Shoemaker Evan P, Tollefson Luke V, Olson Conner, Kennedy Nicholas I, LaPrade Robert F
Twin Cities Orthopedics, Edina, Minnesota, USA.
Video J Sports Med. 2024 Mar 27;4(2):26350254231206153. doi: 10.1177/26350254231206153. eCollection 2024 Mar-Apr.
Contributors to knee degeneration include mechanical axis malalignment, patellar maltracking, meniscal deficiency, and tibiofemoral instability. Full-thickness osteochondral defects in young, active patients can lead to significant pain and instability. The gold standard treatment for large (>2 cm) osteochondral defects is an osteochondral allograft (OCA) which addresses the pathologic articular cartilage loss and underlying bone deficiency. While biologic failure of fresh OCAs is reported, the majority of early failures are attributed to unaddressed mechanical malalignment in the coronal plane. Proximal tibial osteotomy (PTO) corrects malalignment thereby unloading the affected medial compartment and the newly placed OCA, improving long-term survivability.
OCAs are indicated for isolated osteochondral defects and lesions in active young patients. PTO is indicated for patients with varus malalignment who risk potential graft failure of the affected medial compartment.
The articular cartilage defect is identified, and a guide pin is drilled in the center. The defect is templated and scored around the margins. A reamer is used to drill to a total depth of 7 to 8 mm. The recipient site is then dilated for graft insertion. On the donor graft, the harvest site is outlined and drilled to the proper diameter. Careful measurement is utilized to ensure graft depth measurements match the recipient site. Once sized, the graft is tapped into place obtaining an anatomic fit along its entire periphery. The osteotomy is performed by using guide pins to delineate the plane cutting the tibia. Fluoroscopy confirmed the osteotomy site and angle. A spacing plate was securely inserted with screws, with placement confirmed by fluoroscopy.
Fresh OCAs can restore osteochondral defects. PTO corrects malalignment and unloads the affected medial compartment, decreasing the risk of revision graft failure or total knee arthroplasty.
Clinical and biomechanical studies that compared isolated and concomitant procedures demonstrated that OCA with PTOs had significantly greater survival rates. Significant malalignment increases the risk of graft failure. It remains unclear whether concomitant osteotomy with osteoarticular allografts leads to increased complication risk; inherent risks remain associated with individual procedures. In adolescents, simultaneous corrective osteotomy along with fresh OCA may delay arthroplasty and associated ambulatory restrictions.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
导致膝关节退变的因素包括机械轴排列不齐、髌骨轨迹异常、半月板缺损和胫股关节不稳定。年轻、活跃的患者出现全层骨软骨缺损会导致明显的疼痛和不稳定。对于大型（>2 cm）骨软骨缺损的金标准治疗方法是骨软骨异体移植（OCA），它可以解决病理性关节软骨损伤和潜在的骨缺损问题。虽然有报道称新鲜OCA存在生物学失败情况，但大多数早期失败归因于冠状面未解决的机械排列不齐。胫骨近端截骨术（PTO）可纠正排列不齐，从而减轻受影响的内侧间室和新植入的OCA的负荷，提高长期生存率。
OCA适用于活跃的年轻患者的孤立性骨软骨缺损和病变。PTO适用于存在内翻排列不齐且有受影响内侧间室移植失败风险的患者。
确定关节软骨缺损，在中心钻入导针。对缺损进行模板制作并在边缘标记。使用扩孔钻钻至总深度7至8毫米。然后扩大受体部位以插入移植物。在供体移植物上，勾勒出取材部位并钻至合适直径。仔细测量以确保移植物深度测量与受体部位匹配。一旦尺寸确定，将移植物轻敲到位，使其在整个周边获得解剖学贴合。通过使用导针划定切割胫骨的平面来进行截骨术。透视确认截骨部位和角度。用螺钉牢固插入间隔板，透视确认其位置。
新鲜OCA可修复骨软骨缺损。PTO可纠正排列不齐并减轻受影响的内侧间室的负荷，降低翻修移植失败或全膝关节置换术的风险。
比较单独和联合手术的临床和生物力学研究表明，OCA联合PTO的生存率显著更高。明显的排列不齐会增加移植失败的风险。骨关节炎异体移植同时进行截骨术是否会导致并发症风险增加仍不清楚；固有风险仍与个体手术相关。在青少年中，同时进行矫正截骨术和新鲜OCA可能会延迟关节置换术及相关的活动限制。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可能被识别，作者已随本提交发表的文章附上患者的豁免声明或其他书面批准形式。
