| BackgroundOsteochondral lesions of the talus(OLTs)is a common sports injury involving articular cartilage and subchondral bone,which is one of the challenges in the field of sports medicine.More than 50% of ankle sprains or ankle fractures are associated with osteochondral injuries of varying degrees [1,2].Berndt and Harty[3] first classified OLTs into 4 types based on X-ray findings,and Hepple et al [4] defined the MRI findings of subtalar bone cystic changes as Hepple type Ⅴ based on this classification.Some OLTs performed for the process of continuous progress,namely the destruction of the cartilage and subchondral bone plate integrity may cause joint fluid infiltration and formation of cystic change,because the subchondral bone for articular cartilage nutrition support and mechanical support,lesions cystic change can lead to increasing the scope of cartilage stripped,may eventually develop osteogenesis and even collapse of talus [1,5].It seriously affects the normal life and function of patients.For some OLTs,conservative results are poor and surgical treatment are required.At present,the effect of surgical treatment is different,and the choice of surgical method is controversial.Cartilage repair technology represented by microfracture [6] is the current firstline treatment with advantages of less trauma and faster recovery.However,the repair effect of this operation is closely related to the degree of lesion,and this operation is not suitable for OLTs with lesion diameter > 10 mm,depth > 5mm and Hepple type Ⅴ.Autologous osteochondral transplantation(OAT)[7] is an osteochondral replacement technology,which can be applied to Hepple type ⅤOLTs with a wide range of lesions due to the simultaneous reconstruction of articular cartilage and subchondral bone.However,due to the need to obtain a graft from the knee,there is a high incidence of postoperative donor site pain.Recent studies have shown that OAT donor site complication rates are as high as 10% to 54.5%[9-11].Autologous chondrocyte transplantation(ACI)[8] is a kind of technology which significantly reduces the amount of autologous cartilage obtained through in vitro culture and amplification and effectively reduces the donor site complication rate.However,due to high technical requirements,high price and ethical limitations,such technology is difficult to be widely applied in clinical practice in the short term [12].Therefore,effective repair of osteochondral injury is still a challenge in sports medicine and osteology,especially for Hepple type ⅤOLTs with large cartilage injury area,a safe and effective method to promote cartilage repair is still needed to provide new experimental evidence and ideas for cartilage injury repair.As a kind of transplantable tissue,the periosteum has the potential to repair cartilage damage.Studies have shown that there are periosteum stem cells in the periosteum,which are confirmed to be located at the top of differentiation and have the dual characteristics of osteogenesis and chondrogenesis [13-15].Niedermann [16] first reported the clinical and secondary arthroscopic results of applying free periosteum in the treatment of cartilage injury of knee joint,confirming the role of free periosteum in repairing cartilage injury.However,postoperative clinical follow-up suggested several problems with free periosteum transplantation,including inability to repair subchondral bone cystic changes,the need for additional fixation,low survival after transplantation,and periosteum detachment.Periosteum-bone complex transplantation,as an improved way of periosteum transplantation,has strong theoretical feasibility to solve the above problems.Firstly,this method requires no additional fixation,and the stability of the periosteum after transplantation can be maintained by the combination of the graft and the bone interface and the natural fiber connection between the periosteum and bone.Secondly,the bone tissue beneath the graft provides nutritional support to the periosteum,improving the survival rate after the graft.Thirdly,this method can simultaneously repair the lesions of subchondral bone and is suitable for the Hepple type Ⅴosteochondral lesions of talus [14-15].On the basis of previous studies,the project group designed Autologous tibial osteoperiosteal transplantation(ATOPT)for the treatment of osteochondral injury of Hepple type Ⅴtalus.However,due to the relatively short application time of this technique,existing studies have the following problems.Firstly,there is insufficient clinical data to prove the effectiveness of this technique.Secondly,for osteochondral injury of the shoulder of talus,traditional periosteum-bone complex transplantation is difficult to reconstruct the surface curvature of talus.Thirdly,the histological properties of regenerated tissues after transplantation are lacking in large animal experiments.Based on the above problems,this study will carry out relevant research from the following three aspects.Firstly,to evaluate the clinical effect of ATOPT in the treatment of Hepple typeⅤosteochondral lesions of talus through postoperative follow-up.Secondly,the traditional ATPOT method was modified(including surgical instruments and surgical methods)to improve the graft integrity and talus matching degree,and to provide the optimal treatment for osteochondral injury of the talus shoulder.Thirdly,through the establishment and study of large animal model,the properties of regenerated tissue after autologous periosteum-bone complex transplantation were verified from the histological perspective.Part I: Clinical efficacy analysis of autologous tibial osteoperiosteal transplantation for the treatment of Hepple type V osteochondral Lesions of the talus1.1 ObjectiveTo evaluate the postoperative clinical efficacy and cartilage repair through clinical function score,imaging results and secondary arthroscopic exploration.1.2 Data and methodsA retrospective analysis of Hepple typeⅤOLTs patients who received autologous tibial osteoperiosteal transplantation at the Sports Medicine Center of the First Affiliated Hospital of Army Military Medical University from October 2011 to January 2019.The preoperative and postoperative functional scores and imaging results were compared,and the postoperative secondary arthroscopy was used to evaluate the cartilage repair on the surface of the graft area.1.3 results1.3.1 Clinical function evaluation resultsThirty patients who met the inclusion and exclusion criteria were included in this study,including 19 males and 11 females,aged from 18 to 60 years,with an average of(40.2 ± 11.3)years.The follow-up time was 2-10 years,and the lesions were all medial.FAOS score increased from 53.5±6.2 before operation to 88.4±6.6 at the last follow-up,with significant statistical difference(P <0.001),AOFAS increased from 61.6±8.2 before operation to 90.8±6.8 at the last follow-up,with significant statistical difference(P <0.001).VAS score decreased from 4.3±0.2 points to 0.7±0.7 points before and at the last follow-up(P<0.001).1.3.2 Imaging ResultsX-ray results: No obvious degenerative changes were found in the last follow-up of all cases,except for 1 patient with slight narrowing of ankle joint space compared with the preoperative level,and osseous healing on the osteotomy surface.MRI results: The signal range of bone marrow edema after surgery was significantly smaller than that before surgery,and gradually decreased with time.The last follow-up showed that the bone marrow edema signal disappeared completely in 24 cases(80%),1 case(3.4%)was confined to the transplant site,and 5 cases(16.7%)were confined to the surrounding area of recurrent cystic changes.The MOCART score was 66.00±3.01 at 1 year after surgery,and 69.00±4.01 at the last follow-up.1.3.3 Results of secondary arthroscopic explorationTwenty patients underwent secondary arthroscopic exploration,and the results showed that all grafts formed smooth surface regeneration tissue on the surface of cartilage defects,with white color and soft texture,and fused edges with adjacent cartilage.ICRS score was10.51±1.3.1.4 ConclusionsIn this study,the long-term clinical efficacy of ATPOT in the treatment of Hepple typeⅤOLTs was confirmed,and the regenerated tissue was confirmed to be hyaline-like cartilage tissue by secondary joint exploration.Part II: Comparative analysis of modified and traditional autologous tibial Osteoperiosteal transplantation for the treatment of Hepple type Ⅴ osteochondral lesions of the talar shoulder2.1 ObjectiveTo determine whether modified autologous tibial osteoperiosteal transplantation can improve graft integrity and talus fit,thus providing a new treatment strategy for Hepple typeⅤ osteochondral lesions of the talar shoulder.2.2 Data and methods2.2.1 Inclusion methodTwenty patients with Hepple typeⅤ osteochondral lesions of the talar shoulder who underwent surgery at the Sports Medicine Center of the First Affiliated Hospital of Army Military Medical University from September 2019 to August 2021 were prospectively enrolled.Ten patients received conventional ATOPT and 10 patients received modified ATOPT.2.2.2 Surgical methodsTraditional group: same as part 1Modified group: Based on preoperative CT data,computer simulation of the surgical process was used to determine the best surgical plan,including the Angle of osteotomy,the Angle and depth of lesion removal,and the location,direction and depth of graft acquisition.The optimal graft acquisition scheme was determined by indirect method,that is,by computer fitting technology,the matching degree between the grafts obtained from different positions and angles and the lesion clearance tissues in the recipient area was evaluated.The procedure was performed using a second-generation periosteum-bone complex acquisition/implant tool according to the preoperative protocol.2.3 results2.3.1 Intraoperative graft integrity evaluation resultsIntraoperative evaluation of periosteum-bone complex integrity in the traditional group was excellent in 2 cases(20%),good in 3 cases(30%),moderate in 3 cases(30%),and poor in 2 cases(20%).The integrity evaluation of periosteum-bone complex in the improved group was excellent in 6 cases(60%),good in 3 cases(30%),moderate in 1 case(10%)and poor in0 cases(0%),with significant statistical difference(P <0.05).2.3.2 CT results 3 months after surgeryPostoperative CT indicated that the grafts in both groups were embedded into the recipient area to achieve primary bone-bone interface healing.The graft matching degree in the modified group was significantly better than that in the traditional group.2.4 conclusionsCompared with the traditional method,the modified periosteum-bone complex transplantation has a better match with the surface curvature of the talus,better graft integrity,and better postoperative imaging follow-up results.Part III: Animal model study of autologous tibial Osteoperiosteal transplantation for osteochondral lesions3.1 PurposeThe properties of regenerated tissues after ATPOT were verified from the histological perspective,and the reconstruction of subchondral bone was analyzed.To compare the effect of different transplantation sites on the therapeutic effect.3.2 Data and methods3.2.1 Modeling methodEighteen fragrant pigs were randomly divided into three groups with six pigs in each group.All the experimental animals were randomly selected to one side of the experimental group,namely the autoperiosteum-bone complex graft group,and the other side of the control group,namely the autogenous bone graft group.Osteochondral defects(8mm in diameter ×15mm in depth)were created on the medial femoral condyle and medial femoral trochlea respectively.In the experimental group,a column of periosteum-bone graft(8mm in diameter× 15 mm in depth)was obtained from the same position at the proximal tibia of both sides,and the graft was implanted into the the medial femoral condyle and medial femoral trochlea respectively.Control group: a column of periosteum-bone graft(8mm in diameter × 15 mm in depth)was obtained from the same position at the proximal tibia of both sides,and the periosteum on the graft surface was completely removed,and bone grafts were implanted in the same way as the experimental group.3.2.2 Observation IndicatorsThe experimental animals in the three groups were sacrificed at 6,12 and 24 weeks postoperatively.The graft effect was evaluated by gross view,magnetic resonance,micro CT and histological staining.3.3 resultsExperimental group general view,magnetic resonance,the results of histological staining at three time points in significantly better than the control group,In the experimental group,cartilage repair tissues continued to mature over time.From the number,morphology and distribution of chondrocytes,as well as the contents of extracellular matrix,type I collagen and type II collagen and other histological evaluation indexes,the results of the experimental group on the medial femoral condyle at 24 weeks were closest to hyaline cartilage.Micro-ct results suggested that the experimental group showed more obvious subchondral bone reconstruction,which was manifested as bone density,bone volume fraction,bone trabecular number and other indicators were significantly different from those before transplantation.3.4 conclusionsBy autologous periosteum-bone complex transplantation,periosteum can proliferate,differentiate and mature in the grafted area to repair cartilage defects.In addition,the periosteum rebuilds subchondral bone through endochondral osteogenesis.In the osteochondral defect model of the knee joint,the periosteum-bone complex transplantation can achieve better cartilage repair at the medial condyle of the femur,while the subchondral bone reconstruction is more obvious. |
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