关节镜下行膝关节自体软骨移植术后早期个体化康复训练疗效分析

目的分析关节镜下行膝关节自体软骨移植术后早期个体化康复训练的疗效。 方法选取2016年1月至2017年1月在湖州市第一人民医院接受关节镜下软骨移植修复膝关节软骨缺损治疗的37例患者。其中股骨内髁负重面软骨损伤27例,股骨外髁负重面软骨损伤10例;按照国际软骨修复协会标准分级,软骨缺损深度分别为Ⅱ级3例、Ⅲ级34例;34例软骨损伤面积为1.5～3.0 cm²,3例大于3 cm²。术前通过评估建立功能档案,参与康复学堂,制定个体化康复训练方案。术后按训练方案进行早期功能锻炼。采用Brittberg-Peterson功能评定标准评估患者自体软骨移植前后膝关节功能。采用配对t检验比较患者自体软骨移植前后Brittberg-Peterson功能评分。P<0.05为差异有统计学意义。 结果截至2017年1月,37例患者术后随访12～20个月,均无失访。术后12个月行膝关节MRI检查,示原软骨缺损区软骨表面平整,移植骨软骨柱位置良好。经康复训练后,37例患者膝关节Brittberg-Peterson功能评定标准评分平均为(62.2±1.4)分,低于术前(81.6±1.2)分,差异有统计学意义(t＝63.21,P<0.05);其中关节绞锁、关节肿胀、跑步困难、关节疼痛等13项指标较术前均有明显改善(P均<0.05)。 结论早期个体化康复训练对关节镜下膝关节自体软骨移植术后膝关节功能的恢复有显著作用。     

Autologous osteochondral transplantation using the diamond bone-cutting system (DBCS): 6–12 years’ follow-up of 35 patients with osteochondral defects at the knee joint

Thirty-five patients with severe osteochondral defects were treated by autologous osteochondral transplantation between 1986 and 1992. The majority of patients (27) suffered from osteochondrosis dissecans, while 8 patients presented with posttraumatic osteochondral defects. The grafts were harvested with a diamond bone cutter from the posterior part of the medial or lateral femoral condyle. In 29 patients the lesion was located at the lateral part of the medial femoral condyle, in 3 it was at the lateral femoral condyle, and in 3 at the patella. Twenty-nine patients could be examined at the follow-up between 6 and 12 years later (mean follow up 8.1 years). Using the standard cartilage evaluation form, the transplanted knees of 12 patients were graded as normal (grade I), 14 knees were nearly normal (grade II), while 3 patients presented with an abnormal result (grade III). All 3 of them had a varus malalignment and refused a high tibial correction osteotomy against our advice. No patient was assessed as severely abnormal (grade IV). The majority of patients improved their activity level and the functional status of the joint. Twelve patients developed new radiological signs of osteoarthrosis with a decrease in the radiological score of Kellgren and Lawrence by about one stage. We conclude that autologous osteochondral transplantation with the diamond bone-cutting system is an effective method in the treatment of severe osteochondral defects. Received: 17 April 2000     

Osteochondral defects in the knee. A treatment using lateral patella autografts

Sixteen patients (13 males and three females; average age, 27 years) with large symptomatic osteochondral defects of the femoral condyle were treated with an osteochondral autograft taken from the ipsilateral lateral patellar facet. Two patients had bilateral procedures for a total of 18 knees. These patients were followed up prospectively with an average followup of 7.6 years (range, 2-14.6 years). Cincinnati knee scores showed significant changes, from an average preoperative score of 37 to an average final followup score of 85. In all of the patients, knee function was improved, and they were able to return to their normal lifestyle with minimal or no restriction. Eighty-one percent of patients have returned to a high level of functioning.     

Fresh osteochondral allografts for post-traumatic defects in the knee. A survivorship analysis.

Fresh osteochondral allografts were used to repair post-traumatic osteoarticular defects in 92 knees. At the time of grafting, varus or valgus deformities were corrected by upper tibial or supracondylar femoral osteotomies. A survivorship analysis was performed in which failure was defined as the need for a revision operation or the persistence of the pre-operative symptoms. There was a 75% success rate at five years, 64% at ten years and 63% at 14 years. The failure rate was higher for bipolar grafts than for unipolar and the results in patients over the age of 60 years were poor. The outcome did not depend on the sex of the patient and the results of allografts in the medial and lateral compartments of the knee were similar. Careful patient selection, correction of joint malalignment by osteotomy, and rigid fixation of the graft are all mandatory requirements for success. We recommend this method for the treatment of post-traumatic osteochondral defects in the knees of relatively young and active patients.     

Arthroscopic osteochondral transplantation: Histologic results

Purpose: Localized, full-thickness articular cartilage defects of the femoral condyle are challenging. This report presents the histology of clinical cases obtained at intervals from 2 to 12 months after arthroscopic osteochondral transplantation. Type of Study: Longitudinal cohort study. Methods: Patients found at arthroscopy to have full-thickness femoral condyle defects between 1 and 3.5 cm in diameter underwent arthroscopic osteochondral transplantation. Exclusion criteria were associated tibial defects, patellar defects, or generalized arthritic change. The grafts taken from the superior and lateral intercondylar femoral notch were press-fit into holes drilled into the defect starting adjacent to the articular cartilage margin. Cancellous bone bridges were maintained between grafts. At various time intervals from 2 to 12 months after the osteochondral transplantation, arthroscopic biopsy specimens of the recipient sites were obtained. Results: Ten patients (5 male, 5 female) enrolled at 2 centers were evaluated arthroscopically at various intervals up to 13 months after osteochondral transplantation. The average patient age was 40 years (range, 17 to 65 years). One to 3 plugs had been harvested and inserted. Seven patients underwent biopsy at intervals ranging up to 12 months postoperatively. All showed maintenance of the integrity of the grafts with living chondrocytes and osteocytes. Donor sites filled without grafting and were covered with fibrocartilagenous scar. No complications occurred in this group. Conclusions: These histologic results suggest that arthroscopic osteochondral transplantation is a viable alternative for treating full-thickness chondral defects, with the grafts retaining their integrity and living chondrocytes and osteocytes observed in the grafts for up to 12 months after implantation.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: pp 832–835     

Who is the ideal candidate for autologous chondrocyte implantation?

We investigated the prognostic indicators for collagen-covered autologous chondrocyte implantation (ACI-C) performed for symptomatic osteochondral defects of the knee.We analysed prospectively 199 patients for up to four years after surgery using the modified Cincinnati score. Arthroscopic assessment and biopsy of the neocartilage was also performed whenever possible. The favourable factors for ACI-C include younger patients with higher pre-operative modified Cincinnati scores, a less than two-year history of symptoms, a single defect, a defect on the trochlea or lateral femoral condyle and patients with fewer than two previous procedures on the index knee. Revision ACI-C in patients with previous ACI and mosaicplasties which had failed produced significantly inferior clinical results. Gender (p = 0.20) and the size of the defect (p = 0.97) did not significantly influence the outcome.     

Tibial plateu "Kissing Lesion" from a proud osteochondral autograft

Knee osteochondral lesions can be debilitating. Multiple procedures have been used to manage these defects. Osteochondral autograft transplantation is one such option. Reported complications include donor-site morbidity, failed osteointegration, size mismatch, and incongruency. In this article, we report a case of graft incongruency of the medial femoral condyle that resulted in a full-thickness "kissing lesion" groove on the opposing medial tibial plateau. In an osteochondral autograft transplantation procedure, proper surgical technique is paramount to prevent placement of a proud autograft and avoid the difficult complication of associated tibial chondral defects.     

Lateral Compartment Osteoarthritis of the Knee After Meniscectomy Treated by the Transplantation of Tissue-Engineered Cartilage and Osteochondral Plug

Management of osteoarthritis of the knee after meniscectomy has been challenging, especially for young patients, because articular cartilage has very poor healing capacity because of its lack of vessels, nerve supply, and isolation from systemic regulation. Osteoarthritic lesions often involve both femoral and tibial cartilage, requiring treatments for both lesions. We report the case of a 14-year-old girl with lateral compartment osteoarthritis of the knee after a total meniscectomy of the discoid meniscus, who was successfully treated by the transplantation of both tissue-engineered cartilage made ex vivo for a femoral lesion and an autologous osteochondral plug for a tibial lesion. We treated both femoral and tibial cartilage defects simultaneously with this procedure. We confirmed cartilaginous regeneration in both femoral and tibial lesions at second-look arthroscopy. This procedure is one option to prevent further development of osteoarthritis in young patients.     

The transfer of the posterior femoral condyle – first results of a salvage operation

In this study large osteochondral defects on the weight-bearing surface of the medial and lateral femoral condyle were treated by transplantation of the autologous posterior condyle in 20 patients. The cartilage defects, type Outerbridge IV, ranged in size from 2 x 1.5 cm to 5 x 3.5 cm. 8 condyle transfers were done from 1984-1996 at the orthopaedic clinic of the university of Balgrist, Zürich. 12 condyle transfers at the department of orthopedic sports medicine at the technical university of Munich from 1996-1998. Patients were operated before the condyle transfer, 2 times on average. In 9 patients a high tibial osteotomy was performed simultaneously. Clinical evaluation was done according to the Lysholm score. The Lysholm score improved in the patient serie from 1996 from preoperatively 62 (54-81) points to postoperatively 85 (74-95) points. The follow-up was on average 9.8 (2-26) months. 18 patients reported about pain relief, 2 patients didn't improve. We describe the operative technique. Despite the lack of long-term results the transfer of the autologous posterior condyle seems to be an effective alternative for the knee prosthesis, especially for young patients with a great cartilage damage in the weight bearing area.     

Autologous osteochondral grafting for talar cartilage defects

The purpose of this study was to evaluate the clinical results of Osteochondral Autograft Transfer System (OATS) for the treatment of symptomatic osteochondral defects of the talus using standardized outcome analysis. Nineteen patients with symptomatic osteochondral defect (OCD) of the talus were treated with autologous osteochondral grafting. There were six men and 13 women. The average age was 32 years (range, 18 to 48 years). The average duration of symptoms prior to surgery was 4.2 years (range, three months to 12 years). All patients had failed nonoperative treatment, and 13 (68%) patients had failed prior excision, curettage and/or drilling of the lesion. The average size of the lesion prior to autografting was 12 mm x 10 mm (range, 10 x 5 mm to 20 x 20 mm). Donor plugs were harvested from the trochlear border of the ipsilateral femoral condyle. Ankle exposure was obtained with a medial malleolar osteotomy in 13 patients, arthrotomy in five patients and lateral malleolar osteotomy in one patient. Clinical evaluations were performed for both the recipient ankle and donor knee using the AOFAS Ankle/Hindfoot Scale and Lysholm knee scale, respectively. The average follow-up time was 16 months (range, 12 to 30 months). The average postoperative AOFAS ankle score was 88 (range, 60 to 100). Most patients had occasional mild pain, but excellent function, range of motion, stability and alignment. The average postoperative ankle score for the 13 patients who failed prior surgery was 91 (range, 84 to 100). The average postoperative Lysholm knee score was 97 (range, 87 to 100). Only two patients had mild knee pain. Postoperative radiographs were available for 13 patients. There was no evidence of graft subsidence and all grafts healed. All malleolar osteotomies united. Seventeen (89%) patients said that they would undergo the procedure again. The results of osteochondral autograft transplant for OCD lesions of the talus demonstrate excellent postoperative ankle scores including improvement of pain and function with minimal knee donor site morbidity. Also, our results indicate that this is an effective salvage procedure following failed previous procedures and for patients with longstanding symptoms.     

全膝关节置换术后股胫关节运动学轨迹的数字化模型研究

 目的 通过透视技术结合数字化模型注册技术分析全膝关节置换术后股骨假体与胫骨垫片之间的相对运动和接触位置。方法 2007年7月至2008年6月,接受GENESISⅡ假体全膝关节置换术患者16例,均为女性;年龄56～76岁,平均66.4岁。随访48～60个月,平均(56±3)个月。采用膝关节学会评分(Knee Society Score,KSS)评价膝关节功能;采用循环透视方法获取影像学数据,对假体逆向数字建模,进行数字模型和影像学数据的匹配,重建膝关节的三维运动;测量股骨内、外髁接触位置的移动,计算胫骨内旋角度,测量股骨凸轮和胫骨立柱的接触时相和范围。结果 末次随访时KSS膝评分(93±5)分,功能评分(88±13)分,与术前比较差异有统计学意义。股骨内髁的移动范围(8.5±2.5) mm,外髁的移动范围(9.5±4.8) mm,胫骨内旋角度2.5°±8.4°。屈膝约30°～40°时凸轮和立柱发生接触,立柱后方的接触范围(8.0±1.8) mm。胫骨平台后倾角度越大,凸轮和立柱的接触越晚。结论 全膝关节置换术后股胫关节的运动学特征与正常膝关节不同,膝关节屈曲10°~30°时股骨内髁前移,屈曲大于40°后股骨内、外髁后移,胫骨平台后倾与凸轮和立柱的接触时相有相关性。     

关节镜下治疗股骨髁撕脱性骨折

目的探讨关节镜下治疗膝关节后交叉韧带股骨髁起点处撕脱性骨折的效果。方法 21例交叉韧带股骨髁起点处撕脱性骨折患者在关节镜监控下,了解并处理半月板损伤,再进行骨折复位、空心可吸收螺钉内固定。结果 21例均获随访,时间12～18个月。完整随访12个月时按Lysholm标准评价膝关节功能:优19例,可2例。患者均获得满意疗效。结论关节镜治疗股骨髁撕脱性骨折创伤小,疗效好。     

Cartilage regeneration after proximal tibial osteotomy for medial gonarthrosis. An arthroscopic, roentgenographic, and histologic study.

High tibial osteotomy for medial gonarthrosis was performed in 28 patients (28 knees). At the time of surgery, arthroscopy was also performed and a cartilage-bone biopsy was obtained. Postoperatively, 15 patients were randomized to a cylinder plaster cast, whereas 13 patients had a hinged cast brace for early knee mobilization. At follow-up examination, two years after surgery, 16 patients accepted an arthroscopic examination with a cartilage-bone biopsy. In overcorrected knees, cartilage regeneration was found in eight of 14 patients on the medial tibial condyle and in nine of 14 on the medial femoral condyle. The main repair feature was proliferation of fibrocartilage, which covered bone and areas of fibrillated cartilage and filled vertical clefts in hyaline cartilage. The hyaline cartilage showed an increased cellularity with numerous nests of proliferating chondrocytes. No correlation was found between clinical outcome and the degree of cartilage regeneration as observed by arthroscopy, biopsy, or roentgenography. Knees with a brace postoperatively had better knee flexion two years after surgery. No difference in cartilage regeneration was recorded between knees with a plaster cast or a cast brace postoperatively.     

Articular Cartilage Repair in the Knee Joint with Autologous Chondrocytes and Periosteal Graft

Objective Repair of articular cartilage defects of knee to restore a pain-free joint function. Indications Full-thickness chondral or osteochondral posttraumatic lesions and osteochondritis dissecans defects that have not been successfully repaired with methods such as debridement, drilling, and microfracturing. Contraindications Osteoarthritis. Rheumatoid arthritis. Surgical Technique During arthroscopy, the cartilage lesion is evaluated, and cartilage slices weighing 200-300 mg are harvested from the upper medial femoral condyle, a minor load bearing area. The chondrocytes are isolated enzymatically and grown in culture to increase the cell number during approximately 2 weeks. During the second operation, an arthrotomy is performed through a medial or lateral parapatellar approach. The defect is carefully debrided. A periosteal patch is obtained from proximal tibia, placed over the defect and sutured to the surrounding cartilage. The suture line is sealed with fibrin glue, and the chondrocytes are injected into the defect under the patch. Results Recently, Peterson has presented results in 213 patients with a follow-up between 2-10 years. He reported good to excellent results in 90% of 57 patients with single femoral condyle lesions, in 84% of 32 patients with osteochondritis dissecans and in 74% of 27 patients with femoral condyle lesions in combination with anterior cruciate ligament reconstruction. In 32 patients the patella was grafted and 22 improved, in twelve patients the trochlea was grafted and seven improved. and in 53 patients multiple lesions were grafted and 42 improved. Second-look arthroscopies were performed in 46 patients, 26 of them were biopsied; the transplanted tissues showed a hyaline-like appearance in 21 patients (80%).     

Minimum 5-year results of focal articular prosthetic resurfacing for the treatment of full-thickness articular cartilage defects in the knee

Introduction  

The purpose of this study was to evaluate the results of a contoured focal articular femoral condyle resurfacing prosthetic in the treatment of full-thickness cartilage and osteochondral defects at the medial femoral condyle of the knee beyond 5 years.     

关节镜自体骨软骨移植治疗膝关节软骨损伤

目的观察自体骨软骨移植治疗膝关节软骨缺损的效果。方法对7例膝关节股骨髁负重部位软骨损伤患者行膝关节镜清理术。摘除关节腔游离软骨碎块2例，半月板部分切除3例，髌上滑膜内侧皱襞切除3例。在股骨内侧髁部取自体骨软骨柱3～5枚，移植到股骨内侧髁软骨损伤部位。结果7例患者手术后伤口Ⅰ期愈合。随访期内6例患者疼痛症状消失。关节肿胀、假性交锁症状均消失。X线片显示移植骨软骨位置良好。结论自体软骨移植能缓解关节软骨损伤后出现疼痛、交锁症状，修复后的软骨为透明软骨。     

Arthroscopic osteochondral autograft transplantation for chondral lesion of the tibial plateau of the knee

Arthroscopic osteochondral autograft transplantation is often used to treat chondral/osteochondral lesions of the femoral condyle of the knee. However, arthroscopic autologous osteochondral grafting to the tibial plateau has not been reported. We report the surgical technique and the clinical course of a patient who underwent engraftment by this method. A 26-year-old man developed symptoms of pain and catching in his knee. Arthroscopy revealed a deep chondral lesion, 10 × 15 mm in size, down to the subchondral bone on the posterocentral area of the lateral tibial plateau. The injured cartilage was debrided using a curette and an abrader until normal healthy cartilage bordered the debrided defect. An osteochondral plug, 10 mm in diameter and 20 mm long, the chondral surface of which was orientated 25° obliquely, was harvested from the most peripheral and proximal part of the lateral patellar groove. A bony hole was created in the center of the defect through the tibia using a core reamer. The osteochondral plug was inserted from the tibial window through the bony hole. To enhance the stability of the osteochondral fragment, bioactive ceramic fillers were used to fill the space below the plug. A second-look arthroscopy 10 months after surgery showed that the grafted osteochondral plug was well adapted and integrated into the surrounding cartilage on the lateral tibial plateau.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 653–659     

Total posterior condylar separation in a juvenile knee: open fixation through a posterior arthrotomy

The authors report a case of separation involving the posterior aspect of the lateral femoral condyle in a 13-year-old boy. The patient presented with a 2-year history of vague knee discomfort and recurrent knee effusions in the absence of a single acute traumatic event. A large mobile osteochondral fragment involving most of the posterior aspect of the lateral condyle was refixed surgically with two screws via a posterolateral arthrotomy. The knee has recovered full function and the lesion is radiologically stable.     

Long-term results of arthroscopic excision of unstable osteochondral lesions of the lateral femoral condyle

The purpose of this study was to evaluate the long-term functional and radiological outcomes of arthroscopic removal of unstable osteochondral lesions with subchondral drilling in the lateral femoral condyle. We reviewed the outcome of 23 patients (28 knees) with stage III or IV osteochondritis dissecans lesions of the lateral femoral condyle at a mean follow-up of 14 years (10 to 19). The functional clinical outcomes were assessed using the Lysholm score, which improved from a mean of 38.1 (SD 3.5) pre-operatively to a mean of 87.3 (SD 5.4) at the most recent review (p = 0.034), and the Tegner activity score, which improved from a pre-operative median of 2 (0 to 3) to a median of 5 (3 to 7) at final follow-up (p = 0.021). The radiological degenerative changes were evaluated according to Tapper and Hoover's classification and when compared with the pre-operative findings, one knee had grade 1, 22 knees had grade 2 and five knees had grade 3 degenerative changes. The overall outcomes were assessed using Hughston's rating scale, where 19 knees were rated as good, four as fair and five as poor. We found radiological evidence of degenerative changes in the third or fourth decade of life at a mean of 14 years after arthroscopic excision of the loose body and subchondral drilling for an unstable osteochondral lesion of the lateral femoral condyle. Clinical and functional results were more satisfactory.     

Autologous lateral patellar transplant as a reserve method for managing large osteochondral defects of the knee joint in young adults

Between 1995 and 1997, five patients were operated on with a large osteochondral defect of the femoral condyle using the lateral third of the patella. The age of the four male and one female ranged from 18 to 23 years. Initially all of them suffered from an osteochondrosis dissecans which was located at the typical site on the medial condyle of the femur, in the maximal weight bearing region. The follow-up study was 14 to 35 months and showed an improvement from 35 points preoperatively to 89 points postoperatively based on the Cincinnati knee score. All patients returned to there previous profession as well as mild sports activity. The postoperative examination did not show any retropatellar problems and there were no radiological signs of the femoropatellar joint osteoarthritis. For the operative treatment of large chondral defects at the femoral condyle autologous osteochondral transplantation using the lateral third of the patella seems to be a successful alternative.