Surgical Treatment of Ischaemic Necrosis of the Second Metatarsal Head of the Right Foot: Part 1

By Yu Liu

Affiliations

1. Emergency Disposal Department, Gansu Emergency Medical Rescue Centre, Gansu, China

doi: 10.29271/jcpsp.2025.07.941

Sir,

Freiberg's disease is a rare necrotising disease of the metatarsal heads.¹ The second metatarsal head has the highest prevalence, but it can involve any of the five metatarsal heads.² The disease causes necrosis and collapse of the metatarsal heads, which leads to degenerative changes in the metatarsophalangeal joints and the development of arthritis. Freiberg's disease is a more common osteochondroma in women, with a male-to-female ratio of 1:5.³ In the first part of this article, the authors present the diagnosis and early treatment results of a case of Freiberg's disease involving a 16-year male patient.

A 16-year male presented to the hospital with intermittent right foot pain and swelling for three months. Physical examination showed the second metatarsal bone of the right foot to be markedly painful, and the movement of the right foot was limited. The x-ray and CT examinations showed that the cartilage of the second metatarsophalangeal joint of the right foot was destroyed, and the metatarsal head showed ischaemic necrosis (Figure 1A, B).

Figure 1: (A, B) X-ray and CT scan showing the destruction of the cartilage of the second metatarsophalangeal joint and ischaemic necrosis of the metatarsal head. (C) Peroperative view showing ischaemic necrosis of the metatarsal head. (D) Fixation of the metatarsophalangeal joint with a Kirschner's pin.

After admission, under general anaesthesia, the second metatarsal bone of the right foot was examined. It was seen that the cartilage on the surface of the second metatarsal head of the right foot was destroyed, and the head of the metatarsal bone revealed ischaemic necrosis (Figure 1C). Firstly, the necrotic tissue was excised, and then the metatarsal head was wedge osteotomised, and the articular surface was reconstructed with T-plates. Finally, the metatarsophalangeal joint was fixed with a Kirschner's pin (Figure 1D) to facilitate the recovery of the  metatarsophalangeal  joint.

Necrosis of the second metatarsal head of the right foot is a rare condition, and many clinicians lack diagnostic experience, leading to missed diagnoses and misdiagnoses in the early stages of the disease, resulting in delayed diagnosis and treatment. In this case, a clinically experienced orthopaedic surgeon is needed to accurately diagnose the disease. After diagnosis, conservative treatment is often ineffective and requires prompt removal of the necrotic lesions and reconstruction of the physiological structure of the joint. The surgical method can use wedge-shaped osteotomy of the metatarsal head combined with T-plate joint reconstruction, supplemented by Kirschner’s wire fixation of the metatarsophalangeal joint. The authors found this surgical approach to be very effective. It is worth noting that the Kirschner’s pin needs to be removed one month after surgery. Due to the recent date of this case, only the early treatment effect evaluation was conducted, and the later rehabilitation effect has not been followed up. The second part will be supplemented after the collection  of  follow-up  results  is  completed.

FUNDING:
Natural Science Foundation of Gansu Province (21JR11RA 187).

COMPETING   INTEREST:
The  author  declared  no  conflict  of  interest.

AUTHOR’S   CONTRIBUTION:
YL:  Drafted, revised, edited, and approved the manuscript.

REFERENCES

1. Carter KR, Chambers AR, Dreyer MA. Freiberg Infraction. 2023 Nov 22. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
2. Wax A, Leland R. Freiberg disease and avascular necrosis of the metatarsal heads. Foot Ankle Clin 2019; 24(1): 69-82. doi: 10.1016/j.fcl.2018.11.003.
3. Achar S, Yamanaka J. Apophysitis and osteochondrosis: Common causes of pain in growing bones. Am Fam Physician 2019; 99(10):610-8.