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).
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.
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.
1. Binek R, Levinsohn EM, Bersani F, Rubenstein H: Feiberg disease complicating unrelated trauma. Orthopedics 11: 753–757, 1988.
2. Fleischli J, Cheleuitte E: Avascular necrosis of the hallucal sesamoids. J Foot Ankle Surg 34: 358–365, 1995.
3. Freiberg AH: Infarction of the second metatarsal bone: A typical injury. Surg Gynecol Obstet 19: 191–193, 1914.
4. Horne G, Tanzer T, Ford M: Chevron osteotomy for the treatment of hallux valgus. Clin Orthop 183: 32–36, 1984.
5. Jones KJ, Feiwell LA, Freedman EL, et al: The effect of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head. J Bone Joint Surg 77A: 197–204, 1995.
6. Lopatinskaia LN: Bilateral aseptic necrosis of the heads of the first metatarsal bones. Vestn Rentgenol Radiol 4: 60–61, 1993.
7. Meier P, Kenzora JE: The risks and benefits of distal first metatarsal osteotomies. Foot Ankle 6: 7–17, 1985.
8. Meisenheder DA, Harkless LB, Patterson JW: Avascular necrosis after first metatarsal head osteotomies. J Foot Surg 23: 429–435, 1984.
9. Metzger MJ, Levin JS, Clancy JT: Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg 38: 154–163, 1999.
10. Peterson DA: Avascular necrosis of the first metatarsal head: Incidence in distal osteotomy combined with lateral soft tissue release. J Foot Ankle Surg 15: 59–63, 1994.
11. Reach S, Stenstrom A, Gustafson T: Circulatory disturbance of the first metatarsal head after chevron osteotomy as shown by bone scintigraphy. J Foot Ankle Surg 13: 137–142, 1992.
12. Stanley D, Betts RP, Rowley DI, Smith TW: Assessment of etiologic factors in the development of Freiberg’s disease. J Foot Surg 29: 444–447, 1990.
13. Steinberg ME: Early diagnosis, evaluation, and staging avascular necrosis. Instr Course Lect 43: 513–518, 1994.
14. Thomas RL, Espimosa FL, Cantu D, et al: Radiographic changes in the first metatarsal head after distal chevron osteotomy combined with lateral release through a plantar approach. J Foot Ankle Surg 15: 285–292, 1994.
15. Wallace GF, Bellacosa R, Mancuso JE: Avascular necrosis following distal first metatarsal osteotomies: A survey. J Foot Ankle Surg 33: 167–172, 1994.
16. Walsh HP, Dorgan JC: Etiology of Freiberg’s disease: ? trauma. J Foot Surg 27: 243–244, 1988.