关节镜治疗踝关节剥脱性骨软骨炎

目的 探讨踝关节镜下关节清理加微骨折术治疗踝关节剥脱性骨软骨炎的手术效果.方法 对11例踝关节剥脱性骨软骨炎,采用关节清理加微骨折钻孔,通过随访了解患侧踝关节疼痛、肿胀及活动度的改善情况.结果 所有患者均获得随访,平均随访时间11.5个月,术前VAS评分平均为(70.6±3.4)分,术后随访时VAS评分为(17.9±4.6)分,两者差异有统计学意义(P＜0.01);术前AOFAS踝关节功能主观评分平均为(64.3±4.7)分,术后随访时为(87.4±3.2)分,两者差异有统计学意义(P＜0.05).术后1例出现切口皮肤麻木感.结论 关节镜下清理加微骨折术治疗踝关节剥脱性骨软骨炎,具有创伤小、患者症状明显改善及手术并发症少的优点,是一种微创、有效的方法.     

踝关节严重剥脱性骨软骨炎手术治疗

目的:探讨踝关节距骨严重剥脱性骨软骨炎用环钻病灶清除,取自体骨软骨栓植入手术治疗的临床疗效观察。方法:12例患者,病变部位距骨二期以上的剥脱性骨软骨炎,均采用开放性环钻病灶清除,环钻取同侧股骨外髁非负重区骨软骨栓植入病灶。结果:患者伤口均一期愈合,患者症状明显缓解,随访12~24个月(平均14个月),优9例,良2例,可1例。9例患者疼痛消失,踝关节活动正常,3例患者行走时间长,偶尔疼痛出现,休息后消失,影像学提示植入骨软骨栓基本愈合,供区正常,无其他不适。结论:踝关节距骨严重剥脱性骨软骨炎病灶清除,骨软骨栓植入病灶的手术治疗,效果满意。     

经皮钻孔法治疗Ⅴ型距骨剥脱性骨软骨炎

2008年3月～ 2011年6月,我科应用经皮钻孔法、通过跗骨窦行病灶清除并植骨手术治疗7例Ⅴ型距骨剥脱性软骨炎患者,效果良好,报道如下. 1材料与方法 1.1病例资料本组7例,男5例,女2例,年龄32～54岁.6例有慢性反复创伤病史,1例无明确外伤史.病损区:5例位于内侧,2例位于外侧.患者均有踝关节酸痛、活动后加重,伴有踝关节肿胀.术前X线片示距骨软骨下囊性变,MRI检查示软骨下类圆形T1、T2长信号.术前踝关节Kofoed评分为49 ～ 67分.     

不同方法治疗踝部骨折伴随的距骨骨软骨骨折临床效果对比研究

目的 对比研究自体骨软骨移植术和骨软骨折块摘除钻孔术治疗踝部骨折伴随的急性Ⅲ、Ⅳ型距骨骨软骨骨折的临床效果.方法 2002年5月至2007年8月,38例踝部骨折伴随的急性Ⅲ、Ⅳ型距骨骨软骨骨折,术中明确距骨骨软骨骨折的部位以及范围.20例折块摘除后,自同侧膝关节非负重区钻取骨软骨柱,采取打压固定技术将骨软骨柱植入受区的孔中,为移植组;18例骨软骨折块摘除后行钻孔术为钻孔组.对比观察研究两组患者踝关节的功能、X线以及MRI表现.结果 移植组随访1.5～4.0年,平均(2.92±0.65)年,钻孔组随访2.5～5.0年,平均(3.02±0.83)年.7例行多柱移植,13例行单柱移植.根据Baird和Jackson踝关节评分系统进行功能评分:移植组平均(89.85±4.83)分,钻孔组平均(84.28±5.65)分,两组比较差异有统计学意义(t=3.277.P=0.002);X线片示移植组3例踝关节发生创伤性关节炎,发生率为15.0%(3/20),钻孔组8例踝关节发生创伤性关节炎,发生率为44.4%(8/18),两组比较差异有统计学意义(χ2=31.7,P<0.05);MRI显示移植组3例骨软骨柱松动吸收,发生距骨剥脱性骨软骨炎,占15.0%(3/20),其余修复的关节面平滑,骨软骨柱与周围组织结合良好;钻孔组6例发生距骨剥脱性骨软骨炎,发生率为33.3%(6/18),两组比较差异有统计学意义(χ2=39.6,P<0.05);两组膝关节均无远期供区并发症.结论 自体骨软骨移植治疗踝部骨折伴随的急性Ⅲ、Ⅳ型距骨骨软骨骨折是一种有效的手术方法 ,降低了踝关节创伤性关节炎和距骨剥脱性骨软骨炎的发生率,提高了踝关节的功能.     

儿童和青少年距骨剥脱性骨软骨炎

本文报道一组儿童和青少年距骨剥脱性骨软骨炎初期结果。１材料和方法１９８５～１９９６年的１２年作者诊治距骨剥脱性骨软骨炎２１例，其中３例是双侧。随访时间少于１年的３例病人未列入本研究，因此实际上本研究有１８例病人，共１９个踝关节。确诊的平均年龄是１２?..     

自体骨软骨移植治疗距骨骨软骨损伤疗效分析

目的评价同侧股骨髁内侧髌股关节面自体骨软骨移植治疗距骨骨软骨损伤的临床疗效。方法选择从2010年3月至2012年12月在我院就诊的20例距骨骨软骨损伤患者,主要损伤病因包括创伤后软骨缺损13例,距骨剥脱性骨软骨炎3例,局灶性骨关节炎1例,其他3例;StephenⅢ型6例,Ⅳ型11例,Ⅴ型3例。所有患者均采用同侧股骨髁内侧髌股关节面自体骨软骨移植治疗距骨骨软骨损伤。随访患者12个月,观察患者治疗前后踝关节的疼痛情况,踝关节活动范围的改善情况,踝关节的评分比较及同侧膝关节的功能评分情况。踝关节的疼痛情况采用视觉模拟评分进行评价,膝关节功能评分参照Harris的关节功能评分标准,踝关节功能的评分采用美国足踝外科医师协会评分细则。结果所有患者术后均获得随访,术后患者踝关节的VAS疼痛评分明显下降,差异有统计学意义(t=25.662 9,P=0.000 0),而同侧膝关节的功能评分改变与治疗前比较差异无统计学意义(χ2=0.305 3,P=0.761 8),术后踝关节的活动范围及踝关节功能均有明显改善,差异均有统计学意义(P0.05)。结论利用同侧股骨髁内侧髌股关节面自体骨软骨移植治疗距骨骨软骨损伤临床疗效显著,可以很好的改善踝关节功能。     

踝关节镜技术的临床应用和体会

目的 探讨踝关节镜在踝关节损伤治疗中的应用.方法 踝关节镜下治疗踝关节损伤30例,其中非特异性滑膜炎3例,软组织与骨性撞击综合征9例,距下关节炎3例,剥脱性骨软骨炎5例,踝部骨折6例,其他4例.分别行滑膜切除、关节清理、软骨成形术、距下关节融合术等处理.结果 术后平均随访18个月,疗效优25例,良3例,可2例.无感染及...     

自体骨软骨移植修复距骨软骨或骨软骨缺损

目的探讨从同侧膝关节非负重面获取骨软骨柱,行自体移植修复距骨穹窿部局限性软骨或骨软骨缺损的临床效果。方法23例距骨穹窿部软骨病损的患者,包括创伤后软骨缺损11例,剥脱性骨软骨炎9例和局灶性骨关节炎3例。踝关节镜下明确缺损的部位、大小,行关节镜下或加用关节切开移植术,缺损区清创后钻孔,自同侧膝关节非负重区钻取骨软骨小柱,利用骨软骨自体移植系统(osteochondralautografttransfersystem,OATS)的专用器械,采取压配固定技术将移植物植入受区的孔中,行单柱或多柱镶嵌式移植修复距骨软骨缺损。结果术后随访15～30个月,平均22个月。利用标准VAS(visualanaloguescale)尺子评估踝关节疼痛程度,评分从术前平均4.9±1.2降至术后0.8±0.1(P<0.001)。测量踝关节跖屈和背伸角度,关节活动范围由术前平均44.3°±5.8°增加到术后65.6°±11.2°(P<0.001)。按Mazur等方法综合评定踝关节的状况,评分从术前平均(51.7±8.6)分提高到(92.4±6.3)分(P<0.001)。术后MR检查提示修复的关节面平滑,移植物与周围组织结合良好。结论以同侧膝关节非负重区的骨软骨移植修复距骨局限性软骨或骨软骨缺损是一种疗效明显的外科手术方法。     

肱骨小头剥脱性骨软骨炎的关节镜治疗

目的 了解肱骨小头剥脱性骨软骨炎的关节镜下表现，探讨其关节镜下治疗方法及手术疗效。方法 回顾性研究1998年7月～2005年6月期间通过关节镜治疗的33例肱骨小头剥脱性骨软骨炎患者，手术包括取出关节内游离体，切除病灶周围松动的骨软骨，清理关节内其它部位损伤的软骨。结果 平均手术时间为53min，术中发现18例（54．5％）患者肘关节前方存在游离体，11例（33．3％）患者鹰嘴窝中存在游离体，10例（30．3％）患者仅肱桡关节间隙内存在游离体。12例患者伴有尺骨鹰嘴和肱骨滑车软骨的病变。术后仅7例患者需要口服索米痛止痛。所有患者获得平均3．2年（6～70个月）随访，肘关节的HSS评分由术前平均（78．00±16．35）分提高至术后平均（94．00±10．67）分，差异有统计学意义（P〈0．01）。30例患者均恢复术前训练水平，2例患者残留支撑时关节疼痛，1例患者有桡神经深支的损伤。结论 肘关节镜治疗肱骨小头剥脱性骨软骨炎切口小、创伤小、并发症少、效果满意，对病灶的了解和处理更加全面、彻底，是一种安全、满意的治疗方法。     

关节镜下诊治青少年肘关节剥脱性骨软骨炎

目的探讨肘关节镜在青少年肘关节剥脱性骨软骨炎诊断和治疗中的作用。方法2003年5月~2006年2月,应用关节镜诊治肘关节剥脱性骨软骨炎患者11例。男6例,女5例;年龄13~19岁。左侧4例,右侧7例。其中7例有明显外伤史。于伤后7个月~12年手术。术前VAS评分80±10分,屈伸活动度80±10°,旋转活动度100±5°。臂丛神经阻滞麻醉下,经软点、内上、外上等入路,行肘关节探查、游离体取出及清理术。结果术后7~12d,患者均恢复日常生活及工作,无神经、血管损伤等并发症。11例患者均获随访6~18个月,平均12.5个月。参照改良HSS肘关节评分系统进行疗效评定,优7例,良4例。术后末次随访VAS评分32±15分,屈伸活动度110±10°,旋转活动度120±5°,与术前比较差异均有统计学意义(P<0.05)。结论肘关节镜具有损伤小、恢复快、功能改善显著、并发症少等优点,是诊断和治疗青少年肘关节剥脱性骨软骨炎的一种有效方法。     

不同原因所致踝关节软骨损伤的关节镜治疗

目的探讨应用关节镜技术治疗不同原因所致踝关节软骨损伤的临床疗效。方法回顾性分析2008年1月至2010年10月在中山大学孙逸仙纪念医院采用关节镜治疗的39例不同原因所致踝关节软骨损伤患者的临床资料,其中骨折18例、软组织撞击综合征7例、剥脱性骨软骨炎5例、痛风性关节炎5例、色素沉着绒毛结节性滑膜炎4例。采用美国足踝外科协会（AOFAS）踝-后足评分系统评价关节功能,前抽屉应力位X线片评估关节稳定性。结果 37例患者获得随访,随访率为95%;随访时间12～24个月（平均18.5个月）。随访结束时踝-后足评分为（84±4）分,优于术前的（54±6）分,两者比较,差异有统计学意义（t=24.249,P=0.000）。18例骨折患者术前和随访结束时的距骨前移距离分别为（15.2±2.5）mm和（3.5±0.2）mm,两者比较,差异有统计学意义（t=19.792,P=0.000）。1例色素沉着绒毛结节性滑膜炎患者术后6个月复发,再次行关节腔病灶清除术后随访15个月未见复发。结论踝关节镜技术可用于治疗不同原因引起的踝关节软骨损伤,近期疗效满意。     

Arthroscopic surgery of the metatarsophalangeal first joint

Arthroscopic surgery of the metatarsophalangeal first joint was used to treat a dorsal impingement syndrome of the hallux by removing the dorsally located osteophytes. Also, osteochondritis dissecans, painful sesamoid bones resistant to conservative therapy, and hallux rigidus were arthroscopically treated in a prospective study enrolling 24 consecutive patients. Seventeen patients were high-level athletes. Pain, swelling, sports, and work involvement were recorded. The operative technique is described. There was one persistent loss of sensitivity of the hallux. In the dorsal impingement group, 8 of 12 patients had a good or excellent result after a minimum follow-up of 2 years. In patients with osteochondritis dissecans, 3 of 4 showed good or excellent results. In hallux rigidus and sesamoid bone removal the results were less favorable. As in all arthroscopic procedures there was a fast rehabilitation and work resumption. Especially in athletes arthroscopically, treatment of a dorsal impingement syndrome or osteochondritis dissecans can be recommended because of the diminished chance of scar fibrosis. (Arthroscopy 1998 Nov-Dec;14(8):851-5.)     

成年人股骨髁剥脱性骨软骨炎的外科治疗

目的 探讨成年人不同类型股骨髁剥脱性骨软骨炎（OCD）治疗方法.方法 采用回顾性研究方法.纳入标准：18岁以上成年人,股骨髁OCD,采用外科治疗,术后随访24个月以上.排除标准：青少年OCD,非手术治疗患者,术后失随访患者.回顾2007年1月～2011年7月治疗股骨髁OCD 32例,男23例,女9例,男∶女为2.6：1,平均年龄23.6岁（18～52岁）.关节镜下病灶清理、微骨折10例,关节镜下用可吸收软骨钉（SmartNail; ConMed Linvatec,Largo,FL）固定骨软骨片12例,切开复位、AO钛合金空心钉固定骨软骨片8例,外侧单髁置换2例.术前、术后用Lysholm评分和主观IKDC评分评定膝关节功能.结果 本组32例患者平均随访时间35.8个月（24～52个月）.术前Lysholm评分平均（53.77±4.48）分,术后平均（90.89±4.42）分（t=-266.01,P〈0.01）;主观IKDC评分术前平均（58.50±5.99）分,术后平均（92.15±4.16）分（t=-87.62,P〈0.01）.结论 不同类型、不同时期股骨髁OCD有不同治疗选择,选择适当的治疗方法可获得良好的临床疗效,晚期治疗医疗成本增加.     

关节镜下微骨折技术治疗距骨骨软骨损伤60例疗效观察

目的探讨关节镜下微骨折技术治疗距骨骨软骨损伤的疗效。方法采用关节镜下微骨折技术治疗距骨骨软骨损伤60例,观察踝关节功能评分及疼痛评分变化。结果 60例患者术后踝关节功能评分较术前平均提高20.1分,差异具有统计学意义(P<0.05);术后疼痛评分较术前平均降低5.1分,差异具有统计学意义(P<0.05)。结论关节镜下微骨折技术治疗距骨骨软骨损伤,具有显著的临床疗效,值得推广应用。     

Osteochondritis dissecans of the knee: long-term results of excision of the fragment

Optimal treatment of osteochondritis dissecans of the knee has been controversial. Various treatment methods have resulted in good short-term results. Unfortunately, the age range of the patients who typically require treatment of this disorder is young enough that long-term results become critical. We did a retrospective review to evaluate our hypothesis that simple excision of a loose osteochondritis dissecans fragment results in a higher percentage of unacceptable outcomes when compared with treatment methods that preserve the articular cartilage. Between 1982 and 1993, 30 knees in 29 patients had arthroscopic or arthroscopically assisted surgical excision of a symptomatic loose osteochondritis dissecans lesion of the knee. Seventeen patients who had excision were available for followup. There were 12 males and five females. The average age of the patients at the time of surgery was 26 years (range, 12.5-38 years). The average length of followup was 8.9 years (range, 4-15 years). Results were graded using the Hughston rating scale for osteochondritis dissecans. Only six of 17 patients (35%) had a good or excellent result. Eleven of 17 (65%) had a fair or poor result. We think our results at intermediate followup support our hypothesis, and we recommend aggressive attempts to preserve the articular cartilage and avoid excision of the fragments when possible.     

Langzeitergebnisse nach klebung von osteochondralen fragmenten bei osteochondrosis dissecans

Zusammenfassung Anhand von Ergebnissen einer Langzeitnachuntersuchung von operativ behandelten Patienten mit Osteochondrosis dissecaus des Knie- und Sprunggelenks wird die Problematik des früher verwendeten Zyanoakrylatklebers zur Refixation von osteochondralen Fragmenten dargestellt. Bei Osteochondrosis dissecans tali (n = 38) war die einzige erneute Dissekatlokkerung bei der Patientin zu verzeichnen, bei der Zyanoakrylatkleber verwendet worden war. Das Nachuntersuchungsergebnis bei 97 Patienten mit Osteochondrosis dis secans genus durchschnittlich 10 Jahre postoperativ zeigt, daß das Langzeitergebnis vom Knorpelzustand und insbesondere vom operativen Vorgehen und vom Alter des Patienten zum Zeitpunkt der Operation abhängig ist. Je besser der Knorpel erhalten ist, desto besser ist das Resultat bzw. desto geringer ist das AusmaB der Arthrose. Schwer resorbierbarer Kleber (Akrylatkleber) führte regelmäßig zur Ausbildung einer Arthrose. Die zusammenfassende Beurteilung nach dem Schema von Arcq ergab in 59,6% ein sehr gutes und in 18,3% ein gutes Langzeitergebnis; 56% der Kniegelenke wiesen keine gonarthrotischen Veränderungen auf. Aus diesen Ergebnissen kann gefolgert werden, daß leicht resorbierbarer Kleber wie der Fibrinkleber eine gute Refixation von osteochondralen Fragmenten unter den Bedingungen der Frühmobilisation ermöglicht, Schwer-resorbierbarer Kleber wie Zyanoakrylat dagegen aufgrund seines Barriereeffekts die biologische Einheilung erheblich stört und eine Reintegration der Fragmente stört.

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Long-term results after refixation of osteochondral fragments in cases of osteochondritis dissecans at the talar dome and femoral condyles. The use of cyanaocrylateand fibrin glue

Long-term results after surgical treatment of osteochondritis dissecans of the talar dome and joint knee are dependent on the stage of cartilage damage, the age at operation and on the surgical technique. In cases of osteochondritis dissecans of the talar dome the only loosening of a refixed osteochondral fragment was seen after glueing with acrylate. Using the classification of Arcq in 59.6% an excellent and in 18.3% a good result was observed in cases of osteochondritis dissecans at the femoral condyles. In regard to the development of osteoarthritis in 56% no signs of osteoarthritis were visible. Worst results were obtained in knee joints in which acrylate glue was used for refixation of the osteochondral fragments. In conclusion we recommend the use of fibrin glue for refixation of osteochondral fragments in cases of osteochondritis dissecans even when early mobilisation follows the operation. Because of the long-lasting resorption and barrier effect to ingrowing tissue the use of cyanoacrylate should be avoided.

     

Osteochondral lesions of the talus

Osteochondral lesions occur either as osteochondral fractures (so called flake fractures) or osteochondritis dissecans. Both types of lesions are caused in the most of the cases by an adequate trauma. The injury is sustained during inversion of the ankle. If the foot is dorsiflexed, an anterolateral lesion will result from shearing forces by the fibula. If the inversed foot is plantar flexed and followed by rotation of the tibia on the talus, a postero-medial lesion will result from compression of the medial talar dome by the tibia, secondary to spiralling and shortening of the collateral ligaments. The diagnosis is suspected with the most common complaints of the patients to pain on weight bearing or during sports, swelling, crepitus, giving way or locking ankle after an inversion injury. In case of negative standard X-rays and doubtful clinical findings tomograms in the AP and lateral views or even a scintigraphy of both ankles ar indicated. 15 patients with osteochondral lesions were treated, 7 with an antero-lateral transchondral fracture and 8 with a poster-medial osteochondritis dissecans. The lesions were classified after Berndt and Harty and differentiated between type I-IV. 13 patients have been operated, 4 by arthroscopy. The mean follow-up time of the clinical and radiographic examination was 1 year. The results were evaluated by a point score system. 7 patients (46.6%) had good, 5 (33.3%) a fair and 3 (20%) a poor result.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment.

Since the advent of operative ankle arthroscopy and magnetic resonance imaging (MRI) specific treatment of osteochondritis dissecans of the talus has progressed rapidly. Drilling is still the treatment of choice in early stages of osteochondritis dissecans of the talus. Rear-entry guides and preoperative planning with MRI have led to better results with this kind of treatment. Within 5 years, 42 patients (26 male and 16 female) underwent arthroscopic treatment of osteochondritis dissecans of the talus, 22 underwent percutaneous drilling, 13 cancellous bone grafting, 4 refixation, and 3 curettage. The average age of the patients was 28 years (range, 11 to 53 years). A clinical score system was used in a clinical and MRI follow-up of 19 of the patients with K-wire drilling. Up to 100 points are given in the categories pain, stability/insecurity, efficiency/pain-free walking distance, gait, differences in circumference, range of motion, and power. There was a history of trauma in 31 of the 42 patients. The majority of lesions (24 cases) were localized at the lateral talus, and these patients all had trauma. In 11 of the 18 lesions at the medial talus, there was no evidence of trauma. The 19 patients in the follow-up achieved an average of 87 points. K-wire drilling represents the chief component of early stages with intact or partially fractured cartilage surface, whereas arthroscopically controlled cancellous bone grafts after curettage are used in grade II stages only. Results of K-wire drilling are not worse than those of cancellous bone grafts; this is attributable to a generous perforation of the sclerosis. This has contributed to an improved preoperative diagnosis with MRI.     

Arthroscopic Suture-Bridge Repair Technique for an Avulsion of the Talar Insertion of the Anterior Talofibular Ligament

There are several studies about arthroscopic repair techniques for the lesion of the anterior talofibular ligament. However, the research concentrating on the avulsion of the talar insertion of the anterior talofibular ligament is very rare. Among 122 patients who suffered from recurrent ankle sprain and underwent arthroscopic anterior talofibular ligament repair from October 2016 to January 2019 in our hospital, 11 patients with an avulsion of the talar insertion of this ligament were diagnosed and then treated with the arthroscopic suture-bridge repair technique in the present study. The clinical outcomes were assessed using the Karlsson-Peterson score, Ankle and hindfoot score by American Orthopedic of Foot and Ankle Society, Sefton articular stability scale and Visual Analogue Scale. The complications were recorded at the time of observation. The median value of the follow-up time was 30 (range 18-36) months. At the final follow-up, the median value of the Karlsson-Peterson score, American Orthopedic of Foot and Ankle Society ankle-hindfoot score, and Visual Analogue Scale score was 90, 90, 1, respectively. Based on the Sefton stability scale, 10 cases were in the excellent or good category. No wound infections and no neurovascular injuries were encountered, also no case required revision surgery. Only 1 patient complained about mild local irritation at the knotless anchor site. The arthroscopic suture-bridge technique could be suitable for treatment of an avulsion of the talar insertion of the anterior talofibular ligament due to satisfactory activity recovery and few complications.     

Arthroscopic bone peg fixation in the treatment of osteochondritis dissecans in the knee

An arthroscopic method for the treatment of osteochondritis dissecans lesions in the knee is described. The technique involves using autogenous bone pegs for arthroscopic transfixion of femoral osteochondritis dissecans (OCD) lesions. The method represents a simple biological alternative for arthroscopic fixation of OCD lesions.