Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok, 10400, Thailand.
Knee Surg Sports Traumatol Arthrosc. 2021 Apr;29(4):1304-1317. doi: 10.1007/s00167-020-06113-2. Epub 2020 Jun 29.
The aim of this study is to systematically review the current, relevant literature and provide a thorough understanding of the various open surgical approaches utilized to gain access to the talar dome for treatment of osteochondral lesions. Realizing the limits of access from soft tissue exposures and osteotomies, with and without external distraction, will help surgeons to select the appropriate approach for each individual clinical situation.
A literature search was performed using three major medical databases: PubMed (MEDLINE), Scopus, and Embase. The Quality Appraisal for Cadaveric Studies (QUACS) scale was used to assess the methodological quality of each included study.
Of 3108 reviewed articles, nine cadaveric studies (113 limbs from 83 cadavers) evaluating the accessibility of the talar dome were included in the final analysis. Most of these (7/9 studies) investigated talar dome access in the context of treating osteochondral lesions of the talus (OLTs) requiring perpendicular visualization of the involved region. Five surgical approaches (anteromedial; AM, anterolateral; AL, posteromedial; PM, posterolateral; PL, and direct posterior via an Achilles tendon splitting; DP), four types of osteotomy (anterolateral tibial, medial malleolar, distal fibular, and plafondplasty), and two methods of distraction (Hintermann retractor and external fixator) were used among the included studies. The most commonly used methods quantified talar access in the sagittal plane (6/9 studies, 66.7%). The greatest exposure of the talar dome can be achieved perpendicularly by performing an additional malleolar osteotomy (90.9% for lateral, and 100% for medial). The methodological quality of all included studies was determined to be satisfactory.
Gaining perpendicular access to the central portion of the talar dome, measured in the sagittal plane, has clear limitations via soft tissue approaches either medially or laterally from the anterior or posterior aspects of the ankle. It is possible to access a greater talar dome area in a non-perpendicular fashion, especially from the posterior soft tissue approach. Various types of osteotomies can provide greater accessibility to the talar dome. This systematic review can help surgeons to select the appropriate approach for treatment of OLTs in each individual patient preoperatively.
Level IV.
本研究旨在系统地回顾当前相关文献，全面了解用于治疗距骨骨软骨病变而进入距骨穹顶的各种开放手术入路。认识到软组织入路和截骨术（包括和不包括外部牵开）的入路限制，将有助于外科医生根据每个患者的具体情况选择合适的入路。
使用三个主要医学数据库：PubMed（MEDLINE）、Scopus 和 Embase 进行文献检索。使用 Cadaveric Studies 质量评估（QUACS）量表评估每个纳入研究的方法学质量。
在 3108 篇综述文章中，有 9 项尸体研究（来自 83 具尸体的 113 条肢体）评估了距骨穹顶的可及性，最终纳入了分析。其中大多数（7/9 项研究）研究了在需要垂直观察受累区域的情况下治疗距骨骨软骨病变（OLT）时距骨穹顶的可及性。5 种手术入路（前内侧；AM、前外侧；AL、后内侧；PM、后外侧；PL 和经跟腱劈开的直接后入路；DP）、4 种截骨术（前外侧胫骨、内侧踝、远端腓骨和距骨成形术）和 2 种牵开方法（Hintermann 牵开器和外固定器）在纳入的研究中被使用。纳入的研究中，最常用的方法是在矢状面量化距骨的可达性（6/9 项研究，66.7%）。通过进行额外的踝骨切开术，可以实现距骨穹顶中心部分的最大垂直暴露（外侧 90.9%，内侧 100%）。所有纳入研究的方法学质量被确定为满意。
通过踝关节前、后侧面的软组织入路，无论是内侧还是外侧，在矢状面测量时，获得距骨穹顶中心部分的垂直进入具有明显的局限性。以非垂直方式可以获得更大的距骨穹顶区域，特别是从后软组织入路。各种类型的截骨术可以提供更大的距骨穹顶可达性。本系统评价可以帮助外科医生在术前为每个患者选择治疗 OLT 的合适入路。
IV 级。
