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

Comparison of autologous osteochondral transplantation and osteochondral drilling in treatment of acute osteochondral fractures of the talus

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（r=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（r=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。。

Objective To compare autologous osteochondral transplantation and osteoehondral drilling in treatment of osteochondral fracture lesions （types Ⅲ＆Ⅳ） on the talus dome associated with ankle fracture. Methods There were 38 patients with osteochondral fracture defects （types Ⅲ＆Ⅳ） of the talar dome associated with ankle fracture. The position and size of the fracture defects were defined during operation. The procedures involved removal of the fracture segments and drilling for 18 cases （Drilling Group） and transplantation with grafts harvested from the ipsilateral knee for 20 cases （Transplantation Group） . Transplantation was conducted by harvesting osteochondral cylinders from non-weight bearing surface of the ipsilateral knee and implanting the donor grafts into the recipient holes of talus to repair cartilaginous defects with press-fit technique. Single donor transplantation or mosaicplasty was adopted. The outcomes were assessed on the basis of ankle functional rating scores, radiographic findings and MRI findings. Results The patients were followed up for 1.5 to 4.0 （mean, 2.92 ±0.65） years in Transplantation Group, and 2.5 to 5 （mean, 3.02±0. 83） years in Drilling Group. Ankle functions were rated by the Baird and Jackson e- valuation system. The average score was 89.85 ±4.83 for Transplantation Group and 84.28 ± 5.65 for Drilling Group （ P = 0. 002） . Three patients in Transplantation Group （ 15.0% ） and 8 patients in Drilling Group （44.4%） had posttraumatic arthritis （X2 = 31.7, P 〈 0.05）. Six patients had osteochondritis dissecans in Drilling Group （33.3%） . In Transplantation Group, the grafts showed excellent bony integration with surrounding tissues and congruity of the articular surface except in 3 patients who had osteochondritis dissecans （15.0%） （X2 = 39.6, P 〈 0. 05）. Conclusion Autogenous osteoehondral transplantation using ipsilateral knee osteochondral grafts is a better surgical procedure for treating acute local osteochondral fracture lesions of the talus associated with ankle fracture than osteochondral drilling, because it improves the functional recovery of the ankle and reduces postoperative complications.