自体膝关节骨软骨移植治疗距骨骨软骨损伤的临床疗效

doi:10.3877/cma.j.issn.1674-134X.2023.04.021

目的

探讨自体膝关节骨软骨移植术(OAT)治疗距骨骨软骨损伤(OLT)Hepple Ⅴ型20例患者的临床疗效。

方法

采用回顾性病例系列研究分析2018年9月至2021年9月重庆市中医骨科医院足踝外科收治的HeppleⅤ型OLT患者的临床资料20例。记录术前、术后6个月及末次(≥12个月)回访疼痛视觉模拟评分(VAS)、美国足踝外科协会(AOFAS)踝－后足评分、膝关节Lysholm评分。通过VAS、AOFAS、Lysholm等术前、术后评分对踝和膝关节进行疼痛及功能评价。根据CT或MRI表现评估截骨区域、骨软骨移植区域的愈合情况、记录并发症情况。

结果

采用重复测量方差分析、LSD-t检验、Friedman检验、Wilcoxon秩和检验等进行分析。结果　本组20例HeppleⅤ型OLT患者均获得随访，末次随访CT/MRI显示，植骨与周围骨质结合良好。VAS评分由术前6.5(6.0，8.0)分别降为术后6个月2.0(2.0，3.0)分及末次随访2.0(2.0，3.0)分，AOFAS踝－后足评分由术前59.0(48.0，64.0)分别增为术后6个月88.5(87.0，90.0)分及末次随访90.0(88.0，90.0)分(χ²＝33.78、33.56，均为P<0.05)。末次随访VAS评分、AOFAS踝－后足评分与术后6个月比较差异均无统计学意义(均为P>0.05)。术后6个月、末次随访Lysholm评分与术前比较以及末次随访与术后6个月比较，差异均无统计学意义(均为P>0.05)。AOFAS踝－后足评分术后6个月随访优良率为95%，所有患者术后均无相关并发症。

结论

自体骨软骨移植术(OAT)治疗HeppleⅤ型OLT，可明显减轻踝关节疼痛，改善功能，疗效满意，膝关节供区风险可控，有一定的临床实用价值。

关键词: 软骨, 距骨, 移植，自体

Objective

To investigate the clinical effect of 20 patients with osthondral lesion of the talus (OLT) of Hepple type Ⅴ treated with autogenous knee osteochondral autograft transplantation (OAT).

Methods

A retrospective case series study was used to analyze the clinical data of 20 patients with OLT of Hepple type Ⅴ admitted to the Foot and Ankle Surgery Department of Chongqing Orthopaedic Hospital of Traditional Chinese Medicine from September 2018 to September 2021. Visual analogue scale (VAS), American Association of Foot and Ankle Surgery (AOFAS) ankle-posterior foot score and knee Lysholm score were recorded before surgery, six months after surgery and at the last visit (≥12 months). Preoperative and postoperative scores such as VAS, AOFAS and Lysholm were used to evaluate ankle and knee pain and function. CT or MRI findings were used to evaluate the healing of the osteotomy area and the osteochondral graft area, and to record the complications. Repeated measure ANOVA, LSD-t test, Friedman test and Wilcoxon rank sum test were used for analysis.

Results

Twenty patients with OLT of Hepple type Ⅴ were followed up, and CT/MRI at the last follow-up showed that the bone graft was well integrated with the surrounding bone. VAS score decreased from 6.5 (6.0, 8.0) before surgery to 2.0 (2.0, 3.0) at six months after surgery and 2.0 (2.0, 3.0) at the last follow-up, respectively. AOFAS ankle-posterior foot score increased from 59.0 (48.0, 64.0) before surgery to 88.5(87.0, 90.0) at six months after surgery and 90.0(88.0, 90.0) at the last follow-up (χ²=33.78, 33.56, both P<0.05). There was no statistically significant difference in VAS score and AOFAS score between the last follow-up and six months after surgery (all P>0.05). There was no statistically significant difference in Lysholm score between six months after surgery and the last follow-up or between the data before operation and after operation (all P>0.05). The excellent rate of AOFAS ankle-posterior foot score at six months after operation was 95%, and no postoperative complication was observed.

Conclusion

Autologous osteochondral transplantation (OAT) for OLT of Hepple type Ⅴcan significantly reduce ankle pain, improve function, achieve satisfactory results, and control the risk of knee joint donor site, which has certain clinical practical value.

Key words: Cartilage, Talus, Transplantation, autologous

图1 OLT(距骨骨软骨损伤)行OAT(自体骨软骨移植术)术中术后情况。图A为术中见距骨内侧病灶软骨明显剥脱；图B血管钳从囊腔取出淡黄色胶冻样液体；图C距骨囊腔中取出含有囊液的硬化骨组织；图D左内踝截骨术后空心螺钉内固定

Figure 1 Surgical images of OLT (osthondral lesion of the talus) treated by OAT(osteochondral autograft transplantation) and X ray images after operation. A is operation process, showing obvious exfoliation of cartilage of the medial talar lesion; B is operation process, showing yellowish jelly-like fluid was removed from the capsular cavity by vascular forceps; C is sclerotic bone tissues containing capsular fluid removed from the talar capsule cavity; D is the anteroposterior and lateral X ray view of right ankle after surgery, showing internal fixation with hollow screws after left medial ankle osteotomy

表1 OLT患者手术前后VAS、AOFAS踝－后足评分、Lysholm评分比较(n＝20)

Table 1 Comparison of VAS, AOFAS ankle-hind foot score and Lysholm score before and after surgery in OLT patients

时间点Time point	VAS	AOFAS	Lysholm评分(±s) Lysholm score
术前Before operation	6.5(6.0，8.0)	59.0(48.0，64.0)	90.5±2.9
术后6个月Six months after operation	2.0(2.0，3.0)	88.5(87.0，90.0)	90.3±3.0
末次随访Last time follow-up	2.0(2.0，3.0)^a	90.0(88.0，90.0)^b	89.5±3.0
统计值	χ²＝33.78	χ²＝33.56	F＝0.70
P值	<0.001	<0.001	>0.05

表1 OLT患者手术前后VAS、AOFAS踝－后足评分、Lysholm评分比较(n＝20)

Table 1 Comparison of VAS, AOFAS ankle-hind foot score and Lysholm score before and after surgery in OLT patients

时间点Time point	VAS	AOFAS	Lysholm评分(±s) Lysholm score
术前Before operation	6.5(6.0，8.0)	59.0(48.0，64.0)	90.5±2.9
术后6个月Six months after operation	2.0(2.0，3.0)	88.5(87.0，90.0)	90.3±3.0
末次随访Last time follow-up	2.0(2.0，3.0)^a	90.0(88.0，90.0)^b	89.5±3.0
统计值	χ²＝33.78	χ²＝33.56	F＝0.70
P值	<0.001	<0.001	>0.05

图2 OLT病例HeppleⅤ型术前术后左踝关节CT。图A~C为术前CT图像，示距骨体内侧，软骨下骨板完全破坏，呈椭圆状，边缘硬化，未见骨膜反应，明显囊性变；图D术后12个月CT示，软骨柱与周围骨质结合良好，囊性区域较前明显减小

Figure 2 Pre- and postoperative CT images of OLT(osthondral lesion of the talus) of Hepple type Ⅴ in left ankle. A to C are preoperative CT images of the left ankle joint, showing the medial aspect of the talus, complete destruction of the subchondral bone plate, elliptical shape, sclerotic edges, no periosteal reaction, obvious cystic changes; D is CT image at 12 months after surgery, showing that the cartilage column was well integrated with the surrounding bone, and the cystic area was reduced compared with the previous one

图3 左踝关节OLT病例HeppleⅤ型术前CT及术后MRI情况。图A~B为术前左踝CT，示距骨前内侧明显囊相变，软骨面缺损；图C~D为术后17个月左踝MRI，示软骨修复良好，坏死灶面积明显减少

Figure 3 Preoperative CT and postoperative MRI of OLT(osthondral lesion of the talus) of Hepple type Ⅴ in left ankle. A to B are preoperative CT images of the left ankle, showing obvious cystic phase change in the anteromedial aspect of the talus with cartilage facet defects; C to D are postoperative MRI at 17 months after the operation, showing that the cartilage was well repaired, and the area of necrotic foci had been reduced

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Clinical efficacy of osteochondral lesion of talus treated by autogenous knee osteocartilage transplantation

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Clinical efficacy of osteochondral lesion of talus treated by autogenous knee osteocartilage transplantation