of chondromalacia. Almost every second patient suffering from grade 4 chondromalacia complained of recurrent pain 1 year postoperatively. One of every 6 patients received a knee joint prosthesis within the 1st year. Therefore, the patients' preoperative expectations have to be clearly objectified. The surgical procedure as an operation with a low complication risk can also be justified as a temporary alternative to total knee arthroplasty in patients suffering from a high-grade degeneration of the joint.

Reliability of the Lichtman classification of Kienböck's disease.

The purpose of this study was to establish the interobserver reliability and intraobserver reproducibility of the staging of Kienböck's disease according to Lichtman's classification. Posteroanterior and lateral wrist radiographs of 64 patients with a diagnosis of Kienböck's disease and 10 control subjects were reviewed independently by 4 observers on 2 separate occasions. The reviewers included 3 hand fellowship-trained surgeons and 1 orthopedist who was not fellowship-trained in hand surgery. A stage was assigned to each set of radiographs according to the Lichtman classification. Paired comparisons for reliability among the 4 observers showed an average absolute percentage agreement of 74% and an average paired weighted kappa coefficient of 0.71. Furthermore, all the controls were correctly classified as stage I, which is in accordance with the Lichtman system. With regard to reproducibility, observers duplicated their initial readings 79% of the time with an average weighted kappa coefficient of 0.77. These results indicate substantial reliability and reproducibility of the Lichtman classification for Kienböck's disease.

Osteochondral lesions of the talus: a revised classification.

Osteochondral lesions of the talus present a numerically small but therapeutically significant problem to the foot surgeon. The diagnosis and investigation of such lesions have been greatly enhanced by modern high resolution magnetic resonance imaging capabilities, which have provided far greater detail of the pathological anatomy. We have reviewed our experience in this area and suggest a revised classification for osteochondral lesions appropriate to the detail available on magnetic resonance imaging scans. The cause of osteochondral lesions is also discussed.

Osteochondral lesions of the talar dome. A comprehensive review with retrospective study.

The incidence of osteochondral lesions of the talus is increasing because of a greater awareness of this injury following ankle trauma. The treating physician should view the so-called simple ankle sprain as a potential for fractures of the talar dome, especially in patients who are recalcitrant to treatment. It has been the authors' experience that talar dome lesions respond well to arthrotomy with removal of the fracture fragment and subchondral drilling, and yield generally good results. A high index of suspicion following ankle trauma allows for the early recognition and treatment of talar dome lesions.

Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years.

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage. The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.

[A new classification of semilunar bone necrosis]. / Eine neue Klassifikation der Mondbeinnekrose.

The currently accepted classifications of Kienböck's disease by Decoulx and coworkers (1957) as well as Lichtman and coworkers (1977) resp. Lichtman and Degnan (1993) do not take into account early changes in MRI or changes in carpal architecture. A recent publication by Lichtman and Ross (1994) did not solve the problems of precisely describing the disease. This necessitates a new, reliable classification based on the true nature course of the disease. In a prospective study with 49 patients and in a retrospective review of 125 cases of lunate necroses, the regular natural course of the disease was analysed. It begins with normal X-ray appearance but a typical extinguished T1-signal in MRI; a fracture line is part of the later course and not seen in the beginning. Later, collapse of the lunate and the carpus can be observed. A new classification based on the natural course of the disease is proposed. This classification divides the natural course of Kienböck's disease into four stages, subdividing stage I, II and III by A and B. The disease commences with pathology only detectable by MRI (extinguished signal in T1-weighted sequence-stage I A), followed by first changes in the X-ray (condensation or mosaic-like appearance), while the outer form remains preserved (stage I B); the disease proceeds with partial deformation of the lunate with proximal or radial indentation (stage II A), later with a fracture line, while the lunate index of Ståhl remains normal (stage II B); the collapse of the lunate follows, and Ståhl's lunate index becomes pathologic (stage III A); the subsequent collapse of the carpus is characterized by a pathologic Youm-index (stage III B); Kienböck's disease, finally, leads to arthrosis of the wrist.

[Diagnosis and staging of lunate necrosis. A current review]. / Diagnostik und Stadieneinteilung der Lunatumnekrose. Eine aktuelle Ubersicht.

Recently, early diagnosis and staging of Kienböck's disease was mainly influenced by imaging techniques (CT and MRI). New findings led to the staging classification of Lichtman and Ross (1994) which is recommended in the following. MRI allows diagnosis of the reversible bone marrow edema (stage I), which often is equivocal in conventional radiography. High-resolution CT facilities a more precise imaging of later stages in Kienböck's disease including spongiosal sclerosis (stage II), fractures at the proximal pole (stage III A), and initial osteoarthrosis (stage IV). For therapeutic considerations, contrast-enhanced MRI is extremely useful in stages II and III A, whereas MRI is redundant in stages III B and IV. Carpal instability (stage III B) is sufficiently visualized using conventional radiograms exposed in the neutral position. This review article reveals the value and indications of CT and MRI.

[Stress on the wrist joint in semilunar bone necrosis--a morphologic study in vivo]. / Uber die Beanspruchung des Handgelenks bei Mondbeinnekrose--Eine morphologische Untersuchung am Lebenden.

The distribution of subchondral mineralization of the distal articular surface of the radius was examined by CT osteoabsorptiometry in both wrists of twelve patients showing different stages of Kienböck's disease. The pattern of density distribution had already been demonstrated in previous studies to be an adequate parameter for assessing axial loading across the wrist joint in the patients. Contrary to the anticipated presence of predominant stress in the lunate compartment, some patients showed identical stress in the compartment of the scaphoid, and the balanced loading of both compartments, as before. Even when in early stages of the disease the lunate type of mineralization appeared more often, it was still not possible to demonstrate general excessive stress on the lunate. We have therefore concluded that the main stress in the scaphoid compartment might be a secondary effect, which is to be regarded as the expression of the advancing destruction of the lunate and consequent loss of load transmission through this compartment. This hypothesis is also supported by the fact that, in progressive stages of Kienböck's disease, the density maximum in the fovea lunata, generally present in healthy people, is absent. Furthermore, in patients with necrosis of the lunate, the total mineralization in terms of the maximal density values in the distal joint surface of the radius is in the majority of cases less than in the normal subject. In two cases, even the density maximum was absent from the fovea lunata of the contralateral wrist joint, without there being any clinical signs suggesting a possible lunate necrosis on this side. We interpret these pathological changes in the unaffected wrist joint as a further indication that we are dealing with a congenital predisposition which affects both wrist joints.

[Graner operation in therapy of semilunar bone necrosis. Review of the literature and personal results]. / Operation nach Graner zur Therapie der Lunatumnekrose. Literaturübersicht und eigene Ergebnisse.

Intercarpal arthrodesis with interposition of the capitate osteotomized in Graner's technique is performed in the treatment of stage III Kienböck's disease. Although clinical results are satisfactory, there are complications such as necrosis of the capitate, pseudarthrosis of the capitate, and arthrosis of the radiocarpal joint. From 1992 to 1995, twenty patients were treated for Kienböck's disease by Graner's technique in the Clinic of Hand Surgery II in Bad Neustadt/Saale. Seventeen patients were submitted to follow-up studies. The range of motion (extension/flexion) of the wrist was 55 degree. The grip strength was 67% of the other hand. Four patients continued to complain of pain. Necrosis of the capitate was found in four cases, pseudarthrosis in two cases, and arthrosis of the radiocarpal joint in five cases. Based on the poor X-ray results found in this review, the authors feels there is no indication for Graner's technique. They favor STT arthrodesis in stage III of Kienböck's disease.