Hankemeier S, Müller E J, Kaminski A, Muhr G
Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover.
Unfallchirurg. 2003 Jun;106(6):461-6. doi: 10.1007/s00113-003-0603-z.
The optimal operative therapy for the treatment of osteochondritis dissecans tali is still controversial. Beside bone marrow-stimulating techniques like abrasion arthroplasty, drilling and microfracturing, new techniques like autologous osteochondral transplantation and autologous chondrocyte transplantation are increasingly used. This study reviewed the clinical, radiological and subjective long-term outcome of bone marrow-stimulating therapy for 45 ankles with an osteochondritis dissecans tali stage 3 or 4 according to the classification by Berndt and Harty. All ankles were treated by the removal of the dissecate and abrasion of the subchondral bone. In 67%, an additional antegrade drilling of the defect was performed. The average maximum size of the lesion was 1.1 cm. At follow-up examination, 10.4 years (7.1-13.5 years) postoperatively, the average AOFAS-score was 91 points (66-100 points). Using the score of Mazur, the outcome of 28 ankles (62%) was rated excellent, 12 ankles (27%) were rated good and five ankles (11%) fair or poor. Progressive osteoarthritic changes, according to the classification of van Dijk, were seen in seven ankles (16%). Reoperations were necessary in eight cases (18%). Obesity, age older than 40 years and preoperative osteoarthritic changes had a significant negative impact on the clinical outcome. Bone marrow stimulating therapy is an inexpensive, low invasive therapy and a good therapeutic option at least for small Berndt/Harty stage 3 and 4 ODT lesions. Autologous chondrocyte transplantation and osteochondral autografts yield encouraging 2- and 4-year results, but still have to prove their superiority in long-term follow-up studies.
距骨剥脱性骨软骨炎的最佳手术治疗方法仍存在争议。除了诸如关节面磨削术、钻孔术和微骨折术等骨髓刺激技术外，自体骨软骨移植和自体软骨细胞移植等新技术也越来越多地被应用。本研究回顾了根据Berndt和Harty分类法处于3期或4期的45例距骨剥脱性骨软骨炎患者接受骨髓刺激治疗后的临床、影像学及主观长期疗效。所有踝关节均接受了剥脱骨块切除及软骨下骨磨削治疗。67%的患者还对缺损进行了顺行钻孔。病变的平均最大尺寸为1.1厘米。在术后10.4年（7.1 - 13.5年）的随访检查中，美国足踝外科协会（AOFAS）评分平均为91分（66 - 100分）。根据Mazur评分，28例踝关节（62%）的疗效被评为优秀，12例（27%）为良好，5例（11%）为一般或较差。根据van Dijk分类法，7例踝关节（16%）出现了进行性骨关节炎改变。8例（18%）患者需要再次手术。肥胖、年龄超过40岁以及术前存在骨关节炎改变对临床疗效有显著负面影响。骨髓刺激疗法是一种廉价、低侵入性的治疗方法，至少对于小型的Berndt/Harty 3期和4期距骨剥脱性骨软骨炎病变是一种很好的治疗选择。自体软骨细胞移植和自体骨软骨移植在2年和4年时取得了令人鼓舞的结果，但仍需在长期随访研究中证明其优越性。
