Department of Orthopedic Surgery and Sports Medicine, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
Oper Orthop Traumatol. 2024 Apr;36(2):132-144. doi: 10.1007/s00064-023-00833-7. Epub 2023 Oct 12.
Osteochondral lesions of the talus (OLT) with a fragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through a medial distal tibial osteotomy.
Symptomatic osteochondral lesion of the talus with a fragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6 months conservative treatment.
Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score 3 or 4 [3]. Ipsilateral medial malleolus fracture less than 6 months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered.
The OLT is approached through a medial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with a chisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as a hood of a motor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws.
Casting includes 5 weeks of short leg cast non-weightbearing and 5 weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, a CT scan is made to confirm fragment and osteotomy healing, and patients start personalized rehabilitation under the guidance of a physical therapist.
距骨骨软骨病变（OLT）伴距骨穹顶骨软骨碎片，如果保守治疗失败且需要手术治疗，则可从 OLT 的原位固定中获益。固定的优点包括保留天然软骨、修复高质量的软骨下骨以及通过立即稳定碎片来恢复关节一致性。为了提高稳定成功的机会，充分暴露病变至关重要，尤其是在位于距骨穹顶后内侧的难以触及的病变中。在这项研究中，我们描述了用于内侧距骨骨软骨病变的开放式 Lift、Drill、Fill、Fix（LDFF）技术。因此，该病变可被视为需要清创、植骨、稳定和压缩的关节内骨不连。LDFF 手术将这些需求与通过内侧胫骨远端切开术获得的通道相结合。
有症状的距骨骨软骨病变，伴有骨软骨碎片（根据 CT 扫描，直径≥10mm，厚度≥3mm）位于距骨穹顶内侧，经 3-6 个月保守治疗失败。
系统性疾病，包括活动性细菌性关节炎、血友病或其他弥漫性关节病、踝关节类风湿关节炎和恶性肿瘤。神经病。终末期踝关节骨关节炎或 Kellgren 和 Lawrence 评分 3 或 4 [3]。6 个月前同侧内踝骨折。相对禁忌证：创伤后僵硬伴活动度（ROM）<5°。有开放性骨骺的儿童：不要进行截骨术，因为截骨术的固定可能导致骨骺过早闭合，从而导致胫骨远端出现有症状的内翻畸形。在这些情况下，只能考虑关节切开术。
OLT 通过内侧胫骨远端切开术进行治疗，为此预先钻取螺钉，并使用摆动锯进行切开术，然后使用凿子完成，以避免热损伤。此后，检查关节并识别骨软骨碎片。软骨在边界处部分切开，然后将碎片提起作为机动车的罩（lift）。去除软骨下骨，然后钻孔以允许彻底的骨髓刺激（drill），并用取自髂嵴或胫骨远端的自体松质骨移植物填充（fill）。然后将碎片以解剖位置固定（fix），最好用两个螺钉以提供额外的旋转稳定性。最后，减少截骨术并使用两个螺钉固定。
石膏固定包括 5 周的短腿石膏非负重和 5 周的短腿石膏负重，根据耐受情况而定。在 10 周随访时，进行 CT 扫描以确认碎片和截骨愈合，并在物理治疗师的指导下开始个性化康复。
