富血小板血浆关节腔注射联合改良双平面Chevron内踝截骨自体骨软骨移植术治疗HeppleⅤ期距骨骨软骨损伤的临床研究

A clinical study of intra-articular injection of platelet-rich plasma combined with modified dual-plane Chevron medial malleolar osteotomy and autologous osteochondral transplantation for treatment of Hepple stage Ⅴ osteochondral lesion of the talus

目的:观察富血小板血浆(platelet rich plasma,PRP)关节腔注射联合改良双平面Chevron内踝截骨自体骨软骨移植术治疗HeppleⅤ期距骨骨软骨损伤(osteochondral lesion of the talus,OLT)的疗效和安全性。方法:将符合要求的38例OLT患者随机分为2组,每组19例。自体骨软骨移植组采用改良双平面Chevron内踝截骨自体骨软骨移植术治疗;联合治疗组在改良双平面Chevron内踝截骨自体骨软骨移植术治疗的基础上,联合PRP关节腔注射治疗。比较2组患者的美国足与踝关节协会(American Orthopedic Foot and Ankle Society,AOFAS)踝与后足评分、踝关节Karlsson-Peterson评分、踝关节活动度、踝关节疼痛视觉模拟量表(visual analogue scale,VAS)评分及治疗和随访期间的并发症发生情况。结果:①AOFAS踝与后足评分。术前2组患者的AOFAS踝与后足评分比较,差异无统计学意义(t=0.081,P=0.936);术后1年,2组患者的AOFAS踝与后足评分均较术前提高[(61.57±6.98)分,(82.36±7.85)分,t=8.627,P=0.000;(61.39±6.79)分,(89.24±8.12)分,t=11.469,P=0.000];自体骨软骨移植组术后1年的AOFAS踝与后足评分低于联合治疗组(t=2.655,P=0.012)。②踝关节Karlsson-Peterson评分。术前2组患者的踝关节Karlsson-Peterson评分比较,差异无统计学意义(t=0.060,P=0.953);术后1年,2组患者的踝关节Karlsson-Peterson评分均较术前提高[(59.14±6.24)分,(80.24±7.21)分,t=9.646,P=0.000;(59.02±6.11)分,(85.33±7.91)分,t=11.474,P=0.000];自体骨软骨移植组术后1年的踝关节Karlsson-Peterson评分低于联合治疗组(t=2.073,P=0.045)。③踝关节活动度。术前2组患者的踝关节活动度比较,差异无统计学意义(t=0.093,P=0.926);术后1年,2组患者的踝关节活动度均较术前增大(46.11°±4.23°,58.91°±6.22°,t=7.417,P=0.000;45.98°±4.37°,65.03°±6.47°,t=10.635,P=0.000);自体骨软骨移植组术后1年的踝关节活动度小于联合治疗组(t=2.972,P=0.005)。④踝关节疼痛VAS评分。术前2组患者的踝关节疼痛VAS评分比较,差异无统计学意义(t=0.171,P=0.865);术后1年,2组患者的踝关节疼痛VAS评分均较术前降低[(7.55±1.12)分,(3.02±0.34)分,t=16.870,P=0.000;(7.49±1.04)分,(2.13±0.22)分,t=21.979,P=0.000];自体骨软骨移植组术后1年的踝关节疼痛VAS评分高于联合治疗组(t=9.580,P=0.000)。⑤并发症。2组各有1例患者出现下肢深静脉血栓,经常规抗凝治疗后症状均消失。2组患者的并发症发生率比较,差异无统计学意义(P=1.000)。结论:采用PRP关节腔注射联合改良双平面Chevron内踝截骨自体骨软骨移植术治疗HeppleⅤ期OLT,可有效减轻患者的踝关节疼痛、增加踝关节活动度、改善踝关节功能,效果优于单纯改良双平面Chevron内踝截骨自体骨软骨移植术,而且安全性较好。

Objective:To observe the efficacy and safety of intra-articular injection of platelet-rich plasma(PRP)combined with modified dual-plane Chevron medial malleolar osteotomy(MMO)and autologous osteochondral transplantation(AOT)in the treatment of Hepple stage Ⅴ osteochondral lesion of the talus(0LT).Methods:Thirty-eight eligible 0LT patients were enrolled in the study and were randomly divided into AOT group and combination treatment group,19 cases in each group.All patients in the 2 groups were treated with modified dual-plane Chevron MMO and AOT,while the ones in the combination treatment group were further treated with intra-articular injection of PRP.The American Orthopedic Foot and Ankle Society(AOFAS)ankle-hind score,Karlsson-Peterson ankle score,ankle range of motion(ROM),ankle pain visual analogue scale(VAS)score and complications during the treatment and follow-up period were compared between the 2 groups.Results:①There was no signifcant difference in AOFAS ankle-hind score between the 2 groups before the surgery(t=0.081,P=0.936).The AOFAS ankle-hind scores increased in the 2 groups at postsurgical month 12 compared to presurgery(61.57±6.98 vs 82.36±7.85 points,t=8.627,P=0.000;61.39±6.79 vs 89.24±8.12 points,t=11.469,P=0.000),and it was lower in AOT group compared to combination treatment group(t=2.655,P=0.012)②There was no significant difference in Karlsson-Peterson ankle score between the 2 groups before the surgery(t=0.060,P=0.953).The Karlsson-Peterson ankle scores increased in the 2 groups at postsurgical month 12 compared to pre-surgery(59.14±6.24 vs 80.24±7.21 points,t=9.646,P=0.000;59.02±6.11 vs 85.33±7.91 points,t=11.474,P=0.000),and it was lower in AOT group compared to combination treatment group(t=2.073,P=0.045).③There was no significant difference in ankle ROM between the 2 groups before the surgery(t=0.093,P=0.926).The ankle ROM increased in the 2 groups at postsurgical month 12 compared to pre-surgery(46.11±4.23 vs 58.91±6.22 degrees,t=7.417,P=.0.000;45.98±4.37 vs 65.03±6.47 degrees,t=10.635,P=0.000),and it was smaller in AOT group compared to combination treatment group(t=2.972,P=0.005).④There was no significant difference in ankle pain VAS score between the 2 groups before the surgery(t=0.171,P=0.865).The ankle pain VAS scores decreased in the 2 groups at postsurgical month 12 compared to pre-surgery(7.55±1.12 vs 3.02±0.34 points,t=16.870,P=0.000;7.49±1.04 vs 2.13±0.22 points,t=21.979,P=0.000),and it was higher in AOT group compared to combination treatment group(t=9.580,P=0.000).⑤The lower-extremity deep venous thrombosis was found in 1 patient in each group,and the symptoms disappeared after treatment with conventional anticoagulation therapy.There was no significant difference in the incidence of complication between the 2 groups(P=1.000).Conclusion:Intra-articular injection of PRP combined with modifed dual-plane Chevron MMO and AOT can effectively relieve ankle pain,increase ankle ROM and improve ankle function in the treatment of Hepple stage Ⅴ OLT,and its clinical efficacy is better than that of modified dual-plane Chevron MMO and AOT with high safety.