Osteochondral Autograft Transplantation for Subchondral Insufficiency Fracture of the Metatarsal Head in Middle-Aged and Elderly Patients: A Report of Three Cases

Freiberg disease, characterized by osteochondrosis affecting the metatarsal head, typically afflicts adolescent athletes. However, subchondral insufficiency fractures of the metatarsal head, presenting similarly to Freiberg disease, occur in middle-aged and elderly individuals and pose unique challenges in diagnosis and treatment. This study reports three cases of osteochondral autograft transplantation (OAT) for collapsed metatarsal heads resembling Freiberg disease in middle-aged and elderly women with successful outcomes. Case 1 involved a 59-year-old woman with severe metatarsophalangeal joint (MTPJ) pain and restricted range of motion (ROM) in the second toe. Case 2 featured a 66-year-old woman with trauma-induced deformity and cystic changes in the second metatarsal head. Case 3 included a 71-year-old woman with a crushed third metatarsal head and osteophyte formation. Hallux valgus was observed in one patient; the other two had a history of minor trauma. Radiological assessments revealed deformity, with MRI indicating bone marrow edema in the metatarsal head. Histological findings showed no necrosis, differentiating these cases from classical Freiberg disease. Based on these findings, OAT was chosen to restore joint function and minimize complications such as metatarsal shortening. In all cases, metatarsal head reconstruction was performed using an osteochondral column harvested from the femoral condyle. All patients experienced significant pain relief, improved ROM, and favorable imaging findings. No pain recurrence was noted during the three to seven years' follow-up period after surgery. While classical Freiberg disease involves aseptic necrosis often attributed to repetitive stress, insufficiency fractures may arise from shear stress or subtle injury. Our cases demonstrated the effectiveness of OAT in managing advanced subchondral insufficiency fractures, even in elderly patients, by minimizing risks such as metatarsal shortening and compromised joint mobility.