距骨骨软骨损伤的诊断及关节镜治疗

目的 总结、分析距骨骨软骨损伤的症状、体征、影像学特点、关节镜下治疗方法及手术效果.方法 2000年至2005年共收治34例距骨骨软骨损伤患者,对其临床资料包括症状、体征、X线片、MRI表现、关节镜手术方法等进行回顾性分析,术后随访根据主观和客观评分判断疗效.术前美国足踝外科后足评分平均(71±8)分,术前主观疼痛程度评分(7.5±1.3)分.结果 34例患者MRI均有骨软骨损伤征象,其中21例通过X线片检查发现距骨骨软骨损伤.距骨骨软骨损伤的主要症状为负重疼痛以及运动后加重,MRI诊断准确率较X线片高(χ2=16.07,P＜0.001).31例患者获得随访,平均随访时间为28个月.术后美国足踝外科后足评分(91±9)分,显著高于术前(t=9.147,P＜0.001);术后主观疼痛程度评分(2.4±2.3)分,显著低于术前(t=10.853,P＜0.001);临床疗效优良率为87.1%.结论 MRI检查能够提高诊断的正确率,关节镜微创手术治疗距骨骨软骨损伤效果良好.     

Arthroscopic treatment of osteochondral lesions of the talus

In a study of twenty-four patients (twenty-four ankles) with a symptomatic osteochondral lesion of the talus, eighteen of the lesions were found to be associated with trauma. The lesions were evaluated both radiographically and by arthroscopy. The method of treatment was determined at arthroscopy by observing the nature of the articular cartilage overlying the lesion. The cartilage was graded from I to III based on its appearance. It was found that a lesion can progress from grade I to grade III while under observation. There was a lack of correlation between the radiographic appearance and the findings at arthroscopy. The results after an average length of follow-up of thirty months (range, twenty to forty-four months) indicated that osteochondral lesions over which the cartilage is intact (grade I) are best treated by simple restriction of sports activities. Lesions in which the overlying cartilage is soft (grade II) can be treated through the arthroscope by drilling and those in which the overlying cartilage is frayed (grade III) can be treated through the arthroscope by curettage, with minimum morbidity and good results.     

Arthroscopic treatment of osteochondral lesions of the talus

We reviewed, retrospectively, 65 patients who had undergone arthroscopic treatment for osteochondral lesions of the talus. The 46 men and 19 women with a mean age at operation of 34.25 years, were followed up for a mean of 3.5 years. The medial aspect was affected in 45 patients and the lateral aspect in 20. All the lateral lesions and 35 (75%) of the medial lesions were traumatic in origin. Medial lesions presented later than lateral lesions (3 v 1.5 years) and had a much greater incidence of cystic change (46% v 8%). At follow-up, 34 patients had achieved a good result, and 17 and 14 fair and poor results, respectively. Of the 14 poor results, 13 involved medial lesions. Cystic lesions had a poor outcome in 53% of patients. Excision and curettage led to better results than excision and drilling of the base. Further arthroscopic surgery for patients with a poor result was disappointing. There was no association between outcome and the patient's age.     

距骨骨软骨损伤治疗研究进展

踝关节损伤晚期并发症距骨骨软骨损伤,严重影响踝关节功能.根据病史、临床症状及影像学检查一般可确诊,根据临床分期选择合适的治疗方法是取得良好疗效的前提.对急性期无移位或早期距骨骨软骨损伤患者,可采用石膏固定和避免负重的保守治疗方法延缓病程发展.对不稳定或保守治疗无效患者需采用手术治疗,关节镜技术是目前常用的治疗方法,其创伤小且疗效好;内固定的疗效也较好;对缺损较大的患者,可采用自体或异体骨软骨移植术;自体软骨细胞移植术无缺损面积限制,且无供区损伤.该文就距骨骨软骨损伤的分期、诊断及治疗等的研究进展作一综述.     

Approach alternatives for treatment of osteochondral lesions of the talus

Osteochondral lesions of the talus are common injuries, especially in the athletic population. Although multiple etiologies exist, lateral lesions have a higher incidence of association with a specific traumatic event. It has been postulated that lateral lesions are produced when the anterolateral aspect of the talar dome impacts the fibula on application of an inversion or dorsiflexion stress to the ankle [2]. There is general agreement that surgery should be performed only in symptomatic cases, as osteochondral lesions of the talar dome show little tendency to progression and do not seem to lead to osteoarthritis [10,42]. Appropriate preoperative imaging is extremely important. Standard radiographs of the ankle supplemented with lateral plantar flexion and dorsiflexion views and CT or Mr imaging can be helpful in evaluating the size, depth, and exact location of the lesion. This information is essential in planning the appropriate surgical procedure. Although many stage I and II lesions respond well to conservative therapy and a period of immobilization, some higher-grade lesions (stage III and IV) eventually require surgical intervention. Most lesions can be approached arthroscopically. Many arthroscopic procedures have been shown to be successful, including debridement with abrasion chondroplasty, subchondral drilling, and microfracture [18-20]. But certain larger or refractory lesions may require an open approach to the ankle joint to restore the articular cartilage. Most lateral lesions have an anterior location and are easily accessible through a standard anterolateral approach. Most medial lesions are located on the posterior talar dome, and a medial malleolar osteotomy is usually required. Osteotomies, in particular of the medial malleolus, should be approached carefully. The possible complications of nonunion and malunion can lead to progressive arthritis of the ankle joint.     

Acute and chronic osteochondral talus lesions

Osteochondral lesions of the talus are often not or delayed diagnosticated. They mostly are related to traumatic lesions of the upper ankle joint, where by traumatic distorsion are most common among. The degenerative change classified as osteochondrosis dissecans tali shows in the most cases also an originally traumatic generic. The classification by osteochondrosis dissecans tali in four stages by Berndt and Harty is nowadays accepted. These can be distinguished by means of several diagnostic methods. They are regarded as state-of-the-art of therapy and prognosis. Basically for diagnostic purposis the conventional X-ray in two planes with the right feet-allignement is sufficient. Despite the fact, that Szintigraphy and Computertomography for particular questions are the right tools, the MRI gives the highest amount of information. In the case of low levels of defects (Stage I and II) the conservative therapy is appropriate. In more serious cases (Stage III and IV) the surgical intervention has to be used. Beside the open surgical approach the arthroscopy has a growing importancy. In 60% of cases good long term results can be achieved. Beside some advantage there are some limits compared to the arthrotomy. The efficiency of new therapeutic methods like bone-cartilage-transplantation and chondrocyte-transplantation compared to the conventional wound toilet, microfractures and fragmentrefixation has to be proved by long term studies. The results depend on the stage and the localisation of the osteochondral lesion. In the developed stages III and IV surgical actions as wound toilet, removement of dissecate with microfragmentation respectivaly refixation are indicated, since conservative therapy methods lead undoubtedly to worse results. Generally mostly good and very good results connected with painless and weight bearing could be achieved.     

Imaging of osteochondral lesions of the talus

A review of the literature reveals that all studies have been performed retrospectively. These studies have included limited numbers of low-grade lesions and no prospective, randomized, comparison studies have been performed to suggest the superiority of CT scanning over MR imaging. The following conclusions, however, can be made. Plain radiographs are useful in the initial evaluation of patients with acute or chronic complaints of ankle pain and swelling. These initial studies, however, may not identify all osteochondral lesions of the talus, particularly lower grade lesions. CT scanning can accurately identify and localize a lesion while defining its extent. It has been suggested that CT scanning can be used to assess whether bony healing has occurred at follow-up. MR imaging can also precisely identify, localize, and define an OLT with the advantage of assessing the integrity of the overlying cartilage. It can detect lower grade lesions with improved sensitivity and may aid in the differentiation of Stage II and Stage III lesions. Using the preceding observations, the following approach is recommended in the evaluation and work-up of an osteochondral lesion of the talus (Fig. 7). The patient who presents with ankle pain and swelling should have weight-bearing radiographs of the ankle obtained. If these films demonstrate an osteochondral lesion of the talus, staging of the lesion should be performed. In lesions that appear nondisplaced on plain radiography (low grade; stable), MR imaging is recommended so the clinician can evaluate the integrity of the overlying cartilage and assess the true stability of the lesion. In lesions that appear displaced on plain radiography (high grade; unstable), the CT scan is the preferred modality in order to provide accurate assessment of lesion size and location. It should be noted, however, that no study has prospectively [figure: see text] compared the efficacy of these two modalities in the evaluation of osteochondral lesions. If a symptomatic patient presents with negative plain films, then an initial period of immobilization using a cast or boot brace is recommended. This is followed by joint mobilization and range of motion exercises. If the patient remains symptomatic at the 4 to 6 week followup period, then an MR image should be performed. This study provides information regarding soft-tissue impingement, proliferative synovitis, and other bony and soft-tissue pathology. The authors have found that despite the results of bone scintigraphy, an MR image is invariably obtained. Because of this the authors do not recommend bone scintigraphy in the evaluation and diagnosis of OLT.     

Varus ankle and osteochondral lesions of the talus

Considerable recent orthopedic literature is dedicated to either the surgical management of OLTs and correction of varus ankle alignment, but little is published on the combination of these 2 problems. We anticipate that future clinical and biomechanical research will address their simultaneous treatment; until then, we will continue to extrapolate from their independent management.     

踝关节骨折合并距骨软骨损伤的手术治疗

2010年1月～2012年8月,我科共收治踝关节骨折患者36例,术中发现有15例合并距骨软骨损伤,经治疗疗效满意,报道如下。1材料与方法1.1病例资料本组15例,男13例,女2例,年龄25～52岁。踝关节骨折按Lauge-Hansen分类:旋后内收型2例,旋后外旋型6例,旋前外展型3例,旋前外旋型4例。距骨软骨损伤按Berndt-Har-ty分类[1]:Ⅰ型3例,Ⅱ型5例,Ⅲ型3例,Ⅳ型4例。     

Arthroscopic drilling for the treatment of osteochondral lesions of the talus.

BACKGROUND: An osteochondral lesion of the talus is a relatively rare disorder of the ankle. While a number of treatment options have been reported, it appears to be difficult to manage all lesions with a single approach. We evaluated the indications for and the results of arthroscopic drilling for the treatment of an osteochondral lesion of the talus. METHODS: Eighteen ankles (seventeen patients) with a symptomatic osteochondral lesion of the talus were examined. The ages of the patients ranged from ten to seventy-eight years (mean, 28.0 years) at the time of the operation, and the patients were followed postoperatively for two to 9.5 years (mean, 4.6 years). After the continuity of the cartilage overlying the lesion and the stability of the lesion had been confirmed, arthroscopic drilling was performed with use of a Kirschner wire that was 1.0 to 1.2 millimeters in diameter. A cast was not applied postoperatively, and full weight-bearing was allowed six weeks after the procedure. RESULTS: The clinical result was good for thirteen ankles and fair for five; all ankles had improvement. Twelve of the thirteen ankles that were in patients who were less than thirty years old had a good result. In contrast, only one of the five ankles in patients who were fifty years old or more had a good result. Thus, the clinical results tended to be better for younger patients. Improvement was seen radiographically in fifteen ankles. However, the three ankles in patients who were more than sixty years old were found to have no improvement on radiographic examination. Analysis of the group of patients who had a history of trauma revealed that the mean interval between the injury and the operation was 6.3 months for the three ankles that had a good radiographic result and 11.3 months for the six that had a fair result. Thus, the radiographic results tended to be better when the interval between the injury and the operation was shorter. CONCLUSIONS: Arthroscopic drilling for the treatment of medial osteochondral lesions of the talus does not require osteotomy of the medial malleolus or postoperative immobilization; thus, the procedure is less invasive than other types of operative treatment for the condition and it allows early resumption of daily activities and sports. On the basis of the results in this study, we believe that the procedure is effective and useful in young patients, especially those who have not yet had closure of the epiphyseal plate. A specific indication for the procedure is an early lesion with only mild osteosclerosis of the surrounding talar bone, continuity of the cartilaginous surface, and stability of the osteochondral fragment.     

距骨骨软骨损伤的治疗研究进展

距骨骨软骨损伤是运动医学中具有挑战性的疾病之一。临床治疗策略包括保守治疗和手术治疗,保守治疗在儿童患者中效果最佳,对于成人患者常常选择进行手术治疗。目前常见的外科手术治疗方案包括关节镜下骨髓刺激、自体软骨细胞植入、自体骨软骨移植、同种异体骨软骨移植或同种异体青少年软骨微粒移植等。关节镜下骨髓刺激技术(特别是微骨折)适用于较小的病灶,是常见的一线治疗方案,中短期临床疗效令人满意,但长期疗效有待进一步观察。自体骨软骨移植常用于伴有较大囊性病变的距骨骨软骨损伤患者,有着较好的中短期临床疗效,然而术后存在囊肿复发和供区并发症的发生。近年来有大量文献报道其他生物治疗措施,如骨软骨损伤区域注射富含血小板血浆、或者浓缩骨髓细胞等,均有一定的临床疗效。本文对这些技术的应用细节和疗效进行综述,目的是为临床医生能够更好地治疗距骨骨软骨损伤提供依据。     

The mosaicplasty technique for osteochondral lesions of the talus

For years, OCD of the talus has been known as a symptomatic lesion that causes pain, recurrent synovitis, altered joint mechanism, and obstruction from loose bodies. It is a probable precursor of ankle osteoarthritis because of altered joint mechanics and recurrent synovitis. With the notable advance of diagnostic imaging and the advent of ankle arthroscopy, classification of the lesion has become standardized, which allowed for the comparison of treatment options. Arthroscopic procedures (eg, debridement, retrograde drilling, bone grafting, by nature of their minimally invasive approach, have a great advantage in treating small defects and stable OCD lesions compared with open methods. For larger osteochondral defects and unstable OCD lesions, the optimal treatment is the long-term replacement and integration of type-specific hyaline cartilage. In principle, mosaicplasty autogenous osteochondral transplantation fills these criteria. The early- and medium-term results are encouraging, complete with confirmatory radiographs and histology, and hold promise for this procedure to provide lasting relief of symptoms and the prevention of ankle arthrosis. Under the current dichotomy of nonoperative and operative treatments giving satisfactory results, and few comparative studies, there is a need for a randomized, prospective study in the treatment of talar OCD to define a reproducible treatment algorithm.     

Arthroscopic debridement and drilling of osteochondral lesions of the talus

Diagnosis of OLTs requires a high index of suspicion because these lesions are rare and the symptoms can be falsely attributed to acute or chronic ankle sprains. When no abnormality is present on plain radiographs, a bone scan or MRI can reliably identify the presence of an OLT. CT scanning can provide even better detail of the location and size of the fragment and help stage these lesions and guide treatment. Arthroscopic staging is believed to be the best method to determine treatment. In a patient without an obvious loose body, initial nonoperative treatment is warranted. When nonoperative therapy fails or when a high stage lesion is present, operative options should be explored. Arthroscopic techniques provide results that are equal to or better than management by arthrotomy and have the advantages of lower morbidity and quicker overall rehabilitation time. In most cases, arthroscopic treatment involves loose body removal and debridement and drilling of the underlying bone or drilling alone for intact lesions. Although it is unknown whether such treatment can reduce the incidence of late arthrosis in a patient who has an OLT, a recent study suggested that healing occurs and the MRI appearance of the talar dome normalizes in many patients postoperatively.     

YouTube provides low-quality videos about talus osteochondral lesions and their arthroscopic treatment

BackgroundMedical professionals and patients commonly use the YouTubeTM platform in their research on health information. The quality of videos about talus osteochondral defect (OCD) and arthroscopic surgery has not been evaluated previously. The aim of this study was to interpret the quality and sufficiency of YouTubeTM videos about talus OCD and arthroscopic surgery.MethodsThe present study is a quality control study of videos on OCD and their arthroscopic treatment. The videos were interpreted in terms of Journal of the American Medical Association (JAMA), DISCERN (Quality Criteria for Consumer Health Information), The Global Quality Score (GQS) and Talus OCD - Specific Score (TOCDSS) by two blinded observers to assess the accuracy of these methods.ResultsInter-observer agreement was "very high" for JAMA, DISCERN, and TOCDSS, while "high" for GQS. There was a statistical relationship and a positive correlation between the scoring systems.ConclusionThe content and quality of YouTubeTM videos about talus OCD and arthroscopic treatment are insufficient.     

Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions of the talus

The treatment of osteochondral lesions of the talus has evolved with the development of improved imaging and arthroscopic techniques. However, the outcome of treatment for large cystic type-V lesions is poor, using conventional grafting, debridement or microfracture techniques. This retrospective study examined the outcomes of 50 patients with a cystic talar defect who were treated with arthroscopically harvested, cored osteochondral graft taken from the ipsilateral knee. Of the 50 patients, 45 (90%) had a mean good to excellent score of 80.3 (52 to 90) in the Karlsson-Peterson Ankle Score, at a mean follow-up of 36 months (24 to 83). A malleolar osteotomy for exposure was needed in 26 patients and there were no malleolar mal- or nonunions. One patient had symptoms at the donor site three months after surgery; these resolved after arthroscopic release of scar tissue. This technique is demanding with or without a malleolar osteotomy, but if properly performed has a high likelihood of success.     

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。