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陶可主治医师 北京大学人民医院 骨关节科 骨软骨损伤:软骨损伤手术修复后我的活动水平如何?WhatismyActivityLevellikeafterCartilageRepair? 陶可(北京大学人民医院骨关节科)图1.典型的膝关节股骨髁软骨损伤的大体观表现:软骨剥脱,软骨下骨囊性变等,同时可能合并有半月板损伤、前后检查韧带损伤等。图2.典型的关节软骨剥脱损伤的关节镜下表现(左侧),微骨折技术是修复关节软骨缺损的金标准(右侧),但往往需要与其他的技术,如ACI、AMIC等协作发挥作用。图3.典型的髌骨软骨剥脱损伤的大体观表现(左侧),对关节软骨边缘进修修复后,采用微骨折技术诱导软骨下骨渗出含有大量骨髓间充质干细胞的血液填充缺损区域(右侧)。图4.典型的髌骨软骨剥脱损伤的大体观表现(左侧),对关节软骨边缘进修修复后,采用微骨折技术诱导软骨下骨渗出含有大量骨髓间充质干细胞的血液填充缺损区域联合Chondrogide软骨膜修复技术对缺损处进行修复(右侧)。 关节软骨损伤通常与关节功能的显着降低有关,并且经常导致功能和活动的减少(活动受限制),特别是在参与剧烈运动(跑跳、竞技)的高需求运动患者中。关节软骨损伤可能急性(快速)或慢性(长期)发展,但与一般人群相比,运动活跃的患者引起症状和局限性的频率是普通人群的2倍多。对于一般患者,尤其是运动员而言,恢复正常体育活动的能力是关节软骨修复后最重要的功能结果。由于不同体育锻炼和参与体育强度的水平之间的活动需求不同,因此,详细了解每位运动员受伤的严重程度和治疗干预的潜在成功率,对于优化恢复能力和达到现实期望至关重要。目标受众(阅读者)本文适用于任何关节软骨受损的人士及其家人,他们想了解软骨修复后的活动水平,以及任何对软骨问题感兴趣的人群。软骨修复后如何测量活动强度?许多用于评估关节软骨修复后的功能结果评分已被开发和验证。在上述各种可用的结果测量中,国际软骨修复协会ICRS评分(https://www.cartilage.org/index.php?pid=223)、国际膝关节研究委员会(IKDC)评分以及膝关节损伤和骨关节炎结果评分(KOOS)评分被认为是软骨修复患者中非常重要的3种评分。这些基于患者的、经过验证的评分通常使用带有一系列问题的标准化问卷。根据患者的反馈,他们用以计算表明患者整体功能的数字分数。其中一些分数包括允许对体育相关活动进行更具体评估的子项分数。除了一般分数外,还制定了特定活动分数,例如衡量特定体育活动的Tegner分数和每个分数可以达到的水平。同样,Marx活动评分量表使用患者进行运动中经常包含的活动能力来计算功能水平。所有这些经过验证的分数都有助于比较和评估软骨修复手术后的患者。虽然它们提供了重要的科学信息,但这些评分并没有为患者提供有关其术后关节功能的实用测量值。例如,55分的国际软骨修复协会ICRS评分可能有助于临床医生比较术前和术后功能,但对于接受治疗的患者可能不是一个有意义的参数。相比之下,为患者提供描述返回已知体育活动的可能性的百分比,甚至是与先前活动相比的预期体育参与水平,为运动患者提供了一个实用的工具,来评估他们对手术的现实期望。它还提供了有用的数据,可以帮助做出有关手术或非手术治疗的决策,以及评估恢复关节软骨的治疗策略的选择。患者在软骨修复后的恢复和活动方面可以期待什么?有几个因素使患者更有可能恢复运动或以前的活动。重返运动的机会因人而异,例如,年龄是一个非常重要的参数。年轻患者往往做得更好,这主要是由于他们更活跃的细胞代谢以及在治疗的关节软骨缺损内产生新的软骨修复组织的更好能力。一些研究表明,无论使用哪种技术,30-40岁以下的患者在进行软骨修复手术后,都会有更高的活动水平和功能。受伤前的活动水平也起着重要作用。多项研究表明,软骨损伤或软骨手术前较高的活动水平与之后的较高活动水平相关。与在不那么竞争或娱乐水平上进行相同运动的人士相比,更具竞争力的运动员有更高的运动回归率。这被认为是由不同程度的回归运动、社会状况和获得康复资源的动机引起的,这些可能因业余运动员和竞技运动员或职业运动员而异。重要的是,在软骨修复手术后,更专业水平的运动员可以恢复充分的活动,并能够在各种运动中承受极高的冲击负荷,这一事实非常令人鼓舞,但同样,这可能更多是由于职业运动员整体(恢复的就好),而非对软骨手术的具体反应(在同样专业的软骨手术基础上,职业运动员恢复的整体要好一些)。另一个非常重要的参数是患者在接受治疗前软骨损伤的时间(受伤后多久开始的治疗)。现在多项研究表明,如果患者受伤超过一年,恢复到相同活动水平的机会比受伤时间少于12个月的要低得多。这似乎与受影响关节中退化环境的发展有关,这抑制了新的软骨再生。此外,体育参与的长期减少也起到了一定的作用。另一个起作用的因素是软骨缺损的大小。小缺损通常与更高概率的恢复正常体育活动有关。我们在一些研究中确定的临界水平是小于2-3厘米的软骨缺损有更好的成功修复机会。较大的缺陷不太可能允许重返运动,但较大缺陷的成功率仍然令人鼓舞。此外,软骨修复技术的选择会影响恢复运动的能力和继续参加运动的可能性。据报道,运动人群恢复体育活动的平均比率分别是:自体软骨细胞植入(ACI)(74%)、微骨折(68%)、自体骨软骨移植(91%)和同种异体骨软骨移植(88%)。最近对软骨修复技术的系统评价表明,65%的运动员在软骨修复后恢复到受伤前的水平,不同技术之间没有显着差异。已经开发了几种第二代技术,包括基质相关(MACI)或支架增强微骨折,并且已发现与第一代技术相比具有相似的运动恢复率。除了重返运动的能力之外,继续比赛的能力是另一个重要的结果参数。虽然在52个月后接受ACI治疗的运动员中有87%观察到出色的运动活动持久性,但在运动员使用微骨折或自体骨软骨移植治疗后,继续运动活动受到更多限制。患者可以从康复计划中得到什么?康复可能因所使用的修复技术以及是否单独进行软骨修复手术而异。通常,软骨修复技术与其他手术相结合,例如前交叉韧带(ACL)重建或截骨术,以解决相关的膝关节病变,例如不稳定或下肢力线异常。如果最初导致软骨问题的相关病理因素没有得到纠正,软骨修复通常会受到限制并且不太成功。相关手术可能对患者康复产生影响。一般来说,如果患者有单纯的软骨缺损,最重要的方面是教育他们康复会很慢。根据软骨缺损特征和修复技术,通常在手术后2到6周内会有一些负重限制。由熟悉软骨修复手术的经验丰富的物理治疗师指导的逐步增加也至关重要。Injurytojoint(articular) cartilage isoftenassociatedwithasignificantreductioninjointfunction,andfrequentlyresultsinadecreaseinfunctionandactivities,particularlyinhigh-demandathleticpatientsparticipatinginimpactsports.Articularcartilageinjuriesmaydevelopacutely(quickly)orchronically(overalongperiod),buthavebeenshowntocausesymptomsandlimitationsmorethantwiceasofteninactivepatientscomparedtothegeneralpopulation.Forpatientsingeneral,butparticularlyforathletes,theabilitytobeactiveandreturntosportingactivitiespresentsthemostimportantfunctionaloutcomefollowingarticular cartilagerepair.Sinceactivitydemandsaredifferentbetweendifferentsportsandlevelofsportsparticipation,adetailedunderstandingoftheseverityoftheindividualathlete’sinjuryandthepotentialsuccessrateofthetherapeuticinterventioniscriticaltooptimisetherecoverypotentialandmanagerealisticexpectations.IntendedaudienceThisarticleisintendedforanyonesufferingfromdamagetotheirarticularcartilageandtheirfamilieswhowouldliketofindoutaboutactivitylevelsaftercartilagerepair,aswellasanyoneinterestedincartilageproblems.Howisactivitymeasuredaftercartilagerepair?Manyoutcomescoreshavebeendevelopedandvalidatedforevaluatingfunctionafterarticular cartilagerepair.Ofthevariousavailableoutcomemeasures,theICRSscore(https://www.cartilage.org/index.php?pid=223),theInternationalKneeDocumentationCommittee(IKDC)score,andtheKneeInjuryand Osteoarthritis OutcomeScore(KOOS)scoreareconsideredtheveryimportantonesincartilagerepairpatients.Thesepatient-based,validatedscorestypicallyusestandardisedquestionnaireswithaseriesofquestions.Basedonthepatient’sresponse,theyallowcalculationofanumericscorethatindicatesthepatient’soverallfunction.Someofthesescoresincludesub-scoresthatallowmorespecificevaluationofsport-relatedactivities.Besidesthegeneralscores,specificactivityscoreshavebeendeveloped,suchastheTegnerscorethatmeasuresspecificsportsactivitiesandthelevelthatcanbeachievedoneachscore.Similarly,theMarxactivityratingscaleusesapatient’sabilitytoperformactivitiesthatarefrequentlyincludedinsportstocalculatealeveloffunction.Allthesevalidatedscorescanbehelpfultocompareandevaluatepatientsaftercartilagerepairprocedures.Whiletheyprovideimportantscientificinformation,thesescoresdonotprovidethepatientwitharelevantandpracticalmeasureoftheirpostoperativejointfunction.Forexample,anICRSscoreof55canbehelpfulfortheclinicianincomparingpreoperativeandpostoperativefunction,butmaynotbeameaningfulparameterforthetreatedpatient.Incontrast,providingthepatientwithapercentageratedescribingthelikelihoodofreturningbacktoaknownathleticactivity,andeventheexpectedlevelofsportsparticipationcomparedtoprioractivity,givestheathleticpatientapracticaltooltoevaluatetheirrealisticexpectationsforsurgery.Italsoprovidesusefuldatathatcanhelpwithdecision-makingregardingsurgicalornon-surgicaltreatment,andfortheevaluationofoptionsforrestoringarticularcartilage.Whatcanpatientsexpectintermsofrecoveryandactivityaftercartilagerepair?Thereareseveralfactorsthatmakeitmorelikelythatapatientcanreturntosportsorpreviousactivities.Thechancesofareturntosportcanvarybetweenindividuals,andageisaveryimportantparameter,forexample.Youngerpatientstendtodobetter,whichismostlyduetotheirmoreactivecellularmetabolismandresultantbetterabilitytogeneratenewcartilagerepairtissuewithinthetreatedarticularcartilagedefects.Somestudieshaveshownthatpatientsyoungerthan30-40yearswillhavehigheractivitylevelsandfunctionaftercartilagerepairprocedures,regardlessofwhichtechniqueisbeingused.Pre-injuryactivitylevelalsoplaysasignificantrole.Severalstudieshaveshownthathigheractivitylevelsbeforecartilageinjuryorcartilagesurgeryareassociatedwithhigheractivitylevelsafterwards.Morecompetitiveathleteshaveahigherrateofreturntosportsthanpeoplewhoperformthosesamesportsatalesscompetitiveorrecreationallevel.Thisisfelttoresultfromdifferentlevelsofmotivationforreturntosport,socialsituation,andaccessto rehabilitation resourcesthatmayvarybetweenamateurandcompetitiveorprofessionalathletes.Importantly,thefactthatathletesatthemoreprofessionallevelcanreturntofullactivityandareabletoendureextremelyhighimpactloadsinawiderangeofsportsaftercartilagerepairproceduresisveryencouraging,butagain,thismaybemorearesultoftheprofessionalathleteasawholethanaspecificresponsetocartilagesurgery.Anotherveryimportantparameterishowlongthepatienthashadthecartilageinjurybeforeitwastreated.Multiplestudiesnowhaveshownthat,ifapatienthasbeeninjuredformorethanayear,thechancesofreturningtothesameactivitylevelismuchlowerthaniftheyhavehadtheinjuryforlessthan12months.Thisseemstoberelatedtothedevelopmentofadegenerativeenvironmentintheaffectedjoints,whichinhibitsnewcartilageregrowth.Inaddition,along-termreductioninsportsparticipationalsoplaysarole.Anotherfactorthatcomesintoplayisthesizeofthe cartilage defect.Smalldefectsoftenareassociatedwithmorefrequentreturntonormalathleticactivity.Thecut-offlevelthatwehaveidentifiedinsomeofourstudiesisthatacartilagedefectlessthan2–3cmhasamuchbetterchanceofsuccessfulrepair.Largerdefectsarelesslikelytoallowreturntosport,butthesuccessrateforlargerdefectsisstillencouraging.Inaddition,thechoiceofcartilagerepairtechniquecanaffecttheabilitytoreturntosportandlikelihoodforcontinuedsportsparticipation.Averageratesofreturntosportsactivityintheathleticpopulationhavebeenreportedafter autologouschondrocyteimplantation (ACI)(74%), microfracture (68%), osteochondralautologoustransfer (91%)and osteochondralallografttransplantation (88%).Arecentsystematicreviewofcartilagerepairtechniquesdemonstratedthatathletesreturnedtothepre-injurylevelin65%ofcasesaftercartilagerepair,withnosignificantdifferencebetweentheindividualtechniques.Severalsecondgenerationtechniqueshavebeendeveloped,including matrix-associated(MACI)orscaffold-enhanced microfracture,andhavebeenfoundtohavesimilarratesforreturntosportcomparedtothefirstgenerationtechniques.Besidestheabilitytoreturntosport,theabilitytocontinuetoplaypresentsanotherimportantoutcomeparameter.Whileexcellentdurabilityofathleticactivitywasobservedin87%ofathletestreatedwith ACI after52months,continuedsportsactivitywasmorelimitedaftertreatmentusingmicrofractureorosteochondralautograftinathletes.Whatcanpatientsexpectfromarehabilitationprogramme?Rehabilitation canvarydependingontherepairtechniqueusedandwhetheracartilagerepairprocedureisdonealone.Often,cartilagerepairtechniquesarecombinedwithanotherprocedure,suchasananteriorcruciateligament(ACL)reconstructionoran osteotomy,whichaddressassociatedkneepathologysuchasinstabilityormalalignment.Iftheassociatedpathologicfactorsresponsiblefordevelopingthecartilageprobleminthefirstplacearenotcorrected,thecartilagerepairwilloftenbelimitedandlesssuccessful.Theassociatedprocedurescanhaveaneffectonpatientrehabilitation.Ingeneral,ifapatienthasanisolateddefect,themostimportantaspectistoeducatethemthatrecoverywillbeslow.Usuallytherewillbesomelimitationofweightbearingforbetween2and6weeksaftertheproceduredependingonthedefectcharacteristicsandrepairtechnique.Gradualprogressionguidedbyanexperiencedphysicaltherapistfamiliarwithcartilagerepairproceduresiscritical.Furtherreading· FlaniganDC,HarrisJD,TrinhTQ,etal.Prevalenceofchondraldefectsinathletes’knees:asystematicreview.MedSciSportsExerc.2010;42(10):1795-801.· GudasR,GudaiteA,PociusA,GudieneA,CekanauskasE,MonastyreckieneE,BaseviciusA.Ten-yearfollow-upofaprospective,randomizedclinicalstudyofmosaicosteochondralautologoustransplantationversusmicrofractureforthetreatmentofosteochondraldefectsinthekneejointofathletes.AmJSportsMed.2012Nov;40(11):2499-508.· KonE,FilardoG,BerrutoM,BenazzoF,ZanonG,DellaVillaS,MarcacciM.Articularcartilagetreatmentinhigh-levelmalesoccerplayers:aprospectivecomparativestudyofarthroscopicsecond-generationautologouschondrocyteimplantationversusmicrofracture.AmJSportsMed.2011Dec;39(12):2549-57· KreuzPC,SteinwachsM,ErggeletC,etal.Importanceofsportsincartilageregenerationafterautologouschondrocyteimplantation:aprospectivestudywitha3-yearfollow-up.AmJSportsMed.2007;35(8):1261-1268.· KrychA,RobertsonC,Williams,RJ.ReturntoAthleticActivityAfterOsteochondralAllograftTransplantationintheKnee.AmJSportsMed201240:5:1053-59· McAdamsT,MithoeferK,ScoppJ,MandelbaumB,ArticularCartilageRepairinAthletes.Cartilage2010,1(3):165-176.7.MithoeferK.Complexarticularcartilagerestoration.SportsMedArthrosc.2013Mar;21(1):31-7.· MithoeferK,DellaVillaS,SilversH,RicciM,HamblyK.CurrentConceptsofRehabilitationandReturntoSportafterArticularCartilageRepairintheAthlete.JOrthopSportsPhysTher2012;3:254-273.· MithoeferK,SteadmanR.MicrofractureintheFootball(Soccer)Player:Acaseseriesofprofessionalathletesandsystematicreview.Cartilage2012;3:18S-24S.· MithoeferK,PetersonL,SarisD,MandelbaumB.TheEvolutionandCurrentRoleofAutologousChondrocyteTransplantationforTreatmentofArticularCartilageInjuryinFootballPlayers.Cartilage2012;3:31S-36S.· MithoeferK,GillTJ,WilliamsRJ,ColeBJ,MandelbaumBR.ClinicalOutcomeandReturntocompetitionaftermicrofracturechondroplastyintheathlete’sknee.Cartilage2010,1:113-20.· MithoeferK,HamblyK,DellaVillaS,SilversH,Mandelbaum,BR.Returntosportsparticipationafterarticularcartilagerepairintheknee.AmJSportsMed2009,37Suppl1:167S-176S.· MithoeferK,McAdamsTR,ScoppJ,MandelbaumBR.EmergingOptionsforTreatmentofArticularCartilageInjuryintheAthlete.ClinSportsMed2009;28:25-40· MithoeferK,WilliamsRJ,WarrenRF,WickiewiczTL,MarxRG.High-ImpactAthleticsafterKneeArticularCartilageRepair:AProspectiveEvaluationoftheMicrofractureTechnique.AmJSportsMed34(9):1413-1418;2006.· MithöferK,MinasT,PetersonL,YeonH,MicheliLJ.FunctionalOutcomeofArticularCartilageRepairinAdolescentAthletes.AmJSportsMed200533(8):1147-1153.· MithöferK,PetersonL,MandelbaumB,MinasT.ArticularCartilageRepairinSoccerPlayerswithAutologousChondrocyteTransplantation:FunctionalOutcomeandReturntoCompetition.AmJSportsMed2005,33(11):1639-1646.2022年11月02日 481 0 1
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