Moisan Philippe, Lamer Stéphanie, Li Orville, Grimard Guy, Nault Marie-Lyne
CHU Sainte-Justine, Montréal, QC, Canada.
University of Montreal, Montreal, QC, Canada.
Video J Sports Med. 2022 Oct 25;2(5):26350254221104100. doi: 10.1177/26350254221104100. eCollection 2022 Sep-Oct.
Conservative management is the first line of treatment in most osteochondritis dissecans (OCD) cases and can be sufficient for small and stable lesions in skeletally immature patients. Unstable lesions commonly require surgical interventions and may need fixation. The standard surgical approach to fix posteromedial lesions of the talus involves an osteotomy of the medial malleolus. This technique is invasive and requires multiple weeks of immobilization after the surgery. In this video, we present a minimally invasive transmalleolar approach used for the fixation of an OCD lesion of the talus.
The main indication for this procedure is the failure of conservative management with persistent ankle pain and functional impairment of an unstable osteochondral lesion with poor potential for revascularization.
There are 3 key steps to this surgery: ankle arthroscopy, retroarticular drilling, and transmalleolar fixation. The transmalleolar approach is achieved by creating a tunnel through the medial malleoli oriented toward the lesion. To do so, the surgeon combines fluoroscopy and ankle arthroscopy to first insert a Kirschner wire (K-wire) through the medial malleoli. Once the correct orientation is confirmed, a 4.5-mm cannulated drill bit is used to create the tunnel. Arthroscopic visualization is used to avoid iatrogenic cartilage damage during drilling. Once the tunnel is created, ankle dorsiflexion and plantar flexion are used to access the entire lesion and insert screws. The malleolar tunnel is then filled with a bone graft and the wound closed. The patient is immobilized for 2 weeks after which gentle range of motion is initiated. The patient remains non-weight-bearing for 2 months and is then allowed to bear weight using a boot.
Transmalleolar fixation for osteochondritis dissecans of the talus is a minimally invasive procedure that does not require an osteotomy of the medial talus. This approach permits early postoperative range of motion and decreases postoperative pain and edema, but the adequate positioning of the tunnel can prove challenging.
Transmalleolar approach to the talus is minimally invasive and allows adequate fixation of certain osteochondral lesions. Studies comparing the reoperation and complication rate with the standard malleolar osteotomy are lacking and need to be performed.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.
在大多数距骨骨软骨炎（OCD）病例中，保守治疗是一线治疗方法，对于骨骼未成熟患者的小而稳定的病变可能就足够了。不稳定病变通常需要手术干预，可能需要固定。固定距骨后内侧病变的标准手术方法包括内踝截骨术。该技术具有侵入性，术后需要数周的固定。在本视频中，我们展示一种用于固定距骨OCD病变的微创经踝入路。
该手术的主要适应症是保守治疗失败，伴有持续的踝关节疼痛以及不稳定的骨软骨病变导致功能障碍且血管再生潜力差。
该手术有3个关键步骤：踝关节镜检查、关节后钻孔和经踝固定。经踝入路是通过在内踝上创建一个朝向病变的隧道来实现的。为此，外科医生结合荧光透视和踝关节镜检查，首先将一根克氏针（K线）插入内踝。一旦确认正确的方向，使用4.5毫米空心钻头创建隧道。在钻孔过程中，利用关节镜可视化以避免医源性软骨损伤。一旦创建了隧道，通过踝关节背屈和跖屈来处理整个病变并插入螺钉。然后用骨移植填充踝部隧道并缝合伤口。患者固定2周，之后开始进行轻柔的活动范围训练。患者2个月内不负重，之后可使用靴子负重。
距骨骨软骨炎的经踝固定是一种微创手术，不需要内踝截骨术。这种方法允许术后早期进行活动范围训练，并减少术后疼痛和水肿，但隧道的正确定位可能具有挑战性。
距骨的经踝入路是微创的，能够对某些骨软骨病变进行充分固定。缺乏将其再次手术率和并发症发生率与标准内踝截骨术进行比较的研究，需要开展此类研究。作者证明已获得本出版物中出现的任何患者的同意。如果个体可识别，作者已随本投稿发表包含患者发布声明或其他书面批准形式。
