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Idiopathic osteonecrosis of the second metatarsal head
Clinical Imaging 31 (2007) 431 – 433
Idiopathic osteonecrosis of the second metatarsal head Yutaka Mifunea,4, Tomoyuki Matsumotoa,b, Toshiyuki Mizunob, Shinichi Ikutab, Masahiro Kurosakaa, Ryosuke Kurodaa a
The Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan b The Department of Orthopedic Surgery, Rokko Hospital, Kobe, Japan Received 10 March 2007; accepted 24 March 2007
Abstract Idiopathic necrosis of the second metatarsal head is quite unusual in adults. We present a rare case of idiopathic osteonecrosis of the second metatarsal head in an adult via magnetic resonance imaging, which enabled an early diagnosis of the necrosis before osteochondral deformity could develop. This case is noteworthy due to its rarity and its successful nonoperative treatment. D 2007 Elsevier Inc. All rights reserved. Keywords: Osteonecrosis; Second metatarsal head; MRI; Conservative treatment
1. Introduction Osteonecrosis of the first metatarsal head is a wellknown complication of surgical correction of hallux valgus deformity by osteotomy [1– 4], but it is rare that idiopathic osteonecrosis occurs in adults only. Moreover, idiopathic necrosis of the second metatarsal head is quite uncommon in adults, although juvenile osteonecrosis at the epiphysis of the metatarsal head or bFreiberg’s diseaseQ is well known [5]. We present a rare case of idiopathic osteonecrosis of the second metatarsal head in an adult via magnetic resonance imaging (MRI), which enabled an early diagnosis of the necrosis before osteochondral deformity could develop. Relief of pain and reduction of osteonecrosis without surgery were achieved. This case is noteworthy due to its rarity and its successful nonoperative treatment.
excessive alcohol intake, and did not have any arthritic symptoms. She was otherwise in good health and her medical history was clear. On examination, she exhibited weight-bearing pain of the left second metatarsophalangeal joint with no limitation of
2. Case report A 51-year-old woman presented with a 1-month history of pain and irritation around her left second metatarsophalangeal joint. The patient was not aware of any trauma to her foot, had no record of corticosteroid administration, had no
4 Corresponding author. Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Tel.: +81 78 382 5985; fax: +81 78 351 6944. E-mail address: [email protected] (Y. Mifune). 0899-7071/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2007.03.008
Fig. 1. Plain radiograph demonstrating no evidence of collapsed and flattened head or arthritis, such as bone erosion, atrophy, or destructive process.
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joint movement, no tenderness, no swelling, and no fluctuation. The patient did not show clinical, radiological, or serologic evidence of rheumatoid arthritis, as defined by the criteria of the American Rheumatoid Association, and tuberculosis. Plain radiographs showed no evidence of collapsed or flattened head or arthritis, such as bone erosion, atrophy, or destructive process (Fig. 1). MRI demonstrated a markedly distended osteonecrosis of the second metatarsal head that was hypointense on T 1-weighted images and showed a combination of low and high signal intensities on T 2-weighted images (Fig. 2A and B), thus indicating osteonecrosis of the second metatarsal head [6]. According to the classification system defined by Steinberg [7], radiographic staging was assessed as Stage 1.
Fig. 3. MRI 6 months after conservative treatment showing significant reduction of the osteonecrotic area (T 1-weighted image).
A weight-bearing restriction was impaired, and the patient was advised to wear oversized and low-heeled shoes. At 6 months of conservative treatment, the patient had no symptoms of weight-bearing pain, irritation, local heat, swelling, fluctuation, or tenderness. MRI taken 6 months after her first visit to our hospital showed a substantial reduction of the area of necrosis (Fig. 3), and the patient reported that she had been able to return to her normal daily activities. 3. Discussion
Fig. 2. MRI demonstrating a markedly distended osteonecrosis of the second metatarsal head that was hypointense on T 1-weighted images and showing a combination of low and high signal intensity on T 2-weighted images. (A) T 1-weighted image, (B) T 2-weighted image.
Although osteonecrosis has been reported in several bones of the foot, such as the talus, the navicular, and the first metatarsal sesamoid bone [7,8], idiopathic osteonecrosis in the long bones of the foot rarely occurs in adults. However, juvenile osteonecrosis at the epiphysis of the metatarsal head or bFreiberg’s diseaseQ is well known [5]. In Freiberg’s disease, repetitive trauma to the second longest ray of the forefoot may cause a microfracture in the epiphysis, affecting vascularity to the metatarsal head [9–11]. There are two reports to date describing idiopathic osteonecrosis of the first metatarsal head in adults [12,13]. However, to our knowledge, idiopathic osteonecrosis in the second metatarsal head in an adult has never been reported. Successful nonoperative treatment for necrosis in the second metatarsal head is rare. By the time the initial diagnosis is made, osteonecrosis may often have already led to the collapse of the tarsal bone and to the progressive degeneration of the tarsal joint. In such cases, patients usually require surgical treatment to obtain relief of symptoms. It was reported that MRI is very sensitive in identifying and characterizing osteonecrosis [14]. In the present case, an early visit to the hospital after symptoms of only 1 month’s
Y. Mifune et al. / Clinical Imaging 31 (2007) 431 – 433
duration and early diagnosis by MRI led to complete relief of pain and reduction of the necrotic area. The cause of the idiopathic osteonecrosis in the second metatarsal head in our patient was not clear. We speculated and found no obvious etiologic factors or predisposing conditions in our patient. However, the patient’s occupation as a schoolteacher, which involved standing for a long time in front of students on a daily basis, coupled with a tendency to wear high-heeled and narrow-toed shoes, may have led to diminished intraosseous and extraosseous vascularity in the second metatarsal head, resulting in osteonecrosis [14]. Another possibility is that the patient already had juvenile osteonecrosis or bFreiberg’s diseaseQ without symptoms. 4. Conclusion Our results show that early diagnosis by MRI coupled with a conservative restriction on weight bearing and a recommendation to wear oversized and low-heeled shoes leads to a good outcome in our patient with idiopathic osteonecrosis in the second metatarsal head. Acknowledgments We would like to thank Ms. Janina Tubby for her excellent editing assistance.
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References [1] Horne G, Tanzer T, Ford M. Chevron osteotomy for the treatment of hallux valgus. Clin Orthop Relat Res 1984;183:32 – 6. [2] Jones KJ, Feiwell LA, Freedman EL, Cracchiolo A. The effect of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head. J Bone Joint Surg 1995;77A:197 – 204. [3] Meier P, Kenzora JE. The risks and benefits of distal first metatarsal osteotomies. Foot Ankle 1985;6:7 – 17. [4] Meisenheder DA, Harkless LB, Patterson JW. Avascular necrosis after first metatarsal head osteotomies. J Foot Surg 1984;23:429 – 35. [5] Freiberg AH. Infarction of the second metatarsal bone: a typical injury. Surg Gynecol Obstet 1914;19:191 – 3. [6] Gillespy T, Genant HK, Helms CA. Magnetic resonance imaging of osteonecrosis. Radiol Clin North Am 1986;24:193 – 208. [7] Steinberg ME. Early diagnosis, evaluation, and staging avascular necrosis. Instr Course Lect 1994;43:513 – 8. [8] Metzger MJ, Levin JS, Clancy JT. Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg 1999;38:154 – 63. [9] Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease complicating unrelated trauma. Orthopedics 1988;11:753 – 7. [10] Stanley D, Betts RP, Rowley DI, Smith TW. Assessment of etiologic factors in the development of Freiberg’s disease. J Foot Surg 1990;29:444 – 7. [11] Walsh HP, Dorgan JC. Etiology of Freiberg’s disease: trauma. J Foot Surg 1988;27:243 – 4. [12] Lopatinskaia LN. Bilateral aseptic necrosis of the heads of the first metatarsal bones. Vestn Rentgenol Radiol 1993;4:60 – 1. [13] Suzuki J, Tanaka Y, Omokawa S, Takaoka T, Takakura Y. Idiopathic osteonecrosis of the first metatarsal head: a case report. Clin Orthop Relat Res 2003;415:239 – 43. [14] Saini A, Saifuddin A. MRI of osteonecrosis. Clin Radiol 2004; 59:1079 – 93.
Idiopathic osteonecrosis of the second metatarsal head Yutaka Mifunea,4, Tomoyuki Matsumotoa,b, Toshiyuki Mizunob, Shinichi Ikutab, Masahiro Kurosakaa, Ryosuke Kurodaa a
The Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan b The Department of Orthopedic Surgery, Rokko Hospital, Kobe, Japan Received 10 March 2007; accepted 24 March 2007
Abstract Idiopathic necrosis of the second metatarsal head is quite unusual in adults. We present a rare case of idiopathic osteonecrosis of the second metatarsal head in an adult via magnetic resonance imaging, which enabled an early diagnosis of the necrosis before osteochondral deformity could develop. This case is noteworthy due to its rarity and its successful nonoperative treatment. D 2007 Elsevier Inc. All rights reserved. Keywords: Osteonecrosis; Second metatarsal head; MRI; Conservative treatment
1. Introduction Osteonecrosis of the first metatarsal head is a wellknown complication of surgical correction of hallux valgus deformity by osteotomy [1– 4], but it is rare that idiopathic osteonecrosis occurs in adults only. Moreover, idiopathic necrosis of the second metatarsal head is quite uncommon in adults, although juvenile osteonecrosis at the epiphysis of the metatarsal head or bFreiberg’s diseaseQ is well known [5]. We present a rare case of idiopathic osteonecrosis of the second metatarsal head in an adult via magnetic resonance imaging (MRI), which enabled an early diagnosis of the necrosis before osteochondral deformity could develop. Relief of pain and reduction of osteonecrosis without surgery were achieved. This case is noteworthy due to its rarity and its successful nonoperative treatment.
excessive alcohol intake, and did not have any arthritic symptoms. She was otherwise in good health and her medical history was clear. On examination, she exhibited weight-bearing pain of the left second metatarsophalangeal joint with no limitation of
2. Case report A 51-year-old woman presented with a 1-month history of pain and irritation around her left second metatarsophalangeal joint. The patient was not aware of any trauma to her foot, had no record of corticosteroid administration, had no
4 Corresponding author. Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Tel.: +81 78 382 5985; fax: +81 78 351 6944. E-mail address: [email protected] (Y. Mifune). 0899-7071/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2007.03.008
Fig. 1. Plain radiograph demonstrating no evidence of collapsed and flattened head or arthritis, such as bone erosion, atrophy, or destructive process.
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joint movement, no tenderness, no swelling, and no fluctuation. The patient did not show clinical, radiological, or serologic evidence of rheumatoid arthritis, as defined by the criteria of the American Rheumatoid Association, and tuberculosis. Plain radiographs showed no evidence of collapsed or flattened head or arthritis, such as bone erosion, atrophy, or destructive process (Fig. 1). MRI demonstrated a markedly distended osteonecrosis of the second metatarsal head that was hypointense on T 1-weighted images and showed a combination of low and high signal intensities on T 2-weighted images (Fig. 2A and B), thus indicating osteonecrosis of the second metatarsal head [6]. According to the classification system defined by Steinberg [7], radiographic staging was assessed as Stage 1.
Fig. 3. MRI 6 months after conservative treatment showing significant reduction of the osteonecrotic area (T 1-weighted image).
A weight-bearing restriction was impaired, and the patient was advised to wear oversized and low-heeled shoes. At 6 months of conservative treatment, the patient had no symptoms of weight-bearing pain, irritation, local heat, swelling, fluctuation, or tenderness. MRI taken 6 months after her first visit to our hospital showed a substantial reduction of the area of necrosis (Fig. 3), and the patient reported that she had been able to return to her normal daily activities. 3. Discussion
Fig. 2. MRI demonstrating a markedly distended osteonecrosis of the second metatarsal head that was hypointense on T 1-weighted images and showing a combination of low and high signal intensity on T 2-weighted images. (A) T 1-weighted image, (B) T 2-weighted image.
Although osteonecrosis has been reported in several bones of the foot, such as the talus, the navicular, and the first metatarsal sesamoid bone [7,8], idiopathic osteonecrosis in the long bones of the foot rarely occurs in adults. However, juvenile osteonecrosis at the epiphysis of the metatarsal head or bFreiberg’s diseaseQ is well known [5]. In Freiberg’s disease, repetitive trauma to the second longest ray of the forefoot may cause a microfracture in the epiphysis, affecting vascularity to the metatarsal head [9–11]. There are two reports to date describing idiopathic osteonecrosis of the first metatarsal head in adults [12,13]. However, to our knowledge, idiopathic osteonecrosis in the second metatarsal head in an adult has never been reported. Successful nonoperative treatment for necrosis in the second metatarsal head is rare. By the time the initial diagnosis is made, osteonecrosis may often have already led to the collapse of the tarsal bone and to the progressive degeneration of the tarsal joint. In such cases, patients usually require surgical treatment to obtain relief of symptoms. It was reported that MRI is very sensitive in identifying and characterizing osteonecrosis [14]. In the present case, an early visit to the hospital after symptoms of only 1 month’s
Y. Mifune et al. / Clinical Imaging 31 (2007) 431 – 433
duration and early diagnosis by MRI led to complete relief of pain and reduction of the necrotic area. The cause of the idiopathic osteonecrosis in the second metatarsal head in our patient was not clear. We speculated and found no obvious etiologic factors or predisposing conditions in our patient. However, the patient’s occupation as a schoolteacher, which involved standing for a long time in front of students on a daily basis, coupled with a tendency to wear high-heeled and narrow-toed shoes, may have led to diminished intraosseous and extraosseous vascularity in the second metatarsal head, resulting in osteonecrosis [14]. Another possibility is that the patient already had juvenile osteonecrosis or bFreiberg’s diseaseQ without symptoms. 4. Conclusion Our results show that early diagnosis by MRI coupled with a conservative restriction on weight bearing and a recommendation to wear oversized and low-heeled shoes leads to a good outcome in our patient with idiopathic osteonecrosis in the second metatarsal head. Acknowledgments We would like to thank Ms. Janina Tubby for her excellent editing assistance.
433
References [1] Horne G, Tanzer T, Ford M. Chevron osteotomy for the treatment of hallux valgus. Clin Orthop Relat Res 1984;183:32 – 6. [2] Jones KJ, Feiwell LA, Freedman EL, Cracchiolo A. The effect of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head. J Bone Joint Surg 1995;77A:197 – 204. [3] Meier P, Kenzora JE. The risks and benefits of distal first metatarsal osteotomies. Foot Ankle 1985;6:7 – 17. [4] Meisenheder DA, Harkless LB, Patterson JW. Avascular necrosis after first metatarsal head osteotomies. J Foot Surg 1984;23:429 – 35. [5] Freiberg AH. Infarction of the second metatarsal bone: a typical injury. Surg Gynecol Obstet 1914;19:191 – 3. [6] Gillespy T, Genant HK, Helms CA. Magnetic resonance imaging of osteonecrosis. Radiol Clin North Am 1986;24:193 – 208. [7] Steinberg ME. Early diagnosis, evaluation, and staging avascular necrosis. Instr Course Lect 1994;43:513 – 8. [8] Metzger MJ, Levin JS, Clancy JT. Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg 1999;38:154 – 63. [9] Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease complicating unrelated trauma. Orthopedics 1988;11:753 – 7. [10] Stanley D, Betts RP, Rowley DI, Smith TW. Assessment of etiologic factors in the development of Freiberg’s disease. J Foot Surg 1990;29:444 – 7. [11] Walsh HP, Dorgan JC. Etiology of Freiberg’s disease: trauma. J Foot Surg 1988;27:243 – 4. [12] Lopatinskaia LN. Bilateral aseptic necrosis of the heads of the first metatarsal bones. Vestn Rentgenol Radiol 1993;4:60 – 1. [13] Suzuki J, Tanaka Y, Omokawa S, Takaoka T, Takakura Y. Idiopathic osteonecrosis of the first metatarsal head: a case report. Clin Orthop Relat Res 2003;415:239 – 43. [14] Saini A, Saifuddin A. MRI of osteonecrosis. Clin Radiol 2004; 59:1079 – 93.