Atraumatic osteonecrosis of the talus
Atraumatic osteonecrosis of the talus
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DOI：
10.2106/00004623-199804000-00009
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发表时间：
1998-04-01
影响因子：
5.3
通讯作者：
Hungerford, DS
中科院分区：
文献类型：
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作者：
Delanois, RE;Mont, MA;Hungerford, DS
从1974年7月1日至1996年12月31日，24名患者的37个踝关节在我所接受治疗，原因是距骨无创性骨坏死。这一群体代表了在此期间接受治疗的1056名骨坏死患者的2%。有21名女性和3名男性，诊断时他们的平均年龄为40岁(范围从26岁到62岁)。24例患者中有13例(54%)为双侧受累。16名患者(67%)患有影响免疫系统的疾病，包括系统性红斑狼疮(13名患者)、硬皮病(1名)、胰岛素依赖型糖尿病(1名)和多发性硬化症(1名)。四名患者有规律饮酒史，四名患者有中度吸烟史。一名患者患有蛋白质S缺乏症，一名患者曾接受过肾移植，一名患者有哮喘史。两名患者没有可识别的骨关节病危险因素。15名患者(63%)有其他大关节受累，患者出现症状前的平均病程为5.4个月(由两个月至两年不等)。根据Mazur等人的系统，出现时的平均踝关节评分为34分(范围为2至75分)。放射学检查显示，根据Ficat和Arlet的系统，8个脚踝在出现时有III或IV期距骨疾病。其余29个脚踝为II期疾病。在23个有磁共振图像的踝关节中，22个可见距骨圆顶后外侧的骨坏死(矢状位图像上的III和IV区，冠状位图像上的II区、III区和IV区)。在剩余的踝关节中，骨坏死见于距骨穹隆的前内侧(矢状位图像上的I区和II区，冠状位图像上的I区)。对11个脚踝进行了骨扫描，发现距骨摄取增加。所有患者最初都接受了限制负重、踝足矫形器和使用止痛药的非手术治疗；两个脚踝对这种方案有反应。32个仍有严重症状的踝关节接受了髓芯减压术，这在治疗塌陷前期(II期)疾病中是有用的。其中29个踝关节的临床结果为一般至优秀，平均术后7年(2~15年)；其余3个踝关节在核心减压术失败后行关节融合术。三个脚踝最初接受关节融合术治疗后塌陷(M期或IV期)疾病。所有6个关节融合的踝关节术后平均7个月(5~9个月)融合。当有骨坏死史的患者因踝关节疼痛而出现时，应考虑距骨骨坏死的诊断。早期发现可以通过非手术或髓核减压术治疗踝关节，从而减少关节融合术的需要。我们还认为，当患者有距骨坏死时，应该使用标准的X线片或磁共振成像，或两者兼而有之地对髋部进行筛查。
Thirty-seven ankles in twenty-four patients were treated at our institution between July 1, 1974, and December 31, 1996, for atraumatic osteonecrosis of the talus. This group represents 2 per cent of the 1056 patients who were managed for osteonecrosis during this period. There were twenty-one women and three men, and their mean age was forty years (range, twenty-six to sixty-two years) at the time of the diagnosis. Thirteen (54 per cent) of the twenty-four patients had bilateral involvement. Sixteen patients (67 per cent) had a disease that affects the immune system, including systemic lupus erythematosus (thirteen patients), scleroderma (one), insulin-dependent diabetes mellitus (one), and multiple sclerosis (one). Four patients had a history of regular alcohol use, and four patients had a history of moderate smoking. One patient had a protein-S deficiency, one patient had had a renal transplant, and one patient had a history of asthma. Two patients had no identifiable risk factors for osteoarthrosis. Fifteen patients (63 per cent) had involvement of other large joints.The mean duration of symptoms before the patients were seen was 5.4 months (range, two months to two years). The mean ankle score at the time of presentation was 34 points (range, 2 to 75 points), according to the system of Mazur et al. A radiographic review revealed that, according to the system of Ficat and Arlet, eight ankles had stage-III or IV disease of the talus at presentation. The remaining twenty-nine ankles had stage-II disease. The osteonecrosis was seen in the posterolateral aspect of the talar dome (zones III and IV on the sagittal images and zones II, III, and IV on the coronal images) in twenty-two of the twenty-three ankles for which magnetic resonance images were available. The osteonecrosis was seen in the anteromedial aspect of the talar dome (zones I and II on the sagittal images and zone I on the coronal images) in the remaining ankle. Bone scans, which were available for eleven ankles, revealed increased uptake in the talus.All patients were initially managed non-operatively with restricted weight-bearing, an ankle-foot orthosis, and use of analgesics; two ankles responded to this regimen. Thirty-two ankles that remained severely symptomatic were treated with core decompression, which was useful in the treatment of precollapse (stage-II) disease. Twenty-nine of these ankles had a fair-to-excellent clinical outcome a mean of seven years (range, two to fifteen years) postoperatively; the remaining three ankles had an arthrodesis after the core decompression failed. Three ankles were treated initially with an arthrodesis for postcollapse (stage-m or IV) disease. All six of the ankles that had an arthrodesis fused, at a mean of seven months (range, five to nine months) postoperatively.When patients who have a history of osteonecrosis are seen because of pain in the ankle, the diagnosis of osteonecrosis of the talus should be considered. Early detection may allow the ankle to be treated non-operatively or with core decompression and thus reduce the need for arthrodesis. We also believe that when a patient has osteonecrosis of the talus, the hips should be screened with use of standard radiography or magnetic resonance imaging, or both.