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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)見于生長(zhǎng)板開放的兒童和青少年（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。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)疾病的常見原因，當(dāng)一小塊軟骨下骨由于局部血液供應(yīng)障礙而開始與其周圍區(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c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)?？梢詫兠撔怨擒浌茄譕CD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常見的發(fā)病過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)分開來(lái)。病變中心被認(rèn)為是骨壞死（參見“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，就可以通過爬行替代進(jìn)行愈合。游離體組織學(xué)檢查顯示肥大常見，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有骨小梁的軟骨取代?！毕啾戎?，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?？傊?，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?？赡軙?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線在開始使用MRI之前，最初的變化只能通過骨掃描檢測(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)（參見關(guān)節(jié)鏡分類）。為了改進(jìn)評(píng)估（結(jié)果），還可以通過在檢查前，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?？梢酝ㄟ^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，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狀半月板相關(guān)。外側(cè)髁的病變可以主要與盤狀半月板或繼發(fā)于盤狀外側(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，據(jù)我們所知，沒有明確的答案。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有表現(xiàn)出退行性變化。Hughston等建議正常活動(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之間沒有明確的區(qū)別，評(píng)分系統(tǒng)和后續(xù)標(biāo)準(zhǔn)也沒有得到一致的遵守。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?。?，而接受鑲嵌成形術(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)）都可以通過關(guān)節(jié)切開術(shù)、小型關(guān)節(jié)切開術(shù)或關(guān)節(jié)鏡來(lái)完成。使用這兩種技術(shù)，開放式術(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)切開術(shù)后本體感覺受到干擾和康復(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。沒有觀察到供體部位的發(fā)病率和移植區(qū)域邊緣的問題。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。考慮到剝脫性骨軟骨炎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，沒有對(duì)那些有骨移植物和沒有骨移植物的人進(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等比較了通過關(guān)節(jié)切開術(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)?？傮w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]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%。活力降低伴隨著細(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?。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病變與盤狀半月板合并，以及在盤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，盤狀半月板應(yīng)通過手術(shù)縮小至正常半月板的大小。然而，盤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?，并且在“美?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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