Kim Yong Sang, Park Eui Hyun, Koh Yong Gon, Lee Jin Woo
Center for Stem Cell & Arthritis Research, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Korea
Department of Orthopaedic Surgery, Yonsei Altair Hospital, Seoul, Korea.
Am J Sports Med. 2014 Jul;42(7):1558-66. doi: 10.1177/0363546514530669. Epub 2014 Apr 25.
Supramalleolar osteotomy (SMO), which redistributes the load line within the ankle joint, has been reported as an effective treatment for varus ankle osteoarthritis. However, no study has examined cartilage regeneration in the medial compartment of the ankle after SMO.
HYPOTHESIS/PURPOSE: This study aimed to investigate the clinical and radiological outcomes of SMO and to identify the association between the outcomes of SMO and cartilage regeneration evaluated by second-look arthroscopy. The hypothesis was that cartilage regeneration would be an important predictor of the outcomes of SMO and that arthroscopic marrow stimulation would aid in cartilage regeneration.
Case series; Level of evidence, 4.
A total of 31 ankles were retrospectively evaluated after arthroscopic marrow stimulation with SMO for varus ankle osteoarthritis; second-look arthroscopy was conducted for all these ankles. Clinical outcome measures included a visual analog scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiological outcome variables included the tibial-ankle surface angle (TAS), talar tilt (TT), and tibial-lateral surface angle (TLS), and progression of degenerative arthritis of the ankle was assessed. In the second-look arthroscopy, cartilage regeneration was evaluated using the International Cartilage Repair Society (ICRS) grade.
The mean ± standard deviation VAS and AOFAS scores were 7.1 ± 0.8 and 62.9 ± 4.0 preoperatively, and they significantly improved to 3.4 ± 1.3 and 83.1 ± 7.5, respectively (P < .001, for both) at the time of the second-look arthroscopy (mean, 13.2 months postoperatively). However, at final follow-up (mean, 27.4 months postoperatively), they were significantly decreased to 4.1 ± 1.6 and 79.9 ± 8.0, respectively, compared with the values at second-look arthroscopy (P < .001, for both). The mean TAS, TT, and TLS improved significantly after SMO but showed no significant correlation with the clinical outcomes and ICRS grade (P > .05 for all three). At second-look arthroscopy, the ICRS overall repair grades were normal in 1 (3%), nearly normal in 7 (23%), abnormal in 13 (42%), and severely abnormal in 10 (32%). Progressive degenerative arthritis was observed in 13 cases (42%). The ICRS grade was significantly associated with the clinical outcomes (P < .0001) and development of degenerative arthritis of the ankle joint (P = .002).
This study showed improved clinical outcomes after SMO for varus ankle osteoarthritis in comparison to the preoperative assessments. Furthermore, the ICRS grade was significantly associated with the clinical outcomes of SMO at final follow-up and significantly associated with the development of degenerative arthritis of the ankle joint. Therefore, arthroscopic marrow stimulation should be considered with SMO to ensure adequate cartilage regeneration. However, given the ICRS grades observed at the time of the second-look arthroscopies and the progression of degenerative arthritis in 42%, the long-term prognosis in this group of patients is uncertain.
距下关节上截骨术（SMO）可重新分配踝关节内的力线，据报道是治疗内翻型踝关节骨关节炎的有效方法。然而，尚无研究探讨SMO术后踝关节内侧间室的软骨再生情况。
假设/目的：本研究旨在调查SMO的临床和影像学结果，并确定SMO结果与通过二次关节镜检查评估的软骨再生之间的关联。假设是软骨再生将是SMO结果的重要预测指标，并且关节镜下骨髓刺激将有助于软骨再生。
病例系列；证据等级，4级。
对31例接受关节镜下骨髓刺激联合SMO治疗内翻型踝关节骨关节炎的踝关节进行回顾性评估；对所有这些踝关节均进行了二次关节镜检查。临床结果指标包括疼痛视觉模拟量表（VAS）和美国矫形足踝协会（AOFAS）评分。影像学结果变量包括胫距关节面角（TAS）、距骨倾斜角（TT）和胫外侧关节面角（TLS），并评估踝关节退行性关节炎的进展情况。在二次关节镜检查中，使用国际软骨修复协会（ICRS）分级评估软骨再生情况。
术前VAS和AOFAS评分的平均值±标准差分别为7.1±0.8和62.9±4.0，在二次关节镜检查时（平均术后13.2个月）分别显著改善至3.4±1.3和83.1±7.5（两者P均<.001）。然而，在最终随访时（平均术后27.4个月），与二次关节镜检查时的值相比，它们分别显著降至4.1±1.6和79.9±8.0（两者P均<.001）。SMO术后平均TAS、TT和TLS显著改善，但与临床结果和ICRS分级均无显著相关性（三者P均>.05）。在二次关节镜检查时，ICRS总体修复分级为正常1例（3%），接近正常7例（23%），异常13例（42%），严重异常10例（32%）。13例（42%）观察到进行性退行性关节炎。ICRS分级与临床结果（P<.0001）和踝关节退行性关节炎的发生（P=.002）显著相关。
本研究表明，与术前评估相比，SMO治疗内翻型踝关节骨关节炎后的临床结果有所改善。此外，ICRS分级在最终随访时与SMO的临床结果显著相关，且与踝关节退行性关节炎的发生显著相关。因此，应考虑在SMO时进行关节镜下骨髓刺激以确保足够的软骨再生。然而，鉴于二次关节镜检查时观察到的ICRS分级以及42%的退行性关节炎进展情况，该组患者的长期预后尚不确定。
