What is Freiburg’s Disease?
Freiberg’s disease is a condition that affects the joints of the lesser rays. A part of the metatarsal bone which forms one side of the joint loses its blood supply, dies and collapses. New blood vessels grow into the area and new bone fills the void, but often the new surface is not smooth like a normal joint surface, and the new bone is often very large. The joint surface may not be smooth, and the surfaces rub. This wear and tear can lead to osteoarthritis.
If there is osteoarthritis of the joint, there will be pain on movement and often on weight bearing. There may be hard skin under the foot, where there is excessive pressure. There may be some swelling on the top of the foot.
We do not know exactly why Freiberg’s disease occurs. It most frequently occurs in young girls as they go through a growth spurt, but it can also occur in men and can become apparent at any age. It is sometimes caused by a long metatarsal bone or an injury.
The joint can become progressively more painful, and the extra bone around the joint may prevent normally sized shoes being worn.
Forefoot pain may be caused by many different conditions, and a thorough assessment is required to determine the exact cause.
If you have pain in the forefoot, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have xrays taken in a standing position to best assess the foot.
How is Surgery Performed?
Freiberg’s disease can result in pain from a joint. To treat the pain, the joint surfaces must be moved further apart, so that scar tissue can be formed between the surfaces, or the damaged surface is replaced with undamaged cartilage tissue from elsewhere.
There are several options for surgery – shortening the metatarsal bone to increase the space, taking away the end of the metatarsal bone completely, or replacing the damaged joint surface with cartilage tissue from the knee.
The shortening operation is usually successful, but occasionally there is recurrent pain after surgery, especially if the toe bones retract to allow bony contact again. If the end of the metatarsal is removed, then the toe can shorten, giving a strange appearance to the toes, but it should be pain free.
Replacing the cartilage requires an operation on the knee to take cartilage tissue from an area not involved in a joint. This can have risks of it’s own, and is not my usual practice as good results can be achieved by the other types of surgery.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What Happens After Surgery?
The rehabilitation depends on the type of surgery that you have had. If you have had a bone cut and reset or the cartilage replaced, then you will have a shoe with a heel wedge to keep your weight off the forefoot. If you have had the end of the bone removed, then you can wear a flat shoe and weight bear immediately.
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off. Ibuprofen and Diclofenac should not be used for more than a few days after the operation as they can interfere with bone healing.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
you have been given a special shoe that does not allow you to put weight on the front of the foot. This is because the re-set bones are held together by screws, and putting weight on it can dislodge the screws holding the bone. You should wear this continuously for the first two weeks, including in bed. After that, you should wear it whenever you are walking, even at home. Crutches are for balance only.
You should not perform exercises for the toes, but you can draw the alphabet in the air with your foot to keep the ankle and other joints mobile.
RETURNING TO WORK
You will be wearing the special shoe for six weeks, and we will then take an xray. I advise that you do not return to work before this, especially if you are on your feet all day at work. Most people can drive after 8 weeks, if there is no pain.
Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.