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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：軟骨損傷手術(shù)修復(fù)后我的活動(dòng)水平如何？WhatismyActivityLevellikeafterCartilageRepair??陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）圖1.典型的膝關(guān)節(jié)股骨髁軟骨損傷的大體觀(guān)表現(xiàn)：軟骨剝脫，軟骨下骨囊性變等，同時(shí)可能合并有半月板損傷、前后檢查韌帶損傷等。圖2.典型的關(guān)節(jié)軟骨剝脫損傷的關(guān)節(jié)鏡下表現(xiàn)（左側(cè)），微骨折技術(shù)是修復(fù)關(guān)節(jié)軟骨缺損的金標(biāo)準(zhǔn)（右側(cè)），但往往需要與其他的技術(shù)，如ACI、AMIC等協(xié)作發(fā)揮作用。圖3.典型的髕骨軟骨剝脫損傷的大體觀(guān)表現(xiàn)（左側(cè)），對(duì)關(guān)節(jié)軟骨邊緣進(jìn)修修復(fù)后，采用微骨折技術(shù)誘導(dǎo)軟骨下骨滲出含有大量骨髓間充質(zhì)干細(xì)胞的血液填充缺損區(qū)域（右側(cè)）。圖4.典型的髕骨軟骨剝脫損傷的大體觀(guān)表現(xiàn)（左側(cè)），對(duì)關(guān)節(jié)軟骨邊緣進(jìn)修修復(fù)后，采用微骨折技術(shù)誘導(dǎo)軟骨下骨滲出含有大量骨髓間充質(zhì)干細(xì)胞的血液填充缺損區(qū)域聯(lián)合Chondrogide軟骨膜修復(fù)技術(shù)對(duì)缺損處進(jìn)行修復(fù)（右側(cè)）。?關(guān)節(jié)軟骨損傷通常與關(guān)節(jié)功能的顯著降低有關(guān)，并且經(jīng)常導(dǎo)致功能和活動(dòng)的減少（活動(dòng)受限制），特別是在參與劇烈運(yùn)動(dòng)（跑跳、競(jìng)技）的高需求運(yùn)動(dòng)患者中。關(guān)節(jié)軟骨損傷可能急性（快速）或慢性（長(zhǎng)期）發(fā)展，但與一般人群相比，運(yùn)動(dòng)活躍的患者引起癥狀和局限性的頻率是普通人群的2倍多。對(duì)于一般患者，尤其是運(yùn)動(dòng)員而言，恢復(fù)正常體育活動(dòng)的能力是關(guān)節(jié)軟骨修復(fù)后最重要的功能結(jié)果。由于不同體育鍛煉和參與體育強(qiáng)度的水平之間的活動(dòng)需求不同，因此，詳細(xì)了解每位運(yùn)動(dòng)員受傷的嚴(yán)重程度和治療干預(yù)的潛在成功率，對(duì)于優(yōu)化恢復(fù)能力和達(dá)到現(xiàn)實(shí)期望至關(guān)重要。目標(biāo)受眾（閱讀者）本文適用于任何關(guān)節(jié)軟骨受損的人士及其家人，他們想了解軟骨修復(fù)后的活動(dòng)水平，以及任何對(duì)軟骨問(wèn)題感興趣的人群。軟骨修復(fù)后如何測(cè)量活動(dòng)強(qiáng)度？許多用于評(píng)估關(guān)節(jié)軟骨修復(fù)后的功能結(jié)果評(píng)分已被開(kāi)發(fā)和驗(yàn)證。在上述各種可用的結(jié)果測(cè)量中，國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS評(píng)分(https://www.cartilage.org/index.php?pid=223)、國(guó)際膝關(guān)節(jié)研究委員會(huì)(IKDC)評(píng)分以及膝關(guān)節(jié)損傷和骨關(guān)節(jié)炎結(jié)果評(píng)分(KOOS)評(píng)分被認(rèn)為是軟骨修復(fù)患者中非常重要的3種評(píng)分。這些基于患者的、經(jīng)過(guò)驗(yàn)證的評(píng)分通常使用帶有一系列問(wèn)題的標(biāo)準(zhǔn)化問(wèn)卷。根據(jù)患者的反饋，他們用以計(jì)算表明患者整體功能的數(shù)字分?jǐn)?shù)。其中一些分?jǐn)?shù)包括允許對(duì)體育相關(guān)活動(dòng)進(jìn)行更具體評(píng)估的子項(xiàng)分?jǐn)?shù)。除了一般分?jǐn)?shù)外，還制定了特定活動(dòng)分?jǐn)?shù)，例如衡量特定體育活動(dòng)的Tegner分?jǐn)?shù)和每個(gè)分?jǐn)?shù)可以達(dá)到的水平。同樣，Marx活動(dòng)評(píng)分量表使用患者進(jìn)行運(yùn)動(dòng)中經(jīng)常包含的活動(dòng)能力來(lái)計(jì)算功能水平。所有這些經(jīng)過(guò)驗(yàn)證的分?jǐn)?shù)都有助于比較和評(píng)估軟骨修復(fù)手術(shù)后的患者。雖然它們提供了重要的科學(xué)信息，但這些評(píng)分并沒(méi)有為患者提供有關(guān)其術(shù)后關(guān)節(jié)功能的實(shí)用測(cè)量值。例如，55分的國(guó)際軟骨修復(fù)協(xié)會(huì)ICRS評(píng)分可能有助于臨床醫(yī)生比較術(shù)前和術(shù)后功能，但對(duì)于接受治療的患者可能不是一個(gè)有意義的參數(shù)。相比之下，為患者提供描述返回已知體育活動(dòng)的可能性的百分比，甚至是與先前活動(dòng)相比的預(yù)期體育參與水平，為運(yùn)動(dòng)患者提供了一個(gè)實(shí)用的工具，來(lái)評(píng)估他們對(duì)手術(shù)的現(xiàn)實(shí)期望。它還提供了有用的數(shù)據(jù)，可以幫助做出有關(guān)手術(shù)或非手術(shù)治療的決策，以及評(píng)估恢復(fù)關(guān)節(jié)軟骨的治療策略的選擇?；颊咴谲浌切迯?fù)后的恢復(fù)和活動(dòng)方面可以期待什么？有幾個(gè)因素使患者更有可能恢復(fù)運(yùn)動(dòng)或以前的活動(dòng)。重返運(yùn)動(dòng)的機(jī)會(huì)因人而異，例如，年齡是一個(gè)非常重要的參數(shù)。年輕患者往往做得更好，這主要是由于他們更活躍的細(xì)胞代謝以及在治療的關(guān)節(jié)軟骨缺損內(nèi)產(chǎn)生新的軟骨修復(fù)組織的更好能力。一些研究表明，無(wú)論使用哪種技術(shù)，30-40歲以下的患者在進(jìn)行軟骨修復(fù)手術(shù)后，都會(huì)有更高的活動(dòng)水平和功能。受傷前的活動(dòng)水平也起著重要作用。多項(xiàng)研究表明，軟骨損傷或軟骨手術(shù)前較高的活動(dòng)水平與之后的較高活動(dòng)水平相關(guān)。與在不那么競(jìng)爭(zhēng)或娛樂(lè)水平上進(jìn)行相同運(yùn)動(dòng)的人士相比，更具競(jìng)爭(zhēng)力的運(yùn)動(dòng)員有更高的運(yùn)動(dòng)回歸率。這被認(rèn)為是由不同程度的回歸運(yùn)動(dòng)、社會(huì)狀況和獲得康復(fù)資源的動(dòng)機(jī)引起的，這些可能因業(yè)余運(yùn)動(dòng)員和競(jìng)技運(yùn)動(dòng)員或職業(yè)運(yùn)動(dòng)員而異。重要的是，在軟骨修復(fù)手術(shù)后，更專(zhuān)業(yè)水平的運(yùn)動(dòng)員可以恢復(fù)充分的活動(dòng)，并能夠在各種運(yùn)動(dòng)中承受極高的沖擊負(fù)荷，這一事實(shí)非常令人鼓舞，但同樣，這可能更多是由于職業(yè)運(yùn)動(dòng)員整體（恢復(fù)的就好），而非對(duì)軟骨手術(shù)的具體反應(yīng)（在同樣專(zhuān)業(yè)的軟骨手術(shù)基礎(chǔ)上，職業(yè)運(yùn)動(dòng)員恢復(fù)的整體要好一些）。另一個(gè)非常重要的參數(shù)是患者在接受治療前軟骨損傷的時(shí)間（受傷后多久開(kāi)始的治療）?，F(xiàn)在多項(xiàng)研究表明，如果患者受傷超過(guò)一年，恢復(fù)到相同活動(dòng)水平的機(jī)會(huì)比受傷時(shí)間少于12個(gè)月的要低得多。這似乎與受影響關(guān)節(jié)中退化環(huán)境的發(fā)展有關(guān)，這抑制了新的軟骨再生。此外，體育參與的長(zhǎng)期減少也起到了一定的作用。另一個(gè)起作用的因素是軟骨缺損的大小。小缺損通常與更高概率的恢復(fù)正常體育活動(dòng)有關(guān)。我們?cè)谝恍┭芯恐写_定的臨界水平是小于2-3厘米的軟骨缺損有更好的成功修復(fù)機(jī)會(huì)。較大的缺陷不太可能允許重返運(yùn)動(dòng)，但較大缺陷的成功率仍然令人鼓舞。此外，軟骨修復(fù)技術(shù)的選擇會(huì)影響恢復(fù)運(yùn)動(dòng)的能力和繼續(xù)參加運(yùn)動(dòng)的可能性。據(jù)報(bào)道，運(yùn)動(dòng)人群恢復(fù)體育活動(dòng)的平均比率分別是：自體軟骨細(xì)胞植入(ACI)(74%)、微骨折(68%)、自體骨軟骨移植(91%)和同種異體骨軟骨移植(88%)。最近對(duì)軟骨修復(fù)技術(shù)的系統(tǒng)評(píng)價(jià)表明，65%的運(yùn)動(dòng)員在軟骨修復(fù)后恢復(fù)到受傷前的水平，不同技術(shù)之間沒(méi)有顯著差異。已經(jīng)開(kāi)發(fā)了幾種第二代技術(shù)，包括基質(zhì)相關(guān)(MACI)或支架增強(qiáng)微骨折，并且已發(fā)現(xiàn)與第一代技術(shù)相比具有相似的運(yùn)動(dòng)恢復(fù)率。除了重返運(yùn)動(dòng)的能力之外，繼續(xù)比賽的能力是另一個(gè)重要的結(jié)果參數(shù)。雖然在52個(gè)月后接受ACI治療的運(yùn)動(dòng)員中有87%觀(guān)察到出色的運(yùn)動(dòng)活動(dòng)持久性，但在運(yùn)動(dòng)員使用微骨折或自體骨軟骨移植治療后，繼續(xù)運(yùn)動(dòng)活動(dòng)受到更多限制?；颊呖梢詮目祻?fù)計(jì)劃中得到什么？康復(fù)可能因所使用的修復(fù)技術(shù)以及是否單獨(dú)進(jìn)行軟骨修復(fù)手術(shù)而異。通常，軟骨修復(fù)技術(shù)與其他手術(shù)相結(jié)合，例如前交叉韌帶(ACL)重建或截骨術(shù)，以解決相關(guān)的膝關(guān)節(jié)病變，例如不穩(wěn)定或下肢力線(xiàn)異常。如果最初導(dǎo)致軟骨問(wèn)題的相關(guān)病理因素沒(méi)有得到糾正，軟骨修復(fù)通常會(huì)受到限制并且不太成功。相關(guān)手術(shù)可能對(duì)患者康復(fù)產(chǎn)生影響。一般來(lái)說(shuō)，如果患者有單純的軟骨缺損，最重要的方面是教育他們康復(fù)會(huì)很慢。根據(jù)軟骨缺損特征和修復(fù)技術(shù)，通常在手術(shù)后2到6周內(nèi)會(huì)有一些負(fù)重限制。由熟悉軟骨修復(fù)手術(shù)的經(jīng)驗(yàn)豐富的物理治療師指導(dǎo)的逐步增加也至關(guān)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.·???????Mith?ferK,MinasT,PetersonL,YeonH,MicheliLJ.FunctionalOutcomeofArticularCartilageRepairinAdolescentAthletes.AmJSportsMed200533(8):1147-1153.·???????Mith?ferK,PetersonL,MandelbaumB,MinasT.ArticularCartilageRepairinSoccerPlayerswithAutologousChondrocyteTransplantation:FunctionalOutcomeandReturntoCompetition.AmJSportsMed2005,33(11):1639-1646.2022年11月02日
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