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Idiopathic Osteonecrosis of the First Metatarsal Head: A Case Report

Suzuki, Junzo, MD*; Tanaka, Yasuhito, MD**; Omokawa, Shohei, MD*; Takaoka, Takanori, MD*; Takakura, Yoshinori, MD**

Clinical Orthopaedics and Related Research®: October 2003 - Volume 415 - Issue - p 239-243
doi: 10.1097/01.blo.0000092971.12414.7e
SECTION II ORIGINAL ARTICLES: Foot/Ankle
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A 66-year-old woman with idiopathic osteonecrosis of the first metatarsal head was treated by arthrodesis of the first metatarsophalangeal joint with a good result. The patient had no history of foot injury, no record of corticosteroid administration, no excessive alcohol intake, and no other predisposing conditions for osteonecrosis. Surgical intervention, by removal of the necrotic area followed by metatarsophalangeal joint fusion, alleviated her foot pain.

From the *Ishinkai Yao General Hospital/Yao Osaka, Japan;

**Nara Medical University/Kashihara, Nara, Japan

Reprint requests to Shohei Omokawa, MD, Department of Orthopedics, Ishinkai-Yao General Hospital, 1–41, Numa Yao Osaka, 581-0121, Japan. Phone: 81-729-48-2500; Fax: 81-729-7950; E-mail: omokawa@kcn.ne.jp.

Received: October 22, 2001.

Revised: September 23, 2002; November 6, 2002.

Accepted: November 18, 2002.

Osteonecrosis of the fist metatarsal head is a well-known complication of surgical correction of hallux valgus deformity by osteotomy. 4,5,7,8 However, idiopathic osteonecrosis in adults rarely occurs, and no therapeutic method for treatment of this disorder has been reported previously. The authors treated a patient with idiopathic osteonecrosis of the first metatarsal head by arthrodesis of the first metatarsophalangeal joint and obtained a satisfactory result.

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CASE REPORT

A 66-year-old woman presented with pain and swelling in the right first metatarsophalangeal joint at the authors’ institution in May 1998. The patient had experienced gradually worsening pain, without any apparent trauma, since 1995. The range of motion (ROM) in the metatarsophalangeal joint was restricted, reduced to 30° dorsiflexion and 20° plantar flexion. As a child, the patient had purpura and asthma. She was diagnosed as having psychosis at age 20, which had been controlled successfully with tranquilizers. Reliable medical records and an accurate account of her history revealed that she had no history of trauma, alcoholism, diabetes mellitus, or use of corticosteroids.

An anteroposterior (AP) radiograph showed that the first metatarsal head collapsed and flattened (Fig 1A). An oblique radiograph showed osteolytic changes in the subchondral bone of the first metatarsal head, which were characteristic of avascular osteonecrosis (Fig 1B). Computed tomography (CT) scans showed fissuring and collapse in the head of the first metatarsal. The low density in the head indicated osteonecrosis and the high density showed bone sclerosis. Magnetic resonance imaging (MRI) showed specific clinical findings of osteonecrosis. Low signal intensity was seen throughout the distal area of the head on the T1-weighted image (Fig 2A); the T2-weighted image showed a combination of a low and high signal intensities in the first metatarsal head (Fig 2B). Bone scintigraphy showed visible activity in the distal portion of the right first metatarsal head (Fig 3). These findings were interpreted as indicating osteonecrosis of the first metatarsal head. According to the classification system defined by Steinberg, 13 radiographic staging was assessed as Stage 4. Surgical treatment was selected because 4 weeks of nonweightbearing, prescribed as a conservative treatment, had failed to alleviate the foot pain.

Fig 1A

Fig 1A

Figure

Figure

Fig 2A

Fig 2A

Figure

Figure

Fig 3

Fig 3

A medial longitudinal incision was made on the first metatarsophalangeal joint and the joint was exposed by Y-shaped arthrotomy. Excessive stripping of soft tissues from the first metatarsal neck was avoided, so as not to interrupt the blood supply to the metatarsal head. Fissuring and collapse of articular cartilage were observed on the joint surface of the first metatarsal head. The degenerated cartilage and necrotic bone were removed to the vascularized cancellous bone using a small oscillating microsaw. An osteotomy was done in the transverse plane, and the metatarsophalangeal joint was fixed with two small AO cortical screws. The fixed position was held at 10° valgus, in the mediolateral plane, and 20° dorsiflexion in the dorsoplantar plane. No additional bone grafting was done. Postoperatively, the patient was able to walk with partial weightbearing, wearing an insole in her shoe. The postoperative course was unevenful, and fusion was obtained 1 year after the surgery. The patient was satisfied with the treatment at the last examination done 18 months postoperatively. The pain in the first metatarsophalangeal joint was relieved completely, and no recurrence of osteonecrosis was observed on radiographs (Fig 4).

Fig 4

Fig 4

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HISTOLOGIC FINDINGS

The collapse of the articular cartilage was observed in the metatarsal head, and hypertrophy also appeared in the articular cartilage. Fibrous tissue and bone necrosis were seen in the central portion of the first metatarsal head with a few osteoblasts along the bone trabeculae. There also were numerous empty lacunae in the bone tissue (Fig 5). These findings were typical features of osteonecrosis.

Fig 5

Fig 5

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DISCUSSION

Osteonecrosis have been reported in several bones of the foot such as the talus, the navicular, and the first metatarsal sesamoid bone. 2,9 Osteonecrosis may lead to the collapse of the tarsal bone, and eventually progressive degeneration of the tarsal joint. Nonoperative treatment given routinely, has been unsuccessful. Idiopathic osteonecrosis in the long bones of the foot rarely occurs in adults, although juvenile osteonecrosis at the epiphysis of the metatarsal head is well known as Freiberg’s disease. 3 The etiology of Freiberg’s disease is multifactorial, and repetitive trauma to the second longest ray of the forefoot may cause a microfracture in the epiphysis, affecting vascularity to the metatarsal head. 1,12,16. There is only one report to date describing idiopathic osteonecrosis in the first metatarsal head in an adult, published in the Russian literature. 6

Secondary osteonecrosis of the first metatarsal head after osteotomy for hallux valgus deformity has been reported. 10,11,14,15 In 1984, Horne et al 4 reported nine cases of osteonecrosis in the first metatarsal head in the followup of 76 Chevron osteotomies. Jones et al 5 found an extensive network of extraosseous vasculature to the metatarsal head proximal and distal to the metatarsal neck based in their anatomic study. They reported that osteonecrosis of the first metatarsal head may be produced in patients in whom all of the intraosseous and extraosseous vascular supplies to the metatarsal head are interrupted. The authors found no obvious etiologic factor or predisposing condition in the current patient.

Surgical treatment was chosen because a conservative treatment of nonweightbearing had failed to alleviate the patient’s foot pain. Arthrodesis of the metatarsophalangeal joint was selected because the stability of the first ray of the forefoot is essential for walking. Successful fusion of the metatarsophalangeal joint resulted in sufficient revascularization of the metatarsal head and resolved the arthritic condition of the joint. The first ray of the foot was shortened by approximately 1 cm, but no adverse effect on functioning of the foot was observed. This is one of the first reports describing surgical treatment for osteonecrosis of the first metatarsal head in an adult. The results show that solid union of the metatarsophalangeal joint can be achieved when the necrotic area is removed adequately.

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References

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