Treatment Considerations For Avascular Necrosis Of The Second Metatarsal

We recently had a patient present to our institute for continued pain to his right foot six months after plantar plate repair in the right second metatarsophalangeal joint (MPJ). A review of the operative report and computed tomography (CT) scan found that the patient had a second metatarsal plantar condylectomy with Kirschner wire fixation. Unfortunately, he developed avascular necrosis of the second metatarsal head with significant bone resorption. He presented to our institute to discuss his surgical revision options. This condition is difficult to treat and often frustrating.

There is little published literature that specifically addresses the surgical options for lesser metatarsal head avascular necrosis. However, there are several options regarding primary surgical intervention for lesser MPJ arthritis, which is commonly associated with Freiberg’s infraction. Surgical options include joint debridement, dorsal wedge osteotomy, osteochondral autograft transplant, arthroplasty with or without an implant, and even arthrodesis.

When weighing treatment options, consider how active the patient is and the demands on the foot, the age of the patient, the amount of intact bone and cartilage, and the quality of the joint surfaces. Often in cases of lesser metatarsal head avascular necrosis, there is a significant amount of bone destruction and the quality of the bone is very poor. In these cases, the surgeon often needs to remove the remaining damaged bone surfaces and an implant is the best option. However, if the damage is limited to the dorsal surface and there is still some cartilage present and in good condition on the plantar surface of the joint, a debridement or tilt up option may be best.

A Closer Look At The Literature On Avascular Necrosis
Debridement and osteotomy have been the mainstays of treatment for second MPJ avascular necrosis and authors have investigated multiple outcomes of these associated procedures. Kilic and colleagues published a comparison study between cheilectomy and microfracture (group A, six patients) to cheilectomy and dorsal crescentic osteotomy (group B, eight patients) for cases of second metatarsal avascular necrosis and damage.¹ The damage was mainly in the dorsum of the joint surface and the plantar surface was in decent shape. All patients had late-stage avascular necrosis (Smillie grade IV-V) of the metatarsal head. Patients had follow-up for an average of 22 months with postoperative improvement in American Orthopaedic Foot and Ankle Society (AOFAS) scores from 66.3 to 92 in group A and 55.8 to 90.6 in group B. The authors concluded that both surgical options provided significant pain relief and improved MPJ range of motion (ROM).

Kim and coworkers reported on 20 patients who had a modified Weil osteotomy with a dorsal wedge and rotation of the plantar cartilage.² This was their preferred surgical approach to offload the metatarsal head and restore MPJ congruency. The average age of the patients was 33.6 and the mean follow-up was 71.6 months. The authors found that pain on the Visual Analog Scale (VAS) improved from 6.2 to 1.4 postoperative. They also reported improvement in AOFAS scores from 63.3 to 80.4. Most interestingly, they found no significant difference in the VAS, AOFAS scores and range of motion between patients with Smillie’s stage I, II and III versus Smillie’s stage IV and V. The authors related that the modified Weil dorsal wedge osteotomy may be indicated for treatment of Freiberg’s disease in both early and late stages.

For select younger patients who present with associated significant bone or loss of the entire metatarsal head, it is important to consider surgical options that try to maintain a proper metatarsal parabola. One of the newer and more technical advancements in the treatment of second MPJ avascular necrosis is transplant of the second metatarsal head with an osteochondral allograft. Fixation and proper alignment are essential in such cases.

Ajis and colleagues published a review of six patients who had osteochondral distal metatarsal allograft reconstruction.³ The authors augmented metatarsal allograft incorporation with the addition of iliac crest bone marrow aspirate. Surgeons used this as a salvage procedure for end-stage degenerative joint disease to the MPJ and significant bone loss. In the study, patients had follow-up for an average of 36 months. All of the patients maintained viability of the allograft metatarsal head and joint space was normal or Kellgren-Lawrence grade 1 in five of six patients at final follow-up.

Further Insights On Surgical Options
For patients who have low impact demand needs or those who may not be appropriate candidates for osteochondral bone transplantation, a second metatarsal resurfacing or an arthroplasty with tendon grafting may be best. We have performed both of these procedures extensively in our institutes and results have been excellent.

Metatarsal head resurfacing (HemiCAP, Arthrosurface) can serve as an excellent option in cases of avascular necrosis with minimal bone shortening. The Morris taper design allows for excellent bone apposition and also results in a solid fixation with immediate range of motion potential. If there is extensive bone loss and a low demand situation, we have found an arthroplasty with a tendon graft space technique to be an excellent option. We will typically place a peroneal tendon allograft in the resection site and then pierce it with a retrograded K-wire from the tip of the toe into the MPJ. We then spin the tendon into a ball filling the empty joint space before advancing a Kirschner wire into the metatarsal. We have found this technique an effective method for limiting shortening at the resection site.

For patients who are sedentary or those who have low ambulatory demands, lesser MPJ fusion may be a viable option. Karlock published a review of 11 patients who had second MPJ arthrodesis for the treatment of crossover hammertoe deformity.⁴ Ten of the 11 patients reported good or excellent results with no complaints of metatarsalgia or recurrent deformity. However, the majority of the patients had low ambulatory demands and were mostly elderly with an average age of 63.

In Conclusion
There are multiple revision options for lesser metatarsal complications. Therefore, it is essential to evaluate each case critically to provide the best patient care and surgical outcome. Although the problem is often difficult to treat, the multitude of options available allow for more choices. With appropriate patient and procedure selection, outcomes have been improving with long-term results that are standing the test of time.

Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Chief of Podiatric Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and is the Director of the University Foot and Ankle Institute in Los Angeles (https://www.footankleinstitute.com/podiatrist/dr-bob-baravarian ).

Dr. Campbell is a Fellow at the University Foot and Ankle Institute in Los Angeles.

References
1. Kilic A, Cepni KS, Aybar A, Polat H, May C, Parmaksizoglu AS. A comparative study between two different surgical techniques in the treatment of late-stage Freiberg’s disease. Foot Ankle Surg. 2013;19(4):234-8.
2. Kim J, Choi W, Park Y, Clin J. Modified Weil osteotomy for the treatment of Freiberg’s disease. Orthop Surg. 2012;4(4):300-306
3. Ajis A, Seybold JD, Myerson MS. Osteochondral distal metarsal allograft reconstruction: a case series and surgical technique. Foot Ankle Int. 2013:34(8):1158-67.
4. Karlock LG. Second metatarsophalangeal joint fusion: A new technique for crossover hammertoe deformity. A preliminary report. J Foot Ankle Surg. 2003;42(2):178-82.

Additional References
5. Carmont MR, Rees RJ, Blundell CM. Current concepts review: Freiberg’s disease. Foot Ankle Int. 2009;30(2):167-76.
6. Lee HJ, Kim JW, Min WK. Operative treatment of Freiberg disease using extra-articular dorsal closing-wedge osteotomy: technical tip and clinical outcomes in 13 patients. Foot Ankle Int. 2013; 34(11):111-116.
7. Highlander P, VonHerbulis E, Gonzalez A, Britt J, Buchman J. Complications of the Weil osteotomy. Foot Ankle Spec. 2011; 4(3):165–170.
8. Talusan P, Diaz-Collado P, Reach J. Freiberg’s infraction: diagnosis and treatment. Foot Ankle Spec. 2014; 7(1):52-6.

Editor’s note: For related articles, see “How To Address Avascular Necrosis” in the December 2008 issue of Podiatry Today, “Essential Insights On Treating Freiberg’s Infraction” in the March 2006 issue, the December 2013 DPM Blog, “Dealing With An Unusual Case Of Foot Pain Due To Cushing’s Disease,” by William Fishco, DPM, FACFAS, and “Metatarsal Head Resurfacing: Does It Have A Place In Treating Hallux Limitus/Rigidus?” in the January 2008 issue.