Tag Archives: Freiberg’s infraction

Freiberg’s Infraction of the Second Metatarsal Head with Bioorthologic Repair using the NEXA Osteocure™ Bone Graft: A case report

by Al Kline, DPM1

The Foot & Ankle Journal 1 (11): 4

Freiberg’s infraction is a relatively common osteochondritis of the second metatarsal head. It appears to affect young women who are active in sports. Its etiology is thought to be traumatic in nature causing a painful alteration, subchondral disruption and collapse of the articular cartilage. A case report is presented describing this disorder in a young female runner. The use of a bioorthologic bone plug to surgically treat this condition is discussed and presented. It appears that the use of bioorthologic materials provide a promising alternative to surgical osteotomies. It has been shown that bioorthologic materials will provide a porous scaffold allowing blood, marrow and progenitor cells to wick into the pores and provide a stable environment for tissue in-growth and cellular development. Between six and twelve months, the polymer is resorbed and replaces the natural hyaline cartilage of the joint surface.

Key words: Freiberg’s infraction, osteochondritis, osteochondritis dessicans, bioorthologic bone graft

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: October , 2008
Published: November, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0111.0004

In 1914, Alfred H. Freiberg was the first to describe a painful collapse to the articular surface of the second metatarsal head. [1] The etiology of injury can be attributed to trauma and subchondral disruption of the vascular supply to the articular cartilage. The incidence of injury appears to be most commonly found in young women and girls, although the overall incidence of osteochondroses is higher in men. [2] On occasion, the third metatarsal head may also be involved. Osteochondritis, in effect, can involve any of the five metatarsal heads of the foot. However, the incidence is highest involving the second metatarsal head. [1]

There does not appear to be a genetic link to Freiberg’s infraction, although a recent report of Freiberg’s infraction in twins may suggest an underlying genetic predisposition. [8]

In Freiberg’s original article, he described six women with a painful limp and pain isolated to the second metatarsal head. Radiographs revealed collapse of the articular surface of the second metatarsal head with intra-articular loose bodies seen in three of the six patients. He noted that four of the six patients were under 18 years of age and postulated that a long second metatarsal combined with an ineffective first ray complex attributed to overload of the second metatarsal phalangeal (MTP) joint and subsequent articular collapse. [2]

Patients usually present with a painful and often swollen joint. A history of trauma may or may not exist. There is usually point tenderness to the dorsal aspect of the second metatarsophalangeal joint and associated limitation of joint motion. Diagnosis is often confirmed by simple radiographs which show varying stages of metatarsal head injury and articular depression.

MR (magnetic resonance) imaging has been definitively shown to aid in the diagnosis of Freiberg’s infraction before joint changes occur on radiograph. [4] This may be particularly useful in the early stage of the disorder when joint pain is present without observed changes to the joint surface.

In the patient with a normal or even wide joint space, MR imaging allows for early identification of Freiberg’s infraction through low signal intensity changes of subchondral sclerosis. (Fig. 1)

Figure 1 Early flattening (small arrows) with low signal intensity osteochondrosis of the second metatarsal head on a T-1 axial image.  (Courtesy David W. Stoller, MD: Magnetic Resonance Imaging in Orthopaedics & Sports Medicine, pp.488-489, 1993.)

In his original article, Freiberg described his treatment which included simple removal of the loose bodies in the joint. Historically, there have been a number of surgical approaches to the treatment of Freiberg’s infraction. The use of bioorthologics is a relatively new approach to the treatment of osteochondral defects and injury. A case report is presented describing the use of the NEXA Osteocure™ bone graft for repair of a stage II Freiberg’s infraction of the second metatarsal head.

Case Report

An active fifteen year old female runner began having pain and discomfort to the second MTP joint. She did not recall any injury. She is very active in track and basketball. She has been running daily and relates to pain while running. She was using a silicone sleeve over the second toe and takes Tylenol and Motrin for pain and swelling. Her pain began to interfere with her running and she began seeking medical attention.

Her clinical examination revealed a swollen second metatarsophalangeal joint with pain upon dorsiflexion of the second toe. Joint range of motion was limited to about 5 to 10 degrees of dorsiflexion with extreme pain. Radiographic evaluation confirmed second metatarsal head changes consistent with Freiberg’s infraction and a long second ray with Morton’s toe. (Fig. 2)

Figure 2   Initial radiograph shows subchondral disruption of the articular surface of cartilage involving the second metatarsal head.  Note the long second metatarsal and Morton’s toe. 

She underwent MR imaging which revealed diffuse increased signal intensity with local tissue edema and hemorrhage. There was joint effusion with fragmentation of the metatarsal head consistent with Freiberg’s infraction, stage II.

The patient had a track meet within three weeks of our visit and returned about four weeks later and underwent casting and immobilization. After cast immobilization, she was placed in accommodative metatarsal padding and shoes and was asked not to return to running for an additional month. However, she continued to re-develop pain and swelling to the joint and was scheduled for surgery to include osteochondral bone repair with bioorthologic graft using the NEXA Osteocure™ bone graft.

Surgical Technique

The patient was brought to surgery. A local second ray block was performed under intravenous sedation. A small incision was made directly over the second MTP joint. A dorsal capsular incision was performed and upon entry of the joint, we noticed a cartilaginous loose body at the dorsal aspect of the metatarsal head. (Fig. 3)

Figure 3 Once the joint is entered surgically, a dorsal linear capsulotomy reveals a loose joint body.

The soft tissue capsule is delicately reflected to expose the cartilaginous surface of the metatarsal head. A large defect along the dorsal half of the metatarsal head is identified. The cartilage was actually separated from the underlying subchondral bone.

Using a small scalpel, the defect is lifted from the subchondral bone. It is important to identify the loose margin of cartilage and the point of firm attachment of the cartilage cap plantarly in order to preserve the plantar cartilage. (Figs. 4 and 5) Once this margin is identified, the loose cartilage is then excised in a semi-circular fashion. This is done to facilitate the bone plug, which is round in its shape. (Figs. 6 and 7)


Figures 4 and 5  The loose cartilage is identified and demarcated from the subchondral bone.  Care is taken to identify the plantar cartilaginous attachment.


Figures 6 and 7  The loose cartilage is removed and the  plantar cartilaginous attachment is identified.  A semi-circular excision of the cartilage flap has been performed.

A curette is then used to remove the soft, unhealthy subchondral bone. (Fig. 8) Preparation of the site is probably the most crucial aspect of this surgery. In particular, joint range of motion needs to be unimpeded dorsally and requires the removal of joint spurring, loose bodies and bone defects. Using the NEXA Osteocure™ Implant Kit, a corresponding set of color-coded sizers allows for determination of the bone graft size.

Figure 8   A curette is used to remove any diseased subchondral bone.  The diseased portion of bone is usually softer than the underlying cancellous bone.

Color coded sizers of 5, 7, 9 and 11mm diameter correspond to the respective graft size plugs. (Figs. 9,10) Once the graft size is determined, a reaming drill is used to prepare the graft site for implantation. (Figs. 11,12 and 13) The graft is then measured for depth, inserted and tapped within the newly prepared host site. (Figs. 14,15 and 16) The graft is then firmly placed into the host site. The joint can also be placed through its proper range of motion. This will ensure that the graft is articulating with the proximal phalanx. (Figs. 17 and 18)


Figures 9 and 10  The bone plug sizer is used to determine the size diameter of the graft.  Again, the inferior, semi-circular portion of healthy cartilage should fit directly to the sizer.


Figures 11,12 and 13  The drill corresponding to the sizer is used to prepare the host site for the graft plug.


Figures 14,15 and 16  The graft is measured for depth and then inserted into the host site.  A small tap is used to secure the graft into the host site.


Figures 17 and 18  The graft is seated in the defect.  The Osteocure™ graft provides a press fit to the defect with close approximation to the surrounding bone and tissue causing migration of tissue into the scaffolding.  This surface will provide scaffolding for hyaline-like cartilage in 6 to 12 months.

The surgical site is then closed in the customary manner. The patient was then placed non-weight-bearing in a posterior splint and kept on crutches for 4 weeks. This was followed by 2 weeks of partial weight-bearing in a walking shoe. She was able to wear her athletic shoes within 8 weeks after surgery.

The patient was pain free with an increase in joint range of motion. At last visit, she was playing volleyball without pain. (Figs. 19 and 20), however, the patient has been advised not run for six months after surgery to allow the graft to resorb.


Figures 19 and 20  Two months following surgery, incorportation of the graft is already seen.  A thin articular margin is also appreciated.  Although, there is still some flattening of the metatarsal head, the patient is now asymptomatic.  A close up of the radiograph (Fig. 20) reveals new subchondral bone formation in a cancellous pattern with metatarsal head resurfacing.


Several synonyms have been used to described Freiberg’s infraction including Freiberg’s infarction, osteochondrosis of the second metatarsal head, eggshell fracture, Koehler second disease, peculiar metatarsal disease, Panner disease of the metatarsal, osteochondritis deformans metatarso-juvenilis, malacopathia, subchondral bone fatigue fracture of the second metatarsal head and dorsal fatigue stress injury of the second metatarsal head. [2,7]

In the majority of cases, the defect is usually dorsally located to the upper half of the articular surface of the metatarsal head. This would also lend support to the etiology of trauma causing this defect. In observing a number of these cases, mechanical changes appear to cause a dorsal articular jamming and trauma to the joint surface. These include a Morton’s toe or long second digit, a short first metatarsal or elongated second ray and instability of the first ray. Limitation of dorsiflexory motion of the second MTP joint will lead to progressive joint damage and eventual articular shear. This will cause an actual lifting and separation of the articular cartilage from the subchondral bone disrupting the vascular supply to the articular cartilage.

Once the articular cartilage separates, the cartilage can fragment. The fragments that separate from the articular cartilage are called joint bodies or joint ‘mice’.

As previously stated, ‘infraction’ is sometimes called Freiberg’s ‘infarction’. Infarction would suggest a vascular event leading to osteonecrosis. It has been suggested that avascular necrosis from injury will lead to the growth plate or epiphyseal injury in young, growing bone. This may also explain why the incidence is higher in young women and girls.

In 1959, Braddock observed that there is a relative weakness of the second metatarsal epiphysis at a certain stage of epiphyseal maturation. [3] Whatever the etiology, the result appears to cause cartilage lifting and separation from the underlying subchondral bone and vascular osteonecrosis of the joint surface.

The extent of articular damage however, appears to be directly proportional to the extent of joint pain. Treatment, including both conservative and surgical approaches, varies to the extent of injury. In early stages, where the articular cartilage may form a small depression, treatment usually consists of immobilizing the joint.

Conservative treatments should almost always consist of immobilization, offloading and casting irrespective of severity and stage. The goal of non-operative immobilization is to promote a decrease in joint effusion and inflammation including the surrounding soft tissue structures. This may be supplemented with NSAID therapy, joint injections and oral steroids. In patient’s who may not want surgery, shoe modification, metatarsal bars, orthotics and even rocker bottom shoes may provide some temporary relief. In a majority of cases, operative intervention is recommended to provide improved joint mechanics, remove damaged joint spurs and loose joint bodies and treat the osteochondral defect.

Methods of Surgical Treatment

Freiberg initially described removal of the loose bodies to the affected joint. Other treatments have been more aggressive, including the actual removal of the metatarsal head. Unfortunately, this will lead to more complicated conditions of the foot including transfer metatarsalgia, stress fracture and contracture of the corresponding digit.

Some authors have also suggested joint arthroplasty and resecting the base of the proximal phalanx. [6] This may decompress the joint, but joint instability and toe shortening or dorsiflexory rotation of the digit is a major complication.

In 1991, Smith, et al., described simple decompression osteotomy using a T-plate in 15 patients with Freiberg’s infraction of the second metatarsal head. They reported good results and relief of pain within 12 months, although all patients had limited motion of the joint post-operatively. [5]

Dorsiflexory osteotomies have also been described in order to rotate the healthy plantar cartilage dorsally. This is commonly performed by a v-osteotomy and use of cross K-wire technique or screw fixation. However, rotational osteotomies are only indicated in Freiberg’s stages I-III where the plantar hinge of the cartilage is still intact. Implants have also been used including silastic and titanium total implants and titanium hemi-implants. Shih, et al., described the successful use of a titanium hemi-implant in the treatment of Freiberg’s infraction. They reported a successful increase in range of motion of the joint from 15 degrees to 45 degrees, with no pain or activity limitation. [6]

The advantage of using bioorthologics in the treatment of osteochondral defects

Newer techniques are now being introduced in an attempt to actually repair the damaged cartilage and subchondral bone in Freiberg’s infraction. Orthobiologic materials, particularly PolyGraft™ materials, provide a scaffolding for regeneration of tissue and have demonstrated evidence of resurfacing the articular cartilage with hyaline-like cartilage. This is different than resurfacing of the joint with fibrocartilage after damage. Fibrocartilage is primarily Type I collagen and is less desirable than Hyaline cartilage, which is primarily comprised of type II collagen. In a recent land-mark study, Cascio, et al., reported exciting chondral repair with observed hyaline cartilage in a goat model using an injectable hydrogel bone graft. [8]

Critical size chondral defects were created on the stifle joint of adult goats. Experimental defects underwent marrow stimulation to recruit reparative stem cells and were primed with a chondroitin-sulfate based adhesive to anchor the scaffold. Controls received marrow stimulation alone.

The operative goat legs were cast for two weeks and after 13 weeks, cartilage fill and repair quality was assessed by histomorphometry evaluation. Results revealed evidence of hyaline-like repair with a 12% increase in total tissue fill in scaffold-treated defects on histomorphometry. Remodeling and articular cartilage bridging was seen up to twelve months after implantation.

This is an exciting development in the treatment of osteochondral defects by actually healing the cartilage defect with desirable hyaline cartilage and will maintain the joints normal cartilaginous properties. The Osteocure™ bone plug is a porous PolyGraft™ and is the first 100% resorbable composite scaffold material designed to fill osteochondral defects. Its properties include a three dimensional scaffolding structure for tissue incorporation and remodeling. Resorbable polymers and bioactive ceramics are combined to produce the desired strength, stiffness and bone growth characteristics. It also withstands mechanical loads and compression without crushing the material. The Osteocure™ graft provides a press fit to the defect with close approximation to the surrounding bone and tissue causing migration of tissue into the scaffolding. The hydrophilic properties of the porous scaffolding allow blood, marrow and progenitor cells to wick into the pores and provide a stable environment for tissue in-growth and cellular development. Between six and twelve months, the polymer graft is resorbed and replaced with living tissue. [9]


Although there is no one consensus on the best surgical treatment for this condition, the use of orthobiologics provides a promising new attempt to restoring the cartilaginous surface of the joint and eliminating joint destruction and pain. More importantly, these products appear to heal and replace the natural hyaline cartilage of the joint surface.


1. Freiberg, AH. Infraction of the second metatarsal head, a typical injury. Surg Gyn Ob, (19) 163-191, 1914.
2. Boyer, M., DeOrio, J. Freiberg Infraction. E-Medicine, Online article, 2004.
3. Braddock GTF. Experimental epiphyseal injury and Freiberg’s disease. JBJS, 41B (1) February, 1959.
4. Stoller DW. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. J.B. Lippincott Company, Philadelphia, 1st edition, 1993.
5. Smith TW, Stanley D, Rowley DI. Treatment of Freiberg’s disease: A New Operative Technique. JBJS 73B (1), January, 1991.
6. Shih AT, Quint RE, Armstrong DG, Nixon BP. Treatment of Freiberg’s infraction with the Titanium hemi-implant. JAPMA 94 (6), 590-593, Nov/Dec 2004.
7. Blitz NM, Yu JH. Freiberg’s infraction in identical twins: A case report. JFAS, 44(3), May/June 2005.
8. Cascio B, Sharma, MS, Fermanian, BS, Elisseeff, J: Chondral lesion repair in a critical size defect model using injectable hydrogel scaffold in conjunction with marrow stimulation. AOSSM, Poster #32, 2006.
9. Nexa Orthopaedics: Osteocure: PolyGraft™ Material Technology. [Online PDF]

Address correspondence to: Al Kline, DPM
3130 South Alameda, Corpus Christi, Texas 78404.

1 Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiat ry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot & Ankle Journal, 2008

Dorsiflexory Wedge Osteotomy to Treat Freiberg’s Infraction of the Second Metatarsal Head: A case report

by Georgeanne Botek, DPM, FACFAS1, Martha A. Anderson, DPM2 , George Balis, MD3

The Foot & Ankle Journal 1 (11): 3

Freiberg’s infraction is an uncommon diagnosis. The incidence of this disorder is unknown. However, it represents the fourth most common intra-articular osteochondrosis. Treatment is based on supportive measures. The underlying pathology is still not well understood. In cases where conservative treatments fail, surgery is indicated to improve patient symptoms. A case of Freiberg’s infraction is presented that is treated with joint debridement and dorsiflexory wedge osteotomy of the second metatarsal. This procedure is not technically difficult and affords the patient symptomatic relief by rotating the healthy plantar cartilage of the joint dorsally and decompressing the joint surface.

Key words: Freiberg’s infraction, osteochondrosis, osteochondritis dessicans

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: October, 2008
Published: November, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0111.0003

Freiberg’s infraction was first described in 1914. [1] This is the only osteochondrosis that is more common in females and has a ratio of 5:1. [2,3] The typical age range at presentation is between 11-17 years. It was originally termed an infraction because trauma was thought to be the cause of insult to the growing and maturing epiphyseal area. Many other inciting events have been proposed and the etiology of this disease now seems to be multi-factorial. [4-7]

It is suspected that ischemia to the maturing physis plays a part in disease development. [4-7] Some authors have also suggested repetitive microtrauma to the affected part may be the causative agent. [4-8]

The second metatarsal head is the most commonly affected and accounts for approximately 68% of cases. Next is the third metatarsal followed by the fourth and fifth, which are rarely affected. [2,6,8-10]

The most widely used classification system is that of Smillie. [13] This progresses through the stages of deformity from 1 through 5 based on radiographic findings.

Stage 1 of the disease process presents with subchondral epiphyseal fissuring which progresses to collapse of the subchondral plate dorsally with flattening of the articular surface (Stage 3). Late stage disease (4 and 5), there is development of intra-articular loose bodies and degenerative arthrosis with joint space narrowing and metatarsal head flattening. It is also possible to find corresponding degenerative changes at the base of the proximal phalanx in late stage disease. [2,6,8-11] Interestingly, in Europe this infraction is known as Panner’s Disease. [4]

Case Report

An eighteen year old female college student was seen in our department of orthopaedic surgery for right foot pain of eight months duration. She is diagnosed with Freiberg’s infraction of the second metatarsal head. (Figs. 1 and 2)

Figure 1    Pre-operative AP radiograph showing Freiberg’s infraction with subchondral collapse and joint space narrowing.

Figure 2   Pre-operative medial oblique showing large intra-articular loose bodies in the second metatarsophalangeal joint.

Pain is localized over the second metatarsophalangeal joint and worsened with weight bearing and activity. Prior to the onset of pain, she was active in the sport of repelling down large rocks and cliffs.

She had previously been seen by a podiatric physician in her home city and various methods of immobilization were tried. She had minimal improvement with a removable CAM walker. No other immobilization or decrease in activity provided pain relief.

At her initial visit to Cleveland Clinic, she was seen by an orthopaedic surgeon who discussed the case with the collaborating author. The patient underwent a corticosteroid injection. A CAM walker was then worn one week after injection. She was then seen in follow-up and reported approximately one month of pain relief after the injection. Further treatments were then considered and a carbon fiber insert was recommended along with a bone stimulator.

After using the insert over the course of one month, she developed increasing pain to the affected joint. The bone stimulator did not alter the radiographic appearance of her deformity and did not provide any symptomatic relief.

Serial radiographs were taken throughout the course of treatment which remained unchanged. Magnetic resonance imaging (MRI) was also performed prior to surgery. (Figs. 3 and 4)

Figure 3   Pre-operative axial T1 weighted MRI showing the adaptive changes and deformity in the metatarsal head.

Figure 4 Coronal STIR MRI with edema and inflammatory changes at the second metatarsophalangeal joint.

Surgical Technique

A three centimeter incision was placed dorsally over the second metatarsophalangeal joint. Once the capsule was incised and reflected, two large loose bodies were found in the joint measuring approximately three millimeters (mm) each. The dorsal one half to two thirds of the articular cartilage on the metatarsal head was degenerated and atrophic with collapse of the subchondral plate. (Fig. 5)

Figure 5  Post debridement photograph showing extensive loss of the dorsal cartilaginous surface of the metatarsal head.

A dorsiflexory wedge osteotomy of the metatarsal neck was performed to realign the remaining viable plantar articular surface of the metatarsal head. The wedge was taken 1 centimeter proximal to the metatarsal head and was 2-3 mm in width. Temporary fixation was employed using Kirschner wires. The osteotomy was fixated with a 2.0 mm cortical screw using standard AO technique.

Proper positioning was determined using intra-operative fluoroscopy after both the temporary and permanent fixation was in place. (Figs. 6A and B). Soft tissues were approximated and a posterior splint with sugar tong was applied.


Figures 6A and B Intra-operative fluoroscopy after dorsiflexory closing wedge osteotomy fixated with a 2.0 mm screw.

The patient was seen in follow up one week post-operatively and placed in a fiberglass, below-the-knee cast. At fifteen weeks, post-operative radiographs revealed intact fixation and bony trabeculation across the osteotomy site. (Figs. 7A-C)


Figures 7 A-C  Post-operative radiographs taken fifteen weeks after surgery showing consolidation across the osteotomy site.

The patient has minimal discomfort in the second metatarsophalangeal joint and is healing uneventfully. (Fig. 8)

Figure 8  Clinical photograph taken 15 weeks post-operatively showing rectus alignment of the second digit without significant shortening.


Freiberg’s infraction is a rare diagnosis and the true incidence is unknown. This is because many patients do not experience symptoms and may have incidental radiographic evidence of disease sequelae. Although it is rare, it is the fourth most common intra-articular osteochondrosis. [5,8]

Many methods of treatment have been described. Immobilization and limitation of activity or shoe modification is the most common course of conservative treatment. [2,4-6,11]

Several surgical procedures are also available for patients that fail to improve with conservative means. These include joint debridement, core decompression, metatarsal head resection, joint replacement, bioorthologic grafts and metatarsal osteotomies.

A number of authors have published information on the success of dorsiflexory wedge osteotomies for the treatment of Freiberg’s infraction. This procedure seems to be gaining in popularity due to the successful treatment of all stages in Freiberg’s infraction. Gauthier and Elbaz first reported on the technique in 1979. [10] The osteotomy was intra-articular and excised the devitalized dorsal surface of the metatarsal head. Cerclage wire was employed for fixation. This technique was later modified by Kinnard and Lirette who fixated the osteotomy with absorbable suture. [12]

In 1999, Chao, Lee, and Lin published the extra-articular metaphyseal dorsal closing wedge osteotomy for treatment of Freiberg’s infraction. Crossed Kirschner wires were utilized for fixation and were removed in all patients after radiographic signs of healing. Average shortening of the affected metatarsal was 2.1 mm with this procedure. [11]

The principle behind the dorsiflexory wedge osteotomy is to realign the intact plantar metatarsal cartilage and provide for a more physiologic range of motion. Initially the lesion was excised with an intra-articular osteotomy. This technique is also successful when performing it in an extra-articular fashion. The extra-articular osteotomy has the advantage of being technically less difficult and more stable by the use of compressive screw. It also affords a degree of metatarsal shortening to decompress the involved joint.


The dorsiflexory wedge osteotomy for the treatment of Freiberg’s infraction is a generally successful procedure with good subjective outcomes. It may be performed for all stages of disease. Performing the extra-articular osteotomy allows for ease of fixation compared with the intra-articular osteotomy. This procedure also affords a degree of joint decompression and small amount of metatarsal shortening.


1. Freiberg AH. Infraction of the second metatarsal bone. Surg Gynecol Obstet (19):163 – 191, 1914.
2. Katcherian DA. Treatment of Freiberg’s disease. Orthop Clin N Am 25 (1):69-81, 1994.
3. Duthie RB, Houghton GR. Constitutional aspects of the osteochondroses. Clin Orthop Rel Res (158):19-27, 1981.
4. Ary KR, Turnbo M. Freiberg’s infraction an osteochondritis of the metatarsal head. J Am Podiatr Med Assn 69 (2):131-132, 1979.
5. Miller ML, Lenet MD, Sherman, M. Surgical treatment of Freiberg’s infraction with the use of total joint replacement arthroplasty. J Foot Surg 23 (1):35-40, 1984.
6. Scartozzi G, Schram A, Janigian J. Freiberg’s infraction of the second metatarsal head with formation of multiple loose bodies. J Foot Surg 28 (3): 195-199, 1989.
7. Stanley D, Betts, RP, Rowley DI, Smith TW. Assessment etiologic factors in the development of Freiberg’s disease. J Foot Surg 29 (5):444-447, 1990.
8. Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease: Complicating unrelated trauma. Orthopedics 11 (5):753-757, 1988.
9. Nguyen VD, Keh RA, Daehler RW. Freiberg’s disease in diabetes mellitus. Skeletal Radiol (20) (6):425-428, 1991.
10. Gauthier, G and Elbaz, R. Freiberg’s infraction: A subchondral bone fatigue fracture. Clin Orthop Rel Res 142: 93 – 95, 1979.
11. Chao KH, Lee CH, Lin LC. Surgery for symptomatic Freiberg’s disease. Acta Orthop Scand 70: 483-486, 1999.
12. Kinnard, P and Lirette, R. Freiberg’s disease and dorsiflexion osteotomy. J Bone Joint Surg 73B (5): 864-865, 1991.
13. Smillie IS. Treatment of Freiberg’s infraction. Proc R Soc Med. Jan 60(1):29-31, 1967.

Address correspondence to: Martha Anderson, DPM, Kaiser Permanente Department of Podiatry. 12301 Snow Rd. , Parma, OH 44130.

1 Cleveland Clinic, Medical Director of the Diabetic Foot Clinic, Department of Orthopaedic Surgery, Cleveland, OH. 44130
2 Third Year Resident (PGYIII), Cleveland Clinic/Kaiser Permanete Residency Program, Cleveland, OH. 44130
3 Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH. 44130.

© The Foot & Ankle Journal, 2008