Talus Osteokondral Lezyonları
Özet
Talus osteokondral lezyonları (TOKL), ayak bileği ve talustaki subkondral kemik ile kıkırdağı etkileyen, idiyopatik veya travmaya bağlı gelişen patolojilerdir. Ayak bileği kırıklarında %73, burkulmalarda ise %50 oranında görülen bu lezyonlar, kıkırdağın düşük iyileşme potansiyeli nedeniyle zorlu bir tedavi sürecine sahiptir. Tanıda 4-6 haftadan uzun süren ağrı, şişlik ve kilitlenme semptomları önemlidir. Teşhiste direkt grafi %50 oranında yetersiz kalabilirken, BT subkondral kistleri, MRG ise eklem kıkırdağını ve kemik iliği ödemini değerlendirmede etkindir. Lezyon boyutu prognozu belirleyen en önemli faktör olup 15 mm'den büyük alanlar kötü prognoz gösterir. Tedavide altın standart bulunmamakla birlikte; 1 cm'den küçük lezyonlarda eksizyon, küretaj ve debritman uygulanırken, kemik iliği uyarımı (mikrokırık) teknik olarak basit ve ucuz bir birincil seçenektir. Daha geniş ve diğer tedavilere yanıt vermeyen defektlerde hücresiz çatı implantları (scaffold), otolog kondrosit implantasyonu (OKİ), matriks ilişkili otolog kondrosit implantasyonu (MOKİ) ile mozaikoplasti gibi gelişmiş rejeneratif cerrahi yöntemler ve greftleme teknikleri tercih edilmektedir. İleri yaş, sigara kullanımı ve yüksek vücut kitle indeksi gibi faktörler iyileşmeyi olumsuz etkilerken, cerrahi sonrası cerrahın tercihine ve uygulanan işleme bağlı olarak 1 ila 8 hafta arasında immobilizasyon ve fizik tedavi iş birliği içeren rehabilitasyon protokolleri uygulanmaktadır.
Osteochondral lesions of the talus (OLT) are pathologies involving the subchondral bone and cartilage in the talus and ankle joint, arising either idiopathically or secondary to trauma. These lesions, observed at a rate of 73% in ankle fractures and 50% in sprains, present a challenging treatment process due to the low healing potential of the cartilage tissue. Symptoms such as pain, swelling, and locking persisting for more than 4-6 weeks are crucial for diagnosis. While direct radiography can miss up to 50% of cases, CT provides detailed information regarding subchondral cysts, and MRI is highly effective in evaluating articular cartilage and bone marrow edema. The lesion size is the most critical prognostic factor, with lesions larger than 15 mm indicating a poor prognosis. Although there is no gold standard in treatment, excision, curettage, and debridement are preferred for lesions smaller than 1 cm, whereas bone marrow stimulation (microfracture) remains a primary, cost-effective, and technically simple option. For larger or non-responsive defects, advanced regenerative surgical methods and grafting techniques, including acellular scaffolds, autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), and mosaicplasty, are utilized. Factors such as advanced age, smoking, and a high body mass index negatively affect recovery, and rehabilitation protocols involving immobilization between 1 to 8 weeks and physical therapy collaboration are implemented postoperatively depending on the surgical procedure and the surgeon's preference.
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