骨軟骨病

由先天性軟骨發(fā)育不全引起的矮小，可以使用生長(zhǎng)激素進(jìn)行輔助治療。生長(zhǎng)激素能直接作用于軟骨組織，刺激骨細(xì)胞代謝，刺激骨面端軟骨細(xì)胞的分化、增殖，從而促進(jìn)骨長(zhǎng)度增加，使孩子長(zhǎng)高。采用生長(zhǎng)激素治療先天性軟骨發(fā)育不全，能增加患兒的生長(zhǎng)速度，早期治療對(duì)于改善孩子的身高有比較明顯的效果。

先天性軟骨發(fā)育不全(ACH)是一種由于軟骨內(nèi)骨化缺陷導(dǎo)致的先天性發(fā)育異常。軟骨內(nèi)骨化缺陷，指的是軟骨組織中骨細(xì)胞轉(zhuǎn)變成成骨存在障礙，軟骨骨化障礙會(huì)導(dǎo)致患者的四肢長(zhǎng)骨只能和其他骨骼一樣增粗，卻不能向縱向生長(zhǎng)，因此表現(xiàn)為四肢粗短的矮小身材，但軀干和頭部發(fā)育正常，智力及體力發(fā)育良好。軟骨發(fā)育不全為常染色體顯性遺傳性疾病，有很大一部分病例為死胎或在新生兒期即死亡。多數(shù)患者的父母為正常發(fā)育，提示可能是自發(fā)性基因突變的結(jié)果。如果沒有早期治療，患兒年幼時(shí)表現(xiàn)為頭大四短小，個(gè)子矮；長(zhǎng)大后則形成“成人的軀干，小孩的四肢”。

骨軟骨損傷嚴(yán)重程度：1961年Outerbridge分級(jí)概述：2018年作者：CaseySlattery,ChristopherYKweon.作者單位:DepartmentofOrthopaedics&SportsMedicine,UniversityofWashington,Seattle,WA,USA.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）Outerbridge軟骨損傷分類系統(tǒng)的觀察者間和觀察者間一致性從一般到優(yōu)良不等。這種不一致的可靠性仍然是該系統(tǒng)的一個(gè)重大限制。盡管Outerbridge方案仍然是對(duì)軟骨病變進(jìn)行分級(jí)的最廣泛的分類系統(tǒng)，但它不能指導(dǎo)治療決策，而且?guī)缀鯖]有證據(jù)表明它提供了很多預(yù)后信息。為了進(jìn)一步評(píng)估Outerbridge系統(tǒng)，未來的研究應(yīng)包括更大樣本量的驗(yàn)證研究、允許觸覺反饋的方法以及對(duì)各種關(guān)節(jié)的評(píng)估，以便更準(zhǔn)確地評(píng)估關(guān)節(jié)軟骨形態(tài)。評(píng)估軟骨損傷的Outerbridge和類似的宏觀分類方案未能提供在研究環(huán)境中使用所需的信心。該系統(tǒng)已有超過50年的歷史，并且在該時(shí)間范圍內(nèi)沒有整合成像技術(shù)的進(jìn)步。本綜述中發(fā)現(xiàn)的最佳可靠性比較了關(guān)節(jié)鏡和MR圖像。作者建議，Outerbridge系統(tǒng)和任何未來的軟骨病變宏觀分級(jí)系統(tǒng)，都需要結(jié)合高級(jí)成像(MRI)以實(shí)現(xiàn)成功分類系統(tǒng)所需的可靠性。Outerbridge系統(tǒng)也被證明具有一定的預(yù)后價(jià)值。Sofu等[19]顯示，在關(guān)節(jié)鏡下半月板部分切除術(shù)后，III級(jí)和IV級(jí)膝關(guān)節(jié)損傷的視覺模擬評(píng)分和Lysholm評(píng)分更差的結(jié)果一致。Bateman等[2]在III級(jí)或更高級(jí)別病變的患者中，關(guān)節(jié)鏡下肩后盂唇撕裂修復(fù)后的功能結(jié)果更差。Kemp等[8]還發(fā)現(xiàn)，與較低級(jí)別的軟骨病變相比，在髖關(guān)節(jié)鏡檢查中發(fā)現(xiàn)股骨髖臼撞擊的OuterbridgeIII級(jí)和IV級(jí)病變的患者在術(shù)后18個(gè)月的疼痛和功能更差。Fig.1A-FTheseintraoperativearthroscopicimagesdemonstrateexamplesofOuterbridgeclassificationgrades:(A)GradeI;(B-C)GradeII;(D)GradeIII;(E-F)GradeIV.圖1A-F這些關(guān)節(jié)鏡術(shù)中圖像展示了Outerbridge分類等級(jí)的示例：(A)I級(jí)；(B-C)II級(jí)；(D)III級(jí)；(E-F)IV級(jí)。Table1.StudiesevaluatingthereliabilityoftheOuterbridgeclassificationsystemofchondrallesions表1.評(píng)估軟骨損傷Outerbridge分類系統(tǒng)可靠性的研究?原文盡管早在20世紀(jì)初，就已經(jīng)對(duì)軟骨病變進(jìn)行了直接檢查和描述，在Outerbridge于1961年發(fā)表他關(guān)于該主題的第一篇論文之前，人們對(duì)髕骨軟骨軟化癥的病因?qū)W并沒有很好的了解[15]。在這項(xiàng)初步研究中，他評(píng)估了196次內(nèi)側(cè)半月板切除術(shù)期間的髕骨軟骨，以更好地了解軟骨軟化癥如何進(jìn)展以及髕骨的哪些區(qū)域主要受到影響。他發(fā)現(xiàn)，由于與股骨內(nèi)側(cè)髁上緣的邊緣不斷摩擦，軟骨軟化癥最常見于內(nèi)側(cè)關(guān)節(jié)面。他還指出，即使在沒有癥狀的情況下，接受開放內(nèi)側(cè)半月板切除術(shù)的患者髕骨軟骨軟化癥的發(fā)生率也約為50%。為了更好地了解髕骨軟骨軟化癥的病因，Outerbridge開發(fā)了他的分類系統(tǒng)，通過直接可視化來描述不同嚴(yán)重程度的軟骨損傷，他在隨后的論文中繼續(xù)使用該系統(tǒng)[15-17]。自從Outerbridge最初為髕骨軟骨軟化癥設(shè)計(jì)的分類系統(tǒng)被引入以來，它在1989年被改編為包括整個(gè)膝關(guān)節(jié)和推廣到其他關(guān)節(jié)[2,8,13]。除了Outerbridge的方案，還有其他幾種描述軟骨病變的分類方案。其中包括為膝關(guān)節(jié)設(shè)計(jì)的改良Collins[6]和法國關(guān)節(jié)鏡學(xué)會(huì)(FSA)系統(tǒng)[13]以及為髖關(guān)節(jié)設(shè)計(jì)的Beck[3]和Konan[9]分類標(biāo)準(zhǔn)。除了本綜述中引用的研究外，關(guān)于Collins或法國關(guān)節(jié)鏡學(xué)會(huì)FSA分類系統(tǒng)的報(bào)道很少。Collins的系統(tǒng)在Outerbridge的原始論文之前發(fā)表，但與法國關(guān)節(jié)鏡學(xué)會(huì)FSA系統(tǒng)一起未能獲得廣泛的普及。Beck方案基于髖關(guān)節(jié)手術(shù)脫位期間的發(fā)現(xiàn)，而Konan的分類相當(dāng)新，只有兩項(xiàng)研究評(píng)估了其可靠性[1]。盡管提出了其他系統(tǒng)，Outerbridge系統(tǒng)仍然是使用最廣泛的系統(tǒng)，這值得對(duì)其可靠性進(jìn)行調(diào)查。目的1961年最初開發(fā)Outerbridge系統(tǒng)時(shí)，它被用作純粹的描述性系統(tǒng)，以更好地了解髕骨軟骨軟化癥的病因。從那時(shí)起，它就被用來描述膝關(guān)節(jié)、髖關(guān)節(jié)和肩關(guān)節(jié)的軟骨病變[2,7,8,19]。該系統(tǒng)主要用于促進(jìn)外科醫(yī)生之間的溝通。盡管尚未證明它可以指導(dǎo)治療，但一些研究已經(jīng)使用Outerbridge方案將患者分組以進(jìn)行臨床研究和預(yù)后評(píng)估[2,7,8,19]。準(zhǔn)確定義（骨軟骨損傷）缺傷嚴(yán)重程度對(duì)于手術(shù)計(jì)劃和患者教育也很重要。描述基于對(duì)關(guān)節(jié)的直接可視化，無論是關(guān)節(jié)鏡還是開放式手術(shù)，Outerbridge分類系統(tǒng)被開發(fā)為一種簡(jiǎn)單、易于使用且可重復(fù)的關(guān)節(jié)軟骨損傷分級(jí)系統(tǒng)。系統(tǒng)將0到IV的等級(jí)分配給感興趣的軟骨區(qū)域（圖1）。Outerbridge分類系統(tǒng)0級(jí)表示正常軟骨。Outerbridge分類系統(tǒng)I級(jí)軟骨損傷的特點(diǎn)是軟化和腫脹，這通常需要使用探針或其他儀器進(jìn)行觸覺反饋來評(píng)估。II級(jí)病變描述部分厚度缺損，裂縫直徑不超過0.5英寸或達(dá)到軟骨下骨。III級(jí)是直徑>0.5英寸的軟骨開裂，區(qū)域達(dá)到軟骨下骨。最嚴(yán)重的是IV級(jí)，包括暴露軟骨下骨的關(guān)節(jié)軟骨侵蝕[15,16]。驗(yàn)證評(píng)估Outerbridge分類系統(tǒng)可靠性的研究要么使用關(guān)節(jié)鏡視頻或其他成像方式進(jìn)行比較。使用關(guān)節(jié)鏡視頻研究該方案的可重復(fù)性的研究表明，觀察者間的可靠性范圍從0.28到0.52的κ系數(shù)和從0.29到0.8的κ系數(shù)的觀察者內(nèi)再現(xiàn)性（表1）[1,4,5,10,11]。在這些研究中，Brismar等[4]，Cameron等[5]，Marx等[11]和Amenabar等[1]都使用訓(xùn)練有素的骨外科醫(yī)生作為觀察者，而Lasmar等[10]有兩名三年臨床經(jīng)驗(yàn)的住院醫(yī)師和四名骨外科醫(yī)生回顧了他們的視頻，表明培訓(xùn)水平之間存在明顯的觀察者內(nèi)部的可靠性差異（κ=-0.06對(duì)0.50）。Cameron等[5]還發(fā)現(xiàn)，基于兩名外科醫(yī)生在實(shí)踐中超過5年的經(jīng)驗(yàn)水平存在可靠性差異，觀察者間一致性κ=0.72，而經(jīng)驗(yàn)較少的外科醫(yī)生平均κ=0.50。這項(xiàng)研究還發(fā)現(xiàn)，觀察者參與的關(guān)節(jié)鏡評(píng)估與這些觀察者在關(guān)節(jié)切開術(shù)中使用卡尺直接測(cè)量（病變深度和寬度）之間的一致性為68%[5]。Brismar等研究[4]比較了修改后的Collins和FSA分類系統(tǒng)以及Outerbridge，發(fā)現(xiàn)三者之間沒有差異，得出的結(jié)論是，這些分類中沒有一個(gè)足夠可靠，可用于臨床研究。Lasmar等的研究[10]還比較了Outerbridge和FSA方案，觀察者間或觀察者內(nèi)的可靠性之間沒有差異。Amenabar等的研究[1]使用Outerbridge和其他兩個(gè)為髖關(guān)節(jié)設(shè)計(jì)的分類系統(tǒng)（Beck[3]和Konan[9]）評(píng)估了髖關(guān)節(jié)的軟骨損傷。他們發(fā)現(xiàn)系統(tǒng)之間在觀察者間可靠性方面沒有差異，但Konan的系統(tǒng)在髖部具有出色的觀察者間可靠性。與其他方案相比，Outerbridge系統(tǒng)的可靠性較低被認(rèn)為是特定的軟骨損傷模式通常由股骨髖臼撞擊和軟骨盂交界處的解剖結(jié)構(gòu)引起的結(jié)果[1]。使用影像學(xué)作為比較方法的研究（表1）發(fā)現(xiàn)觀察者間的可靠性范圍從一般（κ=0.35，CT關(guān)節(jié)造影）到幾乎完美（κ=0.93，MR圖像）[14,18]。在這些研究中，Omoumi等[14]使用放射科醫(yī)生在沒有直接視覺比較的情況下，評(píng)估CT關(guān)節(jié)造影，是唯一一項(xiàng)測(cè)試觀察者內(nèi)可靠性的研究(κ=0.59–0.92)。這項(xiàng)研究發(fā)現(xiàn)，經(jīng)驗(yàn)豐富的放射科醫(yī)師通常具有更高的觀察者內(nèi)可靠κ值。Outerbridge方案的最高觀察者間可靠性來自Potter等的[18]研究，該研究將膝關(guān)節(jié)的MR圖像與關(guān)節(jié)鏡評(píng)估進(jìn)行了比較。兩位放射科醫(yī)生和三位骨科醫(yī)生發(fā)現(xiàn)了一個(gè)幾乎完美的(0.93)κ統(tǒng)計(jì)量。Outerbridge系統(tǒng)也被證明具有一定的預(yù)后價(jià)值。Sofu等[19]顯示，在關(guān)節(jié)鏡下半月板部分切除術(shù)后，III級(jí)和IV級(jí)膝關(guān)節(jié)損傷的視覺模擬評(píng)分和Lysholm評(píng)分更差的結(jié)果一致。Bateman等[2]在III級(jí)或更高級(jí)別病變的患者中，關(guān)節(jié)鏡下肩后盂唇撕裂修復(fù)后的功能結(jié)果更差。Kemp等[8]還發(fā)現(xiàn)，與較低級(jí)別的軟骨病變相比，在髖關(guān)節(jié)鏡檢查中發(fā)現(xiàn)股骨髖臼撞擊的OuterbridgeIII級(jí)和IV級(jí)病變的患者在術(shù)后18個(gè)月的疼痛和功能更差。（Outerbridge分級(jí)系統(tǒng)的）局限性盡管在過去的幾十年里，Outerbridge分類系統(tǒng)在臨床和研究環(huán)境中得到廣泛應(yīng)用，但仍有一些局限性。對(duì)這種分類最常見的批評(píng)是它在骨外科醫(yī)生中的不一致和可重復(fù)性差。整體的觀察者間可靠性范圍僅從弱(κ=0.28)[1]到中等(κ=0.52)[5]，而觀察者內(nèi)一致性稍好一些，范圍從弱(κ=0.29)[10]到優(yōu)良(κ=0.8)[5]。然而，一些研究提到，審閱者的經(jīng)驗(yàn)數(shù)量會(huì)影響系統(tǒng)的可靠性，經(jīng)驗(yàn)豐富的外科醫(yī)生具有更好的可靠性[5,10]。關(guān)節(jié)鏡檢查也可能使充分區(qū)分2級(jí)和3級(jí)之間的病變大小以及可視化分配1級(jí)所需的柔軟度和腫脹變得有些困難[1]。這種可靠性的變化表明，Outerbridge系統(tǒng)的標(biāo)準(zhǔn)需要修改和/或在該方案中實(shí)施高級(jí)成像(MRI)。目前在Outerbridge分級(jí)中使用的粗略宏觀方法可能會(huì)在外科醫(yī)生之間傳達(dá)軟骨損傷的嚴(yán)重程度，但文獻(xiàn)不支持其用于研究目的的可靠性。在通過關(guān)節(jié)鏡視頻評(píng)估Outerbridge分類系統(tǒng)的可靠性的研究中，樣本量小有一個(gè)普遍的局限性，從6名患者到40名患者不等[1]。此外，驗(yàn)證Outerbridge分類系統(tǒng)可靠性的研究數(shù)量相對(duì)較少。在使用直接可視化來評(píng)估該系統(tǒng)的研究中，只有五項(xiàng)研究測(cè)量了觀察者間的一致性，只有四項(xiàng)測(cè)量了觀察者內(nèi)的一致性。每項(xiàng)評(píng)估Outerbridge分類作為參考分級(jí)系統(tǒng)的研究都使用膝關(guān)節(jié)鏡檢查的視頻記錄，從而阻止分級(jí)外科醫(yī)生使用觸覺反饋?zhàn)鳛檐浌窃u(píng)估工具。這種觸覺反饋尤其重要，因?yàn)檐浌堑拇植诙群蛙浕瘜?duì)于適當(dāng)?shù)姆旨?jí)很重要[11]。任何關(guān)于當(dāng)前Outerbridge系統(tǒng)可靠性的未來研究都應(yīng)將觸覺反饋納入方法學(xué)，這可能會(huì)將研究限制為僅評(píng)估關(guān)節(jié)鏡手術(shù)或使用尸體膝蓋期間的觀察者間可靠性。Outerbridge分類系統(tǒng)也沒有提供與疾病預(yù)后的明確相關(guān)性或治療指南。只有少數(shù)研究顯示出對(duì)Outerbridge系統(tǒng)的一些預(yù)后價(jià)值[2,8,12,19]，并且在本綜述中沒有發(fā)現(xiàn)討論治療指導(dǎo)的研究。因?yàn)檫@是分類系統(tǒng)應(yīng)該包含的兩個(gè)關(guān)鍵特征，所以它們的缺失仍然是該系統(tǒng)的主要限制。結(jié)論Outerbridge軟骨損傷分類系統(tǒng)的觀察者間和觀察者間一致性從一般到優(yōu)良不等。這種不一致的可靠性仍然是該系統(tǒng)的一個(gè)重大限制。盡管Outerbridge方案仍然是對(duì)軟骨病變進(jìn)行分級(jí)的最廣泛的分類系統(tǒng)，但它不能指導(dǎo)治療決策，而且?guī)缀鯖]有證據(jù)表明它提供了很多預(yù)后信息。為了進(jìn)一步評(píng)估Outerbridge的系統(tǒng)，未來的研究應(yīng)包括更大樣本量的驗(yàn)證研究、允許觸覺反饋的方法以及對(duì)各種關(guān)節(jié)的評(píng)估，以便更準(zhǔn)確地評(píng)估關(guān)節(jié)軟骨形態(tài)。評(píng)估軟骨損傷的Outerbridge和類似的宏觀分類方案未能提供在研究環(huán)境中使用所需的信心。該系統(tǒng)已有超過50年的歷史，并且在該時(shí)間范圍內(nèi)沒有整合成像技術(shù)的進(jìn)步。本綜述中發(fā)現(xiàn)的最佳可靠性比較了關(guān)節(jié)鏡和MR圖像。作者建議，Outerbridge系統(tǒng)和任何未來的軟骨病變宏觀分級(jí)系統(tǒng)都需要結(jié)合高級(jí)成像(MRI)以實(shí)現(xiàn)成功分類系統(tǒng)所需的可靠性。?ClassificationsinBrief:OuterbridgeClassificationofChondralLesionsHistoryAlthoughcartilagelesionshadbeendirectlyexaminedanddescribedasfarbackastheearly20thcentury,theetiologyofchondromalaciaofthepatellawasnotwellunderstoodwhenOuterbridgepublishedhisfirstpaperonthesubjectin1961[15].Inthisinitialstudy,heevaluatedthecartilageofthepatelladuring196medialmeniscectomiestobetterunderstandhowchondromalaciaprogressedandwhichareasofthepatellawereprimarilyaffected.Hefoundthatchondromalaciawasmostcommononthemedialfacetasaresultofconstantfrictionwitharimontheupperborderofthemedialfemoralcondyle.Healsonotedtheincidenceofchondromalaciaofthepatellatobeapproximately50%inpatientswhounderwentopenmedialmeniscectomy,evenintheabsenceofsymptoms.Tobetterunderstandtheetiologyofchondromalaciaofthepatella,Outerbridgedevelopedhisclassificationsystemdescribingvaryingseverityofcartilagelesionsbydirectvisualization,whichhecontinuedtouseinhissubsequentpapers[15-17].SincetheintroductionofOuterbridge’sclassificationsystemoriginallydesignedforchondromalaciaofthepatella,ithasbeenadaptedtoincludetheentirekneein1989andotherjointssincethen[2,8,13].InadditiontoOuterbridge’sscheme,thereareseveralotherclassificationschemesdescribingchondrallesions.TheseincludethemodifiedCollins[6]andFrenchSocietyofArthroscopy(FSA)systems[13]designedforthekneeaswellasBeck’s[3]andKonan’s[9]designedforthehip.Asidefromthestudiesreferencedinthisreview,thereisverylittlereportedontheCollinsorFSAclassificationsystems.Collins’systemwaspublishedbeforeOuterbridge’soriginalpaperbut,alongwiththeFSAsystem,hasfailedtogainwidespreadpopularity.TheBeckschemeisbasedonfindingsduringsurgicaldislocationofthehipandKonan’sclassificationisfairlynewwithonlytwostudiesassessingitsreliability[1].Despiteotherproposedsystems,theOuterbridgesystemcontinuestobethemostwidelyused,whichwarrantsinvestigationintoitsreliability.PurposeIn1961,whentheOuterbridgesystemwasoriginallydeveloped,itwasusedasapurelydescriptivesystemtobetterunderstandtheetiologyofchondromalaciaofthepatella.Sincethen,ithasbeenusedtodescribecartilagelesionsintheknee,hip,andshoulder[2,7,8,19].Thesystemislargelyusedtofacilitatecommunicationbetweensurgeons.Althoughithasnotbeendemonstratedtoguidetreatment,severalstudieshaveusedtheOuterbridgeschemetogrouppatientsforclinicalresearchandforprognosticpurposes[2,7,8,19].Accuratelydefiningdefectseverityisalsoimportantforsurgicalplanningandpatienteducation.DescriptionBasedondirectvisualizationofthejoint,eitherarthroscopicoropen,theOuterbridgeclassificationsystemwasdevelopedtobeasimple,easy-to-use,andreproduciblegradingsystemofarticularcartilagelesions.Thesystemassignsagradeof0throughIVtothechondralareaofinterest(Fig.1).Grade0signifiesnormalcartilage.GradeIchondrallesionsarecharacterizedbysofteningandswelling,whichoftenrequiretactilefeedbackwithaprobeorotherinstrumenttoassess.AGradeIIlesiondescribesapartial-thicknessdefectwithfissuresthatdonotexceed0.5inchesindiameterorreachsubchondralbone.GradeIIIisfissuringofthecartilagewithadiameter>0.5incheswithanareareachingsubchondralbone.ThemostsevereisGradeIV,whichincludeserosionofthearticularcartilagethatexposessubchondralbone[15,16].ValidationStudiesthathaveevaluatedthereliabilityofOuterbridge’sclassificationsystemeitherusearthroscopicvideooranotherimagingmodalityforcomparison.Thestudiesthathavelookedatthereproducibilityoftheschemeusingarthroscopyvideoshaveshowninterobserverreliabilityrangingfromaκcoefficientof0.28to0.52andintraobserverreproducibilityrangingfromaκcoefficientof0.29to0.8(Table?(Table1)1)[1,4,5,10,11].Inthesestudies.Brismaretal.[4],Cameronetal.[5],Marxetal.[11],andAmenabaretal.[1]allusedfullytrainedorthopaedicsurgeonsforreviewers,whereasLasmaretal.[10]hadtwothird-yearresidentsalongwithfourorthopaedicsurgeonsreviewtheirvideos,demonstratingaclearintraobserverreliabilitydiscrepancybetweenthelevelsoftraining(κ=-0.06versus0.50).Cameronetal.[5]alsofoundadiscrepancyinreliabilitybasedonlevelofexperiencewiththetwosurgeonsinpracticefor>5yearshavinganinterobserveragreementofκ=0.72andthosesurgeonswithlessexperienceaveragingκ=0.50.Thisstudyalsofounda68%concordancebetweentheparticipatingobservers’arthroscopicevaluationanddirectmeasurementwithcalipers(depthandwidthoflesions)atarthrotomymadebythosesameobservers[5].Brismaretal.’sstudy[4]comparedthemodifiedCollinsandFSAclassificationsystemsaswellasOuterbridgeandfoundnodifferenceamongthethree,concludingthatnoneoftheseclassificationswassufficientlyreliableforuseinclinicalresearch.Lasmaretal.’sstudy[10]alsocomparedOuterbridgeandFSAschemeswithnodifferencebetweeneitherinterobserverorintraobserverreliability.ThestudybyAmenabaretal.[1]evaluatedchondrallesionsofthehipusingOuterbridgeandtwootherclassificationsystemsdesignedforthehip(Beck[3]andKonan[9]).Theyfoundnodifferencebetweenthesystemsregardingintraobserverreliability,butKonan’ssystemwasnotedtohavesuperiorinterobserverreliabilityinthehip.LowerreliabilitywiththeOuterbridgesystemcomparedwithotherschemeswasbelievedtobearesultofthespecificchondraldamagepatternusuallycausedbyfemoroacetabularimpingementandtheanatomyofthechondrolabraljunction[1].Studiesthatusedimagingasamethodofcomparison(Table?(Table1)1)foundaninterobserverreliabilityrangingfromfair(κ=0.35,CTarthrograms)toalmostperfect(κ=0.93,MRimages)[14,18].Amongthesestudies,Omoumietal.[14],whousedradiologiststoevaluateCTarthrogramswithoutadirectvisualcomparison,wastheonlystudytotestintraobserverreliability(κ=0.59–0.92).Thisstudyfoundthatmoreexperiencedradiologistsingeneralhadhigherκvaluesforintraobserverreliability.ThehighestinterobserverreliabilityforOuterbridge’sschemecomesfromPotteretal.’s[18]studythatcomparedMRimagesofthekneewithanarthroscopicevaluation.Thetworadiologistsandthreeorthopaedicsurgeonsfoundanalmostperfect(0.93)κstatistic.TheOuterbridgesystemhasalsoproventohavesomeprognosticvalue.Sofuetal.[19]hasshownGradeIIIandIVkneelesionstohaveworsevisualanalogscoresandLysholmscoresafterarthroscopicpartialmeniscectomy.Batemanetal.[2]demonstratedworsefunctionaloutcomesafterarthroscopicshoulderposteriorlabraltearrepairsinpatientswithGradeIIIlesionsorhigher.Kempetal.[8]alsofoundthatpatientswhohadOuterbridgeGradeIIIandIVlesionsfoundduringhiparthroscopyforfemoroacetabularimpingementhadworsepainandfunctionat18monthspostsurgerycomparedwithlowergradechondrallesions.LimitationsAlthoughwidelyusedbothinclinicalandresearchsettingsoverthepastseveraldecades,theOuterbridgeclassificationsystemhasseverallimitations.Themostcommoncriticismofthisclassificationisitsinconsistentandpoorreproducibilityamongorthopaedicsurgeons.Theoverallinterobserverreliabilityrangedonlyfromweak(κ=0.28)[1]tomoderate(κ=0.52)[5],whereasintraobserveragreementwasslightlybetterrangingfromweak(κ=0.29)[10]tosubstantial(κ=0.8)[5].However,somestudieshavementionedthattheamountofexperienceamongreviewersaffectsthereliabilityofthesystemwithmoreexperiencedsurgeonshavingbetterreliability[5,10].ArthroscopymayalsomakeitsomewhatdifficulttoadequatelydifferentiatethesizeofthelesionbetweenGrades2and3aswellasvisualizingthesoftnessandswellingneededtoassignaGrade1[1].SuchvariationsinreliabilitysuggestthatthecriteriafortheOuterbridgesystemneedsmodificationand/oradvancedimaging(MRI)implementedintothescheme.ThecurrentcrudemacroscopicmethodusedinOuterbridgegradesmayworktocommunicatecartilagelesionseveritybetweensurgeons,buttheliteraturedoesnotsupportitsreliabilityforresearchpurposes.InthestudiesevaluatingthereliabilityoftheOuterbridgeclassificationsystemthrougharthroscopicvideos,therewasacommonlimitationofsmallsamplesizes,whichrangedfromsixpatientsto40[1].Additionally,therehasbeenarelativelysmallnumberofstudiesvalidatingthereliabilityoftheOuterbridgeclassificationsystem.Instudiesusingdirectvisualizationtoassessthissystem,onlyfivestudiesmeasuredinterobserveragreementandonlyfourmeasuredintraobserveragreement.EachstudythatevaluatedtheOuterbridgeclassificationasthereferencegradingsystemusedvideorecordingsofkneearthroscopy,thuspreventinggradingsurgeonsfromusingtactilefeedbackasacartilageassessmenttool.Thistactilefeedbackisespeciallycriticalbecauseroughnessandsofteningofthecartilageareimportantforappropriategrading[11].AnyfuturestudiesonthepresentOuterbridgesystem’sreliabilityshouldincorporatetactilefeedbackintothemethodology,whichmaylimitthestudytoonlyassessinginterobserverreliabilityduringarthroscopicsurgeryortheuseofcadaverknees.TheOuterbridgeclassificationsystemalsodoesnotprovideaclearcorrelationwithdiseaseprognosisoraguidetotreatment.ThereareonlyafewstudiesthathaveshownsomeprognosticvaluetotheOuterbridgesystem[2,8,12,19]andnostudieswerefoundinthisreviewthatdiscusstreatmentguidance.Becausethesearetwokeyfeaturesthataclassificationsystemshouldincorporate,theirabsenceremainsamajorlimitationforthissystem.ConclusionsTheinter-andintraobserveragreementfortheOuterbridgeclassificationsystemforchondrallesionsrangesfromfairtosubstantial.Thisinconsistentreliabilityremainsasubstantiallimitationofthissystem.AlthoughtheOuterbridgeschemeremainsthemostwidespreadclassificationsystemforgradingcartilagelesions,itfailstoguidetreatmentdecisionsandthereislittleevidencethatitprovidesmuchprognosticinformation.TofurtherevaluateOuterbridge’ssystem,futureresearchshouldincludevalidationstudieswithlargersamplesizes,methodologythatallowsfortactilefeedback,andevaluationinavarietyofjointsformoreaccurateassessmentofarticularcartilagemorphology.Outerbridgeandsimilarmacroscopicclassificationschemesthatevaluatechondrallesionsfailtoprovidetheconfidenceneededforuseinresearchsettings.Thissystemis>50yearsoldanddoesnotincorporatetheadvancesinimagingtechnologyoverthattimeframe.ThebestreliabilityfoundinthisreviewcomparedarthroscopicandMRimages.TheauthorsrecommendthattheOuterbridgesystemandanyfuturemacroscopicgradingsystemofchondrallesionsneedtoincorporateadvancedimaging(MRI)toachievethereliabilityneededforasuccessfulclassificationsystem.文獻(xiàn)出處：CaseySlattery,ChristopherYKweon.ClassificationsinBrief:OuterbridgeClassificationofChondralLesions.Review,ClinOrthopRelatRes.2018Oct;476(10):2101-2104.doi:10.1007/s11999.0000000000000255.

假性軟骨發(fā)育不全（PSACH）Pseudoachondroplasticdysplasia/Pseudoachondroplasia1.病因同義詞：假性軟骨脊柱骨骺發(fā)育不全癥，假性軟骨發(fā)育不全癥。假性軟骨發(fā)育不全的特征是出生時(shí)長(zhǎng)度正常和相貌正常。呈現(xiàn)的特征通常是步態(tài)蹣跚，在行走開始時(shí)就被識(shí)別出來。通常，年生長(zhǎng)速度大約在兩歲之內(nèi)就低于標(biāo)準(zhǔn)增長(zhǎng)曲線，導(dǎo)致嚴(yán)重的不成比例的短肢中等程度矮身材。兒童時(shí)期，特別是下肢大關(guān)節(jié)的關(guān)節(jié)痛很常見。退化性關(guān)節(jié)疾病是進(jìn)行性的；約有50％的假性軟骨發(fā)育不全患者最終需要進(jìn)行髖關(guān)節(jié)置換手術(shù)。已知其缺陷基因是位于第19號(hào)染色體上中心體周圍（pericentromeric）的區(qū)域，缺陷基因稱為軟骨低聚體基質(zhì)蛋白基因（Cartilageoligomericmatrixproteingene,COMP），此基因已被確認(rèn)位于第19號(hào)染色體上19p13.1，在臨床上會(huì)表現(xiàn)出輕型與嚴(yán)重型兩種類型。被報(bào)告出的多數(shù)患者多為散發(fā)性與推測(cè)由新的突變所造成。另外有相當(dāng)罕見的情況，未罹病的父母在精卵受精時(shí)有可能會(huì)產(chǎn)生性腺鑲嵌型(gonadalmosaicism)，所以同時(shí)會(huì)產(chǎn)生正常和異常的精卵，當(dāng)發(fā)生這樣的情形后，下一胎發(fā)生性腺鑲嵌型(gonadalmosaicism)的再發(fā)率則會(huì)增加4%的遺傳風(fēng)險(xiǎn)。軟骨低聚體基質(zhì)蛋白基因（Cartilageoligomericmatrixproteingene,COMP）也已經(jīng)被鑒別出可導(dǎo)致多發(fā)性骨發(fā)育不全癥MultipleEpiphysealDysplasia(MED)，意味著一些多發(fā)性骨發(fā)育不全癥(MultipleEpiphysealDysplasia,MED)的類型，有假性軟骨發(fā)育不全（Psedoachondroplasia）的等位基因(allele)。2.臨床表現(xiàn)（1）生長(zhǎng)發(fā)育：身體肢體較短為一種生長(zhǎng)的缺陷，發(fā)生于出生后?？捎?8個(gè)月大時(shí)至2歲之間被觀察到。成人期的身高為82-130公分。患兒出生后20月齡內(nèi)發(fā)育正常，20月齡后出現(xiàn)侏儒癥狀，如四肢短小、關(guān)節(jié)增大、手指短粗、下肢彎曲等。（2）2歲后出現(xiàn)生長(zhǎng)緩慢、步態(tài)蹣跚、關(guān)節(jié)及韌帶松弛等癥狀，智力發(fā)育正常。（3）顱面部發(fā)育正常，管狀骨干骺端和骨骺有明顯改變，脊柱腰段前突、臀部后翹，步態(tài)蹣跚。（4）肢體：比較短且呈不成比例分布，韌帶松弛與關(guān)節(jié)過度伸展，尤其是手部，膝部與腳踝等部位。主要部位關(guān)節(jié)(除了肘部以外)會(huì)過度變形顯著（hypermobile），膝外翻(genuvalgum)與膝內(nèi)翻(genuvarum)以及反屈（recurvatum）等癥狀。手部尺側(cè)彎曲(ulnardeviation)，手指較短且過度變形顯著（hypermobile）。手肘與髖部伸展受限制，下肢肢體畸形，輕微脊柱側(cè)彎，脊柱前凸(約50%的患者)，兒童時(shí)期患有關(guān)節(jié)痛尤其是在下肢末端較大關(guān)節(jié)處。臨床特點(diǎn)：(1)假性軟骨發(fā)育不全的特征是出生時(shí)長(zhǎng)度正常和相貌正常。(2)呈現(xiàn)的特征通常是步態(tài)蹣跚，在行走開始時(shí)就被識(shí)別出來。(3)通常，年生長(zhǎng)速度大約在兩歲之內(nèi)就低于標(biāo)準(zhǔn)增長(zhǎng)曲線，導(dǎo)致嚴(yán)重的不成比例的短肢中等程度矮身材。(4)兒童時(shí)期，特別是下肢大關(guān)節(jié)的關(guān)節(jié)痛很常見。(5)退化性關(guān)節(jié)疾病是進(jìn)行性的；(6)約有50％的假性軟骨發(fā)育不全患者最終需要進(jìn)行髖關(guān)節(jié)置換手術(shù)。3.影像檢查（1）X線檢查可見四肢管狀骨對(duì)稱性粗短、變形，愈向遠(yuǎn)端愈嚴(yán)重。短的長(zhǎng)骨并有較寬的干端(metaphyses)，干端呈現(xiàn)較小、不規(guī)則或是不完整，尤其是在股骨頭骺（capitalfemoralepiphysis，SCFE)的地方。（2）顯著的短指畸形(brachydactyly)，掌骨與指骨過短，小而不規(guī)則的腕骨(carpal)。指骨橫徑幾乎與長(zhǎng)徑相等，呈方形，髓腔增寬，干骺端增大，不規(guī)則，邊緣唇狀突出。表面呈蕈狀膨?。ㄏリP(guān)節(jié)）、杯口狀凹陷（尺骨遠(yuǎn)端）和波浪狀凹凸不平（脛骨遠(yuǎn)端），松質(zhì)骨粗疏、結(jié)構(gòu)亂、雜以斑點(diǎn)狀致密影；（3）脊柱的異常包括扁平的角度變異性并伴隨有雙凹終板，以及來自于身體體表前端的中央前端骨頭的破裂。而腰椎上下的椎弓根寬度距離是正常的。有齒突骨發(fā)育不全(odontoidhypoplasia)的現(xiàn)象，薦骨切跡（sacralnotch）較短。肋骨傾向變成匙型，終端的趾骨也較小。（4）其他：骨骺出現(xiàn)延遲但卻提前愈合。椎體通常變扁，間隙增寬，其前部臺(tái)階狀缺如。腰椎脊柱前凸與后凸，脊柱側(cè)彎。（5）平片基本可以識(shí)別骨骺及干骺端的發(fā)育異常，脊柱、骨盆和下肢的骨骺及干骺端的發(fā)育異常多于上肢，變化與年齡相關(guān)，嬰兒期正常，兒童時(shí)期最顯著，成人期并不嚴(yán)重。（6）骨盆：不全發(fā)育，尤其是恥骨，延遲發(fā)育的特征是Y形骨骺及扁平的髖臼角，髖臼的中央和邊緣可見釘狀骨突，（7）脊柱：兒童椎骨：椎體前部呈舌狀突起，椎體呈橢圓形或雙凹變形，成人椎體：楔狀、扁平狀或正常，齒突發(fā)育不全：寰樞椎不穩(wěn)，增加腰椎前凸和側(cè)彎（8）四肢:肢根部短縮,管狀骨縮短并增粗，尤其是手和腳,兒童期骨骺小而扁平，成人期變成不規(guī)則，造成過早發(fā)生骨性關(guān)節(jié)炎,在成年期干骺端持續(xù)擴(kuò)張，以致骨端膨大,髖內(nèi)翻，膝內(nèi)翻或外翻4.基因檢測(cè)：發(fā)現(xiàn)COMP基因突變。5.另外的檢查:(1)在特定疾病的生長(zhǎng)圖上進(jìn)行高度評(píng)估和繪制生長(zhǎng)曲線(2)通過病史和體格檢查評(píng)估骨骼表現(xiàn)：韌帶松弛和關(guān)節(jié)炎(3)“遺傳”骨骼調(diào)查包括：臀部，膝蓋和手的AP視圖以及膝蓋和脊椎的側(cè)面視圖(4)由于與頸椎不穩(wěn)相關(guān)的潛在嚴(yán)重臨床并發(fā)癥而對(duì)頸椎進(jìn)行評(píng)估，可以通過屈曲/延伸X線片或頸椎MRI檢查進(jìn)行評(píng)估，尤其是在有神經(jīng)系統(tǒng)癥狀提示臍帶受壓的患者中(5)咨詢臨床遺傳學(xué)家和/或遺傳咨詢師6.臨床診斷：可以根據(jù)臨床表現(xiàn)和影像學(xué)特征對(duì)假軟骨發(fā)育不全進(jìn)行診斷。如果臨床特征尚無定論，則在分子遺傳學(xué)檢測(cè)中發(fā)現(xiàn)COMP基因的雜合致病性突變可建立診斷。7.鑒別診斷（1）軟骨發(fā)育不全：本病顱面部骨異常；腰椎椎弓根間距自上向下逐漸變窄，骨骺不受累，出生即可診斷。（2）多發(fā)性骨骺發(fā)育不全：多發(fā)性骨骺發(fā)育不全與假性軟骨發(fā)育不全很相似，兩者均為短肢性侏儒，尤其是青春期兩者的鑒別困難。本病無脊柱病變或僅有輕度改變，干骺端不受累，而假性軟骨發(fā)育不全干骺端有明顯改變。呼吸異常。（3）佝僂病：類似鞠躬畸形，骺板正常，生長(zhǎng)板不規(guī)則，血清磷降低（4）莫基奧綜合征：顱面骨畸形，正常恥骨骨化8.治療選擇臨床處理以受侵犯小兒骨科合并癥為主，關(guān)節(jié)痛可以止痛劑來控制，但并無系統(tǒng)性研究可評(píng)估在此癥中疼痛控制的多變類型有無其有效作用。在兒童時(shí)期通常會(huì)進(jìn)行切骨術(shù)來減低肢體的畸形現(xiàn)象。需要接受手術(shù)治療脊柱側(cè)彎的現(xiàn)象并不常見，但是針對(duì)嚴(yán)重脊柱側(cè)彎的患者時(shí)就必需考慮采用手術(shù)來進(jìn)行矯正。有關(guān)身材短小所帶來的心理沖擊，包括污名化(stigmatization)與歧視(discrimination)等狀況，必需特別小心處理，并且給予社會(huì)支持。針對(duì)身體上的主要臨床特征給予預(yù)防處理，當(dāng)患者活動(dòng)時(shí)應(yīng)保護(hù)關(guān)節(jié)避免受到傷害。9.如何預(yù)防：（1）假性軟骨發(fā)育不全為遺傳性疾病，有家族史者，需要進(jìn)行遺傳咨詢與產(chǎn)前診斷，有利于優(yōu)生優(yōu)育。（2）鼓勵(lì)進(jìn)行不會(huì)造成過度磨損和/或損壞關(guān)節(jié)的體育活動(dòng)。例如游泳10.注意事項(xiàng)：應(yīng)避免的藥物/情況：在齒狀突發(fā)育不全的患者中，應(yīng)避免頸部過度屈伸。11.典型病例：病例1:股骨頭小，骨骺不規(guī)則，椎體前舌呈頸脊骨狀，髖臼不規(guī)則。病例2：假性軟骨發(fā)育不全癥1例4歲男童，表現(xiàn)為膝外翻和身材矮小(a-d)。a)骨盆顯示大股骨骺小而圓，髂骨下部發(fā)育不全且形狀不規(guī)則，導(dǎo)致髖臼頂呈水平外觀。b)下肢x線片顯示膝內(nèi)翻，股骨遠(yuǎn)端中期寬且明顯不規(guī)則;膝關(guān)節(jié)骨骺發(fā)育不良，股骨端呈三角形，部分內(nèi)陷到股骨中期杯狀;發(fā)育不良的干骺端改變也見于脛骨遠(yuǎn)端。c)脊柱x線片顯示椎體的上、下終板有輕微的頸椎狀隆起和相當(dāng)不規(guī)則;假性軟骨發(fā)育不全的中中央舌伴椎體沿上下終板的骺端發(fā)育不良，導(dǎo)致雙凸外形。d)掌骨短，干骺端拔火罐，不規(guī)則，骨骺小而圓;短而粗短的指骨伴輕微的干骺端拔罐;小而不規(guī)則的腕骨延遲骨化，橈骨和尺骨遠(yuǎn)端有明顯的干骺端增寬和不規(guī)則。

骨軟骨損傷：我該如何判斷我是否患有軟骨及相關(guān)疾??？（軟骨損傷后的影像學(xué)檢查都有哪些？）你需要高分辨核磁共振MRI檢查HowdoIknowifIhaveaCartilageProblem?(ImagingofCartilageInjuries)陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）圖1.膝關(guān)節(jié)股骨髁軟骨損傷（cartilagedamage），主要表現(xiàn)為不同程度的軟骨剝脫、丟失。圖2.膝關(guān)節(jié)不同類型的軟骨損傷（cartilagedamage），主要包括：①軟骨下骨板的缺血壞死（avascularnecrosis），進(jìn)而導(dǎo)致軟骨自下而上的營養(yǎng)缺失，最終發(fā)生軟骨剝脫脫離；②剝脫性骨軟骨炎（osteochondritisdissecans）；③自發(fā)性膝關(guān)節(jié)軟骨壞死（spontaneousosteonecrosisoftheknee）；④軟骨損傷（chondrallesion）；⑤骨軟骨損傷（osteochondrallesion）。Fig.3.23-year-oldmanwithamoderateosteochondraldefectonthepatellarcartilageseenonaxialprotondensity-weightedMRI(a).T1before(b)andafterintravenouscontrastadministration(c)showasignificantdecreaseofT1relaxationtimesinthecartilagelesionareaofthemedialfacetofthepatella.Thereisafocalsmallbutdeeplesionandalargersuperficiallesionmediallywhichcorrespondtoregionsoflowerglycosaminoglycan(GAG)content.PrecontrastT1map(a)doesnotshowsignificantchanges,underscoringtheimportanceofpostcontrastT1mapping(c)forGAGevaluation.圖3.軸向質(zhì)子密度加權(quán)MRI顯示的23歲男性，髕骨軟骨中度骨軟骨缺損（a）。（b）靜脈注射造影劑前和靜脈注射造影劑后（c）的T1顯示髕骨內(nèi)側(cè)小面積軟骨損傷區(qū)域的T1弛豫時(shí)間顯著減少。內(nèi)側(cè)有一個(gè)小而深的局灶性病變和一個(gè)較大的淺表病變，對(duì)應(yīng)于糖胺聚糖(GAG)含量較低的區(qū)域。造影前T1圖(a)沒有顯示出顯著變化，強(qiáng)調(diào)了造影后T1映射(c)對(duì)于GAG評(píng)估的重要性。Fig.4.62-year-oldwomanwithadvancedOAinthemedialfemorotibialcompartment.Sagittalprotondensity-weightedMRI(a)showsmarkedthinningofcartilageattheweight-bearingcentralmedialfemuradjacenttothemedialmeniscus(largewhitearrows).Notethelargeintrachondralosteophyteoftheanteriorpartoftheweight-bearingmedialfemur(smallwhitearrows).Diffusecartilagedamageisalsoshownattheanteriormedialfemur(arrowhead).Thetibialcartilageappearsmorphologicallynormal.ThecorrespondingdGEMRICimage(b)showsadecreaseinthedGEMRICindexparticularlyintheweightbearingareasatthecentralandposteriortibia(largewhitearrows)aswellasinthesuperficialzonesofthecentralmedialfemoralcartilage(smallwhitearrows)representinglowGAGconcentration.圖4.62歲女性，股骨內(nèi)側(cè)間室晚期OA。矢狀質(zhì)子密度加權(quán)MRI（a）顯示與內(nèi)側(cè)半月板相鄰的負(fù)重中央內(nèi)側(cè)股骨處的軟骨明顯變薄（大的白色箭頭）。注意負(fù)重內(nèi)側(cè)股骨前部的大軟骨內(nèi)生骨贅（白色小箭頭）。股骨前內(nèi)側(cè)（箭頭）也顯示彌漫性軟骨損傷。脛骨軟骨形態(tài)正常。相應(yīng)的dGEMRIC圖像(b)顯示dGEMRIC指數(shù)下降，特別是在脛骨中央和后部的負(fù)重區(qū)域（大的白色箭頭）以及股骨中央內(nèi)側(cè)軟骨的淺表區(qū)域（小白色箭頭），代表低GAG含量。Fig.5.Cartilagelossinapatientwithbaselinemeniscaltearsintherightknee.(A)CoronalDESSMRIatbaselineshowsnormalcartilageatthemedialtibiofemoraljoint.(B)Sagittalintermediate-weightedfat-suppressedMRIatbaselineshowsahorizontaltearoftheposteriorhornofthemedialmeniscus(smallarrows)withsmallsubchondralfemoralbonemarrowlesion(largearrow).(C)CoronalDESSMRIattwo-yearfollow-upshowsdramaticcartilagelossatboththeweight-bearingmedialfemur(smallarrows)andthetibia(largearrow),whichisconfirmedon(D),thesagittalintermediate-weightedfat-suppressedMRI.Inaddition,thereareextensivetibialandfemoralsubchondralbonemarrowlesions(largearrows)andnewjointeffusion(asterisk).Also,aslightincreaseinthesizeoftheanteriorfemoralandtibialosteophytesisobserved(smallarrows)圖5.伴有軟骨損傷的右膝半月板撕裂患者。(A)冠狀DESSMRI顯示內(nèi)側(cè)脛股關(guān)節(jié)處的軟骨正常。(B)矢狀位中等加權(quán)脂肪抑制MRI顯示內(nèi)側(cè)半月板后角水平撕裂（小箭頭）和小的軟骨下股骨骨髓病變（大箭頭）。(C)兩年隨訪時(shí)的冠狀位DESSMRI顯示，負(fù)重的股骨內(nèi)側(cè)（小箭頭）和脛骨（大箭頭）均出現(xiàn)明顯的軟骨損傷，這在(D)矢狀加權(quán)脂肪抑制核磁共振中得到證實(shí)。此外，還有廣泛的脛骨和股骨軟骨下骨髓病變（大箭頭）和新的關(guān)節(jié)積液（星號(hào)）。此外，觀察到股骨前部和脛骨骨贅的大小略有增加（小箭頭）Thefirstthingtoexplain,especiallyforpatients,iswhyimagingofthekneeisrequired.Whenpatientsarrivewithacartilageproblem,ofteninthekneejoint(althoughsometimesintheankleorhip),thefirststepisclinicalevaluation.However,imagingisalsorequired,particularlyinpatientswithapossiblecartilageproblem.IfanX-rayistaken,itonlyrevealswhetherornotthereisosteoarthritisor,aftertrauma,whetherornotthereisafracture.YoungerpatientsinparticularcanhaveproblemsintheirkneethatarenotshownonX-ray,andmagneticresonanceimaging(MRI)isthereforerequired.IntendedaudienceThisinformationisaimedatpatientswhohavebeenidentifiedasneedingimagingforcartilagedisorders.Itisdesignedtoofferanoverviewofwhattheproceduresentail,aswellasbrieflydiscusstheadvantages,disadvantagesandexpectationsyoushouldhavewhenundergoingsuchprocedures.首先要解釋的是，尤其是對(duì)患者來說，為什么需要對(duì)膝關(guān)節(jié)進(jìn)行拍片（影像學(xué)）檢查。當(dāng)患者出現(xiàn)軟骨問題時(shí)，通常是膝關(guān)節(jié)（盡管有時(shí)是踝關(guān)節(jié)或髖關(guān)節(jié)），第一步是臨床評(píng)估。然而，也需要成像，特別是在可能有軟骨問題的患者中。如果拍X線片，它只能顯示是否有骨關(guān)節(jié)炎，或者在外傷后，是否有骨折。特別是較年輕的患者，他們的膝關(guān)節(jié)可能會(huì)出現(xiàn)X線未顯示的問題（CT檢查可理解成斷面X線片檢查，對(duì)于骨關(guān)節(jié)軟組織成像顯示有限），因此需要進(jìn)行磁共振成像(MRI)。目標(biāo)受眾（閱讀者）此信息針對(duì)已被確定為需要對(duì)軟骨疾病進(jìn)行影像學(xué)檢查的患者。它旨在概述這些影像學(xué)檢查所需的內(nèi)容，并簡(jiǎn)要討論您在進(jìn)行此類影像學(xué)檢查時(shí)應(yīng)具備的優(yōu)點(diǎn)、缺點(diǎn)和期望。什么是核磁共振？MRI機(jī)器使用磁場(chǎng)和無線電波來形成體內(nèi)各種結(jié)構(gòu)的圖像。需要進(jìn)行MRI以查看關(guān)節(jié)中可能存在的軟骨問題，更重要的是，MRI必須是好的（高清的）。為此，需要1.5特斯拉，甚至更好的是3T特斯拉MRI?！疤厮估盩esla是MRI磁場(chǎng)強(qiáng)度的量度?，F(xiàn)代MR系統(tǒng)通常具有1.5或3.0特斯拉的場(chǎng)強(qiáng)?；旧希朋w的場(chǎng)強(qiáng)越高，MRI的質(zhì)量就越好。此外，對(duì)于高質(zhì)量的MRI，需要專用的關(guān)節(jié)線圈。線圈是關(guān)節(jié)周圍的一個(gè)小籠子，可提高M(jìn)RI的質(zhì)量。例如，在膝關(guān)節(jié)中，有一種特殊的線圈，稱為“專用多通道膝關(guān)節(jié)線圈”，有8個(gè)或16個(gè)通道。這些通道進(jìn)一步提高了MRI的質(zhì)量，因?yàn)榭梢垣@得更多信號(hào)，因此可以更詳細(xì)地對(duì)軟骨層進(jìn)行成像。線圈越好，掃描儀越好，MRI圖像的質(zhì)量就越好。如果你的圖像分辨率高、質(zhì)量好、對(duì)比度好、信噪比好，就可以看到這個(gè)相對(duì)微小的軟骨層有沒有病變。此外，執(zhí)行MRI的醫(yī)生應(yīng)該意識(shí)到您可能有軟骨問題，以便他們可以使用高分辨率和良好的MRI程序來正確顯示軟骨。否則，圖像可能會(huì)顯示問題，但無法確定軟骨病變的大小、病變的數(shù)量以及半月板、前后交叉韌帶和下方骨骼的狀態(tài)。了解骨骼狀況非常重要，因?yàn)榛颊呖赡苡泄铝⒌能浌菗p傷或軟骨缺損，或者可能有骨骼和軟骨（“骨軟骨”）缺陷，包括下面的骨骼。這對(duì)于選擇正確的治療方式非常重要。此外，軟骨缺損的大小至關(guān)重要。對(duì)于非常小的缺陷，可以使用微骨折治療。但如果缺損較大，且周圍軟骨質(zhì)量不佳，則可能需要進(jìn)行軟骨移植，如ACI、MACI或骨軟骨移植。事先知道這一點(diǎn)很有幫助，因?yàn)榛颊呖梢院炇鹨环萏厥獾男g(shù)前文件，允許外科醫(yī)生進(jìn)行軟骨活檢，這對(duì)于這些程序是必要的。未經(jīng)患者事先許可，不能進(jìn)行第二次手術(shù)的軟骨活檢，因?yàn)樗徽J(rèn)為是一種治療形式。因此，MRI不僅允許外科醫(yī)生選擇最合適的程序，還可以選擇正確的術(shù)前文件供患者簽署。這也很重要，因?yàn)榛颊叩男g(shù)后護(hù)理可能完全不同，康復(fù)計(jì)劃不同或更長(zhǎng)。這就是為什么患者在手術(shù)前進(jìn)行核磁共振檢查很重要，尤其是對(duì)軟骨敏感的核磁共振檢查，這樣醫(yī)生才能看到軟骨發(fā)生了什么情況、缺損的大小和缺損的數(shù)量。其他成像技術(shù)能否提供與MRI相同的信息？如上所述，X線片顯示關(guān)節(jié)的狀態(tài)，以及是否存在骨關(guān)節(jié)炎或骨折。換句話說，X線片只是可視化骨骼結(jié)構(gòu)和異常。因此，軟骨缺損無法真正可視化。超聲波可視化肌肉或肌腱損傷。如果軟骨在穿透超聲波的深度內(nèi)，則可以部分顯示軟骨。然而，這種能力是有限的，因?yàn)楦叻直媛食暰哂薪M織穿透率低的缺點(diǎn)。計(jì)算機(jī)斷層掃描(CT)對(duì)軟骨也不敏感。此外，與CT相關(guān)的輻射也存在問題?？梢赃M(jìn)行CT聯(lián)合關(guān)節(jié)內(nèi)造影劑，稱為關(guān)節(jié)CT。然而，這仍然存在輻射問題，以及與關(guān)節(jié)內(nèi)（關(guān)節(jié)內(nèi)）注射造影劑相關(guān)的感染風(fēng)險(xiǎn)。僅當(dāng)患者由于嚴(yán)重的幽閉恐懼癥或存在起搏器或類似的植入設(shè)備而無法進(jìn)入MRI機(jī)器時(shí)，才使用此技術(shù)。然而，大多數(shù)軟骨損傷患者更年輕，通?？梢赃M(jìn)入MRI機(jī)器。MRI有什么缺點(diǎn)嗎？MRI沒有真正的缺點(diǎn)，尤其是在不需要造影劑的情況下。唯一的風(fēng)險(xiǎn)是MRI的經(jīng)典禁忌癥，如心臟起搏器、心臟直視手術(shù)或開顱手術(shù)，以及有源電子設(shè)備，如輸液泵等。有大型金屬植入物的患者，尤其是鐵磁體（即被磁鐵吸引），也不允許進(jìn)行核磁共振檢查。核磁共振機(jī)器里有一些噪音，但給病人戴了護(hù)耳器。如果患者非常幽閉恐懼癥，機(jī)器也可能令人不快。常見問題(FAQ)保險(xiǎn)公司會(huì)支付核磁共振的費(fèi)用嗎？MRI不是很貴，但也不是特別便宜。如果您的醫(yī)生認(rèn)為您的膝關(guān)節(jié)、髖關(guān)節(jié)或踝關(guān)節(jié)的軟骨有問題并且您需要進(jìn)行核磁共振檢查，則保險(xiǎn)公司必須支付費(fèi)用。然后，患者通常會(huì)在MRI掃描后詢問保險(xiǎn)公司是否會(huì)支付軟骨修復(fù)程序的費(fèi)用。這是非常昂貴的。然而，它旨在或多或少地治愈關(guān)節(jié)，或者推遲正在進(jìn)行的骨關(guān)節(jié)炎或防止它發(fā)展。如果醫(yī)生提出這樣的治療，保險(xiǎn)公司必須支付費(fèi)用。這取決于您居住的國家和相關(guān)的醫(yī)療保健系統(tǒng)。我需要做核磁共振嗎？患者通常希望進(jìn)行核磁共振檢查，因此經(jīng)常會(huì)問這個(gè)問題。如果懷疑軟骨缺損，答案將是“是”。WhatisMRI?MRImachinesusemagneticfieldsandradiowavestoformimagesofawiderangeofstructuresinthebody.AnMRIisrequiredtoseepossiblecartilageproblemsinthejointand,moreimportantly,theMRIhastobeagoodone.Forthat,eithera1.5Teslaor,evenbetter,a3TeslaMRIisneeded.‘Tesla’isameasureofthestrengthoftheMRI’smagnetfield.ModernMRsystemsusuallyhavefieldstrengthof1.5or3.0Tesla.Basically,thehigherthefieldstrengthofthemagnet,thebetterthequalityoftheMRI.Additionally,forahigh-qualityMRI,adedicatedjointcoilisneeded.ThecoilisasmallcagearoundthejointthatimprovesthequalityoftheMRI.Inthekneejoint,forexample,therearespecialcoilscalled‘dedicatedmulti-channelkneecoils’,whichhave8or16channels.ThesechannelsfurtherimprovethequalityoftheMRI,asmoresignalscanbegainedand,therefore,thecartilagelayercanbeimagedingreaterdetail.Thebetterthecoil,andthebetterthescanner,thebetterthequalityoftheMRIimages.Ifyouhaveimageswithhighresolutionandgoodquality,goodcontrastandagoodsignal-to-noiseratio,itwillbepossibletoseeifthereareanylesionsinthisrelativelytinycartilagelayer.Furthermore,thephysiciansperformingtheMRIshouldbeawarethatyoumighthaveacartilageproblem,sothattheycanuseahighresolutionandagoodMRIprotocoltoproperlyvisualisethecartilage.Otherwise,theimagesmayshowaproblem,butitwillnotbepossibletodeterminethesizeofthecartilagelesion,thenumberoflesions,andthestatusofthemeniscus,thecruciateligaments,andtheunderlyingbone.Itisveryimportanttohaveanideaoftheconditionofthebones,asthepatientmayhaveisolatedcartilageinjuriesorcartilagedefects,ormayhaveboneandcartilage(‘osteochondral’)defects,whichincludetheunderlyingbone.Thisisveryimportantforchoosingtherightkindoftherapy.Inaddition,thesizeofthecartilagedefectiscrucial.Forverysmalldefects,microfracturetherapycanbeused.However,ifthereisabiggerdefect,andthesurroundingcartilageisnotgoodquality,cartilagetransplantation,suchasACI,MACI,orosteochondraltransplantation,mayberequired.Itishelpfultoknowthatbeforehand,asthepatientcansignaspecialpreoperativedocumentthatgivesthesurgeonpermissiontoperformacartilagebiopsy,whichisnecessaryfortheseprocedures.Cartilagebiopsyforasecondsurgerycannotbeperformedwithoutpriorpatientpermission,asitisconsideredaformoftherapy.MRIthereforenotonlyallowsthesurgeontochoosethemostappropriateprocedurebutalsoselectthecorrectpreoperativedocumentsforthepatienttosign.Itisalsoimportantbecausethepostoperativecareofthepatientcouldbecompletelydifferent,withadifferentorlongerrehabilitationprogramme.ThisiswhyitisimportantthatpatientshaveanMRIbeforetheirprocedure,particularlyonethatiscartilage-sensitive,sothatthedoctorcanseewhatishappeningwiththecartilage,thesizeofthedefectandthenumberofdefects.CanotherimagingtechniquesgivethesameinformationasMRI?AnX-ray,asdiscussedabove,showsthestatusofthejoint,andwhetherthereisosteoarthritisorafracture.Inotherwords,X-raysimplyvisualisesbonystructuresandabnormalities.Therefore,cartilagedefectscannotreallybevisualised.Ultrasoundvisualisesmuscleortendoninjuries.Cartilagecanbepartiallyvisualisedifitiswithinthedepthofthepenetratingultrasoundwaves.Thisabilityislimited,however,ashighresolutionultrasoundhasthedisadvantageoflowtissuepenetration.Computedtomography(CT)isalsonotsensitiveforcartilage.Inaddition,theradiationassociatedwithCTpresentsaproblem.CTcombinedwithintra-articularcontrastagent,knownasarthroCT,canbeperformed.However,thisstillhastheproblemoftheradiation,coupledwiththeinfectiousriskassociatedwithanintra-articular(withinthejoint)injectionofcontrastagent.ThistechniqueisonlybeusedifthepatientcannotgointoanMRImachineduetosevereclaustrophobiaorthepresenceofapacemakerorsimilarimplanteddevice.Themajorityofcartilageinjurypatients,however,areyoungerandcanusuallygointoanMRImachine.ArethereanydisadvantagestoMRI?TherearenorealdisadvantagestoMRI,especiallyifacontrastagentisnotneeded.TheonlyrisksaretheclassicalcontraindicationsforMRI,suchascardiacpacemakers,openheartsurgeryoropencranialsurgery,andactiveelectronicdevicessuchasinfusionpumps,etc.Patientswithlargemetalimplants,particularlyifferromagnetic(i.e.,attractedtomagnets),arealsonotallowedtohaveanMRI.ThereissomenoiseintheMRImachine,butpatientsaregiveneardefenders.Themachinecanalsobeunpleasantifpatientisveryclaustrophobic.FrequentlyAskedQuestions(FAQs)WilltheinsurancecompanypayfortheMRI?MRIisnotveryexpensive,butitisnotparticularlycheapeither.Ifyourdoctorbelievesthatthereisaprobleminthecartilageofyourknee,hiporanklejointandyouneedanMRI,theinsurancecompanyhastopayforit.Patientsthentypicallyaskwhethertheinsurancecompanywillpayforthecartilagerepairprocedure,followingtheMRIscan.Thisisveryexpensive.However,itisintendedtomoreorlesshealthejoint,andeitherpostponeongoingosteoarthritisorpreventitfromdeveloping.Ifaphysicianindicatessuchatreatment,theinsurancecompanyhastopayforit.Thisisdependentonthecountryinwhichyouliveandtheassociatedhealthcaresystem.WillIgetanMRI?PatientsusuallywanttohaveanMRI,andsooftenaskthisquestion.Ifacartilagedefectissuspected,theanswerwillbe‘yes’.Furtherreading·GriffinJW,MillerMD.MRIofthekneewitharthroscopiccorrelation.ClinSportsMed.2013;32:507-523.·TrattnigS,DomayerS,WelschGW,MosherT,EcksteinF.MRimagingofcartilageanditsrepairintheknee–areview.EurRadiol.2009;19:1582-1594.·WelschGH,MamischTC,HughesT,DomayerS,MarlovitsS,TrattnigS.Advancedmorphologicalandbiochemicalmagneticresonanceimagingofcartilagerepairproceduresinthekneejointat3Tesla.SeminMusculoskeletRadiol.2008;12:196-211.·TrattnigS,WinalskiCS,MarlovitsS,JurvelinJS,WelschGH,PotterHG.MagneticResonanceImagingofCartilageRepair:AReview.Cartilage.2011;2:5-26.Keywordscartilagerepair,computedtomography,imaging,Magneticresonanceimaging,MRI,ultrasound,X-ray關(guān)鍵詞軟骨修復(fù)，計(jì)算機(jī)斷層掃描，成像，磁共振成像，MRI，超聲波，X線

髕股關(guān)節(jié)軟骨包括髕骨軟骨和股骨滑車軟骨，又些又會(huì)被診斷為髕骨軟化，PRP治療，效果拔群。唯一的缺點(diǎn)就是費(fèi)錢。?最近給個(gè)髕股關(guān)節(jié)軟骨損傷的大哥做PRP治療，已經(jīng)打了兩次，他很滿意效果，正好每次做的時(shí)候也沒法拍視頻，征得大哥的同意，第三次治療就讓他的腿和聲音出鏡了。

新的（修復(fù)骨軟骨損傷的）生物支架和細(xì)胞NewScaffolds&Cells?Classictechniqueforautologouschondrocyteimplantation(ACI).?A,?Arthroscopicevaluationofthekneejointandidentificationofafull-thicknessmedialfemoralcondyleinjury.Acartilagebiopsyistakenfromthesuperiorintercondylarnotch,digested,andcultured.Autologouschondrocytetransplantationwilloccurwhenthecellshavereachedavolumethatcanfillthearticularcartilagedefect.?B,?Atwo-incisionapproachismadetotheknee.Thefirstisamedialarthrotomytoexposethefull-thicknessmedialfemoralcondyledefect.Thesecondisanincisiondistaltothepesanserinustendoninsertiontoharvestperiosteumtemplatedexactlytothedefectafteritisdebrided.?C,?ThetechniqueofACI.Aperiostealpatchisharvesteddistaltothepesanserinustendons.Itismicrosuturedwithinterrupted6.0Vicrylsuturesflushtothearticularsurfaceandtestedforwaterintegritytightness.Itisthensealedwithfibringluetomaintainwatertightness.Theautologouschondrocytesuspensionisinjecteddeeptotheperiostealcovertofillthedefect,andtheopeningissuturedoverandsealedwithfibringlue.Thekneejointisclosed.Thepatientundergoescarefulrehabilitationtorestoremotionandallowthegrafttomatureuneventfully.圖1：2步支架移植法修復(fù)軟骨缺損：自體軟骨細(xì)胞移植（ACI）的經(jīng)典技術(shù)。A，膝關(guān)節(jié)的關(guān)節(jié)鏡評(píng)估和鑒定全層厚度的股骨髁骨軟骨損傷。軟骨塊是股骨髁窩上部取得的（非負(fù)重關(guān)鍵區(qū)），被消化和培養(yǎng)。當(dāng)細(xì)胞達(dá)到可以填補(bǔ)關(guān)節(jié)軟骨缺陷的體積時(shí)，將準(zhǔn)備自體軟骨細(xì)胞移植。B，膝關(guān)節(jié)采取了兩種切口方法。首先是髕旁內(nèi)側(cè)關(guān)節(jié)切開術(shù)，可暴露全層厚度股骨內(nèi)側(cè)髁缺損。第二個(gè)是髂脛束肌腱附著處的遠(yuǎn)端切口，以收獲骨膜，這些骨膜被清理后，精確地插入了骨軟骨缺損處（與骨軟骨缺損處形態(tài)一致）。C，自體軟骨細(xì)胞移植ACI技術(shù)。從髂脛束肌腱附著處的遠(yuǎn)端切口收集骨膜塊。用6.0vicryl微創(chuàng)可吸收線縫合至關(guān)節(jié)表面并測(cè)試完整性、水緊密性。然后用纖維蛋白膠將其密封以保持密封性。自體軟骨細(xì)胞懸浮液植入骨膜下以填補(bǔ)缺損，并用纖維蛋白膠將開口縫合并密封。膝關(guān)節(jié)關(guān)閉?；颊哌M(jìn)行了認(rèn)真的術(shù)后康復(fù)，以恢復(fù)運(yùn)動(dòng)，并使移植物與自體軟骨相融合為一體。數(shù)十年來，已經(jīng)提出并嘗試了許多手術(shù)方式，以治療關(guān)節(jié)軟骨（稱為軟骨病變）或軟骨以及基礎(chǔ)（骨軟骨病變）的損害，目的是盡可能緊密地恢復(fù)（移植修復(fù)）組織到原始軟骨。但是，迄今為止，沒有任何方法能夠完全修復(fù)正常、健康軟骨的特性。軟骨生物支架是臨時(shí)的3D生物降解結(jié)構(gòu)，由于患病或受損的軟骨而被放置在軟骨缺損處。軟骨生物支架通常分為四種主要類型：基于蛋白質(zhì)的支架，基于碳水化合物的支架，合成或基于人造聚合物的支架，以及這些類型材料的復(fù)合支架。軟骨生物支架也可以以幾種形式：膜狀，多孔狀或水凝膠狀。軟骨生物支架應(yīng)該是：?生物相容性，體內(nèi)幾乎沒有炎癥反應(yīng)；?能被身體分解時(shí)無害物質(zhì)；?多孔，足以允許新的軟骨細(xì)胞生長(zhǎng)和最終的軟骨生物支架降解，同時(shí)形成“網(wǎng)狀”以維持最合適的軟骨修復(fù)微環(huán)境；?易于生產(chǎn)和多種功能，具體取決于所需的尺寸和形狀；?能夠承受關(guān)節(jié)內(nèi)的壓應(yīng)力和剪切應(yīng)力（例如，膝關(guān)節(jié)）。軟骨生物支架可以作為兩步軟骨修復(fù)手術(shù)的一部分植入，其中軟骨生物支架與先前在實(shí)驗(yàn)室中擴(kuò)增的軟骨細(xì)胞相結(jié)合。這是一個(gè)類似于自體軟骨細(xì)胞植入（ACI）的過程，稱為基質(zhì)輔助自體軟骨細(xì)胞移植（MACT）或基質(zhì)輔助自體軟骨細(xì)胞植入（MACI）。或者，將支架植入一步過程中，其中軟骨生物支架刺激后的軟骨生物支架被放置在有缺損的軟骨中，或者是移植柱，或作為促進(jìn)新軟骨生長(zhǎng)（稱為“智能”軟骨生物支架）。盡管有長(zhǎng)期的隨訪表明先前使用的軟骨生物支架和軟骨細(xì)胞會(huì)產(chǎn)生良好的結(jié)果，但正在等待新的“智能”軟骨生物支架的長(zhǎng)期研究數(shù)據(jù)。下面討論了軟骨修復(fù)中軟骨生物支架的用途，優(yōu)勢(shì)和缺點(diǎn)以及臨床證據(jù)。目標(biāo)受眾（閱讀者）本文適用于任何關(guān)節(jié)軟骨受損的人及其家人，他們想了解新的支架，以及任何對(duì)軟骨問題感興趣的人。什么是新的軟骨修復(fù)支架？用于軟骨再生的支架在1990年代后期被引入臨床。這些是先進(jìn)的生物聚合物，用作從患者身上提取的軟骨細(xì)胞或“自體軟骨細(xì)胞”的支持物。與自體軟骨細(xì)胞移植ACI的手術(shù)相似，外科醫(yī)生首先進(jìn)行（關(guān)節(jié)鏡檢查）以從關(guān)節(jié)的非負(fù)重部分采集含有軟骨細(xì)胞（軟骨細(xì)胞）的小塊軟骨。軟骨片被送到實(shí)驗(yàn)室，在那里分離和培養(yǎng)（增殖）細(xì)胞3-5周以獲得足夠數(shù)量的細(xì)胞（通常在5到1200萬個(gè)細(xì)胞之間）。然后將軟骨細(xì)胞放置在支架上，以便它們可以繁殖和成熟1到幾天。隨后將與軟骨細(xì)胞結(jié)合的支架移植到關(guān)節(jié)的受損或患病區(qū)域。與此同時(shí)，一步技術(shù)也變得可用。對(duì)于這些程序，一種改進(jìn)的“智能”生物材料被放置在軟骨缺損內(nèi)，該材料能夠幫助身體自身的“構(gòu)建細(xì)胞”形成軟骨組織。骨髓刺激技術(shù)通常與這些支架結(jié)合使用，以允許身體自身的細(xì)胞離開骨髓并參與填充支架。這些骨髓細(xì)胞遷移到支架中，支架的目標(biāo)是引導(dǎo)軟骨單獨(dú)或骨和軟骨細(xì)胞生長(zhǎng)、成熟并構(gòu)建相應(yīng)的組織。今天，有設(shè)計(jì)用于僅重建軟骨（軟骨缺損）或骨和軟骨（骨軟骨缺損）的支架?；|(zhì)輔助自體軟骨細(xì)胞移植MACT或具有自體軟骨細(xì)胞的支架與“智能”支架之間的區(qū)別在于是否存在軟骨細(xì)胞，以及是否需要進(jìn)行一次或兩次手術(shù)。軟骨生物支架和細(xì)胞的優(yōu)缺點(diǎn)是什么？新軟骨生物支架和細(xì)胞的優(yōu)點(diǎn)是什么？與其他手術(shù)治療相比，使用不含軟骨細(xì)胞的支架具有優(yōu)勢(shì)。例如，自體骨軟骨移植需要兩次手術(shù)，并且確實(shí)去除了一小塊“正常軟骨”。從尸體（供體）中采集的同種異體移植物的使用在歐盟存在問題，因?yàn)樗鼈冸y以獲得。此外，使用同種異體材料（即來自其他人）具有與潛在疾病傳播相關(guān)的風(fēng)險(xiǎn)（盡管極低）。結(jié)合軟骨細(xì)胞的支架已經(jīng)上市大約15年，研究人員報(bào)告了良好的結(jié)果。使用沒有軟骨細(xì)胞的智能支架的優(yōu)點(diǎn)是：它們是現(xiàn)成的，并且作為一步手術(shù)操作，也就是說，外科醫(yī)生可以決定是否在他們?cè)谑中g(shù)室時(shí)使用它，當(dāng)他們對(duì)軟骨損傷有更清晰的術(shù)中判斷。新軟骨生物支架和細(xì)胞的缺點(diǎn)是什么？就缺點(diǎn)而言，這完全取決于您放入的生物材料。換句話說，你有鉆石、紅寶石、藍(lán)寶石和祖母綠。都是寶石，但都不同。軟骨生物支架也是如此——你不能直接比較它們，因?yàn)槊總€(gè)軟骨生物支架都是不同的。使用基質(zhì)輔助自體軟骨細(xì)胞移植MACT，它是一種相當(dāng)統(tǒng)一的技術(shù)：軟骨被收獲，軟骨細(xì)胞增殖并放置在支架上/支架內(nèi)。然后將支架放置在軟骨缺損處。對(duì)于“智能”支架技術(shù)，只需將支架放置在患病或受損的關(guān)節(jié)中，無論是否進(jìn)行骨髓刺激（例如鉆孔或微骨折）。最終結(jié)果與所使用的生物材料有關(guān)。“智能”支架已經(jīng)很久沒有使用了，因此缺乏長(zhǎng)期甚至中期的成果。一些支架的短期結(jié)果令人鼓舞，但我們需要一些時(shí)間來了解這些支架是否表現(xiàn)良好。常見問題(FAQ)新的軟骨需要多長(zhǎng)時(shí)間才能在支架內(nèi)生長(zhǎng)？這因患者而異（骨軟骨損傷面積大小、程度、部位以及是否合并有其他臨近部位組織的損傷及程度）。請(qǐng)與您的醫(yī)生在術(shù)前進(jìn)行詳細(xì)的討論。Numeroussurgicalprocedureshavebeensuggestedandtriedovermanydecadestotreatdamagetojoint(‘a(chǎn)rticular’)?cartilage?(knownaschondrallesions)orcartilageandtheunderlyingbone(osteochondrallesions),withtheaimofrestoringthetissueascloselyaspossibletotheoriginalcartilage.However,nomethodstodatehavebeenabletocompletelymatchthepropertiesofnormal,healthycartilage.Scaffolds?aretemporary3Dbiodegradablestructuresthatareplacedinsidecartilagedefectsasaresultofdiseasedordamagedcartilage.Thescaffoldstypicallyfallintofourmaintypes:protein-basedscaffolds,carbohydrate-basedscaffolds,syntheticorartificialpolymer-basedscaffolds,andacombinationofanyofthesetypes.?Scaffolds?canalsobeinseveralforms:membranes,meshesorhydrogels.Scaffolds?shouldbe:·???????Biocompatible,andcauselittleornoinflammatoryresponseinthebody·???????Harmlesswhenbrokendownbythebody·???????Porousenoughtoallownewcartilagegrowthandtheeventualbreakdownofthescaffold,whileforminga‘net’tomaintainthemostsuitableenvironmentforcartilagerepair·???????Easytoproduceandversatile,dependingonthesizeandshaperequired·???????Abletowithstandthestressesandforceswithinthejoint(e.g.,theknee)Scaffolds?canbeimplantedaspartofatwo-stepprocedure,inwhichthescaffoldsarecombinedwithcartilagecells(chondrocytes)multipliedpreviouslyinthelaboratory.Thisisaprocesssimilartothatusedin?autologouschondrocyteimplantation(ACI)?andiscalledmatrix-assistedautologouschondrocytetransplantation(MACT)ormatrix-assistedautologouschondrocyteimplantation(MACI).Alternatively,thescaffoldsareimplantedinaone-stepprocedure,inwhichthescaffoldisplacedinthedefectivecartilageeitheraftermarrowstimulation(drillingor?microfracture)?orasaplugthatencouragesnewcartilagegrowth(knownas‘smart’scaffolds).Whilethereislong-termfollow-upshowingthatthepreviouslyusedscaffoldspluschondrocytesproducegoodresults,longer-termdataforthenewer‘smart’scaffoldsisawaited.Theuses,advantagesanddisadvantages,andclinicalevidenceforscaffoldsincartilagerepairarediscussedbelow.IntendedaudienceThisarticleisintendedforanyonesufferingfromdamagetotheirarticularcartilageandtheirfamilieswhowouldliketofindoutaboutnewscaffolds,aswellasanyoneinterestedincartilageproblems.Figure2:NewScaffolds2Steps.圖2：2步支架移植法修復(fù)軟骨缺損：自體軟骨細(xì)胞移植（ACI）的經(jīng)典技術(shù)（與圖1中的描述一致）。?Whatarenewscaffoldsforcartilagerepair?Scaffolds?forcartilageregenerationwereintroducedthelate1990s.Thesewereadvancedbiopolymersusedasasupportfor?cartilage?cellstakenfromthepatient,or‘a(chǎn)utologouschondrocytes’.Similarlytotheprocedurefor?ACI,thesurgeonfirstperforms(arthroscopy)toharvestsmallpiecesofcartilagecontainingcartilagecells(chondrocytes),fromanon-weight-bearingpartofthejoint.Thecartilagepiecesaresenttoalaboratory,wherethecellsareisolatedandcultured(multiplied)for3–5weekstoobtainsufficientnumberofcells(usuallybetween5and12millioncells).Thechondrocytesarethenplacedonthescaffoldsothattheycanmultiplyandmatureforonetoseveraldays.Thescaffoldcombinedwithchondrocytesissubsequentlytransplantedintothedamagedordiseasedareaofthejoint.Inparallel,one-steptechniqueshavealsobecomeavailable.Fortheseprocedures,animproved,‘smart’biomaterial,whichiscapableofassistingthebody’sown“buildingcells”toformcartilagetissue,isplacedinsidethecartilagedefect.Bonemarrowstimulationtechniquesareoftenusedinconjunctionwiththesescaffoldstoallowthebody’sowncellstoleavethebonemarrowandparticipateinpopulatingthescaffold.Thesebonemarrowcellsmigrateintothescaffold,andthescaffold’sgoalistodirectcartilagealoneorboneandcartilagecellstogrow,mature,andbuildthecorrespondingtissues.Today,therearescaffolddesignedforthereconstructionofcartilageonly(chondraldefects),orofbothboneandcartilage(osteochrondraldefects).ThedifferencesbetweenMACT,orscaffoldswithautologouschondrocytes,and‘smart’scaffoldsarethepresenceofcartilagecells,orchondrocytes,andwhetheroneortwosurgeriesarerequired.WhataretheadvantagesanddisadvantagesofNewScaffolds&Cells?WhataretheadvantagesofNewScaffolds&Cells?Theuseofscaffoldswithoutchondrocyteshasadvantagescomparedtootherprocedures.Forexample,autologousosteochondraltransplantation?requirestwosurgeriesanddoesremoveasmallpieceof“normalcartilage”.Theuseof?allografts,whichareharvestedfromcadavers(donors),isproblematicintheEuropeanUnionastheyaredifficulttoobtain.Moreover,theuseofallogenicmaterials(i.e.,fromotherpeople)hasrisks(thoughextremelylow)associatedwithpotentialdiseasetransmission.Scaffolds?combinedwithchondrocyteshavebeenonthemarketforaround15years,andresearchershavereportedgoodresults.Theadvantagesofusingasmartscaffoldwithoutchondrocytesare:theyareavailableoff-the-shelfandareperformedasaone-stepprocedure,thatis,thesurgeoncandecidewhethertouseitwhiletheyareintheoperatingroom,whentheyhaveaclearerideaofthecartilagedamage.WhatarethedisadvantagesofNewScaffolds&Cells?Intermsofdisadvantages,itdependscompletelyonthebiomaterialyouareputtinginside.Toputitanotherway,youhavediamonds,rubies,sapphiresandemeralds.Allarepreciousstones,buttheyarealldifferent.It’sthesamewithscaffolds–youcannotcomparethemdirectly,becauseeachscaffoldisdifferent.WithMACT,itisaratheruniformtechnique:thecartilageisharvested,thechondrocytesaremultipliedandtheplacedon/inthescaffold.Thescaffoldisthenplacedinthecartilagedefect.Forthe‘smart’scaffoldtechniques,thescaffoldissimplyplacedinthediseasedordamagedjoint,withorwithoutmarrowstimulation(e.g.,drillingor?microfracture.?ThefinalresultisrelatedtothebiomaterialusedThe‘smart’scaffoldshavenotbeeninuseforalongtime,sothereisalackoflong-orevenmedium-termresults.Theshort-termresultsforsomescaffoldsareencouraging,butwewillneedsometimetounderstandwhetherthesescaffoldsareperformingwellornot.FrequentlyAskedQuestions(FAQs)Howlongwillthenewcartilagetaketogrowinsidethescaffold?Thisvariesfrompatienttopatient.Pleasediscusswithyourdoctor.FurtherreadingTherehavebeennumerousstudiesontheoutcomesofscaffoldsforcartilagerepair.Somepapersthatgiveagoodoverviewoftheevidencesofarinclude:進(jìn)一步閱讀已經(jīng)有許多關(guān)于支架用于軟骨修復(fù)的結(jié)果的研究。迄今為止，一些對(duì)證據(jù)進(jìn)行了很好的概述的論文包括：·???????FilardoG,KonE,RoffiA,DiMartinoA,MarcacciM.Scaffold-basedrepairforcartilagehealing:asystematicreviewandtechnicalnote.Arthroscopy.2013;29(1):174-186.·???????GoyalD,GoyalA,KeyhaniS,LeeEH,HuiJH.Evidence-BasedStatusofSecond-andThird-GenerationAutologousChondrocyteImplantationOverFirstGeneration:ASystematicReviewofLevelIandIIStudies.Arthroscopy.2013·???????IrionVH,FlaniganDC.NewandEmergingTechniquesinCartilageRepair:OtherScaffold-BasedCartilageTreatmentOptions.OperativeTechniquesinSportsMedicine.2013;21:125-137.·???????KonE,VerdonkP,CondelloV?etal.?Matrix-assistedautologouschondrocytetransplantationfortherepairofcartilagedefectsoftheknee:systematicclinicaldatareviewandstudyqualityanalysis.AmJSportsMed.2009;37Suppl1:156S-166S.·???????KonE,VanniniF,BudaR?etal.?Howtotreatosteochondritisdissecansoftheknee:surgicaltechniquesandnewtrends:AAOSexhibitselection.JBoneJointSurgAm.2012;94(1):e1(1-e18).·???????KonE,FilardoG,DiMartinoA?etal.?ClinicalResultsandMRIEvolutionofaNano-CompositeMultilayeredBiomaterialforOsteochondralRegenerationat5Years.AmJSportsMed.2013·???????KonE,FilardoG,DiMatteoB,PerdisaF,MarcacciM.Matrixassistedautologouschondrocytetransplantationforcartilagetreatment:Asystematicreview.BoneJointRes.2013;2(2):18-25.·???????MarcacciM,FilardoG,KonE.Treatmentofcartilagelesions:whatworksandwhy?Injury.2013;44Suppl1:S11-S15.·???????OlsonA,GraverA,GrandeD.Scaffoldsforarticularcartilagerepair.JLongTermEffMedImplants.2012;22(3):219-227.Keywordsautologous,?biomaterial,?chondrocytes,?regeneration,?Scaffolds

Risks&ComplicationsinCartilageRepair骨軟骨損傷：軟骨修復(fù)手術(shù)治療的風(fēng)險(xiǎn)及并發(fā)癥陶可(北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科)圖1:膝關(guān)節(jié)外側(cè)髁關(guān)節(jié)骨軟骨損傷后可以采用如下的幾種治療方案：(a)采用特制的工具將制作骨軟骨損傷部位進(jìn)行充分的清理，深達(dá)軟骨下骨板，(b)采用自體或異常具有增殖能力的間充質(zhì)干細(xì)胞MSC移植，充填于上述骨軟骨缺損區(qū)；或(c)采用混合有誘導(dǎo)因子（多為各種生長(zhǎng)因子，如TGF-beta，IGF，F(xiàn)GF等）的間充質(zhì)干細(xì)胞MSC移植于上述骨軟骨缺損區(qū)；或(d)也可以采用將間充質(zhì)干細(xì)胞MSC移植于預(yù)制好的生物支架材料，再添加誘導(dǎo)生長(zhǎng)因子，最后充填于骨軟骨缺損區(qū)。上述3種不同類型的骨軟骨缺損的修復(fù)方法，最終的目的都是修復(fù)較大面積的全層骨軟骨缺損，并且在臨床上，均已經(jīng)取得了良好的治療效果。圖2:膝關(guān)節(jié)內(nèi)側(cè)髁關(guān)節(jié)骨軟骨損傷后可以采用如下的治療方案：(a)將膝關(guān)節(jié)軟骨組織收集，碎化，并消化成軟骨微粒；(b)將上述軟骨微粒與異體間充質(zhì)干細(xì)胞MSCs混合，并移入預(yù)裝號(hào)纖維蛋白膠的注射器，通過涂抹于骨軟骨缺損部位，從而達(dá)到修復(fù)骨軟骨缺損的目標(biāo)。?圖3:通過向膝關(guān)節(jié)腔內(nèi)注射scSOX9蛋白也是一種修復(fù)骨軟骨缺損的策略。?圖4:膜片狀的生物材料修復(fù)膝關(guān)節(jié)股骨髁骨軟骨損傷的示意圖。?圖5:柱狀的生物材料修復(fù)膝關(guān)節(jié)股骨髁骨軟骨損傷的示意圖。??需要注意的是，一般來說，軟骨修復(fù)是一種風(fēng)險(xiǎn)相對(duì)較低、安全的手術(shù)，并發(fā)癥很少見。然而，與任何手術(shù)一樣，了解風(fēng)險(xiǎn)——無論是一般性的還是特定個(gè)體的——都很重要，因?yàn)槿魏侮P(guān)于手術(shù)的決定都是一個(gè)充分知情的決定。雖然并非詳盡無遺，但以下信息是選擇（計(jì)劃）軟骨手術(shù)都應(yīng)考慮的一些風(fēng)險(xiǎn)情況。但是，患者與其醫(yī)專業(yè)人員進(jìn)行積極對(duì)話非常重要（術(shù)前醫(yī)患雙方應(yīng)該進(jìn)行充分的、誠懇的針對(duì)手術(shù)治療的溝通，包括但不限于：手術(shù)方式；應(yīng)對(duì)突發(fā)狀況的應(yīng)急預(yù)案；術(shù)中可能的風(fēng)險(xiǎn)及并發(fā)癥；術(shù)后可能遇到的恢復(fù)問題如傷口管理、疼痛等；康復(fù)鍛煉指導(dǎo)方案；可能達(dá)到的恢復(fù)水平；回歸正常生活的時(shí)間；可能的后遺癥等等）。因此，此處的信息僅有助于形成患者與其醫(yī)生之間討論的基礎(chǔ)，并為可能需要進(jìn)一步思考的領(lǐng)域提供一些初步見解。根據(jù)所討論的特定部位的關(guān)節(jié)，軟骨修復(fù)程序具有不同的風(fēng)險(xiǎn)和獲益，每一個(gè)關(guān)節(jié)都需要仔細(xì)考慮。此外，在進(jìn)行麻醉和手術(shù)時(shí)，需要考慮個(gè)別患者的情況，包括其他健康問題，例如長(zhǎng)期疾病?？紤]到這一點(diǎn)，其中包含的一些信息可能會(huì)為患者提供他們向醫(yī)療專家提出任何疑慮的起點(diǎn)。目標(biāo)受眾（閱讀者）本文適用于任何關(guān)節(jié)軟骨受損的人及其家人，他們想了解手術(shù)后的軟骨修復(fù)和物理治療，以及任何對(duì)軟骨問題感興趣的人。我應(yīng)該知道哪些風(fēng)險(xiǎn)或并發(fā)癥？所有手術(shù)都可能遇到的風(fēng)險(xiǎn)或并發(fā)癥手術(shù)的一般風(fēng)險(xiǎn)（即，不特定于軟骨修復(fù)）是討論的第一個(gè)領(lǐng)域。出血和感染雖然不常見，但會(huì)顯著影響結(jié)果，尤其是在老年患者中。盡管由循環(huán)系統(tǒng)并發(fā)癥引起的中風(fēng)、血栓、肺部血栓和心臟病發(fā)作（心肌梗塞）在年輕且健康的患者中極為罕見，但在患有潛在疾病的患者中更為常見。吸煙使用會(huì)增加感染和其他并發(fā)癥（傷口愈合不良、潰爛等）的風(fēng)險(xiǎn)，并對(duì)任何類型的軟骨修復(fù)結(jié)果產(chǎn)生嚴(yán)重的負(fù)面影響。許多并存的健康問題，例如心臟病或肥胖癥，可以在手術(shù)前將其對(duì)結(jié)果的影響降至最低，從而確?；颊咛幱谧罴褷顟B(tài)。協(xié)作或“多學(xué)科”的方法將幫助手術(shù)團(tuán)隊(duì)將并發(fā)癥的風(fēng)險(xiǎn)降至最低。使用麻醉劑會(huì)帶來一些風(fēng)險(xiǎn)，但其中大部分是與使用的藥物、插管過程或使用神經(jīng)阻滯有關(guān)的輕微、暫時(shí)的問題。據(jù)報(bào)道，嚴(yán)重過敏反應(yīng)極為罕見，大約每100000名接受全身麻醉的患者中就有1人死亡。軟骨修復(fù)手術(shù)可能遇到的風(fēng)險(xiǎn)或并發(fā)癥拿軟骨修復(fù)手術(shù)過程來看，可能需要不止一個(gè)手術(shù)操作。雖然大多數(shù)軟骨手術(shù)是一步法技術(shù)，但軟骨修復(fù)可能會(huì)在不同時(shí)間通過多個(gè)手術(shù)進(jìn)行計(jì)劃。在自體軟骨細(xì)胞植入(ACI)等兩階段手術(shù)治療中，從身體中采集軟骨細(xì)胞（軟骨細(xì)胞）（初始手術(shù)），在實(shí)驗(yàn)室中增殖，然后通過手術(shù)將其重新植入軟骨缺損處（第二次手術(shù)）。雖然很少見，但手術(shù)后的并發(fā)癥（“術(shù)后并發(fā)癥”）是另一個(gè)考慮因素。移植失?。ɡ绶謱踊蜻^度生長(zhǎng)）可能需要進(jìn)一步的操作。但是，如果采取適當(dāng)?shù)拇胧?，可以將風(fēng)險(xiǎn)降到最低。物理治療師應(yīng)與外科醫(yī)生合作，以確?？祻?fù)是適當(dāng)?shù)?。手術(shù)后過早進(jìn)行過度激進(jìn)或要求苛刻的物理治療，會(huì)導(dǎo)致移植并發(fā)癥、并危及最佳結(jié)果?？紤]到這一點(diǎn)，外科醫(yī)生和物理治療師都應(yīng)該與患者討論允許的運(yùn)動(dòng)范圍和關(guān)節(jié)的負(fù)重限制。還有一種可能是，盡管醫(yī)療團(tuán)隊(duì)盡了最大的努力，該手術(shù)治療仍無法達(dá)到預(yù)期的結(jié)果。在這種情況下，患者和醫(yī)生將討論未來的治療選擇以及進(jìn)一步治療或手術(shù)的可能性。軟骨修復(fù)手術(shù)相對(duì)風(fēng)險(xiǎn)由于軟骨修復(fù)程序?qū)Ｗ⒂陉P(guān)節(jié)，因此在手術(shù)過程中對(duì)主要器官或血管造成意外損傷的風(fēng)險(xiǎn)很小。但是，對(duì)周圍結(jié)構(gòu)（包括血管、神經(jīng)或相鄰軟骨）造成損害的風(fēng)險(xiǎn)很小。由于手術(shù)是計(jì)劃好的或“選擇性的”，因此可以提前權(quán)衡風(fēng)險(xiǎn)、收益和替代方案。同樣，充足的術(shù)前護(hù)理時(shí)間，意味著同時(shí)存在健康問題的高風(fēng)險(xiǎn)患者可以為手術(shù)做好更好的準(zhǔn)備。重要的是，與整個(gè)外科手術(shù)程序相比，重要的是要記住，選擇性軟骨修復(fù)總體上是相對(duì)安全和低風(fēng)險(xiǎn)的。常見問題(FAQ)手術(shù)后多久可以回家？在大多數(shù)情況下（國外），軟骨手術(shù)是在門診（手術(shù)室）進(jìn)行的，或者可能只需要很短的住院時(shí)間。更復(fù)雜的手術(shù)治療可能需要更長(zhǎng)的住院時(shí)間。從長(zhǎng)遠(yuǎn)來看，手術(shù)解決軟骨問題的機(jī)會(huì)有多大？軟骨修復(fù)手術(shù)治療仍然是相對(duì)較新的領(lǐng)域。關(guān)于未經(jīng)治療的軟骨病變的自然史或可以預(yù)測(cè)未來數(shù)年和數(shù)年手術(shù)結(jié)果的研究的長(zhǎng)期數(shù)據(jù)很少。話雖如此，令人鼓舞的中期結(jié)果有望持續(xù)到長(zhǎng)期（滿意的骨軟骨治療效果）。手術(shù)后我需要最少的休假時(shí)間嗎？在幾乎所有軟骨修復(fù)手術(shù)治療后，通常您必須休息的最短時(shí)間是6周（6周以后，視恢復(fù)情況，決定復(fù)查以及康復(fù)鍛煉指導(dǎo)意見）。手術(shù)后我需要休息多久？這將取決于個(gè)人手術(shù)方案和治療結(jié)果。請(qǐng)咨詢您的醫(yī)療專業(yè)人員以獲得更具體的評(píng)估。進(jìn)一步閱讀目前，許多使用的軟骨修復(fù)技術(shù)具有出色的中期結(jié)果，并且有充分的樂觀情緒認(rèn)為，隨著時(shí)間的推移，將會(huì)有類似的令人鼓舞的長(zhǎng)期結(jié)果數(shù)據(jù)。目前有幾種特定的技術(shù)和工具正在臨床試驗(yàn)中，特別是，生物工程支架、基于細(xì)胞的療法和輔助生長(zhǎng)因子均處于臨床前試驗(yàn)和其他臨床應(yīng)用中，預(yù)計(jì)將在可預(yù)見的未來推廣。關(guān)鍵詞：軟骨修復(fù)，并發(fā)癥，臨床療效；風(fēng)險(xiǎn)?Itisimportanttonotethat,ingeneral,?cartilagerepair?isarelativelylow-risk,safeprocedure,andcomplicationsarerare.However,aswithanysurgery,beingawareoftherisks–bothingeneralandforaspecificindividual–isimportantasanydecisionmadeoversurgeryisafullyinformedone.Whilebynomeansexhaustive,thefollowinginformationoffersabackgroundtosomeoftherisksthatshouldbeconsideredforelective(planned)cartilagesurgery.However,itisveryimportantthatapatientengageswiththeirhealthcareprofessionalinaproactivedialogue.Theinformationherethereforemerelyhelpstoformthebasisofadiscussionbetweenapatientandtheirdoctor,andoffersomeinitialinsightsintoareasthatmayneedfurtherthought.Dependingonthejointinquestion,?cartilagerepair?procedurescarrydifferentrisksandbenefits,eachofwhichneedtobeconsideredcarefully.Inaddition,individualpatientcircumstances,includingotherhealthconcerns,suchaslong-standingdisease,needtobefactoredinwhenundergoinganaesthesiaandsurgery.Withthisinmind,someoftheinformationcontainedwithinmayprovideastartingpointforpatientstobringupanyconcernstheyhavewiththeirhealthcareprovider.IntendedaudienceThisarticleisintendedforanyonesufferingfromdamagetotheirarticularcartilageandtheirfamilieswhowouldliketofindoutaboutcartilagerepairandphysiotherapyfollowingsurgery,aswellasanyoneinterestedincartilageproblems.WhatrisksorcomplicationsshouldIknowabout?SurgeryingeneralThegeneralrisksofsurgery(i.e.,notspecifictocartilagerepair)arethefirstareafordiscussion.Bleedingandinfection,whileuncommon,cansignificantlyaffectoutcomes,especiallyinolderpatients.Althoughstrokes,bloodclots,bloodclotsgoingtothelungsandheartattacks(myocardialinfarction)causedbycomplicationswithinthecirculationareextremelyrareinyoungandfitpatients,theycanbemorecommoninthosewithunderlyingmedicalconditions.Tobaccouseincreasestheriskofinfectionandothercomplications,andhasaseriousnegativeeffectontheoutcomeofanytypeof?cartilagerepair.Manycoexistinghealthconcerns,suchasheartdiseaseorobesity,canhavetheirimpactontheoutcomeminimisedbeforeanoperation,ensuringthebestsituationforthepatient.Acollaborative,or‘multidisciplinary’,approachwillhelpthesurgicalteamtominimisetheriskofcomplications.Theuseofanaesthesiacarriessomerisks,butmostofthesearemild,temporaryissuesrelatedtotheagentsused,theprocessofintubationortheuseofnerveblocks.Extremelyrareinstancesofsevereallergicreactionhavebeenreported,anddeathisreportedinapproximately1in100,000patientsundergoinggeneralanaesthesia.CartilagerepairLookingatcartilagerepairproceduresinparticular,morethanoneproceduremayberequired.Whilemostcartilageproceduresaresingle-stagetechniques,cartilagerepairmaybeplannedoverseveralproceduresatdifferenttimes.Intwo-stageproceduressuchas?autologouschondrocyteimplantation(ACI),cartilagecells(chondrocytes)areharvestedfromthebody(initialoperation),multipliedinalaboratory,andthensurgicallyreplantedintothecartilagedefect(secondoperation).Whilerare,complicationsaftersurgery(‘postoperativecomplications’)areanotherconsideration.?Graft?failure(suchasdelaminationorovergrowth)maymakeafurtheroperationnecessary.However,theriskscanbeminimisedifduecareistaken.Physicaltherapists?shouldworkwithsurgeonstoensurethatthe?rehabilitation?isappropriate.Overlyaggressiveordemandingphysicaltherapytoosoonaftertheoperationcancause?graft?complicationsandjeopardiseoptimaloutcomes.Withthisinmind,boththebothsurgeonand?physiotherapist?shouldtalktothepatientabouttheallowedrangesofmotionandweight-bearingrestrictionsofthejoint.Thereisalsothepossibilitythat,despitethebesteffortsofthehealthcareteam,theproceduredoesnotachievethedesiredoutcome.Insuchcases,thepatientandthedoctorwilldiscussfutureoptionsandthepotentialforfurthertreatmentsorprocedures.RelativerisksAscartilagerepairproceduresfocusonthejoints,theriskofaccidentaldamagetomajororgansorbloodvesselsduringsurgeryisminimal.However,thereisasmallriskofdamagetosurroundingstructures,includingvessels,nerves,oradjacentcartilage.Asthesurgeriesareplanned,or‘elective’,weighingtherisks,benefits,andalternativescanbedonewellinadvance.Similarly,ampletimeforpre-operativecaremeansthathigherriskpatientswithcoexistinghealthconcernscanbebetterpreparedforsurgery.Importantly,whencomparedwiththeentirespectrumofsurgicalprocedures,itisimportanttorememberthatelectivecartilagerepairis,overall,relativelysafeandlow-risk.FrequentlyAskedQuestions(FAQs)HowlongaftersurgerywillIbeabletoreturnhome?Inmostcases,cartilageproceduresareperformedonanoutpatientbasis,ormightrequireonlyaverybriefhospitalstay.Morecomplexproceduresmayrequirealongerlengthofstay.Whatarethechancesofanoperationsolvingcartilageproblemsinthelong-term?Cartilagerepairproceduresarestillrelativelynewfield.Thereislittlelong-termdatabothonthenaturalhistoryofuntreatedcartilagelesionsorstudiesthatcanpredictsurgicalresultsyearsandyearsintothefuture.Thatbeingsaid,encouragingmid-termresultsarehopedtocarryonintothelong-term.IsthereaminimumamounttimeoffworkIwillneedafterthesurgery?Afteralmostanycartilagerepairprocedure,thetypicalminimumamountoftimethatyouwillhavetotakeoffworkis6weeks.HowmuchtimeoffworkwillIneedafterthesurgery?Thiswilldependonboththeindividualoperationandtheoutcome.Askyourhealthcareprofessionalformorespecificestimates.FurtherreadingManycurrentlyusedcartilagerepairtechniqueshaveexcellentmid-termoutcomes,andthereiswell-foundedoptimismthat,astimeprogresses,therewillbesimilarlyencouraginglong-termdataonoutcomes.Currentlythereareseveralspecifictechniquesanddevicesinthe?pipeline.Inparticular,bioengineered?scaffolds,?cell-basedtherapies,andadjuvant?growthfactors?arebothinpre-clinicaltrialsandclinicaluseelsewhere,andareexpectedtobeavailableintheforeseeablefuture.?Keywordscartilagerepair,?complications,?outcomes,?Risks

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)分已被開發(fā)和驗(yàn)證。在上述各種可用的結(jié)果測(cè)量中，國際軟骨修復(fù)協(xié)會(huì)ICRS評(píng)分(https://www.cartilage.org/index.php?pid=223)、國際膝關(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)過驗(yàn)證的評(píng)分通常使用帶有一系列問題的標(biāo)準(zhǔn)化問卷。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)能力來計(jì)算功能水平。所有這些經(jīng)過驗(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（受傷后多久開始的治療）?，F(xiàn)在多項(xiàng)研究表明，如果患者受傷超過一年，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)之間沒有顯著差異。已經(jīng)開發(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。患者可以從康復(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)定或下肢力線異常。如果最初導(dǎo)致軟骨問題的相關(guān)病理因素沒有得到糾正，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。一般來說，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.

骨軟骨病變：髖關(guān)節(jié)軟骨病變：相關(guān)解剖學(xué)、影像學(xué)檢查和治療方式的最新進(jìn)展：2019年作者：AlisonADallich,EhudRath,RanAtzmon,JoshuaRRadparvar,AndreaFontana,ZacharySharfman,EyalAmar.作者單位:DivisionofOrthopaedicSurgery,TelAvivSouraskyMedicalCenter,SacklerFacultyofMedicine,TelAvivUniversity,TelAviv,Israel.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要髖關(guān)節(jié)軟骨病變的診斷和治療一直是骨科領(lǐng)域的挑戰(zhàn)。軟骨病變很常見，并且存在幾種分類系統(tǒng)，以根據(jù)嚴(yán)重程度、病變位置、放射學(xué)相關(guān)參數(shù)和可能的治療選擇來對(duì)其進(jìn)行分類。當(dāng)處理可能患有髖關(guān)節(jié)軟骨病變的患者時(shí)，必須進(jìn)行完整的病史采集、全面的體格檢查和輔助影像學(xué)檢查。應(yīng)對(duì)患者站立、仰臥、俯臥和側(cè)方等全方位進(jìn)行體格檢查。普通X線片是一線（最基本的）拍片檢查方法。然而，除關(guān)節(jié)鏡檢查外，磁共振成像目前是診斷軟骨病變的金標(biāo)準(zhǔn)。多種治療方式可以解決髖關(guān)節(jié)存在的軟骨病變，并繼續(xù)研究報(bào)道新的治療方法。目前，軟骨成形術(shù)、微骨折術(shù)、軟骨移植（自體骨軟骨移植、鑲嵌成形術(shù)、同種異體骨軟骨骨移植術(shù)）和骨生物學(xué)聯(lián)合方式（自體軟骨細(xì)胞植入ACI，自體基質(zhì)誘導(dǎo)的軟骨再生AMIC，PRP）均被用來成功治療髖關(guān)節(jié)軟骨病變。進(jìn)一步完善研究這些方法和新技術(shù)，以繼續(xù)提高骨科醫(yī)生解決髖關(guān)節(jié)中軟骨病變的能力。Fig.1.(A,B)Ilizaliturri’s[19]sixacetabularzones(Zone1:anterior-inferioracetabulum,Zone2:anterior-superior,Zone3:centralsuperior,Zone4:posterior-superior,Zone5:posterior-inferior,Zone6:acetabularnotch)fortheright(A)andleft(B)hip.ReproducedwithpermissionfromIlizaliturrietal.[19].圖1.?(A,B)Ilizaliturri的髖臼六分區(qū)法右側(cè)(A)和左側(cè)(B)髖關(guān)節(jié)（1區(qū)：前-下髖臼；2區(qū)：前-上；3區(qū)：中-上；4區(qū)：后-上；5區(qū)：后-下；6區(qū)：髖臼切跡）。表I.?髖關(guān)節(jié)軟骨病變分類系統(tǒng)分類名稱???????????????????????????等級(jí)????????????????????????????????????描述Outerbridge????????????????????????0期?????????????????????????????????????正常????????????????????????????????????????????1期?????????????????????????????????????軟骨軟化和腫脹????????????????????????????????????????????2期?????????????????????????????????????部分區(qū)域軟骨病變，厚度和直徑<0.5英寸????????????????????????????????????????????3期????????????????????????????????????部分區(qū)域軟骨病變，厚度和直徑>0.5英寸????????????????????????????????????????????4期????????????????????????????????????全層厚度軟骨病變，累及軟骨下骨Beck????????????????????????????????????0期????????????????????????????????????正常????????????????????????????????????????????1期????????????????????????????????????軟化????????????????????????????????????????????2期????????????????????????????????????剝離????????????????????????????????????????????3期????????????????????????????????????碎裂????????????????????????????????????????????4期????????????????????????????????????全層厚度骨軟骨病變國際軟骨修復(fù)協(xié)會(huì)ICRS???0期????????????????????????????????????正常????????????????????????????????????????????1期????????????????????????????????????幾乎正常：軟骨淺表層病變????????????????????????????????????????????2期????????????????????????????????????異常：病變<軟骨深度的50％????????????????????????????????????????????3期????????????????????????????????????嚴(yán)重異常：病變>軟骨深度的50％????????????????????????????????????????????4期????????????????????????????????????嚴(yán)重異常：深達(dá)軟骨下骨的病變Konan??????????????????????????????????0期????????????????????????????????????正常????????????????????????????????????????????1期????????????????????????????????????波紋征????????????????????????????????????????????2期????????????????????????????????????表層撕裂????????????????????????????????????????????3期????????????????????????????????????軟骨分層????????????????????????????????????????????4期????????????????????????????????????髖臼軟骨下骨的裸露頭????????????????????????????????????????????????????????????????????????????????????????髖臼區(qū)（Ilizaliturri等）????????????????????????????????????????????????????????????????????????????????????????尺寸????????????????????????????????????????????????????????????????????????????????????????A（<1/3髖臼邊緣到馬蹄窩的距離）????????????????????????????????????????????????????????????????????????????????????????B（1/3至2/3髖臼邊緣到馬蹄窩的距離）????????????????????????????????????????????????????????????????????????????????????????C（>2/3髖臼邊緣到馬蹄窩的距離）Konan最終分類區(qū)域-（1-6）1級(jí)（A，B或C）區(qū)域-（1-6）2級(jí)區(qū)域-（1-6）3級(jí)（A，B或C）區(qū)域-（1-6）4級(jí)（A，B或C）?表II?Sampson分類治療系統(tǒng)指南????????????????????????????????????????????????????????????描述???????????????????????????????????????????治療建議股骨頭?????HC0??????????????????????????????????沒有損害???????????????????????????????????幾乎不需要治療?????????????????HC0T????????????????????????????????均勻稀疏（T）????????????????????????幾乎不需要治療?????????????????HC1???????????????????????????????????軟化??????????????????????????????????????????幾乎不需要治療?????????????????HC2???????????????????????????????????纖維??????????????????????????????????????????清創(chuàng)術(shù)（軟骨清理術(shù)）?????????????????HC3???????????????????????????????????髖臼的骨質(zhì)裸露?????????????????HC4???????????????????????????????????任何分層???????????????????????????????????清創(chuàng)術(shù)和微骨折?????????????????HTD???????????????????????????????????創(chuàng)傷缺損（尺寸為mm）?????????游離片段的切除?????????????????HDZ???????????????????????????????????髖臼股骨撞擊FAI分界區(qū)域????按照Cam畸形關(guān)節(jié)鏡處理?髖臼?????????AC0??????????????????????????????????沒有損害???????????????????????????????????????????????????????????幾乎不需要治療?????????????????AC1??????????????????????????????????軟化但無波紋征??????????????????????????????????????????????幾乎不需要治療?????????????????AC1w???????????????????????????????軟化伴有波紋征和盂唇軟骨連接完整???????????微骨折和縫合?????????????????AC1wTj????????????????????????????軟化伴有波紋征和盂唇軟骨連接撕裂???????????微骨折和縫合?????????????????AC1wD???????????????????????????軟化伴有波紋征和盂唇軟骨連接完整，但有分層???????????????????????????????????????????????????????????????????????????????????????????????軟骨缺損抬高，微骨折，必要時(shí)修剪術(shù)?????????????????AC2??????????????????????????????????纖維化????????????????????????????????清理或切除到骨質(zhì)（聯(lián)合微骨折）?????????????????AC2Tj?????????????????????纖維化伴有盂唇軟骨連接撕裂????邊緣修剪、盂唇重固定、清理術(shù)?????????????????AC3????????????????????????????????暴露軟骨下骨面積<1cm2????????????????????????????????軟骨清理術(shù)?????????????????AC4????????????????????????????????暴露的骨骼較大面積>1cm2????????????????????????????微骨折A:髖臼；C:軟骨缺陷；D:分層；DZ:FAI的分界區(qū)；HC:股骨頭軟骨；t:稀疏；TD:創(chuàng)傷性缺損；TJ:撕裂的盂唇軟骨連接；W:波紋征?表III?髖關(guān)節(jié)軟骨病變的治療流程、適應(yīng)癥、禁忌癥和注意事項(xiàng)治療流程????????????????????????????????適應(yīng)癥????????????????????????????????禁忌癥????????????????????????????????評(píng)論軟骨成形術(shù)????????????????????????????低級(jí)別，?????????????????????????????????????????????????????????????????不應(yīng)進(jìn)行射頻消融（清創(chuàng)術(shù)）????????????????????????????部分層厚的軟骨病變微骨折術(shù)???????????????????????????????病變<2-4cm2????????????????局部層厚的軟骨缺損?????患者的年齡、活動(dòng)???????????????????????????????????????????????????????????????????????????????????????或潛在的骨質(zhì)病變????????水平和術(shù)后康復(fù)計(jì)劃????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????依從性應(yīng)注意考慮ACI?????????????????????????????????????病變太大而無法單獨(dú)進(jìn)行微骨折術(shù)???????????????????????髖關(guān)節(jié)脫位可能會(huì)發(fā)????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????生嚴(yán)重并發(fā)癥AMIC????????????????????????????????????3、4級(jí)髖臼軟骨缺損，2-4cm2，年齡在18-55歲的患者M(jìn)CC聯(lián)合PRP????????????????????與微骨折結(jié)合使用關(guān)節(jié)腔注射擴(kuò)增的MSCs?????尋求非關(guān)節(jié)置換治療的彌漫性軟骨損傷，輕度OA患者骨軟骨移植術(shù)OAT?????????????無法進(jìn)行微骨折的太大病變，??????????????????????????????????????????????軟骨下?lián)p傷，微骨折或??????????????????????????????????????????????磨消軟骨成形術(shù)失敗的患者????????????????????????????????????????????????????????????????????????????????????????????????50歲以上患者，??髖關(guān)節(jié)脫位可能會(huì)發(fā)????????????????????????????????????????????????????????????????????????????????????????????????OA跡象????????????????生嚴(yán)重并發(fā)癥鑲嵌成形術(shù)???????????????????????????多個(gè)較小的股骨頭病變????????????????????????????????????髖關(guān)節(jié)脫位并發(fā)癥可能OCA移植???????????????????????????年輕的AVN患者和股骨頭部分塌陷???????????????髖關(guān)節(jié)脫位并發(fā)癥可能???????????????????????????????????????????????????????????????????????????????????????????圍手術(shù)期因全身性激素使用可能導(dǎo)致失敗纖維蛋白粘合劑?????????????????分層的軟骨損傷（波紋征或地毯征）???????????????????????????????????????????????????縫合修復(fù)和支架植入的持續(xù)時(shí)間比單獨(dú)纖維蛋白膠修復(fù)時(shí)間更長(zhǎng)ACI:自體軟骨細(xì)胞植入；AMIC:自體基質(zhì)誘導(dǎo)的軟骨再生；MCC在PRP中:在富含血小板的漿基質(zhì)中的單核濃縮物；MSCs:基質(zhì)擴(kuò)增的間充質(zhì)干細(xì)胞；OA:骨關(guān)節(jié)炎；OAT:骨軟骨自體移植；OCA:骨軟骨同種異體移植；AVN，股骨頭壞死。?表IV?Oliver-Welsh針對(duì)關(guān)節(jié)軟骨缺損制定的治療流程???????????????????????????????????????????????????病變大小???????????????????????????????????????????????????<2–3cm2???????????????????????????????????????????????????≥2–3cm2一線治療???????????????????????????????????低活動(dòng)量：???????????????????????????????????????????????低活動(dòng)量：???????????????????????????????????????????????????軟骨成形術(shù)???????????????????????????????????????????????軟骨成形術(shù)???????????????????????????????????????????????????微骨折（聯(lián)合或不聯(lián)合骨生物學(xué)，如PRP中的MCC）??????????????????????????????????????????????????????????????????????????????????????????????????????????????????異體表面處理、OCA、ACI???????????????????????????????????????????????????高活動(dòng)量：??????????????????????????????????????????????????高活動(dòng)量：???????????????????????????????????????????????????軟骨成形術(shù)??????????????????????????????????????????異體表面處理、OCA、ACI???????????????????????????????????????????????????微骨折（聯(lián)合或不聯(lián)合骨生物學(xué)，如PRP中的MCC）???????????????????????????????????????????????????異體表面處理???????????????????????????????????????????????????OAT二線治療???????????????????????????????????異體表面處理???????????????????????????????????異體表面處理???????????????????????????????????????????????????OAT或OCA?????????????????????????????????????OAT或OCA???????????????????????????????????????????????????ACI?????????????????????????????????????????????????????ACIACI:自體軟骨細(xì)胞植入；MCC在PRP中:在富含血小板的血漿基質(zhì)中的單核濃縮物；OAT:骨軟骨自體移植；OCA:骨軟骨同種異體移植。?表V.?ElBitar等基于出現(xiàn)癥狀的患者的股骨頭病變和髖臼病變的全層厚度而制定的處理流程病變大小??????????????????????<2cm2??????????????????????2–6cm2??????????????????????6–8cm2?????????????????????>8cm2治療?????????????????????????????一線：???????????????????微骨折（FH，A）???全髖關(guān)節(jié)置換術(shù)??全髖關(guān)節(jié)置換術(shù)?????????????????????????微骨折（FH，A）????????????OCA移植（FH）????OCA移植（FH）?????????????????????????縫合修理（FH）????????????????????????????????????二線：?????????????????????????鑲嵌成形術(shù)（FH）?????????????????????????OCA移植（FH）A髖臼；FH，股骨頭。??Chondrallesionsinthehip:areviewofrelevantanatomy,imagingandtreatmentmodalities.AbstractThediagnosisandtreatmentofchondrallesionsinthehipisanongoingchallengeinorthopedics.Chondrallesionsarecommonandseveralclassificationsystemsexisttoclassifythembasedonseverity,location,radiographicparameters,andpotentialtreatmentoptions.Whenworkingupapatientwithapotentialhipchondrallesion,acompletehistory,thoroughphysicalexam,andancillaryimagingarenecessary.Thephysicalexamisperformedwiththepatientinstanding,supine,prone,andlateralpositions.Plainfilmradiographsareindicatedasthefirstlineofimaging;however,magneticresonancearthrogramiscurrentlythegoldstandardmodalityforthediagnosisofchondrallesionsoutsideofdiagnosticarthroscopy.Multipletreatmentmodalitiestoaddresschondrallesionsinthehipexistandnewtreatmentmodalitiescontinuetobedeveloped.Currently,chondroplasty,microfracture,cartilagetransplants(osteochondralautografttransfer,mosaicplasty,Osteochondralallografttransplantation)andincorporationoforthobiologics(Autologouschondrocyteimplantation,Autologousmatrix-inducedchondrogenesis,Mononuclearconcentrateinplatelet-richplasma)aresometechniquesthathavebeensuccessfullyappliedtoaddresschondralpathologyinthehip.Furtherrefinementofthesemodalitiesandresearchinnoveltechniquescontinuestoadvanceasurgeon'sabilitytoaddresschondrallesionsinthehipjoint.文獻(xiàn)出處：AlisonADallich,EhudRath,RanAtzmon,JoshuaRRadparvar,AndreaFontana,ZacharySharfman,EyalAmar.Chondrallesionsinthehip:areviewofrelevantanatomy,imagingandtreatmentmodalities.ReviewJHipPreservSurg.2019Apr16;6(1):3-15.doi:10.1093/jhps/hnz002.eCollection2019Jan.