距骨骨软骨损伤的流行病学特点、影像学及关节镜下表现
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摘要
目的:分析踝关节距骨骨软骨损伤的流行病学特点,X线及MRI上的影像学表现,包括病灶位置、大小、分布,并根据关节镜下的表现进行分级。方法:对我科2010年1月到2015年1月期间经关节镜检查确诊为距骨骨软骨损伤的412例病例的临床资料进行回顾性分析研究。所有研究对象均行踝关节镜检查,并且术前均进行了踝关节正侧位X线及MRI检查。分别根据Loomer改良标准及Hepple标准进行影像学分型,依据Cheng的关节镜分级标准进行关节镜下病灶分级。在PACS系统上应用测量软件工具分析距骨骨软骨损伤的影像学特点,确定病灶位置,测量其前后径、左右径及深度。结果:本研究412例患者平均年龄35.5岁,其中20～40岁患者占76.9%,男性所占比率(n=298,67.5%)高于女性(n=113,32.5%);366例(88.9%)有外伤史,并以内翻伤最多见(n=246例,59.7%)。X线片上188例有阳性发现,Ⅴ型为31例。412例经MRI检查发现411处损伤(14例有2处病灶,15例经关节镜确诊的病灶MRI上未发现)。根据Hepple’s MRI分型:Ⅰ型13例,Ⅱ型161例,Ⅲ型93例,Ⅳ型37例,Ⅴ型107例。在MRI冠状位上,314例病灶位于内侧,97例病灶位于外侧。在MRI矢状位上,59例病灶位于前部,254例位于中部,87例位于后部,8例为前中后区域均有,3例为中后区域均有。在MRI上按六分区法统计,内中侧最多,为229例(55.7%);其次为内后侧,53例(12.9%);外前侧和外中侧分别为41例(10%)、38例(9.3%)。PACS系统上测量:病损前后径10.5±3.9 mm,左右径9.5±3.4 mm;深度8.0±3.8 mm;314例内侧组和97例外侧组病灶大小的差异无统计学意义;107例Ⅴ型病灶的前后径为13.3±3.7 mm、左右径为11.4±3.1 mm,差异有统计学意义(t=5.252,P<0.001)。412例病例均行踝关节镜检查,根据关节镜下分级标准,A级13例,B级35例,C级121例,D级217例,E级34例,F级5例。107例经MRI确诊为HeppleⅤ型距骨骨软骨损伤的病例关节镜下分级:C级26例、D级73例、E级7例、F级1例。结论:距骨骨软骨损伤多发生于中青年人,男性多于女性;原因多为外伤所致,尤其对于外侧损伤,外伤更是最主要的致病因素。X线检查可以作为初步检查工具,进一步确诊需要行MRI检查;MRI显示病损多位于内侧中部及外侧前中部,可能与受伤机制有关,内外侧病损的大小无明显差别;Hepple Ⅴ型距骨骨软骨损伤则表现为前后径大于左右径的椭圆形。关节镜目前作为诊断金标准,镜下表现以C、D级为主。
Objective To analyze the epidemiological characteristics and the imaging manifestation of the osteochondral lesions of the talus(OLT), including the location, size and distribution, and to grade the damage level based on the arthroscopic examination. Methods The clinical data of 412 OLT patients diagnosed based on the arthroscopic examination between January 2010 and January 2015 in our department were analyzed retrospectively. All subjects underwent X-ray and MRI examination of the ankle before surgery. The imaging classification was performed according to the modified Loomer's and Hepple's standard and arthroscopic classification was according to Cheng's grading criteria. The le?sion location of the talus osteochondral injury,its anteroposterior diameter,mediolateral diameter and depth were analyzed using the PACS system. Results The average age of 412 patients in this study was 35.5 years,of which 76.9% ranged from 20 to 40,with more males(n=298,67.5%) and less fe?males(n=113,32.5%). Moreover,366 cases(88.9%) had a history of trauma,with the varus injury be?ing the most common(n=246 cases,59.7%). Totally 188 cases showed positive manifestation and 31 cases were classified as type Ⅴ according to their X-ray. Of all the 412 cases, 411 lesions were found by MRI(14 of 2 lesions,and 15 of lesions found by the arthroscopy examination but not by MRI). According to Hepple's MRI classification,there were 13 patients of type Ⅰ,161 of type Ⅱ,93 of type Ⅲ,37 of type Ⅳ,and 107 of type Ⅴ. In the MRI coronal position: 314 lesions were lo?cated on the medial side,97 lesions were located on the lateral side; in the MRI sagittal position: 59 lesions were located in the anterior,254 in the middle,87 in the posterior,8 in the anterior,mid?dle and posterior,and 3 in the middle and posterior. According to the method of six zones on the MRI,the most lesions were located in the upper and middle sides(229/55.7%),followed by the medi?al posterior side(53.9%),the external anterior and external middle sides(41/10% and 38/9.3%). Ac?cording the PACS system,the lesion's anteroposterior diameter,mediolateral diameter and depth were10.5 ± 3.9 mm,9.5 ± 3.4 mm,and 8.0 ± 3.8 mm respectively. There were no significant differences in the focal size between the 314 medial lesions and the 97 lateral ones. Of the 107 type Ⅴ lesions,significant differences were observed between the anteroposterior diameter(3.3 ± 3.7 mm) and the me?diolateral diameter(11.4 ± 3.1 mm)(t=5.252,P<0.001). The arthroscopic examination was performed in all 412 cases and according to arthroscopy classification criteria,13 cases were of grade A,35 of grade B,121 of grade C,217 of grade D,34 of grade E and 5 of grade F. Of 107 cases diagnosed as Hepple Ⅴ type talar osteochondral injury according to MRI,their arthroscopic grades were as fol?lows: 26 of grade C,73 of grade D,7 of grade E,and 1 of grade F. Conclusions The talus osteo?chondral injury occurs more often in youth and middlemales,and trauma,especially the outside trauma,is the most prominent risk factor. X-ray examina?tion can be used as a preliminary examination tool and MRI examination is needed for further diagno?sis. MRI results show that the lesions are mostly located in the medial middle and lateral medial re?gion,which may be related to the injury mechanism. Hepple Ⅴ type talus osteochondral damage is characterized by an elliptical shape with an anteroposterior diameter greater than the mediolateral diame?ter. The arthroscopy examination is currently used as a gold standard in the diagnosis,and the micro?scopic classification is mainly grade C and D.
Objective To analyze the epidemiological characteristics and the imaging manifestation of the osteochondral lesions of the talus(OLT), including the location, size and distribution, and to grade the damage level based on the arthroscopic examination. Methods The clinical data of 412 OLT patients diagnosed based on the arthroscopic examination between January 2010 and January 2015 in our department were analyzed retrospectively. All subjects underwent X-ray and MRI examination of the ankle before surgery. The imaging classification was performed according to the modified Loomer's and Hepple's standard and arthroscopic classification was according to Cheng's grading criteria. The le?sion location of the talus osteochondral injury,its anteroposterior diameter,mediolateral diameter and depth were analyzed using the PACS system. Results The average age of 412 patients in this study was 35.5 years,of which 76.9% ranged from 20 to 40,with more males(n=298,67.5%) and less fe?males(n=113,32.5%). Moreover,366 cases(88.9%) had a history of trauma,with the varus injury be?ing the most common(n=246 cases,59.7%). Totally 188 cases showed positive manifestation and 31 cases were classified as type Ⅴ according to their X-ray. Of all the 412 cases, 411 lesions were found by MRI(14 of 2 lesions,and 15 of lesions found by the arthroscopy examination but not by MRI). According to Hepple's MRI classification,there were 13 patients of type Ⅰ,161 of type Ⅱ,93 of type Ⅲ,37 of type Ⅳ,and 107 of type Ⅴ. In the MRI coronal position: 314 lesions were lo?cated on the medial side,97 lesions were located on the lateral side; in the MRI sagittal position: 59 lesions were located in the anterior,254 in the middle,87 in the posterior,8 in the anterior,mid?dle and posterior,and 3 in the middle and posterior. According to the method of six zones on the MRI,the most lesions were located in the upper and middle sides(229/55.7%),followed by the medi?al posterior side(53.9%),the external anterior and external middle sides(41/10% and 38/9.3%). Ac?cording the PACS system,the lesion's anteroposterior diameter,mediolateral diameter and depth were10.5 ± 3.9 mm,9.5 ± 3.4 mm,and 8.0 ± 3.8 mm respectively. There were no significant differences in the focal size between the 314 medial lesions and the 97 lateral ones. Of the 107 type Ⅴ lesions,significant differences were observed between the anteroposterior diameter(3.3 ± 3.7 mm) and the me?diolateral diameter(11.4 ± 3.1 mm)(t=5.252,P<0.001). The arthroscopic examination was performed in all 412 cases and according to arthroscopy classification criteria,13 cases were of grade A,35 of grade B,121 of grade C,217 of grade D,34 of grade E and 5 of grade F. Of 107 cases diagnosed as Hepple Ⅴ type talar osteochondral injury according to MRI,their arthroscopic grades were as fol?lows: 26 of grade C,73 of grade D,7 of grade E,and 1 of grade F. Conclusions The talus osteo?chondral injury occurs more often in youth and middlemales,and trauma,especially the outside trauma,is the most prominent risk factor. X-ray examina?tion can be used as a preliminary examination tool and MRI examination is needed for further diagno?sis. MRI results show that the lesions are mostly located in the medial middle and lateral medial re?gion,which may be related to the injury mechanism. Hepple Ⅴ type talus osteochondral damage is characterized by an elliptical shape with an anteroposterior diameter greater than the mediolateral diame?ter. The arthroscopy examination is currently used as a gold standard in the diagnosis,and the micro?scopic classification is mainly grade C and D.
引文
[1]曲绵域,于长隆,敖英芳,等.距骨骨软骨损伤(距骨剥脱性骨软骨炎及切线骨软骨骨折)[M].实用运动医学,北京大学医学出版社,2003:880-882.
[2]Berndt AL,Harty M.Transchondral fractures(osteochondritis dissecans)of the talus[J].J Bone Joint Surg Am,1959,41-A:988-1020.
[3]Stroud CC,Marks RM.Imaging of osteochondral lesions of the talus.Foot Ankle Clin[J],2000,5(1):119-133.
[4]Ferkel RD,Flannigan BD,Elkins BS.Magnetic resonance imaging of the foot and ankle:correlation of normal anatomy with pathologic conditions[J].Foot Ankle,1991,11:289-305.
[5]史尉利,郭秦炜,胡跃林等.Hepple V型距骨骨软骨损伤的影像学特点及关节镜下表现.中国运动医学杂志[J],2015,34:726-729.
[6]Loomer R,Fisher C,Lloyd-Smith R,et al.Osteochondral lesions of the talus[J].Am J Sports Med,1993,1-2(1):13-19.
[7]Hepple S,Winson IG,Glew D.Osteochondral lesions of the talus:a revised classification[J].Foot Ankle Int,1999,20(12):789-793.
[8]赵斌、邢更彦.距骨骨软骨损伤的发病机制与诊断治疗[J].中国医学前沿杂志,2014,6:40-44.
[9]Parisien JS.Arthroscopic treatment of osteochondral lesions of the talus[J].Am J Sports Med,1986,14:211-217.
[10]Canale ST,Belding RH.Osteochondral lesions of the talus[J].J Bone Joint Surg Am,1980,62:97-102.
[11]Flick AB,Gould N.Osteochondritis dissecans of the talus(transchondral fractures of the talus):review of the literature and new surgical approach for medial dome lesions[J].Foot Ankle,1985,5(4):165-185.
[12]Verhagen RA,Struijs PA,Bossuyt PM,et al.Systematic review of treatment strategies for osteochondral defects of the talar dome[J].Foot Ankle Clin,2003,8(2):233-242,viii-ix.
[13]Elias I,Zoga AC,Morrison WB,et al.Osteochondral lesions of the talus:localization and morphologic data from 424 patients using a novel anatomical grid scheme[J].Foot Ankle Int,2007,28(2):154-161.
[14]Pettine KA,Morrey BF.Osteochondral fractures of the talus.a long-term follow-up[J].J Bone Joint Surg Br,1987,69(1):89-92.
[15]Schuman L,Struijs PA,van Dijk CN.Arthroscopic treatment for osteochondral defects of the talus.Results at follow-up at 2 to 11 years[J].J Bone Joint Surg Br,2002,84(3):364-368.
[16]AK SHDTM.Arthroscopic treatment of osteochondritis dissecans of the talus[J].Foot Ankle Surg,2004,10:181-186.
[17]Zengerink M,Struijs PA,Tol JL,et al.Treatment of osteochondral lesions of the talus:a systematic review[J].Knee Surg Sports Traumatol Arthrosc,2010,18:238-246.
[18]Badekas T,Takvorian M,Souras N.Treatment principles for osteochondral lesions in foot and ankle[J].Int Orthop,2013,37(9):1697-1706.
[19]Han SH,Lee JW,Lee DY,et al.Radiographic changes and clinical results of osteochondral defects of the talus with and without subchondral cysts[J].Foot Ankle Int,2006,27(12):1109-1114.
[20]刘金来.崔树森.距骨骨软骨损伤的MR分期诊断[J].中外医学研究,2013,11(24):77-79.
[2]Berndt AL,Harty M.Transchondral fractures(osteochondritis dissecans)of the talus[J].J Bone Joint Surg Am,1959,41-A:988-1020.
[3]Stroud CC,Marks RM.Imaging of osteochondral lesions of the talus.Foot Ankle Clin[J],2000,5(1):119-133.
[4]Ferkel RD,Flannigan BD,Elkins BS.Magnetic resonance imaging of the foot and ankle:correlation of normal anatomy with pathologic conditions[J].Foot Ankle,1991,11:289-305.
[5]史尉利,郭秦炜,胡跃林等.Hepple V型距骨骨软骨损伤的影像学特点及关节镜下表现.中国运动医学杂志[J],2015,34:726-729.
[6]Loomer R,Fisher C,Lloyd-Smith R,et al.Osteochondral lesions of the talus[J].Am J Sports Med,1993,1-2(1):13-19.
[7]Hepple S,Winson IG,Glew D.Osteochondral lesions of the talus:a revised classification[J].Foot Ankle Int,1999,20(12):789-793.
[8]赵斌、邢更彦.距骨骨软骨损伤的发病机制与诊断治疗[J].中国医学前沿杂志,2014,6:40-44.
[9]Parisien JS.Arthroscopic treatment of osteochondral lesions of the talus[J].Am J Sports Med,1986,14:211-217.
[10]Canale ST,Belding RH.Osteochondral lesions of the talus[J].J Bone Joint Surg Am,1980,62:97-102.
[11]Flick AB,Gould N.Osteochondritis dissecans of the talus(transchondral fractures of the talus):review of the literature and new surgical approach for medial dome lesions[J].Foot Ankle,1985,5(4):165-185.
[12]Verhagen RA,Struijs PA,Bossuyt PM,et al.Systematic review of treatment strategies for osteochondral defects of the talar dome[J].Foot Ankle Clin,2003,8(2):233-242,viii-ix.
[13]Elias I,Zoga AC,Morrison WB,et al.Osteochondral lesions of the talus:localization and morphologic data from 424 patients using a novel anatomical grid scheme[J].Foot Ankle Int,2007,28(2):154-161.
[14]Pettine KA,Morrey BF.Osteochondral fractures of the talus.a long-term follow-up[J].J Bone Joint Surg Br,1987,69(1):89-92.
[15]Schuman L,Struijs PA,van Dijk CN.Arthroscopic treatment for osteochondral defects of the talus.Results at follow-up at 2 to 11 years[J].J Bone Joint Surg Br,2002,84(3):364-368.
[16]AK SHDTM.Arthroscopic treatment of osteochondritis dissecans of the talus[J].Foot Ankle Surg,2004,10:181-186.
[17]Zengerink M,Struijs PA,Tol JL,et al.Treatment of osteochondral lesions of the talus:a systematic review[J].Knee Surg Sports Traumatol Arthrosc,2010,18:238-246.
[18]Badekas T,Takvorian M,Souras N.Treatment principles for osteochondral lesions in foot and ankle[J].Int Orthop,2013,37(9):1697-1706.
[19]Han SH,Lee JW,Lee DY,et al.Radiographic changes and clinical results of osteochondral defects of the talus with and without subchondral cysts[J].Foot Ankle Int,2006,27(12):1109-1114.
[20]刘金来.崔树森.距骨骨软骨损伤的MR分期诊断[J].中外医学研究,2013,11(24):77-79.