Definition
Bilateral aseptic bone necrosis of the
2nd metatarsal head, Freiberg-Kohler type (II)]
Kohler's Disease II, Freiberg-Kohler (both sides)
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Radiographic Appearance
Freiberg's disease is the only bone necrosis that is more
often seen in girls than in boys.
Grade
II: partially detached osteochondral lesion
III: completely detached, non-displaced fragment
IV: detached and displaced fragment
There are 4 stages:
1. Initial stage with cartilaginous edema and joint effusion. The
X-ray is still unnoticeable, in MRI bone marrow edema.
2. Condensation-density of bone structures in hypermineralization of
necrotic bony trabecula. In the X-ray it is already seen, in MRI
double-line sign.
3. Fragmentation with deformity of joint structures. Up until this
stage, 2 or 3 years since begin of disease may have passed.
4. Repair with replacement of necrotic tissue with the new bone
substance. Requirement: Revascularisation
An early diagnosis is possible , next to MRI, with the 3-phase
skeletal szintigraphy. Avascular bone areas are known as so-called
"cold-spots".
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Pathology
Aseptic bone necrosis are seen in children along with cartilage
ossification defects throughout growth or throughout increased
exertion. A cause may be passing intraossic vascularization
disturbances through a mycotic-embolic vessel obstruction, bland
infections, trauma, vessel spasms, vegetative dysregulations or
vessel trauma. Constitutional and alimentary factors seem to play a
role as well. The infestation can be unilateral or bilateral.
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Treatment:
Conservative: decompression and increased circulation. bed rest, no
sports, decompressing wraps, support insoles. Antiphlogistical,
hyperemic and physical therapy. Prostaglandin analogs such as
Ilomedin (Schering)
Surgical: Drilling to result in pressure decompression and increased
revascularization. Nailing/Pinning, correction in Freiberg-Kohler
as, for example, open-flap osteotomies in the later stages with pain
and deformation.
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Useful Link
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