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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 骨軟骨損傷：剝脫性骨軟骨炎OCD：病因、病理學(xué)和影像學(xué)，特別關(guān)注膝關(guān)節(jié)：2018年作者：JuergenBruns,MathiasWerner,ChristianHabermann.作者單位:OrthopedicSurgery,Krankenhaus"Gro?-Sand",Hamburg,Germany.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要本文回顧了當(dāng)前對(duì)病因、發(fā)病機(jī)制以及如何診斷和治療膝關(guān)節(jié)剝脫性骨軟骨炎(OCD)的理解，然后分析了可用的治療方法和結(jié)果。剝脫性骨軟骨炎(OCD)見(jiàn)于生長(zhǎng)板開(kāi)放的兒童和青少年（青少年剝脫性骨軟骨炎OCD）和生長(zhǎng)板閉合的成人（成人剝脫性骨軟骨炎OCD）。剝脫性骨軟骨炎OCD病變的病因尚不清楚，其特征是軟骨下骨區(qū)域出現(xiàn)無(wú)菌性壞死。機(jī)械因素似乎起著重要作用。臨床癥狀不具特異性。因此，影像學(xué)技術(shù)是最重要的。關(guān)于治療，存在大量文獻(xiàn)。除非有不穩(wěn)定的碎片，否則預(yù)計(jì)會(huì)自然愈合，治療包括休息和不同程度的固定，直到愈合。骺板開(kāi)放和低度病變的患者保守治療效果良好。當(dāng)需要手術(shù)時(shí)，手術(shù)取決于臨床分期和軟骨的狀態(tài)。對(duì)于完整的軟骨，重新植入手術(shù)是有利的。當(dāng)軟骨受損時(shí)，可以使用幾種技術(shù)。雖然鉆孔和微骨折等技術(shù)產(chǎn)生修復(fù)性軟骨，但其他技術(shù)通過(guò)額外的骨軟骨移植物或基于細(xì)胞的手術(shù)（如軟骨細(xì)胞移植）以重建骨軟骨缺損。臨床結(jié)果的趨勢(shì)是：采用骨骼和軟骨的重建手術(shù)會(huì)有更好結(jié)果，并且在治療合并癥時(shí)也會(huì)有更好的長(zhǎng)期療效。嚴(yán)重程度的骨關(guān)節(jié)病很少見(jiàn)。關(guān)鍵詞：病因；總體原則；影像學(xué)；膝關(guān)節(jié)；剝脫性骨軟骨炎；病理。?表1.?剝脫性骨軟骨炎（OCD）流行病學(xué)峰值（最高發(fā)生）發(fā)病率：15歲瑞典的患病率：6/10000年齡在2至5歲之間的發(fā)病率：0年齡在6至19歲之間的發(fā)病率：9.5/100000男性：15.4/100000女性：3.3/1000006至11歲之間的發(fā)病率：6.8/100000男性：11.1/100000女性：2.3/100000年齡在12至19歲之間的發(fā)病率：11.2/100000男性：18.1/100000女性：3.9/1000004膝關(guān)節(jié)發(fā)生剝脫性骨軟骨炎（OCD）的風(fēng)險(xiǎn)6-11歲與12-19歲比率：1:3.3膝關(guān)節(jié)發(fā)生剝脫性骨軟骨炎（OCD）的風(fēng)險(xiǎn)男性：3.8女性：1?表2.?剝脫性骨軟骨炎（OCD）的致病因素病因因素???膝關(guān)節(jié)主要位置???股骨內(nèi)外側(cè)髁創(chuàng)傷???++輕微創(chuàng)傷???+++遺傳學(xué)因素???+感染???+???????????排除血管病變???+行走步態(tài)???股骨內(nèi)側(cè)髁：內(nèi)翻畸形???????????????????股骨外側(cè)髁：外翻畸形???????????????????外側(cè)盤(pán)狀半月板代謝因素???+++證據(jù)等級(jí)：++++=非常高；+++=高；++=臨床觀察；+=假設(shè)。??Figure1.(a)Histologyofanadvancedosteochondritisdissecans(OCD)lesion(kneejoint,toluidineblue)showingapartiallyloosened“jointmouse”withabroadcleft(arrow)betweenthepartialloosebody(top)andthenormalsubchondralbone(bottom).Inthelesion,subchondralbonecystsarevisible(C)andnecroticareas(N).(b)Magnificationoffig,1a:Thelesionexhibitsanareaofosteonecrosis(whitearrow),subchondralbonecysts(blackarrow),andinthe“mousebed,”thesublesionalboneathickenedosteoidlayerasasignofenlargedendostalactivity(arrowheads).圖1.（a）晚期剝脫性骨軟骨炎（OCD）的組織學(xué)病變（膝關(guān)節(jié)，甲苯胺藍(lán)染色），顯示部分松散的“關(guān)節(jié)鼠（游離體）”，在部分游離體（頂部）和正常的軟骨下骨（底部）之間具有寬闊的裂縫（箭頭）。在病變中，可見(jiàn)軟骨下骨囊性變（C）和壞死區(qū)域（N）。（b）圖1a的放大：病變表現(xiàn)出骨壞死（白箭頭），軟骨下骨囊性變（黑色箭頭）和“游離體骨床”，病變骨質(zhì)是一層增厚的骨質(zhì)硬化層，是增強(qiáng)的（骨）內(nèi)膜活動(dòng)（短箭頭）。?Table3presentstheOCDclassificationschemes.表3展示了剝脫性骨軟骨炎OCD的分類方案。表3.分類方案總體原則（適合多個(gè)不同的關(guān)節(jié)）??????????????????????????????????膝關(guān)節(jié)（特定的）ICRS分類法（關(guān)節(jié)鏡）????????????????????????????????????????????????????Arcq：3個(gè)放射學(xué)階段第一階段(I期)：病變穩(wěn)定，關(guān)節(jié)完整，軟骨軟化?????????Rodegerdts和Gleissner：5個(gè)放射學(xué)階段第二階段(II期)：局部不連續(xù)性的病變，但病變穩(wěn)定第三階段(III期)：具有完全連續(xù)性的病變，尚未游離第四階段(IV期)：骨床內(nèi)軟骨下骨裸露或骨軟骨碎片脫落或形成游離體Bruns分類法????????????????????????????X射線????????????????????????MRI第一階段(I期)：沒(méi)有變化???????????????????骨挫傷，骨髓水腫第二階段(II期)：局部硬化???????????????????骨溶解與骨硬化并存第三階段(III期)：部分剝離???????????????????部分剝離，軟骨下積液第四階段(IV期)：完全剝離???????????????????完全剝離、缺損，游離體、關(guān)節(jié)鼠???????????????????????????????游離體骨掃描???????????????????????????????????????????????????????????骨掃描CT??????????????????????????????????????????????????????????????????CTMRI????????????????????????????????????????????????????????????????MRI骨骺愈合或未愈合???????????????????????????????????????骨骺愈合或未愈合關(guān)節(jié)鏡檢查???????????????????????????????????????????????????關(guān)節(jié)鏡檢查穩(wěn)定性???????????????????????????????????????????????????????????穩(wěn)定或不穩(wěn)定CT=計(jì)算機(jī)斷層掃描；ICRS=國(guó)際軟骨維修協(xié)會(huì)；MRI=磁共振成像第三和四階段可以細(xì)分為嚴(yán)重階段（M）和骨軟骨分離形式（D）。?表4.（剝脫性骨軟骨炎發(fā)生）部位方案Aichroth-Lindholm劃分法：前后視圖：內(nèi)側(cè)髁：定位“中央”，“中外側(cè)”和“次外側(cè)”前后視圖：外側(cè)髁：“次中央”，“前方”和“次外側(cè)”Hughston劃分法：前后視圖：從內(nèi)側(cè)到外側(cè)分為5個(gè)區(qū)域：半月板，非半月板區(qū)（內(nèi)側(cè)髁），髁間，非半月板區(qū)，半月板（外側(cè)髁）外側(cè)視圖：在切線位將股骨后髁成2個(gè)部分：直接遠(yuǎn)端或后部或者外側(cè)視圖：A=Blumensaat線的前部，B=Blumensaat線的后部C=最后1/3部?Figure2.X-rayoftheknee.Anterior-posteriorviewshowinganosteochondritisdissecanslesionatthetypicallocation(medialcondyle),blackarrowsindicatestageIVwithanemptylacuna.Theloosebodyisnotvisible.圖2.膝關(guān)節(jié)的X線片。前后視圖顯示典型位置（內(nèi)側(cè)髁）的剝脫性骨軟骨炎病變，黑色箭頭指示IV期帶缺損區(qū)域，未見(jiàn)游離體。?Figure3.(a)Magneticresonanceimaging(MRI)(protondensityfatsaturation)ofthesamekneejointexhibitingtheemptylacunaatthemedialcondyle(dottedwhitearrows)andtheloosebodylocatedatthelateralrecessus(whitearrows),coronalplane.(b)MRI(protondensityfatsaturation)ofthesamekneejointexhibitingtheemptylacunaatthemedialcondyle(dottedwhitearrows)andtheloosebodylocatedatthelateralrecessus(whitearrows),sagittalplane.圖3.（a）同一膝關(guān)節(jié)的磁共振成像（MRI），該膝關(guān)節(jié)在內(nèi)側(cè)髁（白色箭頭指示）和位于外側(cè)凹處（白色箭頭）的游離體（白色箭頭）上表現(xiàn)出空的空隙（白色箭頭），冠狀位。（b）同一膝關(guān)節(jié)的MRI在內(nèi)側(cè)髁出現(xiàn)的空隙（白色箭頭指示）和位于外側(cè)凹處（白色箭頭）的游離體，矢狀位。?表5.（剝脫性骨軟骨炎OCD）治療選項(xiàng)（參考文獻(xiàn)請(qǐng)見(jiàn)文中）??????????????????????????????????????????????????????總體原則（適合多個(gè)不同的關(guān)節(jié)）???????????????膝關(guān)節(jié)（特定的）I期：青少年剝脫性骨軟骨炎OCD???????保守???????????????????????????????????????????????????????????????保守成人剝脫性骨軟骨炎OCD???????????保守???????????????????????????????????????????????????????????????保守II期：青少年剝脫性骨軟骨炎OCD???????保守、鉆孔減壓????????????????????????????????????????????保守、鉆孔減壓成人剝脫性骨軟骨炎OCD???????????保守、鉆孔減壓????????????????????????????????????????????保守、鉆孔減壓III期：青少年剝脫性骨軟骨炎OCD+成人剝脫性骨軟骨炎OCD???????????????????????????????????????????????????(病灶清除術(shù))，REFIX，MFX，???????(病灶清除術(shù))，REFIX，MFX，???????????????????????????????????????????????ACI,AMIC,MOPLA,OAT,BMS??????ACI,AMIC,MOPLA,OAT,BMS???????????????????????????????????????????????????骨組織+細(xì)胞???????????????????????????????????????????骨組織+細(xì)胞IV期：青少年剝脫性骨軟骨炎OCD+成人剝脫性骨軟骨炎OCD???????????????????????????????????????????????????(病灶清除術(shù)，REFIX，MFX)，???????(病灶清除術(shù)，REFIX，MFX)，???????????????????????????????????????????????ACI,AMIC,MOPLA,OAT,BMS??????ACI,AMIC,MOPLA,OAT,BMS???????????????????????????????????????????????????骨組織+細(xì)胞???????????????????????????????????????????骨組織+細(xì)胞????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????同種異體移植ACI=自體軟骨細(xì)胞植入；AMIC=自體基質(zhì)誘導(dǎo)的軟骨再生；AOCD=成年剝脫性骨軟骨炎；BMS=骨髓刺激；JOCD=青少年剝脫性骨軟骨炎；MFX=微骨折術(shù)；MOPLA=馬賽克鑲嵌成形術(shù)；OAT=骨軟骨自體移植術(shù)；REFIX=重錨定術(shù)。?Figure4.Exampleofarefixatedloosebodyinthemedialcondyleoftheknee.Priortotherefixation,thesubchondralsclerosishadbeenremoved,cancellousbonetakenfromtheiliaccresttransplantedintothedefect,followedbytherefixationusingfibringlue(Tissucol,Baxter,Unterschlei?heim,Germany)andresorbablepins(Ethipin,Ethicon,Hamburg,Germany).圖4.膝關(guān)節(jié)內(nèi)側(cè)髁重新固定的病例。在重新固定之前，已去除軟骨下硬化組織，將取自髂嵴的松質(zhì)骨移植到骨缺損處，然后使用纖維蛋白膠（Tissucol，Baxter，Unterschlei?heim，Germany）和可吸收針固定（Ethipin，Ethicon，Hamburg，德國(guó)）。?Figure5.Adultosteochondritisdissecans(AOCD)stageIVlesionatthemedialcondyleofthekneewithalreadyvisiblesecondaryarthriticchangestreatedwith5osteochondralplugsimplantedasamosaicplastywithsmallcleftsbetweentheplugs.圖5.膝關(guān)節(jié)內(nèi)側(cè)髁的成人剝脫性骨軟骨炎(AOCD)IV期病變，已經(jīng)可見(jiàn)的繼發(fā)性骨關(guān)節(jié)炎變化，用5個(gè)骨軟骨移植柱行鑲嵌成形術(shù)植入治療，在移植柱之間有小裂縫。?Figure6.Adultosteochondritisdissecans(AOCD)stage-IVlesionatthelateralfemoralcondyletreatedwithremovalofthesubchondralsclerosis,transplantationofcancellousbonetakenfromtheiliaccrestandimplantationofanautologouschondrocyteimplantation(ACI)ofthesecondgenerationusingagelascarrierforthechondrocytes(CaReS,ArthroKinetics,Bebenhausen,Germany).圖6.通過(guò)去除軟骨下硬化組織、移植取自髂嵴的松質(zhì)骨和植入載有第2代自體軟骨細(xì)胞的凝膠植入物(ACI)治療股骨外側(cè)髁的成人剝脫性骨軟骨炎(AOCD)IV期病變（CaReS，ArthroKinetics，Bebenhausen，Germany）。?正文介紹剝脫性骨軟骨炎(OCD)是骨骼未成熟和成年患者膝關(guān)節(jié)疾病的常見(jiàn)原因，當(dāng)一小塊軟骨下骨由于局部血液供應(yīng)障礙而開(kāi)始與其周圍區(qū)域分離時(shí)，就會(huì)發(fā)生這種情況。最后，這一小塊骨頭和覆蓋它的軟骨可能會(huì)開(kāi)始破裂并（從關(guān)節(jié)表面上）脫落。正如之前假設(shè)的那樣，AmbroiseParé（而不是Paget）是第一個(gè)（在1870年）描述在關(guān)節(jié)中發(fā)現(xiàn)的這種關(guān)節(jié)游離體的人。關(guān)節(jié)游離體形成的3種可能原因：①急性骨軟骨骨折的直接創(chuàng)傷；②發(fā)展成骨壞死和連續(xù)碎裂的最小創(chuàng)傷；③沒(méi)有自發(fā)創(chuàng)傷的證據(jù)，K?nig稱之為“剝脫性骨軟骨炎”（OCD）。剝脫性骨軟骨炎OCD的確切患病率尚不清楚，但據(jù)報(bào)道，每100000人中有15至29人。Kessler等已經(jīng)表明，6至19歲患者膝關(guān)節(jié)剝脫性骨軟骨炎OCD的發(fā)病率為每100000人中有9.5人，而男性和女性患者分別為每100000人15.4和3.3（表1）。12至19歲的患者占剝脫性骨軟骨炎OCD的大多數(shù)，其發(fā)病率為每100000人11.2人，而6至11歲的患者為每100000人6.8人?？傊?，與女性患者相比，男性患者的剝脫性骨軟骨炎OCD發(fā)生率更高，發(fā)生剝脫性骨軟骨炎OCD的風(fēng)險(xiǎn)幾乎是女性患者的4倍。本文中的剝脫性骨軟骨炎OCD是指受累關(guān)節(jié)的慢性疾病，不是由急性創(chuàng)傷引起的。急性創(chuàng)傷是由新鮮的骨軟骨或軟骨損傷(OCL)組成，有或沒(méi)有脫落的骨軟骨碎片。剝脫性骨軟骨炎OCD通常被認(rèn)為是青少年剝脫性骨軟骨炎（=JOCD）（發(fā)生于未閉合的骨骺板）或成人剝脫性骨軟骨炎（=AOCD）（在骨骺閉合后）。這些定義表明，骨骺仍然未閉合的患者比骨骺已經(jīng)閉合的剝脫性骨軟骨炎OCD病變的成人患者，更有可能成功進(jìn)行非手術(shù)治療。本文是對(duì)剝脫性骨軟骨炎OCD已知情況的回顧，特別關(guān)注受影響的最大關(guān)節(jié)：膝關(guān)節(jié)。在以后的文章中，將討論肘關(guān)節(jié)和踝關(guān)節(jié)。可以將剝脫性骨軟骨炎OCD的病因分為4種不同的可能原因：外傷性、缺血性、遺傳性和特發(fā)性（表2）。然而，多因素病因是最可能的原因。①外傷：可能是由間接外傷引起，是剝脫性骨軟骨炎OCD損傷最常見(jiàn)病因，即股骨內(nèi)側(cè)髁后內(nèi)側(cè)位置。在脛骨內(nèi)旋期間，對(duì)未成熟膝關(guān)節(jié)和股骨內(nèi)側(cè)髁外側(cè)相對(duì)應(yīng)的脛骨的重復(fù)壓力可能導(dǎo)致剝脫性骨軟骨炎OCD。這種軟骨下壓力刺激反應(yīng)可能會(huì)干擾骨小梁愈合并阻礙骨愈合的能力。由于缺乏軟骨的底層（軟骨下骨）支撐，后期可導(dǎo)致關(guān)節(jié)軟骨與軟骨下骨連接的分離，相關(guān)骨軟骨區(qū)域部分脫落。②缺血：血管分布不良和誘發(fā)的缺血被描述為剝脫性骨軟骨炎OCD的潛在原因。一些研究表明，在剝脫性骨軟骨炎OCD定位部位觀察到的血管模式存在差異。這種關(guān)節(jié)形態(tài)與該部位的局灶性反復(fù)創(chuàng)傷以及獨(dú)特的血管結(jié)構(gòu)相結(jié)合，可能引發(fā)缺血和隨后的剝脫性骨軟骨炎OCD。③遺傳學(xué)：幾位作者已經(jīng)研究了剝脫性骨軟骨炎OCD的潛在遺傳聯(lián)系，但仍然相對(duì)未研究剝脫性骨軟骨炎OCD發(fā)展中的遺傳和發(fā)育因素。Skagen等提出，OCD病變是由軟骨細(xì)胞基質(zhì)合成的改變引起的，導(dǎo)致內(nèi)質(zhì)網(wǎng)貯積病表型，這會(huì)擾亂或突然的軟骨內(nèi)骨化。此外，具有相似疾病過(guò)程的同卵雙胞胎病例高度暗示遺傳病因。剝脫性骨軟骨炎OCD常見(jiàn)的發(fā)病過(guò)程盡管病因尚不完全清楚，但對(duì)剝脫性骨軟骨炎OCD的發(fā)病機(jī)制已比較了解。獨(dú)立于病因，至少可以描述4個(gè)階段。階段1（I期）剝脫性骨軟骨炎OCD病變始于軟骨下骨，伴有軟骨下骨質(zhì)骨髓減少，這只能通過(guò)磁共振成像(MRI)或核素骨掃描檢測(cè)到。第二階段（II期）病變與軟骨下骨的骨髓水腫有關(guān)。骨挫傷可能是初始階段，軟骨下骨小梁微骨折可能是與骨髓水腫的形態(tài)學(xué)相關(guān)。第三階段（III期）持續(xù)的自然病程以放射學(xué)可檢測(cè)到的硬化環(huán)為特征，將病變與周圍健康骨質(zhì)區(qū)分開(kāi)來(lái)。病變中心被認(rèn)為是骨壞死（參見(jiàn)“剝脫性骨軟骨炎OCD組織學(xué)”部分）。在這個(gè)階段，在MRI和計(jì)算機(jī)斷層掃描(CT)等成像技術(shù)中，軟骨似乎仍然完好無(wú)損。第4階段（IV期）“軟骨的軟化現(xiàn)象和機(jī)械特性的改變”促進(jìn)了壞死邊緣的骨質(zhì)對(duì)周圍健康骨骼的反應(yīng)。仍然存在的機(jī)械負(fù)荷可能是軟骨現(xiàn)在參與并顯示出分離跡象的原因。最后，持續(xù)的自然過(guò)程導(dǎo)致骨軟骨碎片脫落，導(dǎo)致單個(gè)關(guān)節(jié)游離體或出現(xiàn)多個(gè)碎片（即所謂的“惡意變體”，首先由Wagner描述）。關(guān)于生物力學(xué)病因的建議，有幾個(gè)以生物力學(xué)為導(dǎo)向的分析。1950年，Rehbein能夠通過(guò)人工產(chǎn)生的重復(fù)應(yīng)力，在狗的膝關(guān)節(jié)中實(shí)驗(yàn)性地產(chǎn)生游離體。這些標(biāo)本在組織學(xué)上類似于下面描述的那些發(fā)現(xiàn)，這些發(fā)現(xiàn)是從人類膝關(guān)節(jié)的游離體中獲得的。一項(xiàng)使用環(huán)氧樹(shù)脂制成的平面和立體膝關(guān)節(jié)模型的實(shí)驗(yàn)試驗(yàn)，以及股骨遠(yuǎn)端的有限元分析，揭示了剝脫性骨軟骨炎OCD病變發(fā)生區(qū)域的峰值應(yīng)力。在膝關(guān)節(jié)中使用光敏箔來(lái)模擬臨床上明顯的致病因素，例如內(nèi)翻或外翻畸形（膝關(guān)節(jié)）與穩(wěn)定和不穩(wěn)定的韌帶，在剝脫性骨軟骨炎OCD病變臨床常見(jiàn)的那些區(qū)域表現(xiàn)出顯著的應(yīng)力集中。從臨床上看，膝關(guān)節(jié)骨挫傷被認(rèn)為是軟骨下骨小梁的主要損傷，這可能引發(fā)剝脫性骨軟骨炎OCD。剝脫性骨軟骨炎OCD組織學(xué)晚期病變的組織學(xué)如圖1所示。據(jù)我們所知，Green和Banks是第一個(gè)將軟骨下骨壞死描述為仍然具有完整的軟骨覆蓋的初始病變的人。由于失去了對(duì)軟骨的骨骼機(jī)械支撐，正在進(jìn)行的病理過(guò)程會(huì)導(dǎo)致軟骨層繼發(fā)性損傷。作者建議，只要覆蓋的軟骨仍然完好無(wú)損，就可以通過(guò)爬行替代進(jìn)行愈合。游離體組織學(xué)檢查顯示肥大常見(jiàn)，53%有層狀鈣化。Chiroff和Cooke在分離水平和游離體的骨組織部分檢測(cè)到纖維軟骨組織，發(fā)現(xiàn)在幾乎正常的軟骨下成骨細(xì)胞和溶骨活性增加。此外，Milgram在一半的游離體中沒(méi)有發(fā)現(xiàn)骨組織。Koch等分析了來(lái)自16至44歲患有晚期剝脫性骨軟骨炎OCD的患者的30份標(biāo)本，并觀察到軟骨中PH1的甲苯胺染色減少。在軟骨下骨板和松質(zhì)骨中可以看到軟骨細(xì)胞數(shù)量減少以及骨折改變。此外，他們發(fā)現(xiàn)骨吸收增強(qiáng)和被脂肪骨髓包圍的軟骨下骨壞死區(qū)域。Uozumi等描述了3種類型的剝脫性骨軟骨炎OCD組織病理學(xué)特征：①伴有軟骨下骨小梁壞死的剝脫性骨軟骨炎OCD②具有可存活的軟骨下骨小梁的剝脫性骨軟骨炎OCD③沒(méi)有骨小梁的剝脫性骨軟骨炎OCD軟骨。他們總結(jié)認(rèn)為：“軟骨下區(qū)最初的變化是骨壞死或軟骨下骨折；然后骨壞死的骨組織被吸收并被有功能的軟骨下骨小梁或沒(méi)有骨小梁的軟骨取代。”相比之下，從股骨內(nèi)側(cè)髁穩(wěn)定的青少年剝脫性骨軟骨炎JOCD病變中心的8針活檢中，沒(méi)有發(fā)現(xiàn)任何退行性變化，未檢測(cè)到骨壞死。只發(fā)現(xiàn)了厚的軟骨層和纖維組織，或下面有混合有軟骨的薄軟骨層，分離區(qū)域的軟骨下骨小梁和纖維組織和纖維軟骨也是如此。最近，對(duì)游離體的分析表明，游離體中的軟骨細(xì)胞表現(xiàn)出正常的行為，這些細(xì)胞被認(rèn)為可用于自體軟骨細(xì)胞移植(ACI)。對(duì)已發(fā)表的組織學(xué)分析數(shù)據(jù)進(jìn)行的薈萃分析得出了不一致的結(jié)果：在包括軟骨下骨在內(nèi)的10項(xiàng)研究中，有7項(xiàng)報(bào)告了骨壞死的跡象；在11篇文獻(xiàn)中有2篇提到了退變或不規(guī)則的軟骨。關(guān)于可能的潛在病因，11篇文章中有5篇認(rèn)為一次主要或多次重復(fù)性微創(chuàng)傷是主要病因。總之，組織學(xué)結(jié)果表明軟骨基質(zhì)的局灶性改變起源于關(guān)節(jié)軟骨的深層，可能是礦化層或軟骨下骨。剝脫性骨軟骨炎OCD的診斷剝脫性骨軟骨炎OCD相關(guān)癥狀癥狀通常模糊不清，定位不是很準(zhǔn)確。可能會(huì)出現(xiàn)不同程度的疼痛和僵硬；可能會(huì)出現(xiàn)關(guān)節(jié)腫脹和積液以及關(guān)節(jié)“打軟腿”、“卡住”或“別住”。在任何關(guān)節(jié)中都沒(méi)有典型的剝脫性骨軟骨炎OCD臨床癥狀。Wilson試驗(yàn)被推薦為膝關(guān)節(jié)的臨床診斷試驗(yàn)，但并不可靠。剝脫性骨軟骨炎OCD定位方案如表4所示。評(píng)估剝脫性骨軟骨炎OCD影像學(xué)技術(shù)普通X線在開(kāi)始使用MRI之前，最初的變化只能通過(guò)骨掃描檢測(cè)到，或者在常規(guī)X線片上懷疑（出現(xiàn)剝脫性骨軟骨炎OCD病變）。隨著MRI的引入，可以更輕松地區(qū)分階段。然而，仍然難以可靠地估計(jì)軟骨層的機(jī)械性能。懷疑剝脫性骨軟骨炎OCD病變時(shí)的最初診斷計(jì)劃是從2個(gè)X線片檢查開(kāi)始。標(biāo)準(zhǔn)系列包括站立前后位(AP)視圖（圖2）、膝關(guān)節(jié)屈曲35°的側(cè)視圖和45°髕骨軸位（sunrise切線位）視圖。其他特殊X線視圖可能很有用，例如tunnel視圖，使病變區(qū)域與成像平面更加一致。磁共振成像MRI是成像檢查中第二步的首選方法（圖3a和b）。由于MRI系統(tǒng)的可用性在過(guò)去10年中有所增加，無(wú)輻射、更高場(chǎng)強(qiáng)（1.5和3T）的突然發(fā)展、專用線圈設(shè)置和高分辨率序列為MRI的發(fā)展節(jié)省了道路在肌肉骨骼成像中。常規(guī)MR方法在所有3個(gè)空間方向上使用T1和T2加權(quán)圖像。最大切片厚度應(yīng)為3mm，檢測(cè)距骨骨軟骨缺損的靈敏度為96%（特異性0.96）。Diapola等開(kāi)發(fā)了一個(gè)有用的MRI系統(tǒng)，用于評(píng)估剝脫性骨軟骨炎OCD，有4個(gè)等級(jí)：階段1（I期）：關(guān)節(jié)軟骨增厚和低信號(hào)變化。第2階段（II期）：關(guān)節(jié)軟骨破裂，碎片后面的低信號(hào)邊緣表明有纖維附著。第3階段（III期）：關(guān)節(jié)軟骨破裂，碎片后面的高信號(hào)變化，表明碎片和下面的骨組織之間有滑液填充第四階段（IV期）：游離體。在評(píng)估MR圖像上的剝脫性骨軟骨炎OCD時(shí)，也可以使用關(guān)節(jié)鏡國(guó)際軟骨修復(fù)協(xié)會(huì)(ICRS)的剝脫性骨軟骨炎OCD分類標(biāo)準(zhǔn)和Guhl的分類標(biāo)準(zhǔn)（參見(jiàn)關(guān)節(jié)鏡分類）。為了改進(jìn)評(píng)估（結(jié)果），還可以通過(guò)在檢查前，將gadolinium釓MR對(duì)比材料注入檢查關(guān)節(jié)來(lái)進(jìn)行MRI掃描。這樣的dGemericMRI提供了有關(guān)矩陣質(zhì)量的信息。使用T2加權(quán)序列，高信號(hào)線或骨軟骨病變下方的囊腫的存在表明存在液體并表明存在不穩(wěn)定的骨軟骨缺損，即使該信號(hào)可以反映代表愈合反應(yīng)的血管肉芽組織。質(zhì)子密度圖像和具有脂肪飽和度的三維T1加權(quán)序列使用低于1毫米的各向像素（isotropicvoxels），具有專用視野（14-20厘米）和靜脈造影劑，可提供出色的圖像印象，還可以區(qū)分細(xì)微的變化。使用在這些序列中，MRI在檢測(cè)甚至不穩(wěn)定的骨軟骨病變方面提供了出色的診斷能力。因此，評(píng)估骨軟骨病變不需要常規(guī)的關(guān)節(jié)內(nèi)給藥。使用新實(shí)施的高分辨率MRI序列來(lái)區(qū)分不同類型的骨軟骨缺損可提供超過(guò)90%的總體準(zhǔn)確度。在日常臨床常規(guī)中，可以使用1.5-和3-T系統(tǒng)。比較兩個(gè)系統(tǒng)上的專用線圈設(shè)置，使用更高場(chǎng)強(qiáng)（3-T系統(tǒng)）的圖像印象可能更好。然而，尚未證明3-T系統(tǒng)對(duì)軟骨病變能提供更好的診斷結(jié)果。應(yīng)用計(jì)算機(jī)斷層掃描CT的兩個(gè)重要缺點(diǎn)是輻射，特別是在檢查患者的年齡方面，以及缺乏軟骨的可視化掃描結(jié)果。可以通過(guò)使用關(guān)節(jié)內(nèi)對(duì)比材料來(lái)克服軟骨可視化的缺乏，該材料可以通過(guò)直接穿刺關(guān)節(jié)應(yīng)用并提供軟骨的間接可視化。CT掃描可用于評(píng)估剝脫性骨軟骨炎OCD剝脫碎片再固定后的骨整合情況。閃爍骨掃描顯像檢查Paletta及其同事發(fā)現(xiàn)，定量骨掃描對(duì)骨骺未閉合的剝脫性骨軟骨炎OCD患者的預(yù)后具有100%的預(yù)測(cè)價(jià)值，但對(duì)于骨骺閉合的患者，預(yù)測(cè)價(jià)值較低。Cahill和Berg開(kāi)發(fā)了一種用于評(píng)估青少年剝脫性骨軟骨炎OCD患者的閃爍顯像結(jié)果的分類標(biāo)準(zhǔn)：①0期.正常的射線照相和閃爍照相外觀。②1期.病灶在平片上可見(jiàn)，但骨掃描顯示正常。③2期.掃描顯示病變區(qū)域的攝取增加。④3期.此外，整個(gè)股骨髁的同位素?cái)z取增加。⑤4期.此外，病變對(duì)面的脛骨平臺(tái)有攝取。膝關(guān)節(jié)剝脫性骨軟骨炎OCD的治療膝關(guān)節(jié)的剝脫性骨軟骨炎OCD病變主要位于股骨內(nèi)側(cè)髁，通常與內(nèi)翻畸形有關(guān)。少數(shù)剝脫性骨軟骨炎OCD病變位于外側(cè)髁，與外翻畸形有關(guān)。剝脫性骨軟骨炎OCD病變位置股骨外側(cè)髁的病變也可能與盤(pán)狀半月板相關(guān)。外側(cè)髁的病變可以主要與盤(pán)狀半月板或繼發(fā)于盤(pán)狀外側(cè)半月板完全切除后發(fā)生。假設(shè)膝關(guān)節(jié)的生物力學(xué)改變與盤(pán)狀半月板或完全外側(cè)半月板切除術(shù)后，是導(dǎo)致剝脫性骨軟骨炎OCD病變發(fā)展的原因。盤(pán)狀半月板患者的外側(cè)髁突出率明顯大于對(duì)照組。只有少數(shù)病變位于髕股關(guān)節(jié)。剝脫性骨軟骨炎OCD病變穩(wěn)定性對(duì)于青少年剝脫性骨軟骨炎JOCD和成人剝脫性骨軟骨炎AOCD，采用保守治療或手術(shù)方法的適應(yīng)癥取決于骨軟骨碎片的穩(wěn)定性（表5）。然而，什么是穩(wěn)定病變？Wall等指出“穩(wěn)定的剝脫性骨軟骨炎OCD被定義為關(guān)節(jié)或軟骨下骨損傷界面沒(méi)有破裂?！盩rinh等意識(shí)到他們的審查包含對(duì)穩(wěn)定或不穩(wěn)定病變的不同定義，并將其改編為DeSmet等使用的定義：如果存在病變不穩(wěn)定性，在MRI的T2加權(quán)圖像上可以看到碎片深處的一條高信號(hào)線。由高信號(hào)指示的關(guān)節(jié)骨折穿過(guò)軟骨下骨板。存在局灶性骨軟骨缺損。一個(gè)直徑5毫米、充滿液體的囊腫位于病灶深處。保守治療已經(jīng)發(fā)表了一些文章，區(qū)分了提倡保守治療，但治療方案不同的青少年剝脫性骨軟骨炎JOCD和成人剝脫性骨軟骨炎AOCD。青少年剝脫性骨軟骨炎JOCD大多數(shù)患有青少年剝脫性骨軟骨炎JOCD的兒童可以通過(guò)保守治療成功。建議限制負(fù)重和體育活動(dòng)，或簡(jiǎn)單地限制日?；顒?dòng)和固定。一個(gè)常見(jiàn)的治療建議是，患者有6到12周的支具，部分負(fù)重，并定期進(jìn)行物理治療訓(xùn)練。如果患者在12周時(shí)無(wú)疼痛并且影像學(xué)顯示愈合，則患者可以開(kāi)始跑步活動(dòng)，但應(yīng)限制更激進(jìn)的活動(dòng)，直到患者在運(yùn)動(dòng)和休閑活動(dòng)（例如跳躍）中進(jìn)行了幾個(gè)月的無(wú)癥狀活動(dòng)，扭曲和沖擊載荷。在最近發(fā)表的一項(xiàng)針對(duì)42名青少年剝脫性骨軟骨炎JOCD患者的回顧性研究中，三分之二(66%)的穩(wěn)定病變?cè)谑喙潭ǔ跏贾委熀笥?，隨后進(jìn)行支撐和活動(dòng)限制長(zhǎng)達(dá)6個(gè)月。然而，作者在34%的患者中經(jīng)歷了治療失敗。大的病灶比較小的病灶（相對(duì)和絕對(duì)）明顯治療結(jié)果更糟，但所有的外側(cè)病灶都愈合了。諸如病變大小、股骨髁或非股骨髁定位、患者的年齡和性別等前瞻性因素仍存在爭(zhēng)議。令人感興趣的是一項(xiàng)歐洲多中心研究，迄今為止患者人數(shù)最多（452名患者，509個(gè)膝關(guān)節(jié)）。在最少隨訪1年的452名患者中，他們將A組276名骺板未閉合患者（例如，14歲以下的男性和13歲以下的女性）與B組所謂的“早熟”患者區(qū)分開(kāi)來(lái)，例如男性14歲以上，女性13歲以上。共有154名患者接受了保守治療，355名患者需要手術(shù)。A組患者的結(jié)果明顯好于B組。情況良好的患者（無(wú)肉眼解剖，大小<20cm2）明顯優(yōu)于已經(jīng)可檢測(cè)到的患者（所謂的“不利條件”）。與沒(méi)有石膏的治療相比，石膏的應(yīng)用不影響保守治療的結(jié)果（正常和接近正常的膝關(guān)節(jié)分別為69.2%和72%）。相比之下，與手術(shù)治療（33.1%的膝關(guān)節(jié)異常）相比，那些狀況不佳的患者在保守治療（44%的膝關(guān)節(jié)異常）后的結(jié)果明顯更差。成人剝脫性骨軟骨炎AOCD關(guān)于成人剝脫性骨軟骨炎AOCD患者，知之甚少。同時(shí)，問(wèn)題是成人剝脫性骨軟骨炎AOCD患者的剝脫性骨軟骨炎OCD是從頭發(fā)生還是在骨骺閉合之前已經(jīng)存在，但由于治療失敗，骨骺閉合后仍然存在。保守治療的問(wèn)題是“那些患有成人剝脫性骨軟骨炎AOCD的人如何受到影響？”一般來(lái)說(shuō)，據(jù)我們所知，沒(méi)有明確的答案。只有一項(xiàng)研究將13歲以下（女孩）或14歲（男孩）的患者與早熟期患者（13歲以上的女孩或14歲以上的男孩）進(jìn)行了比較，并提供了一些可靠的數(shù)據(jù)。青少年剝脫性骨軟骨炎JOCD患者在任何類型的治療后的結(jié)果都好于任何處于早熟期的患者。對(duì)于成人剝脫性骨軟骨炎AOCD，保守治療成功的可能性較小。Lindén指出，無(wú)論采用何種保守治療方案，結(jié)果都非常好，并且骺板未閉合的兒童沒(méi)有表現(xiàn)出退行性變化。Hughston等建議正?；顒?dòng)和加強(qiáng)肌肉而不是固定。非手術(shù)治療后的愈合率范圍為50%至94%。手術(shù)治療當(dāng)保守治療失敗時(shí)，關(guān)節(jié)鏡評(píng)估和治療被用作下一步治療策略。接受手術(shù)治療的一般適應(yīng)癥如下：①已經(jīng)可見(jiàn)的游離體的不穩(wěn)定病變；②預(yù)計(jì)在6至12個(gè)月內(nèi)發(fā)生骨骺閉合時(shí)，在觀察或非手術(shù)治療期間發(fā)生的脫落；③盡管進(jìn)行了充分的非手術(shù)治療，但幼年骨軟骨損傷仍然有癥狀時(shí)；④當(dāng)可檢測(cè)到已確定的骨軟骨碎片不愈合時(shí)。有幾種不同的分類系統(tǒng)可用于關(guān)節(jié)鏡下對(duì)剝脫性骨軟骨炎OCD病變的評(píng)估。最著名的是根據(jù)Guhl的關(guān)節(jié)鏡分類標(biāo)準(zhǔn)：第一階段：穩(wěn)定病變第二階段：病變顯示早期分離跡象第三階段：部分脫落的病變第四階段：有游離體的骨軟骨缺損。國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS開(kāi)發(fā)了一個(gè)評(píng)估軟骨損傷的系統(tǒng)和一個(gè)剝脫性骨軟骨炎OCD評(píng)估系統(tǒng)。國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS剝脫性骨軟骨炎OCD分類是一種改進(jìn)的Guhl分類，用于將剝脫性骨軟骨炎OCD損傷的軟骨評(píng)估調(diào)整為常見(jiàn)的國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS評(píng)估系統(tǒng)：國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS剝脫性骨軟骨炎OCD?0期：穩(wěn)定、正常、完整的覆蓋軟骨；國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS剝脫性骨軟骨炎OCD?I：穩(wěn)定，有連續(xù)但軟化的區(qū)域，軟骨完整；國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS剝脫性骨軟骨炎OCD?II：穩(wěn)定但有部分不連續(xù)；國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS剝脫性骨軟骨炎OCD?III：完全不連續(xù)的原位病變；國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS剝脫性骨軟骨炎OCD?IV：有脫位或游離碎片的骨軟骨缺損。手術(shù)治療的適應(yīng)癥然而，手術(shù)指征是有爭(zhēng)議的且不明確。在最近的一篇評(píng)論文章中，對(duì)783名受試者和862個(gè)膝關(guān)節(jié)的30項(xiàng)研究（僅1項(xiàng)I級(jí)）進(jìn)行了評(píng)估。術(shù)后平均隨訪時(shí)間為77個(gè)月，最少2年。在短期、中期和長(zhǎng)期隨訪中，幾乎所有患者在手術(shù)治療的青少年剝脫性骨軟骨炎JOCD方面都表現(xiàn)出顯著的臨床和影像學(xué)改善。與其他手術(shù)技術(shù)相比，切除負(fù)重剝脫性骨軟骨炎OCD病變導(dǎo)致臨床和影像學(xué)結(jié)果較差。青少年剝脫性骨軟骨炎JOCD的結(jié)果明顯優(yōu)于成人剝脫性骨軟骨炎AOCD。不同的手術(shù)技術(shù)，例如逆行或順行鉆孔（單獨(dú)或與松質(zhì)骨移植相結(jié)合），僅適用于病變較輕者，最好是青少年剝脫性骨軟骨炎JOCD。順行技術(shù)比逆行方法容易操作，但為了到達(dá)受累的軟骨下骨，必須對(duì)軟骨層進(jìn)行穿孔。由于未閉合骨骺，逆行方法更加困難，但它確實(shí)使軟骨層完好無(wú)損。建議使用影像學(xué)技術(shù)，例如X線透視、MRI、超聲或關(guān)節(jié)鏡，以便能夠?qū)@頭導(dǎo)向骨軟骨缺損處。兩種策略的目標(biāo)都是穿過(guò)軟骨下骨硬化區(qū)或促進(jìn)血液供應(yīng)到軟骨下骨壞死區(qū)。最重要的預(yù)后因素是年齡。影像學(xué)觀察到，多達(dá)100%的青少年剝脫性骨軟骨炎JOCD患者的病灶在術(shù)后6周至2年內(nèi)愈合，但僅25%的成人剝脫性骨軟骨炎AOCD病例能完全愈合。大病灶比小病灶需要更長(zhǎng)的時(shí)間才能愈合。青少年剝脫性骨軟骨炎JOCD對(duì)青少年剝脫性骨軟骨炎JOCD有一篇總結(jié)25篇文章的最新綜述表明，對(duì)于穩(wěn)定病變，最常見(jiàn)的技術(shù)是鉆孔和使用生物可吸收針固定碎片。主要研究結(jié)果是，無(wú)論采用何種技術(shù)，絕大多數(shù)病變均在術(shù)后愈合，并且需要高質(zhì)量的試驗(yàn)來(lái)更恰當(dāng)?shù)乇容^技術(shù)的有效性。在回顧順行和逆行鉆孔后發(fā)表了類似的結(jié)果。成人剝脫性骨軟骨炎AOCD關(guān)于在成人剝脫性骨軟骨炎AOCD中，鉆孔治療穩(wěn)定病灶幾乎一無(wú)所知。不穩(wěn)定的成人剝脫性骨軟骨炎AOCD病變大多通過(guò)手術(shù)治療。幾年來(lái)，在軟骨層受損的情況下，建議去除脫落的軟骨或骨軟骨碎片，可能與清創(chuàng)手術(shù)相結(jié)合。然而，如今，由于結(jié)果不佳，已不再這樣做，骨關(guān)節(jié)炎(OA)變化率高達(dá)71%。由于這些原因，建議盡可能對(duì)部分或完全脫落的游離體進(jìn)行碎片重新固定（參見(jiàn)圖4中的示例）。組織學(xué)上，這些碎片主要包含有生存活力的軟骨。將碎片重新固定與軟骨下骨鉆孔相結(jié)合，建議對(duì)軟骨下骨硬化區(qū)穿孔，或去除硬化骨，然后進(jìn)行松質(zhì)骨移植，然后進(jìn)行碎片重新固定。骨軟骨碎片修復(fù)技術(shù)幾種方法已用于剝脫性骨軟骨炎OCD碎片的再固定，例如骨軟骨針、骨軟骨柱或釘子、金屬螺釘或針，或可吸收螺釘、錨、箭頭或針，都可能與纖維蛋白膠結(jié)合使用。成功率據(jù)報(bào)道，這一比例在91.7%和100%之間，具體取決于成像技術(shù)或成功的定義。然而，75%的患者在放射學(xué)上可檢測(cè)到退行性關(guān)節(jié)間隙變窄。最佳碎片再固定技術(shù)仍在討論中。實(shí)驗(yàn)觀察到，螺釘固定效果最好，但可吸收材料會(huì)引發(fā)過(guò)敏和/或滑膜反應(yīng)以及軟骨損傷。作者的觀點(diǎn)是，成功的碎片再固定取決于碎片上是否存在大量骨骼，以允許與軟骨下缺損底部的骨質(zhì)固定。如果由于游離體過(guò)于碎片化或顯示出所謂的“惡意形式”而無(wú)法進(jìn)行碎片修復(fù)，則需要使用重建技術(shù)。無(wú)法進(jìn)行碎片修復(fù)時(shí)膝關(guān)節(jié)剝脫性骨軟骨炎OCD治療的替代技術(shù)關(guān)于這些各種手術(shù)操作的報(bào)道很多，但幾乎所有的文章都是病例系列，即IV級(jí)報(bào)告；雖然具有前瞻性，但沒(méi)有與其他手術(shù)技術(shù)進(jìn)行比較。只有少數(shù)I/II級(jí)出版物可用。即使這些文章也并不總是能清楚地區(qū)分骨軟骨損傷OCL和典型的剝脫性骨軟骨炎OCD。青少年剝脫性骨軟骨炎JOCD和成人剝脫性骨軟骨炎AOCD之間沒(méi)有明確的區(qū)別，評(píng)分系統(tǒng)和后續(xù)標(biāo)準(zhǔn)也沒(méi)有得到一致的遵守。由于文獻(xiàn)中描述了不同的手術(shù)方法和保守治療方法的混合，以及所有不同的定義，幾乎不可能進(jìn)行深入的比較。單獨(dú)的骨髓刺激技術(shù)微骨折(MFX)，或其他骨髓刺激與支持性基質(zhì)相結(jié)合，即所謂的“自體基質(zhì)誘導(dǎo)軟骨形成”(AMIC)是其他可能的替代方案。然而，微骨折MFX術(shù)后超過(guò)5年可能會(huì)面臨失敗。在比較微骨折MFX和自體基質(zhì)誘導(dǎo)軟骨形成AMIC在治療小的非剝脫性骨軟骨炎OCD病變方面，發(fā)現(xiàn)小軟骨病變沒(méi)有顯著差異。自體骨軟骨植入物（自體骨軟骨移植[OAT]和馬賽克成形術(shù)）Wirth等報(bào)道了首批自體骨軟骨移植OAT的研究之一，在幾乎所有12名患有剝脫性骨軟骨炎OCD的患者中都取得了良好的結(jié)果。Laprell和Petersen發(fā)表了第一個(gè)長(zhǎng)期結(jié)果。在他們的病例系列中，他們?cè)?年和12年（平均8.1年）的隨訪中報(bào)告了29名患者中的26名（主要是剝脫性骨軟骨炎OCD病變）獲得了良好和優(yōu)異的療效（ICRS評(píng)分）。他們使用內(nèi)側(cè)髁非負(fù)重區(qū)作為供體區(qū)域，但沒(méi)有填補(bǔ)剩余的缺損。在隨訪中，他們?cè)?6名患者的取材區(qū)觀察到囊性病變。Hangody等報(bào)告了76名患者中，89%的患者獲得了良好或優(yōu)秀的結(jié)果，這些患者都患有剝脫性骨軟骨炎OCD。在另一項(xiàng)使用骨軟骨鑲嵌成形術(shù)的研究中，并非所有病變都是由剝脫性骨軟骨炎OCD引起的（33%），作者表示，股骨髁病變患者的結(jié)果（92%良好和優(yōu)異的結(jié)果）比脛骨表面重新修復(fù)(87%)或髕骨或滑車損傷(79%)患者取得了更好的效果。對(duì)骨軟骨移植技術(shù)文獻(xiàn)的概述表明，盡管存在很大差異，但許多論文并未區(qū)分骨軟骨移植術(shù)OAT和鑲嵌成形術(shù)。與最初的骨軟骨移植術(shù)OAT技術(shù)相比，在2項(xiàng)研究中，鑲嵌成形術(shù)填充的缺損僅包含60%至70%的透明軟骨（參見(jiàn)圖5中的示例）。其余(30%-49%)是纖維軟骨組織。命名法的不同使用使得精確比較變得困難。為數(shù)不多的I級(jí)文章之一在18歲以下的青少年剝脫性骨軟骨炎JOCD患者中比較了微骨折MFX與鑲嵌成形術(shù)的修復(fù)結(jié)果。雖然術(shù)后長(zhǎng)達(dá)1年隨訪，兩種技術(shù)之間沒(méi)有顯著差異，但在4.2年后的第二次隨訪中，微骨折MFX患者表現(xiàn)出顯著惡化（41%失?。邮荑偳冻尚涡g(shù)治療的患者保持穩(wěn)定，91%的結(jié)果優(yōu)秀或良好。另一項(xiàng)后續(xù)研究分析了微骨折MFX或鑲嵌成形術(shù)后的57名運(yùn)動(dòng)員，包括43%的剝脫性骨軟骨炎OCD病變。92名鑲嵌成形術(shù)患者取得了優(yōu)異或良好的結(jié)果，而接受微骨折MFX治療的患者中有52%的患者在術(shù)后最長(zhǎng)37.1個(gè)月時(shí)明顯惡化。在10年的長(zhǎng)期隨訪后觀察到了類似的結(jié)果鑲嵌成形術(shù)的失敗率為25%，而微骨折MFX的失敗率為75%。這兩項(xiàng)獨(dú)立研究表明，微骨折MFX似乎不是治療剝脫性骨軟骨炎OCD病變的手術(shù)替代方案。原則上，這是可以預(yù)料的，因?yàn)椴∽兪枪擒浌嵌皇蔷哂型暾浌窍鹿前宓膯为?dú)的軟骨病變。兩種骨軟骨塞技術(shù)（OAT，鑲嵌成形術(shù)）都可以通過(guò)關(guān)節(jié)切開(kāi)術(shù)、小型關(guān)節(jié)切開(kāi)術(shù)或關(guān)節(jié)鏡來(lái)完成。使用這兩種技術(shù)，開(kāi)放式術(shù)式允許移植物的精確定位，使其能夠適應(yīng)高度和形狀以適應(yīng)周圍、健康的關(guān)節(jié)面。一個(gè)缺點(diǎn)是與關(guān)節(jié)鏡檢查相比，關(guān)節(jié)切開(kāi)術(shù)后本體感覺(jué)受到干擾和康復(fù)期延長(zhǎng)。相反，關(guān)節(jié)鏡檢查技術(shù)需要非常有經(jīng)驗(yàn)的外科醫(yī)生。巨大骨軟骨移植Mega-OATS在病變相當(dāng)大的情況下，巨大骨軟骨移植mega-OAT手術(shù)是一種替代方法。該技術(shù)使用從股骨髁背側(cè)非負(fù)重區(qū)外植的大塊骨軟骨柱，由Imhoff等開(kāi)創(chuàng)。然而，在此之前，后髁被描述為潛在的供體部位。手術(shù)膝關(guān)節(jié)的第一個(gè)結(jié)果，平均跟隨9.8個(gè)月（范圍2-26個(gè)月）顯示93.8%的患者(15/16)有明顯的術(shù)后改善。作者還治療了受累膝關(guān)節(jié)力線異常，但沒(méi)有觀察到對(duì)結(jié)果的影響。另一篇關(guān)于這項(xiàng)技術(shù)的文章報(bào)道了29名患者中的26名在長(zhǎng)達(dá)18個(gè)月的隨訪后取得了令人滿意的結(jié)果。此外，高位脛骨截骨術(shù)對(duì)結(jié)果沒(méi)有顯著影響。29名患者中共有26名（89.7%）主觀滿意。16名患者(55.2%)能夠恢復(fù)到術(shù)前的體育活動(dòng)水平。沒(méi)有觀察到供體部位的發(fā)病率和移植區(qū)域邊緣的問(wèn)題。巨大骨軟骨移植Mega-OAT的優(yōu)點(diǎn)是移植物是固定的，無(wú)需將它們錘入到位。這意味著可以避免移植中的軟骨細(xì)胞死亡。5年后16名患者（4個(gè)外側(cè)病灶，12個(gè)內(nèi)側(cè)病灶）的巨型骨軟骨移植OAT結(jié)果顯示，15名患者（93.8%）有顯著改善。未檢測(cè)到供體部位發(fā)病率，但作者提到了移植部位的新形成組織。關(guān)于同種異體巨型骨軟骨移植OAT移植，僅發(fā)表了一份關(guān)于5名患者的報(bào)告。自體軟骨細(xì)胞移植(ACI)自第一次發(fā)表關(guān)于自體軟骨細(xì)胞移植ACI的文章以來(lái)，已經(jīng)發(fā)表了幾篇大多為IV級(jí)質(zhì)量的文章。今天，這種技術(shù)已經(jīng)有好幾代了，主要是將細(xì)胞懸浮液播種在骨膜下或播種到支架基質(zhì)中或支架基質(zhì)上。自體軟骨細(xì)胞移植ACI的科學(xué)情況與骨軟骨移植OAT/mosaicplasty或碎片修復(fù)相同。只有少數(shù)I級(jí)和II級(jí)研究。Peterson等報(bào)道了58名剝脫性骨軟骨炎OCD患者、35名青少年剝脫性骨軟骨炎JOCD患者和23名成人剝脫性骨軟骨炎AOCD患者的成功治療。平均隨訪5.6年后，91%的患者總體結(jié)果良好或優(yōu)異；93%的人報(bào)告了自我評(píng)估的改善?？紤]到剝脫性骨軟骨炎OCD不僅是軟骨也是骨軟骨損傷OCL，一些患者接受了額外的骨移植。然而，不幸的是，沒(méi)有對(duì)那些有骨移植物和沒(méi)有骨移植物的人進(jìn)行區(qū)分。另一項(xiàng)IV級(jí)研究在40名青少年剝脫性骨軟骨炎JOCD患者中報(bào)告了類似的結(jié)果。經(jīng)典自體軟骨細(xì)胞移植ACI治療后80%的患者隨訪成功率為85%，失敗率為19%。Ferruzzi等比較了通過(guò)關(guān)節(jié)切開(kāi)術(shù)(n=48)與使用細(xì)胞種子基質(zhì)的關(guān)節(jié)鏡手術(shù)(n=50)進(jìn)行的自體軟骨細(xì)胞移植ACI。25名患者患有剝脫性骨軟骨炎OCD。他們觀察到兩組都有顯著改善，但開(kāi)放手術(shù)后的失敗率為19%，明顯高于關(guān)節(jié)鏡技術(shù)后的失敗率(4%)。此外，他們注意到關(guān)節(jié)鏡介導(dǎo)的治療后康復(fù)更快。一項(xiàng)對(duì)80名患者進(jìn)行的I級(jí)研究比較了自體軟骨細(xì)胞移植ACI（n=40）和微骨折MFX（n=40），包括65%的創(chuàng)傷性病變、28%的OCD病變和7%的未明確診斷的患者，顯示兩組之間沒(méi)有顯著差異。在2年和5年的隨訪中，每組報(bào)告的成功率為77%，失敗率為23%。Bentley等對(duì)自體軟骨細(xì)胞移植ACI與鑲嵌成形術(shù)進(jìn)行了兩次比較。第一次在2003年，平均隨訪時(shí)間為1.7年，第二次在2012年，最短隨訪時(shí)間為10年。在第一次隨訪中，42名鑲嵌成形術(shù)患者中有9名（21%）表現(xiàn)出優(yōu)異的結(jié)果，而自體軟骨細(xì)胞移植ACI組58名患者中有23名（40%）表現(xiàn)出優(yōu)異的結(jié)果。此外，鑲嵌成形術(shù)患者的不良結(jié)果率（17%）明顯高于自體軟骨細(xì)胞移植ACI組（0%）。術(shù)后1年的關(guān)節(jié)鏡檢查顯示自體軟骨細(xì)胞移植ACI后82%的修復(fù)良好或良好。在馬賽克成形術(shù)后，34%的人有良好的結(jié)果，沒(méi)有“優(yōu)秀”的結(jié)果。在至少10年的隨訪中，58名自體軟骨細(xì)胞移植ACI患者中有10名（17%）和鑲嵌成形術(shù)組42名中的23名（55%）修復(fù)失敗。假設(shè)無(wú)法追蹤患者的移植物是完整的（“最佳情況”），失訪患者的移植物不完整（“最壞情況”），比較Kaplan-Meier曲線顯示自體軟骨細(xì)胞移植ACI后的結(jié)果明顯優(yōu)于鑲嵌成形術(shù)后的結(jié)果。馬賽克成形術(shù)后的結(jié)果在術(shù)后約2年開(kāi)始惡化。Basad等分析了兩步手術(shù)的結(jié)果，該手術(shù)使用雙層技術(shù)在細(xì)胞接種支架手術(shù)之前植入缺損處的自體骨移植物。他們所有的患者在術(shù)后24個(gè)月都有明顯的平均改善。其他兩項(xiàng)研究均使用一步程序和細(xì)胞接種的膠原蛋白支架或凝膠中的軟骨細(xì)胞（CaReS，圖6中的示例），在長(zhǎng)達(dá)36個(gè)月的隨訪后顯示出顯著改善。剝脫性骨軟骨炎OCD患者。Steinhagen等顯示所有剝脫性骨軟骨炎OCD患者從術(shù)前到術(shù)后3個(gè)月和更長(zhǎng)（術(shù)后長(zhǎng)達(dá)36個(gè)月）的持續(xù)改善。在Steinhagen等和Ochs等的研究中，病變的大小分別是12cm2和9cm2。據(jù)我們所知，只有1項(xiàng)I級(jí)研究比較了2種以上的技術(shù)。這些作者描述了一項(xiàng)非常有趣的、前瞻性的、針對(duì)青少年剝脫性骨軟骨炎JOCD和成人剝脫性骨軟骨炎AOCD患者的隨機(jī)試驗(yàn)。該試驗(yàn)比較了以下程序：大面積自體骨軟骨移植；自體骨軟骨膏移植物；自體軟骨細(xì)胞移植（第2代）與骨移植相結(jié)合；仿生骨軟骨支架；骨髓來(lái)源的細(xì)胞移植。在總共60名患者中，他們沒(méi)有發(fā)現(xiàn)顯著差異，但青少年剝脫性骨軟骨炎JOCD患者有更好結(jié)果的趨勢(shì)。總體而言，IKDC（國(guó)際膝關(guān)節(jié)文獻(xiàn)委員會(huì)）客觀評(píng)分從術(shù)前的37%增加到最后一次隨訪時(shí)的97%向上。然而，隨訪時(shí)間從2.3年（骨髓來(lái)源的細(xì)胞）到12.2年（大量骨軟骨移植物）不等，特定組的患者數(shù)量從7人（骨來(lái)源細(xì)胞植入）到28人（軟骨細(xì)胞與骨移植物）。不同技術(shù)的結(jié)果之間的唯一區(qū)別是自體軟骨細(xì)胞移植ACI(0.06)后結(jié)果更好的趨勢(shì)。同種異體移植物多年來(lái)，新鮮、冷凍或儲(chǔ)存的同種異體移植物也被用于晚期膝關(guān)節(jié)剝脫性骨軟骨炎OCD病變。新鮮、冷藏的同種異體移植物是骨軟骨同種異體移植物的標(biāo)準(zhǔn)選擇，因?yàn)槔鋬龊蛢龈傻能浌菦](méi)有足夠的活軟骨細(xì)胞。當(dāng)冷藏的同種異體移植物新鮮時(shí)，高達(dá)98%的軟骨細(xì)胞存活7天；到28天，這一比例下降到70%?；盍档桶殡S著細(xì)胞密度降低和代謝活動(dòng)降低?；|(zhì)和軟骨細(xì)胞已在長(zhǎng)期恢復(fù)研究中顯示存活。然而，在同種異體移植之前，必須對(duì)移植物進(jìn)行廣泛的血清學(xué)、細(xì)菌和病毒檢測(cè)，直到確保檢測(cè)結(jié)果為陰性。必須篩選供體。必須提供全天候的移植服務(wù)。此外，尚未完全消除疾病的免疫原性和計(jì)劃外轉(zhuǎn)移。然而，據(jù)估計(jì)，艾滋病毒傳播的風(fēng)險(xiǎn)低至大約萬(wàn)分之一，自1980年代后期以來(lái)，沒(méi)有關(guān)于這種疾病傳播途徑的報(bào)道。雖然軟骨細(xì)胞被基質(zhì)細(xì)胞保護(hù)以抵抗免疫反應(yīng)，但移植物骨性部分的細(xì)胞應(yīng)在很大程度上被去除。與似乎完全整合的軟骨相比，骨整合可能是失敗的原因。有2項(xiàng)研究專門(mén)報(bào)告剝脫性骨軟骨炎OCD；其他出版物包括高達(dá)45%的剝脫性骨軟骨炎OCD患者。一方面，剝脫性骨軟骨炎OCD患者的成功率相對(duì)較高，7.7年后的存活率為72%，10年后為82%。20年后存活率降至66%（45%的剝脫性骨軟骨炎OCD病變）。另一方面，在15%至47%中，失敗率和/或進(jìn)一步手術(shù)的必要性很高。Lyon等報(bào)道青少年剝脫性骨軟骨炎JOCD中的同種異體移植物；手術(shù)后，患者（平均年齡15.2歲）在6個(gè)月內(nèi)毫無(wú)困難地恢復(fù)了日常生活活動(dòng)，并在第9至第12個(gè)月之間恢復(fù)了全面的體育活動(dòng)。對(duì)14名患者的26份標(biāo)本進(jìn)行的檢索分析顯示，存活42個(gè)月后，82%的軟骨細(xì)胞存活。組織學(xué)上，所有標(biāo)本都顯示出一些軟骨纖維化，但沒(méi)有移植排斥的跡象。不同治療方法后的長(zhǎng)期結(jié)果有大量文章的平均隨訪時(shí)間在5到34年之間。這些文章包括至少2項(xiàng)縱向研究，其中對(duì)患者進(jìn)行了兩次隨訪。然而，所有文章都只有IV級(jí)，這意味著對(duì)長(zhǎng)期結(jié)果的解釋很困難，特別是因?yàn)樽髡呖赡艽嬖谄?jiàn)。關(guān)于剝脫性骨軟骨炎OCD碎片的切除或去除，結(jié)果顯示在10到20年后結(jié)果明顯傾向于較差或一般。Michael等觀察到28年后只有35%的結(jié)果良好和良好，大部分是在切除后骨關(guān)節(jié)炎OA率為92%。Twyman等報(bào)道了類似的數(shù)據(jù)。一份關(guān)于僅外側(cè)髁剝脫性骨軟骨炎OCD的報(bào)告描述了大多數(shù)患者（22/28膝關(guān)節(jié)）在關(guān)節(jié)鏡切除和軟骨下鉆孔后14年的中度骨關(guān)節(jié)炎OA但更好的臨床結(jié)果。相比之下，85%到92%的患者在5到15年后碎片再固定后的結(jié)果是優(yōu)秀或良好的。似乎再固定導(dǎo)致骨關(guān)節(jié)炎OA的發(fā)生率明顯降低，并且在34年的隨訪中，35%的中度骨關(guān)節(jié)炎OA被發(fā)現(xiàn)。就可以進(jìn)行比較而言，重建療法傾向于以較低的骨關(guān)節(jié)炎OA率獲得更好的長(zhǎng)期結(jié)果，如骨軟骨移植OAT所述：大多數(shù)患者(48%)在8.1年后表現(xiàn)出相同的術(shù)后骨關(guān)節(jié)炎OA等級(jí)，當(dāng)與術(shù)前相比，34%的患者受損程度為1級(jí)。Peterson等提到58名患者中有91%的患者在軟骨細(xì)胞移植術(shù)ACI后獲得了優(yōu)異或良好的臨床結(jié)果，平均隨訪時(shí)間為5.6年，但近50%的患者也提到了骨關(guān)節(jié)炎OA的跡象。同種異體移植修復(fù)后的長(zhǎng)期結(jié)果顯示成功率相對(duì)較高，7.7年后（所有剝脫性骨軟骨炎OCD病變）的存活率為72%，10年后為82%。然而，20年后僅為66%（45%剝脫性骨軟骨炎OCD)并且在15%到47%之間存在很高的失敗率和/或再手術(shù)率。合并癥膝關(guān)節(jié)力線異常幾位作者報(bào)道了膝關(guān)節(jié)內(nèi)側(cè)髁剝脫性骨軟骨炎OCD病變與內(nèi)翻畸形以及外側(cè)病變與外翻畸形之間的關(guān)系。Jacobi等分析了他們患者的雙側(cè)下肢全長(zhǎng)X線片，并發(fā)現(xiàn)剝脫性骨軟骨炎OCD病變和內(nèi)翻或外翻機(jī)械軸的偏差分別與內(nèi)側(cè)（內(nèi)翻）和外側(cè)病變（外翻）顯著相關(guān)。受影響和未受影響的膝關(guān)節(jié)之間的差異對(duì)于外側(cè)而不是內(nèi)側(cè)病變也很顯著。隨后，矯正畸形應(yīng)被視為一個(gè)額外的治療目標(biāo)，內(nèi)翻比外翻畸形更重要。Slawski報(bào)道了6名成人剝脫性骨軟骨炎AOCD患者的7個(gè)膝關(guān)節(jié)內(nèi)翻畸形，并進(jìn)行了高位脛骨截骨術(shù)，術(shù)后Lysholm評(píng)分明顯改善。前交叉韌帶ACL不穩(wěn)定和半月板損傷前交叉韌帶ACL不穩(wěn)定或半月板損傷也應(yīng)該在治療上得到解決。Hangody等報(bào)道了85%的伴隨手術(shù)干預(yù)率。這些手術(shù)中的大多數(shù)是前交叉韌帶ACL重建、重新排列截骨術(shù)、半月板手術(shù)或髕股關(guān)節(jié)重新排列。有報(bào)道稱股骨外側(cè)髁的剝脫性骨軟骨炎OCD病變與盤(pán)狀半月板合并，以及在盤(pán)狀半月板全半月板切除術(shù)后發(fā)展為剝脫性骨軟骨炎OCD病變。隨后，我們認(rèn)為，盤(pán)狀半月板應(yīng)通過(guò)手術(shù)縮小至正常半月板的大小。然而，盤(pán)狀半月板的全半月板切除術(shù)也可能導(dǎo)致同側(cè)剝脫性骨軟骨炎OCD病變的發(fā)展。結(jié)論剝脫性骨軟骨炎OCD仍然是一個(gè)病因?qū)W、組織學(xué)和治療學(xué)的謎團(tuán)。關(guān)于剝脫性骨軟骨炎OCD病變的分類和定義及其與其他病變的區(qū)別，以及關(guān)于青少年剝脫性骨軟骨炎JOCD和成人剝脫性骨軟骨炎AOCD的明確定義，存在很多混淆。此外，對(duì)于應(yīng)該使用哪種治療策略，沒(méi)有明確且科學(xué)依據(jù)良好的建議。此外，仍然缺少對(duì)臨床和影像學(xué)成功和/或愈合的明確和統(tǒng)一使用的定義。盡管有大量關(guān)于不同關(guān)節(jié)剝脫性骨軟骨炎OCD的各個(gè)方面的文獻(xiàn)，但缺乏科學(xué)可靠的前瞻性隨機(jī)研究。至少對(duì)于膝關(guān)節(jié)的剝脫性骨軟骨炎OCD病變?nèi)匀淮嬖诨煜⑶以凇懊绹?guó)骨科醫(yī)師學(xué)會(huì)”的一個(gè)工作組制定的“剝脫性骨軟骨炎的診斷和治療”出版物中的“建議摘要”中表達(dá)了這一點(diǎn)。由Chambers等發(fā)表。他們發(fā)現(xiàn)，關(guān)于16個(gè)不同方面的建議強(qiáng)度在10個(gè)方面不確定，在2個(gè)方面較弱；小組僅在4個(gè)方面達(dá)成共識(shí)。未來(lái)，處理骨關(guān)節(jié)疾病的機(jī)構(gòu)的國(guó)際目標(biāo)應(yīng)該是制定一種協(xié)議，以提供比從IV級(jí)研究中獲得的數(shù)據(jù)更令人滿意的數(shù)據(jù)，這些數(shù)據(jù)幾乎沒(méi)有科學(xué)價(jià)值。?OsteochondritisDissecans:Etiology,Pathology,andImagingwithaSpecialFocusontheKneeJoint.AbstractThisarticleisareviewofthecurrentunderstandingoftheetiology,pathogenesis,andhowtodiagnoseandtreatkneeosteochondritisdissecans(OCD)followedbyananalysisofandoutcomesofthetreatmentsavailable.OCDisseeninchildrenandadolescentswithopengrowthplates(juvenileOCD)andadultswithclosedgrowthplates(adultOCD).TheetiologyofOCDlesionsremainsunclearandischaracterizedbyanasepticnecrosisinthesubchondralbonearea.Mechanicalfactorsseemtoplayanimportantrole.Clinicalsymptomsareunspecific.Thus,imagingtechniquesaremostimportant.Regardingtreatment,atremendousnumberofpublicationsexist.Spontaneoushealingisexpectedunlessthereisanunstablefragment,andtreatmentinvolvesrestanddifferentdegreesofimmobilizationuntilhealing.Patientswithopenphysesandlow-gradelesionshavegoodresultswithconservativetherapy.Whensurgeryisnecessary,theproceduredependsonthestageandonthestateofthecartilage.Withintactcartilage,retrogradeproceduresarefavorable.Whenthecartilageisdamaged,severaltechniquescanbeused.Whiletechniquessuchasdrillingandmicrofracturingproducereparativecartilage,othertechniquesreconstructthedefectwithadditionalosteochondralgraftsorcell-basedproceduressuchaschondrocytetransplantation.Thereisatendencytowardbetterresultswhenusingproceduresthatreconstructtheboneandthecartilageandthereisalsoatrendtowardbetterlong-termresultswhencomorbiditiesaretreated.Severegradesofosteoarthrosisarerare.Keywords:etiology;general;imaging;kneejoint;osteochondritisdissecans;pathology.文獻(xiàn)出處：JuergenBruns,MathiasWerner,ChristianHabermann.OsteochondritisDissecans:Etiology,Pathology,andImagingwithaSpecialFocusontheKneeJoint.ReviewCartilage.2018Oct;9(4):346-362.doi:10.1177/1947603517715736.?IntroductionOsteochondritisdissecans(OCD)isacommoncauseofkneedisorderamongskeletallyimmatureandadultpatientsanditoccurswhenasmallpieceofsubchondralbonebeginstoseparatefromitssurroundingareaduetoadisturbanceofthelocalbloodsupply.Finally,asmallfragmentofboneandthecartilagecoveringitmaybegintocrackandgetloosened.ItwasAmbroiseParéandnotPaget,aswaspreviouslyassumed,whowasthefirst(in1870)todescribesuchloosebodiesfoundinajoint,1Thetermosteochondritisdissecanswasinitiallymentionedin1888byK?nig1whosuggested3possiblecausesofthedevelopmentofloosebodies:DirecttraumawithacuteosteochondralfractureMinimaltraumathatdevelopsintoosteonecrosisandconsecutivefragmentationNoevidenceoftraumawithaspontaneousdevelopment,whichK?nigcalled“osteochondritisdissecans”(OCD).1TheexactprevalenceofOCDisunknownbutratesofbetween15and29per100,000havebeenreported.2,3Kessleretal.4haveshownthattheincidenceofOCDofthekneeinpatientsaged6to19yearswas9.5per100,000and15.4and3.3per100,000formaleandfemalepatients,respectively(Table1).Patientsaged12to19yearsrepresentedthemajorityofOCD,withanincidenceof11.2per100,000versus6.8per100,000forthoseaged6to11years.Insummary,malepatientshadmuchgreaterincidenceofOCDandalmost4timestheriskofOCDcomparedwithfemalepatients.4OCDinthisarticlemeansachronicdiseaseoftheinvolvedjointthathasnotresultedfromanacutetrauma.Itisconsistingofafreshosteochondralorchondrallesion(OCL)andwithorwithoutalooseosteochondralfragment.OCDisusuallyregardedaseitherjuvenileOCD(=JOCD)(occurringwithanopenepiphysealplate)oradultOCD(=AOCD)(afterthephysishasclosed).ThesedefinitionssuggestagreaterchanceofasuccessfulnonsurgicalmanagementinpatientswherethephysesarestillopenthaninadultpatientswithOCDlesionswherethephysesarealreadyclosed.6ThisarticleisareviewonwhatisknownaboutOCDandwithaspecialfocusonthelargestjointaffected;thekneejoint.Inafuturearticle,theelbowandtheanklejointwillbeaddressed.EtiologyOnemaydividetheOCDetiologyinto4differentpossiblecauses;traumatic,ischemic,hereditary,andidiopathic7,8(Table2).However,etiologyofmultifactorialoriginisthemostprobablecause.Trauma:ProbablycausedbyindirecttraumaasseenonthemostcommonOCDlesion,theposteromedialmedialfemoralcondylarposition.7RepetitivestresstoimmaturekneesandonthetibialspineonthelateralaspectofthemedialfemoralcondyleduringinternalrotationofthetibiamaycontributetothedevelopmentofhumanOCD.Suchasubchondralstressreactionprobablyinterfereswithbonytrabecularhealingandimpedestheabilityofthebonetoheal.Owingtothelackofunderlyingsupportofthecartilage,laterstagescanleadtoaseparationofthearticularcartilageboneconnectionwithpartiallooseningoftheinvolvedosteochondralregion.Ischemia:PoorvascularityandinducedischemiahavebeendescribedasapotentialcauseofOCD.8SomestudieshaveshowndifferenceinvascularpatternthathasbeenseenattheOCD-positionedsites.SuchajointmorphologycombinedwithfocalrepeatedtraumaonthissitewithauniquevasculararchitecturemaytriggerischemiceventsandsubsequentOCD.9Genetics:SeveralauthorshaveinvestigatedapotentialgeneticlinkforOCDbutstillgeneticanddevelopmentalfactorsinthedevelopmentofOCDremainrelativelyunstudied.Skagenetal.10proposethatOCDlesionsarecausedbyanalterationinchondrocytematrixsynthesiscausinganendoplasmicreticulumstoragediseasephenotype,whichdisturbsorabruptendochondralossification.Furthermore,casesofidenticaltwinspresentingwithasimilardiseaseprocessarehighlysuggestiveofageneticcomponent.11GeneralOCDPathogenesisAlthoughtheetiologyisnotfullyclear,thepathogenesisofOCDisrelativelywellunderstood.Independentfromtheetiology,atleast4stagescanbedescribed.Stage1OCDlesionsstartinthesubchondralbonewithintraosseoussubchondralosteopenia,whichisonlydetectablewithmagneticresonanceimaging(MRI)orbonescans.Stage2Thelesionsareassociatedwithanintraosseousedemaofthesubchondralbone.12-14Abonebruiseisprobablytheinitialstageandsubchondraltrabecularmicrofracturesmightbethemorphologicalcorrelateofthebonemarrowedema.15-20Stage3Thecontinuing,naturalcourseischaracterizedbyaradiologicallydetectablescleroticring,whichdemarcatesthelesionsfromthesurroundinghealthybone.Thecenterofthelesionsisthoughttobeanosteonecrosis(seesection“OCDHistology”).Atthisstage,thecartilagestillseemstoappearintactinimagingtechniquessuchasMRIandcomputedtomography(CT).12Stage4A“softeningphenomenonandalterationinthemechanicalpropertiesofcartilage”19promotesareactionoftheboneattheborderofthenecrosistowardthehealthysurroundingbone.Stillremainingmechanicalloadsareprobablyresponsibleforthecartilagenowbeinginvolvedandshowingsignsofseparation.Finally,theongoingnaturalcourseleadstoalooseningofanosteochondralfragmentresultinginasingleloosebodyortheoccurrenceofmultiplefragments(theso-called“maliciousvariant”firstdescribedbyWagner.21,22Thereareseveralbiomechanicallyorientatedanalysesconcerningthesuggestionofabiomechanicaletiology.Rehbein23in1950wasabletoexperimentallyproduceloosebodiesinkneejointsofdogsbyartificiallyproducedrepetitivestress.Thespecimenshistologicallyresembledthosefindingsdescribedbelow,whichwereobtainedfromloosebodiesinthekneejointsofhumans.Anexperimentaltrialusingplaneandstereoscopickneemodelsmadefromepoxyresins,24aswellasafiniteelementsanalysisofthedistalfemur,25revealedpeakstressesintheregionwhereanOCDlesionoccurs.Usingphotosensitivefoilsinthekneemimickingtheclinicallyobviousfactors,suchasvarusorvalgusmalalignment(knee)withstableandunstableligaments,exhibitedasignificantstressconcentrationinthoseareaswell-knownfortheclinicaldevelopmentofOCDlesions.26,27Seenclinically,bonebruisesfollowingabonecontusionofthekneeareassumedtobeprimarylesionsofthesubchondraltrabecularbone,whichprobablyinitiatesanOCD.17,18OCDHistologyHistologyofanadvancedlesionispresentedinFigure1.GreenandBanks28,29were,toourknowledge,thefirsttodescribeasubchondralosteonecrosisastheinitiallesionwithstillintactoverlyingcartilage.Owingtothelossofthemechanicalsupportoftheboneforthecartilage,theongoingprocessresultsinsecondarydamagetothecartilagelayer.30Theauthorssuggestedthathealingmightbepossiblebycreepingsubstitutionprovidedthattheoverlyingcartilageisstillintact.Histologicalexaminationsofloosebodiesrevealedthathypertrophywascommonandlaminarcalcificationwasfoundin53%.31,32ChiroffandCooke33detectedfibrocartilaginoustissueatthelevelofseparationandinthebonypartoftheloosebodies,anincreasedosteoblasticandosteolyticactivityunderthealmostnormalcartilagewasfound.Furthermore,Milgram34foundnoboneinhalfoftheloosebodies.Kochetal.35analyzed30specimensfrompatientsaged16to44yearswhohadadvancedstagesofOCDandobservedadecreasedtoluidinestainingofPH1inthecartilage.Areducednumberofchondrocytescouldbeseenaswellasfracturedareasinthesubchondralboneplateandinthecancellousbone.Furthermore,theyfoundareasofenhancedboneresorptionandnecroticsubchondralbonesurroundedbyfattybonemarrow.Uozumietal20havedescribed3typesofhistopathologicalfeatures:OCDwithnecroticsubchondraltrabeculaeOCDwithviablesubchondraltrabeculaeOCDcartilagewithoutbonetrabeculae.Theysummarizedthat“theinitialchangeinthesubchondralareaisbonenecrosisorsubchondralfracture;thenecroticboneisthenabsorbedandreplacedbyviablesubchondraltrabeculaeorcartilagewithoutbonetrabeculae.”20Incontrast,osteonecrosiscouldnotbedetectedinanyof8needlebiopsiesfromthecenterofstableJOCDlesionsinthemedialfemoralcondyleswithoutanydegenerativechanges.36Onlyathickcartilagelayerandfibroustissue,orthincartilagewithmixedcartilageunderneathwerefound,asweresubchondraltrabeculaeandfibrousandfibrocartilageattheareasofseparation.Mostrecently,ananalysisofloosebodiesshowedthatthechondrocytesfromtheloosebodiesdisplayedanormalbehaviorandthecellswereregardedtobeusableforautologouschondrocyteimplantation(ACI).37Ameta-analysisofthealreadypublisheddataonhistologicalanalyses38resultedininconsistentfindings:In7outof10studies,whichincludedthesubchondralbone,signsofabonynecrosishadbeenreported;in2outof11publications,degenerativeorirregularcartilagewasmentioned.Regardingthepossibleunderlyingetiology,5outof11articlessuggestedonemajorormultiplerepetitivemicrotraumataastheetiologicalfactor.Inconclusion,thehistologicalresultssuggestafocalalterationofcartilagematrixoriginatingfromthedeeplayersofthejointcartilage,potentiallythemineralizedlayerorthesubchondralbone.37DiagnosisofOCDOCD-relatedSymptomsSymptomsareoftenvagueandpoorlylocalized.Differentdegreesofpainandstiffnessmaybepresent;swellingandeffusionofthejointand“givingway,”“catching,”or“blocking”ofthejointmightoccur.TherearenotypicalclinicalsignsforanOCDinanyjoint.12,30,39,40TheWilsontest,recommendedasaclinicaldiagnostictestatthekneejointisnotreliable.41-43OCDlocalizationschemesarepresentedinTable4.ImagingTechniquesforOCDEvaluationPlainX-raysBeforetheuseofMRIstarted,initialchangescouldonlybedetectedwithbonescans,orsuspectedonconventionalradiographs.WiththeintroductionofMRI,itwaspossibletodifferentiatestagesmoreeasily.However,itisstilldifficulttoestimatereliablythemechanicalpropertiesofthecartilagelayer.TheinitialdiagnosticschedulewhenanOCDlesionissuspectedstartswithanX-rayin2orthogonalplanes.Thestandardseriesincludeastandinganterior-posterior(AP)view(Fig.2),alateralviewwiththekneeflexed35°,anda45°patellasunriseview.AdditionalspecialX-rayviewscouldbeusefulsuchasatunnelviewbringingtheareawiththelesionmoreinlinewiththeimagingplaneup.65MagneticResonanceImagingMRIisthemethodofchoiceasthesecondstepinanimagingworkup(Fig.3aandb).SincetheavailabilityofMRsystemshasincreasedinthepast10years,thelackofradiation,thesuddendevelopmentofhigherfieldstrengths(1.5and3T),dedicatedcoilsettings,andhigh-resolutionsequencessavedthewayfortheadvanceofMRIinmusculoskeletalimaging.TheregularMRapproachusesT1-andT2-weightedimagesinall3spatialdirections.Themaximalslicethicknessshouldbe3mm,offeringasensitivityof96%(specificity0.96)fordetectingosteochondraldefectsatthetalus.Diapolaetal.50havedevelopedausefulMRIsystemforOCDevaluationwith4gradings:Stage1:Thickeningofarticularcartilageandlowsignalchanges.Stage2:Articularcartilagebreached,lowsignalrimbehindfragmentindicatingfibrousattachment.Stage3:Articularcartilagebreached,highsignalchangesbehindfragment,indicatingsynovialfluidbetweenfragmentsandunderlyingboneStage4:Loosebody.ItisalsopossibletousethearthroscopicInternationalCartilageRepairSociety(ICRS)OCDclassificationandGuhl’sclasssifiaction44,56whenevaluatingOCDonMRimages(seeArthroscopicClassifications).Toimprovetheevaluation,MRIcanalsobeperformedbyinjectinggadoliniumMRcontrastmaterialintotheexaminedjointshortlybeforetheexamination.SuchadGemericMRIgivesinformationaboutthematrixquality.UsingT2-weightedsequences,thepresenceofahighsignallineoracystbelowanosteochondrallesionindicatesthepresenceoffluidandsuggeststhepresenceofanunstableosteochondraldefect,eventhoughthissignalcanreflectvasculargranulationtissuerepresentingahealingreaction.Protondensityimagesand3-dimensionalT1-weightedsequenceswithfatsaturationusingisotropicvoxelsbelow1mmwithadedicatedfieldofview(14-20cm)andintravenouscontrastmaterialofferabrilliantimageimpressionandcanalsodifferentiatesubtlechanges.65Usingthesesequencesaswell,MRIoffersexcellentdiagnosticcapabilitiesindetectingevenunstableosteochondrallesions.Consequently,routinelyintra-articularadministrationisnotnecessaryforevaluatingosteochondrallesions.Usingnewlyimplementedhigh-resolutionsequencestodifferentiatedifferenttypesofosteochondraldefectsoffersanoverallaccuracyofmorethan90%.66Inthedailyclinicalroutine,1.5-and3-Tsystemsareavailable.Comparingdedicatedcoilsettingsonbothsystems,theimageimpressionmightbebetterusinghigherfieldstrength(3-Tsystems).However,3-Tsystemshavenotyetprovedtoofferbetterdiagnosticresultswithregardtocartilagelesions.67ComputedTomographyThe2importantshortcomingsofCTaretheappliedradiation,especiallywithregardtotheageofexaminedpatients,andthelackofvisualizationofthecartilage.Thelackofcartilagevisualizationcanbeovercomebyusingintra-articularcontrastmaterial,whichcanbeappliedbyadirectpunctureofthejointandoffersanindirectvisualizationofthecartilage.CTscanscanbeusedtoassesstheosseousintegrationafterrefixationofOCDloosefragments.68ScintigraphicExaminationPalettaandcolleagues69foundthatquantitativebonescanninghada100%predictivevaluefortheprognosisinOCDpatientswithopenphyses,butforthosewithclosedphysesthepredictivevaluewasless.CahillandBerg47havedevelopedaclassificationusefulwhentoevaluatescintigraphicresultsofjuvenileOCDpatients:0.Normalradiographicandscintigraphicappearance.1.Thelesionisvisibleonplainradiographs,butbonescansrevealnormalfindings.2.Thescanrevealsincreaseduptakeintheareaofthelesion.3.Inaddition,thereisincreasedisotopicuptakeintheentirefemoralcondyle.4.Inaddition,thereisuptakeinthetibialplateauoppositethelesion.TreatmentofOCDoftheKneeJointOCDlesionsinthekneejointarelocatedpredominantlyinthemedialfemoralcondyleandareoftenassociatedwithavarusmalalignment.AminorityofOCDlesionsarelocatedinthelateralcondyleandisassociatedwithvalgusmalalignment.61,70-72LesionLocationLesionsatthelateralfemoralcondylecanalsooccurinassociationwithdiscoidmenisci.Alesionatthelateralcondylecandevelopeitherprimarilywithadiscoidmeniscusorsecondarily,afteratotalresectionofadiscoidlateralmeniscus.73-78Ithasbeenassumedthatthealteredbiomechanicsofthekneewithadiscoidmeniscus,oraftertotallateralmeniscectomy,areresponsibleforthedevelopmentofanOCDlesion.73-78Theprominenceratioofthelateralcondylesofpatientswithadiscoidmeniscusissignificantlylargerthanthatofcontrols.78Onlyasmallnumberoflesionsarelocatedinthepatellofemoraljoint.12,79,80LesionStabilityForbothJOCDandAOCD,theindicationtofollowaconservativetherapyorgoforasurgicalapproachdependsonthestabilityoftheosteochondralfragment(Table5).However,whatisastablelesion?Walletal.81stated,“AstableOCDwasdefinedasoneshowingnobreachinthearticularorthesubchondralbone-lesioninterface.”Trinhetal.82realizedthattheirreviewcontainedvaryingdefinitionsforastableorunstablelesionandadaptedthemtothoseusedbyDeSmetetal.51LesioninstabilityissaidtoexistsifAlineofhigh-signaldeeptothefragmentisseenonT2-weightedimageonMRI.Anarticularfracture,indicatedbyahighsignal,passesthroughthesubchondralboneplate.Afocal,osteochondraldefectispresent.A5-mmdiameter,fluid-filledcystisdeeptothelesion.ConservativeTreatmentAfewarticleshavebeenpublishedthatdifferentiatebetweenJOCDandAOCDadvocatingconservativetreatmentbutwithdifferenttreatmentregimesJOCDMostchildrensufferingfromJOCDcanbesuccessfullytreatedconservatively.6,19,48,56,83Restrictionsonweightbearingandsportsactivitieshavebeensuggestedorsimplylimitationofdailyactivitiesandimmobilisation.5,6,33,48,51,62-64,84,85Acommontreatmentsuggestionisthatthepatienthasabracefor6to12weekswithpartialweightbearingandfollowsregularlywithphysiotherapytraining.Ifthepatientispainfreeat12weeksandiftheimagingshowshealing,thepatientcouldstartrunningactivitiesbutmoreaggressiveactivitiesshouldberestricteduntilthepatienthavebeenfollowedformoremonthsofsymptomfreeactivitiesinsportandleisuresuchasjumping,twistingandimpactloading.Inarecentlypublished,retrospectivestudyon42JOCDpatients,two-thirds(66%)ofthestablelesionshealedafteraninitialtreatmentwithplaster-castimmobilizationfollowedbybracingandlimitationofactivityforupto6months.81However,theauthorsexperiencedfailureoftreatmentin34%ofthepatients.Largelesionsdidsignificantlyworsethanthesmallerones(relativelyandabsolutely),butallthelaterallesionshealed.Prospectivefactorssuchassizeofalesion,condyleornoncondylelocalization,age,andgenderofthepatientarestillbeingcontroversiallydiscussed.5,6,48,63,84-89OfinterestisaEuropeanmulticenterstudy6withthelargestnumberofpatientsuptonow(452patientswith509affectedkneejoints).In452patientswithaminimalfollow-upof1year,theydifferentiatedagroupAof276patientswithopenphyses,forexample,malesupto14yearsofageandfemalesuptotheageof13years,fromagroupBofso-called“premature”patients,forexample,over14yearsofageformalesandover13yearsforfemales.Atotalof154patientsreceivedconservativetreatmentwhile355patientsneededsurgery.SignificantlybetterresultswereseeninpatientsfromgroupAthanfromgroupB.Thosewhosesituationwasfavorable(nogrossdissection,size<20cm2)didsignificantlybetterthanthosewithanalreadydetectabledissection(so-called“unfavorableconditions”).Applicationofaplaster-castdidnotinfluencetheresultoftheconservativetreatmentincomparisontotreatmentwithoutacast(normalandnear-normalknees69.2%vs72%,respectively).Incontrast,thosepatientswithanunfavorableconditionhadsignificantlyworseresultsafterconservativetreatment(abnormalkneesin44%)whencomparedwithsurgicaltherapy(abnormalkneesin33.1%).6AOCDRegardingAOCDpatients,littleknowledgeexists.Meanwhile,thequestionisastowhetherOCDinAOCDpatientsoccurdenovoorwhetheritisalreadypresentpriortoepiphysealclosurebut,owingtoafailedtreatment,isstillthereafterepiphysealclosure.Thequestionastoconservativetherapyis“HowarethosepersonswithanAOCDaffected?”Ingeneral,toourknowledgethereisnoexplicitanswer.Only1studyhascomparedpatientsuptoanageof13(girls)or14years(boys)withthoseinaprematurestage(girlsolderthan13orboysolderthan14years)andpresentedsomereliabledata.TheresultsforJOCDpatientswerebetterafteranytypeoftreatmentthanforanypatientinaprematurestage.ForAOCD,successfulconservativetreatmentislesslikely.6Lindén5notedexcellentresults,regardlessoftheconservativetherapeuticregime,andthatchildrenwithopenphysesdisplaynodegenerativechanges.Hughstonetal.63recommendednormalactivityandstrengtheningofthemusclesratherthanimmobilization.Therateofhealingfollowingnonoperativetreatmentrangedfrom50%to94%.5,6,29,33,48,63,64,81,84,85,90SurgicalTreatmentArthroscopicevaluationandtreatmentisusedasnextstepwhenconservativetreatmenthasfailed.Accepted,generalindicationsforsurgicaltreatmentare4,47,54,64,91Unstablelesionswithalready-visibleloosebodiesDetachmentthatoccursduringobservationornonoperativetreatmentwhenaphysealclosureispredictedtooccurwithin6to12monthsWhenjuvenilelesionsremainsymptomaticdespiteadequatenonoperativetreatmentWhenanestablishednonunionofafragmentisdetectableThereexistseveraldifferentclassificationsystemsforthearthroscopicevaluationofanOCDlesion.Themostwell-knownisthearthroscopicclassificationaccordingtoGuhl56:Stage1:StablelesionStage2:LesionsshowingsignsofearlyseparationStage3:PartiallydetachedlesionsStage4:Craterswithloosebodies.ICRShasdevelopedasystemforevaluatingofcartilagelesionsandalsoasystemforOCDevaluations.2TheICRSOCDclassificationisamodifiedGuhlclassificationtoadjustcartilageevaluationofOCDlesionstothecommonICRSevaluationsystem44ICRSOCD0:Stable,normalintactoverlyingcartilageICRSOCDI:StablewithcontinuousbutsoftenedareawithintactcartilageICRSOCDII:StablewithpartialdiscontinuityICRSOCDIII:InsitulesionwithcompletediscontinuityICRSOCDIV:EmptydefectwithdislocatedorloosefragmentsGeneralRemarksofOperativeTreatmentHowever,indicationsforsurgeryarecontroversialandunclear.82Inarecentreviewarticle,8230studies(only1level-I)on783subjectswith862kneeswereevaluated.Themeanpostoperativefollow-upwas77months,minimum2years.NearlyallpatientsdemonstratedsignificantclinicalandradiographicimprovementsinsurgicallytreatedJOCDatshort-,mid-,andlong-termfollow-up.ExcisionofweightbearingOCDlesionsledtopoorerclinicalandradiographicresultsthanothersurgicaltechniques.OutcomesweresignificantlybetterforJOCDversusAOCD.Differentsurgicaltechniques,suchasretrogradeoranterogradedrilling(aloneorincombinationwithcancellousbonegrafting),54,57,92-95shouldonlybeindicatedforlow-gradelesionspreferablyJOCD.54,96Theanterogradetechniqueiseasierthantheretrogradeapproach,butperforationofthecartilagelayerisnecessaryinordertoreachtheinvolvedsubchondralbone.Theretrogradeapproachismoredifficultowingtotheopenphysesbutitdoesleavethecartilagelayerintact.Imagingtechniques,suchasfluoroscopy,MRI,ultrasound,orarthroscopyarerecommendedinordertobeabletonavigatethedrillstowardthedefect.95,97-100Thegoalofbothvariantsiseithertoperforatethesubchondralsclerosisortopromotebloodsupplytothesubchondralnecroticarea.Themostimportantprognosticfactorisage.Itwasobservedradiographicallythatthelesionshadhealedwithin6weeksto2yearspostoperativelyinupto100%oftheJOCDpatientsbutinonly25%oftheAOCDcases.56,57,82,91,101,102Largelesionsneedalongertimetohealthansmallones.101JOCDAsummaryofthemostrecentreviewof25articles,allonJOCD,103showedthatthemostcommontechniquesweretransarticulardrillingforstablelesionsandtheuseofbioabsorbablepin-fixationforfragmentrefixation.Thekeyfindingswerethatthevastmajorityoflesionshealedpostoperatively,regardlessoftechnique,andthathigh-qualitytrialsarerequiredtomoreappropriatelycomparetheeffectivenessoftechniques.103Asimilarrésuméwaspublishedafterreviewinganterogradeandretrogradedrilling.97AOCDNearlynothingisknownaboutdrillingstablelesionsinAOCD.UnstableAOCDlesionsaremostlytreatedsurgically.Forseveralyears,incasesofdamagetothecartilagelayer,removaloftheloosecartilageorosteochondralfragmentswasrecommended,possiblyincombinationwithadebridementprocedure.Nowadays,however,thisisnolongerdoneowingtopoorresults,withupto71%rateofosteoarthritic(OA)changes.2,6,47,55,58,63,83,87,91,104-115Forthesereasons,fragmentrefixationofpartiallyorcompletelyloosebodies—asfarasispossible—isrecommended(seeexampleinFig.4).Histologically,thesefragmentscontainmostlyviablecartilage.35,37Eithercombiningfragmentrefixationwithdrillingofthesubchondralbone,inordertoperforatethesubchondralsclerosis,orremovalofthesclerosisfollowedbycancellousbonegraftingfollowedbyfragmentrefixation4,6,64,91,103isrecommended.TechniquesforFragmentRefixationSeveralmethodshavebeenusedforOCDfragmentrefixation,suchasosteochondralpins,plugsorpegs,metallicscrewsorpins,orresorbablescrews,anchors,arrowsorpins,allprobablyincombinationwithfibringlue.2,64,82,103,110,112,114,116Thesuccessratereportedhasbeenbetween91.7%and100%,dependingontheimagingtechniqueordefinitionofsuccess.103,116However,degenerativejoint-spacenarrowinghasbeenradiographicallydetectablein75%.110Theoptimalfragmentrefixationtechniqueisstillunderdiscussion.Ithasbeenobservedexperimentallythatscrew-fixationgavethebestresults117butthatresorbablematerialcaninitiateallergicand/orsynovialreactionsandcartilagedamage.118Theauthors’opinionisthatsuccessfulfragmentrefixationdependsontheexistenceofasubstantialamountofboneonthefragmenttoallowbonyconsolidationwiththesubchondraldefectbottom.Incaseswherefragmentrefixationisnotpossiblebecausetheloosebodyistoofragmented,orshowstheso-called“maliciousform,”21reconstructivetechniquesareindicated.AlternativeTechniquesforKneeOCDTreatmentwhenFragmentRefixationIsNotPossibleTherearenumerousreportsonthesevariousoperativeproceduresbutalmostallthearticlesarecaseseries,thatis,level-IVreports;althoughwithaprospectivecharacterbutwithoutcomparisonwithotherprocedures.Onlyafewlevel-I/IIpublications119-126areavailable.EventhesearticleshavenotalwaysdifferentiateddistinctlybetweenanOCL124andatypicalOCD.119-121CleardifferentiationbetweenJOCDandAOCDhasnotbeenmadeandscoringsystemsandfollow-upcriteriahavenotbeenconsistentlyadheredto.Withthemixtureofdifferentmethodsofsurgeryandconservativetreatmentdescribedintheliterature,andwithallthedifferentdefinitions,profoundcomparisonsarenearlyimpossible.BoneMarrowStimulationTechniquesMicrofracture(MFX)alone,orotherbonemarrowstimulationscombinedwithasupportivematrixso-called“autologousmatrix-inducedchondrogenesis”(AMIC)areotherpossiblealternatives.127-129However,failurescanbeexpectedbeyond5yearsfollowingMFX.120,130InacomparisonbetweenMFXandAMICinthetreatmentofsmallnon-OCDlesions,nosignificantdifferencesforsmallcartilagelesionswerefound.131OsteochondralAutologousPlugImplants(OsteochondralAutograftTransfer[OAT]andMosaicplasty)OneofthefirststudiesonOATwasreportedbyWirthetal.132withfavorableresultsinalmostallofthe12patientssufferingfromOCD.Firstlong-termresultswerepublishedbyLaprellandPetersen.133Intheircaseseries,theyreportedgoodandexcellentresults(ICRSscore)in26outof29patients(mostlyOCDlesions)atafollow-upof6and12years(mean8.1years).Theyhadusedthedorsalmedialcondyleasthedonorregionbutdidnotfilluptheremainingdefect.Atthefollow-up,theyobservedcysticlesionsintheharvestareain26patients.133Hangodyetal.134reportedgoodorexcellentresultsin89%of76patients,allofwhomweresufferingfromOCD.Inanotherstudyusingthemosaicplasty,inwhichnotallthelesionswerecausedbyOCD(33%),theauthorsstatedthatbetterresultswereachievedinpatientswhohadacondylarlesion(92%goodandexcellentresults)thaninthosewithatibialresurfacing(87%)orapatellarortrochlearlesion(79%).135AnoverviewoftheliteratureonosteochondraltransplantationtechniquesshowsthatalotofpapersdonotdifferentiatebetweenOATandmosaicplasty,althoughthereisasubstantialdifference.IncontrasttotheoriginalOATtechnique,in2studiesthemosaicplastyfilleddefectsconsistedofonly60%to70%hyalinecartilage(seeexampleinFig.5).Therest(30%-49%)werefibrocartilagetissues.135,136Thevaryinguseofthenomenclaturemakesexactcomparisondifficult.116,121,122,136-140Oneoftheveryfewlevel-Iarticles122comparedMFXwithmosaicplastyinexclusivelyJOCDpatientsuptoanageof18years.Whileupto1yearpostoperative,therewasnosignificantdifferencebetweenthe2techniques,atthesecondfollow-upafter4.2years,MFXpatientsexhibitedasignificantdeterioration(41%failure)whilethosetreatedbymosaicplastyremainedstablewith91%excellentorgoodresults.Anotherfollow-upstudyanalyzed57athletesaftereitherMFXormosaicplasty,including43%OCDlesions.Ninety-twoofthemosaicplastypatientshadexcellentorgoodresultswhile52%ofthepatientswhoweretreatedwithMFXweresignificantlyworseatamaximumof37.1monthspostoperation.121Similarresultswereobservedafteralong-termfollow-upof10yearswheretherewasa25%failureratewithmosaicplastyasopposedto75%withMFX.137These2independentstudiesshowedthatMFXdoesnotseemtobeasurgicalalternativeinthetreatmentofOCDlesions.Inprinciple,thiscanbeexpectedsincethelesionisanosteochondralandnotasolelychondrallesionwithanintactsubchondralboneplate.Bothosteochondralplugtechniques(OAT,mosaicplasty)canbeappliedviaanarthrotomy,mini-arthrotomy,orarthroscopically.133-135Withbothtechniques,theopenvariantallowsaprecisepositioningofthetransplant,enablingittoadaptinheightandshapetothesurrounding,healthy,articularsurface.Adisadvantageisthedisturbedproprioceptionandprolongedrehabilitationperiodafterarthrotomythanafterarthroscopy.135,141,142Incontrast,arthroscopictechniquesrequireaveryexperiencedsurgeon.Mega-OATSIncaseswithfairlylargelesions,themega-OATprocedureisanalternative.ThistechniqueuseslargeosteochondralplugsexplantedfromthedorsalcondylesandwasinauguratedbyImhoffetal.143However,wellbeforethat,theposteriorcondylewasdescribedasapotentialdonorsite.21,22,144Firstresultsonoperatedkneejointswithameanfollow-upof9.8months(range2-26months)showedadistinctpostoperativeimprovementin93.8%ofpatients(15/16).143Theauthorsalsotreatedmalalignmentsoftheinvolvedlegbutdidnotobserveaninfluenceontheresults.Anotherarticleonthistechnique145reportedsatisfactoryresultsfor26outof29patientsafterafollow-upofupto18months.Furthermore,ahightibialosteotomydidnotsignificantlyinfluencetheresults.Altogether26outof29patients(89.7%)weresubjectivelysatisfied.Sixteenpatients(55.2%)wereabletoreturntotheirpreoperativelevelofsportsactivities.Neitherdonorsitemorbiditynorproblemsattherimoftheexplantregionwereobserved.Mega-OAThastheadvantagethatthetransplantsarefixedwithouthavingtohammerthemintoplace.Thismeansthatchondrocytedeathinthetransplantscanbeavoided.Resultsofmega-OATin16patients(4laterals,12mediallesions)after5yearsshowedasignificantimprovementin15patients(93.8%).Nodonorsitemorbiditywasdetectedbuttheauthorsmentionednewly-formedtissueintheregionfromwherethetransplantshadbeentaken.146Regardingallogenicmega-OATtransplants,only1reporton5patientshasbeenpublished.147AutologousChondrocyteImplantation(ACI)SincethefirstpublicationsonACI,148severalarticlesofmostlylevel-IVqualityhavebeenpublished.Today,thereareseveralgenerationsofthistechniquemostlywithcellsuspensionseededunderaperiostealmembraneorseededintooronscaffoldingmatrices.ThescientificsituationofACIisthesameasforOAT/mosaicplastyorfragmentrefixation.Thereareonlyafewlevel-Iand-IIstudies.Petersonetal.149reportedsuccessfultreatmentin58patientswithOCD,35withJOCD,and23withAOCD.Afterameanfollow-upof5.6years,91%ofthepatientshadagoodorexcellentoverallresult;93%reportedaself-assessedimprovement.TakingintoconsiderationthatOCDisnotonlyachondralbutalsoanOCL,someofthepatientsreceivedadditionalbonegrafts.However,unfortunately,nodifferentiationwasmadebetweenthosewithandthosewithoutbonegrafts.Anotherlevel-IVstudy150reportedsimilarresultsin40exclusivelyJOCDpatients.Afollow-upin80%aftertheclassicACItreatedpatientsasuccessrateof85%wasfoundwhilethefailureratewas19%.Ferruzzietal.151comparedACIviaanarthrotomy(n=48)withanarthroscopicprocedure(n=50)usingacellseededmatrix.Twenty-fiveofthepatientsweresufferingfromOCD.Theyobservedasignificantimprovementinbothgroupsbutthefailurerateafteranopenprocedurewas19%,distinctlyhigherthanafterthearthroscopictechnique(4%).Inaddition,theynotedafasterrehabilitationfollowingarthroscopy-mediatedtreatment.Onelevel-Istudyon80patientscomparingACI(n=40)withMFX(n=40),119,120including65%traumaticlesions,28%OCDlesionsand7%withunspecifieddiagnosesrevealednosignificantdifferencesbetweenbothgroups.Atafollow-upof2and5years,asuccessrateof77%andafailurerateof23%werereportedforeachgroup.TwocomparisonsofACIwithmosaicplastyweremadebyBentleyetal.thefirstin2003withameanfollow-upof1.7years125andthesecondin2012126withaminimumfollow-upof10years.Atthefirstfollow-up,9outof42mosaicplastypatients(21%)exhibitedanexcellentresultincontrastto23outof58(40%)intheACIgroup.Furthermore,therateofpoorresultsforthemosaicplastypatientswasdistinctlyhigher(17%)thanintheACIgroup(0%).Arthroscopyat1yearpostoperativelydemonstratedexcellentorgoodrepairsin82%afterACI.Followingmosaicplasty,34%hadgoodresults,no“excellent”outcome.Ataminimumof10years’follow-up,126therepairhadfailedin10outof58ACIpatients(17%)and23outof42(55%)fromthemosaicplastygroup.Assumingthatthegraftsofpatientswhocouldnolongerbetracedwereintact(“best-casescenario”),graftsofpatientslosttofollow-upwerenotintact(“worst-casescenario”),comparisonoftheKaplan-MeiercurvesrevealeddistinctlybetterresultsafterACIthanaftermosaicplasty.Deteriorationoftheresultsaftermosaicplastystartedatapproximately2yearspostoperatively.126Basadetal.152analyzedtheresultsofa2-stepprocedureusingautologousbonegraftsimplantedintothedefectpriortothecellseededscaffoldprocedurewithadouble-layertechnique.Alltheirpatientshadadistinctmeanimprovement24monthspostoperatively.Twootherstudies,153,154bothusinga1-stepprocedureandcell-seededcollagenscaffoldorchondrocytesinagel(CaReS,exampleinFig.6),demonstratedasignificantimprovementafterafollow-upofupto36monthsinalloftheOCDpatients.Steinhagenetal.153showedacontinualimprovementfrompreoperativeto3monthspostoperativelyandlonger(upto36monthspostoperatively)inalloftheOCDpatients.Thesizeofthelesionsmeasuredupto12cm2and9cm2inthestudiesbySteinhagenetal.153andOchsetal.,154respectively.Toourknowledge,thereisonly1level-Istudycomparingmorethan2techniques.123Theseauthorsdescribedaveryinteresting,prospective,randomizedtrialonJOCDandAOCDpatients.Thetrialcomparedthefollowingprocedures:MassiveautologousosteochondraltransplantsAutologousbone-cartilage-pastegrafts,Autologouschondrocytetransplantation(secondgeneration)incombinationwithabonegraftBiomimeticosteochondralscaffoldsBonemarrow–derivedcelltransplantation.Inatotalof60patients,theydidnotfindsignificantdifferencesbuttherewasatendencytowardbetterresultsinJOCDpatients.123Overall,theIKDC(InternationalKneeDocumentationCommittee)objectivescoreincreasedfrom37%preoperativelyto97%atthelastfollow-up.However,thefollow-uptimevariedfrom2.3years(bonemarrow–derivedcells)to12.2years(massiveosteochondralgrafts)andthenumberofpatientsinaparticulargroupfrom7(bone-derivedcellimplantation)to28(chondrocyteswithbonegrafts).TheonlydifferenceamongtheresultsofthedifferenttechniqueswasatrendtowardbetterresultsfollowingACI(0.06).123AllograftsFormanyyearsfresh,fresh-frozenorstoredallograftshavealsobeenusedinadvancedkneeOCDlesions.154-161Fresh,refrigeratedallograftsarethestandardchoiceforosteochondralallograftssincefrozenandfreeze-driedcartilagehasinsufficientviablecartilagecells.142,162Whentherefrigeratedallograftisfresh,upto98%ofthechondrocytesareviablefor7days;thisdecreasesto70%by28days.65,163Thedecreasedviabilityisaccompaniedbydiminishedcelldensityanddecreasedmetabolicactivity.65,164Thematrixandchondrocyteshavebeenshowntosurviveinlong-termrecoverystudies.142However,extensiveserological,bacterial,andviraltestingofgraftsisnecessarypriortoallografttransplantationuntilnegativetestresultshavebeenensured.Donorsmustbescreened.Around-the-clocktransplantationservicemustbeavailable.142,165Furthermore,theimmunogenicityandunplannedtransferofdiseaseshasnotyetbeenfullyeliminated.However,theriskofHIVtransmissionisestimatedtobeaslowasapproximately1in1.6million,andtherehavebeennoreportsofthisrouteofdiseasetransmissionsincethelate1980s.142,165Whilechondrocytesarepreservedagainstimmunologicalreactionsbythematrixcells,cellsinthebonypartofthegraftshouldberemovedtoagreatextent.Incontrasttothecartilage,whichseemstobecompletelyintegrated,bonyintegrationcanbeacauseoffailure.142Thereare2studiesreportingexclusivelyonOCD;otherpublicationsincludeupto45%OCDpatients.Ononehand,arelativelyhighsuccessrateisdescribedforOCDpatientswithasurvivalrateofbetween72%after7.7years159and,at10years,82%.Thesurvivalratedecreasesto66%after20years(45%OCDlesions).160Ontheotherhand,in15%to47%,thereisahighrateoffailureand/orthenecessityoffurtheroperations.154,158TheuseofallograftsinJOCDwasreportedbyLyonetal.161;aftersurgery,patients(meanage15.2years)hadreturnedwithin6monthswithoutdifficultytotheactivitiesofdailylivingand,betweenthe9thand12thmonthtofullsportsactivities.Aretrievalanalysisof26specimensfrom14patientsrevealed82%viablechondrocytesafterasurvivalof42months.Histologically,allspecimensshowedsomecartilagefibrillationbutnosignsoftransplantrejection.166Long-termResultsafterDifferentTreatmentsTherearealargenumberofarticleswithameanfollow-upofbetween5and34years.5,14,59-61,87,107-109,111,133,135,166-170Thearticlesincludedatleast2longitudinalstudiesinwhichpatientswereexaminedtwice.107,109However,allthearticlesareonlylevelIV,whichmeansthattheinterpretationofthelong-termresultsisdifficult,particularlysincetheauthorsmaybebiased.107,108,112RegardingexcisionorremovalofOCDfragments,resultsrevealedacleartendencytowardpoororfairresultsafteraperiodof10to20years.166,170Michaeletal.108observedexcellentandgoodresultsinonly35%after28yearsmostlyfollowingexcisionwitharateofOAof92%.SimilardatawerementionedbyTwymanetal.109OnereportonexclusivelylateralcondylarOCD105describedamoderateOAbutbetterclinicalresults14yearsafterarthroscopicexcisionandsubchondraldrillinginmostofthepatients(22/28kneejoints).Incontrast,resultsafterfragmentrefixationwereexcellentorgoodin85%to92%ofpatientsafter5to15years.57ItseemsthatrefixationresultsinadistinctlylowerrateofOAandatafollow-upof34years,arateof35%ofmoderateOAwasseen.111,112Sofarascomparisonispossible,reconstructivetherapieshaveatendencytobetterlong-termresultswithalowerrateofOA,asisdescribedforOAT133:Mostofthepatients(48%)exhibitthesamepostoperativegradeofOAafter8.1yearswhencomparedwithpreoperatively,and34%exhibitedanimpairmentofonegrade.Petersonetal.148referredtoexcellentorgoodclinicalresultsafterACIin91%of58patientswithameanfollow-upof5.6yearsbutalsomentionedsignsofOAinnearly50%.Long-termresultsafterrepairwithallograftsshowedarelativelyhighrateofsuccesswithasurvivalrateof72%after7.7years(allOCDlesions)and82%after10years.158However,itwasonly66%after20years(45%OCD)160andtherewasahighfailurerateand/orreoperationsbetween15%upto47%.155,159,160,171ComorbiditiesMalalignmentSeveralauthorshavereportedontherelationbetweenmedialOCDlesionsinthekneejointandvarusmalalignmentaswellasbetweenlaterallesionsandvalgusmalalignment.26,96,135,142,172-176Jacobietal.173analyzedthebilateralfull-legradiographsoftheirpatientsandfoundthatOCDlesionsanddeviationofthemechanicalaxisinthevarusorvalguswerecorrelatedsignificantlywithmedial(varus)andlaterallesions(valgus),respectively.Thedifferencebetweenaffectedandunaffectedlegswasalsosignificantforlateralbutnotmediallesions.Subsequently,correctionofthemalalignmentshouldbeconsideredasanadditionaltherapeuticgoal,moreforvarusthanforvalgusmalalignment.Slawski176reportedon6AOCDpatientssufferingfromavarusmalalignmentin7oftheirkneeswithahigh-tibialosteomyandachievedadistinctimprovementofthepostoperativeLysholmscore.ACLInstabilityandMeniscalLesionsACLinstabilityormeniscallesionsshouldalsobetherapeuticallyaddressed.133,135,142,143Hangodyetal.135reportedarateof85%concomitantsurgicalinterventions.ThemajorityoftheseprocedureswereACLreconstructions,realignmentosteotomy,meniscalsurgery,orpatellofemoralrealignment.TherearereportsonthecombinationofOCDlesionsatthelateralfemoralcondylewithadiscoidmeniscus,andthedevelopmentofanOCDlesionafteratotalmeniscectomyofadiscoidmeniscus.75Subsequently,inouropinion,discoidmeniscishouldbesurgicallyreducedtothesizeofanormalmeniscus.However,atotalmeniscectomyofdiscoidmeniscicanalsoresultinthedevelopmentofanipsilateralOCDlesion.76ConclusionOCDremainsanetiological,histological,andtherapeuticmystery.ThereismuchconfusionregardingtheclassificationanddefinitionofOCDlesionsandtheirdifferentiationfromothers,aswellaswithregardtoacleardefinitionofJOCDandAOCD.Furthermore,therearenoclearandscientificallywell-basedrecommendationsastowhichtherapeuticstrategyshouldbeused.Inaddition,aclearanduniformlyuseddefinitionoftheclinicalandradiographicalsuccessand/orhealingisstillmissing.AlthoughthereareatremendousnumberofpublicationsonallaspectsregardingOCDindifferentjoints,thereisagreatlackofscientificallyreliableprospectiverandomizedstudies.Confusionstillremains,atleastforOCDlesionsintheknee,andisexpressedinthe“SummaryofRecommendations”inthepublication“TheDiagnosisandTreatmentofOsteochondritisDissecans”elaboratedbyaworkinggroupofthe“AmericanAcademyofOrthopaedicSurgeons”andpublishedbyChambersetal.2,177Theyfoundthatthestrengthofrecommendationsregarding16differentaspectswasinconclusivein10andweakin2.Onlyin4aspectsdidthegroupfindconsensus.Inthefuture,itshouldbeaninternationalaimofinstitutionsdealingwithosteoarticulardiseasestodevelopaprotocolforprovidingmoresatisfactorydatathanthoseobtainedfromlevel-IVstudies,thesebeingoflittlescientificworth.2022年10月28日
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