自体胫骨带骨膜骨移植治疗距骨内侧骨软骨损伤

Autogenous Tibial Periosteum Bone Graft for Treating Medial Osteochondral Lesion of the Talus

目的:探讨经内踝截骨、胫骨带骨膜骨移植治疗距骨内侧骨软骨损伤的临床疗效。方法:总结第三军医大学西南医院2014年1月至2015年8月,采用内踝截骨、病灶清理、胫骨带骨膜骨移植治疗距骨内侧骨软骨损伤28例。术中经内踝截骨,显露内侧距骨顶,清理碎裂软骨,去除病灶及囊肿,自同侧胫骨钻取带骨膜骨柱,采取打压固定技术将骨柱植入受区钻好的孔中,固定内踝截骨块。观察患者术前术后踝关节X线片、MRI,在PACS系统测量比较距骨骨软骨损伤水肿区域的左右径、前后径及深度变化,比较术前及术后末次随访时美国足踝外科协会(AOFAS)踝与后足评分。结果:本组共23例患者获最终随访,随访时间15个月(10~28月),X线片证实术后平均11周(9~14周)内踝截骨端愈合,MRI检查显示患者术后病灶骨髓水肿区域较术前明显减小,差异具有统计学意义(P<0.01),1例患者形成软骨组织稍高于周围关节软骨,2例患者软骨下骨囊肿未完全消失,6例取内固定时行关节镜检,其中5例移植物与周围关节软骨愈合良好,表面被软骨样组织覆盖,其色泽、光滑度等与周围软骨面差异较小,患者AOFAS踝与后足评分均较术前明显改善(P<0.05),随访期间未见供区疼痛、伤口感染、内固定失效等并发症。结论:对于Ⅲ~Ⅴ期距骨骨软骨损伤,经内踝截骨、病灶清理、胫骨带骨膜骨移植可修复软骨缺损,减轻疼痛,改善关节功能,是一种有效的治疗方法。

Objective To evaluate the clinical effect of treating the medial osteochondral lesions ofthe talus（OLTs） using the malleolar osteotomy and bone grafting with periosteum. Methods A total of28 patients who underwent medial malleolar osteotomy,lesions debridement and bone grafting with peri-osteum between January 2014 and August 2015 were reviewed retrospectively. The oblique medial mal-leolar osteotomy was performed to expose the talar lesion,followed by cyst debridement and bone graft-ing with periosteum,then the medial malleolus fracture was fixed. X-rays and MRI examination wereconducted before and after the operation. MRI was used for the measurement of radiographic parame-ters such as the length,width and depth of the edema area. The patients were also evaluated using theAmerican orthopaedic foot and ankle society（AOFAS）-ankle and hindfoot score questionnaires. Results Twenty-three subjects completed the follow-up over a mean period of 15 months（range,10~28 months）. According to X-rays,the mean time for osseous union was 11 weeks（range,9-14 weeks）.MRI results showed significant reduce in the bone marrow edema area after the operation,except forone case of fibrous cartilage higher than the surrounding articular cartilage,and two with the chondro-cyst not disappearing completely. The arthroscopy of 6 patients revealed 5 good integrations with simi-lar color and smoothness. The AOFAS ankle-hindfoot scores increased significantly after the surgery（P〈0.05）. No wound pain,infection,and failure of internal fixation were observed during the follow-up peri-od. Conclusions The combination of medial malleolar osteotomy,lesions debridement and bone graftingwith periosteum can be used to treat patients with stage III-V OLTs,as this technique can effectivelyrelieve pain and enhance the joint function.