骨软骨损伤：软骨损伤手术修复后我的活动水平如何？

骨软骨损伤：软骨损伤手术修复后我的活动水平如何？

What is my Activity Level like after Cartilage Repair?

陶可（北京大学人民医院骨关节科）

图1. 典型的膝关节股骨髁软骨损伤的大体观表现：软骨剥脱，软骨下骨囊性变等，同时可能合并有半月板损伤、前后检查韧带损伤等。

图2. 典型的关节软骨剥脱损伤的关节镜下表现（左侧），微骨折技术是修复关节软骨缺损的金标准（右侧），但往往需要与其他的技术，如ACI、AMIC等协作发挥作用。

图3. 典型的髌骨软骨剥脱损伤的大体观表现（左侧），对关节软骨边缘进修修复后，采用微骨折技术诱导软骨下骨渗出含有大量骨髓间充质干细胞的血液填充缺损区域（右侧）。

图4. 典型的髌骨软骨剥脱损伤的大体观表现（左侧），对关节软骨边缘进修修复后，采用微骨折技术诱导软骨下骨渗出含有大量骨髓间充质干细胞的血液填充缺损区域联合Chondrogide软骨膜修复技术对缺损处进行修复（右侧）。

关节软骨损伤通常与关节功能的显着降低有关，并且经常导致功能和活动的减少（活动受限制），特别是在参与剧烈运动（跑跳、竞技）的高需求运动患者中。

关节软骨损伤可能急性（快速）或慢性（长期）发展，但与一般人群相比，运动活跃的患者引起症状和局限性的频率是普通人群的2倍多。

对于一般患者，尤其是运动员而言，恢复正常体育活动的能力是关节软骨修复后最重要的功能结果。

由于不同体育锻炼和参与体育强度的水平之间的活动需求不同，因此，详细了解每位运动员受伤的严重程度和治疗干预的潜在成功率，对于优化恢复能力和达到现实期望至关重要。

目标受众（阅读者）

本文适用于任何关节软骨受损的人士及其家人，他们想了解软骨修复后的活动水平，以及任何对软骨问题感兴趣的人群。

软骨修复后如何测量活动强度？

许多用于评估关节软骨修复后的功能结果评分已被开发和验证。在上述各种可用的结果测量中，国际软骨修复协会ICRS评分(https://www.cartilage.org/index.php?pid=223)、国际膝关节研究委员会(IKDC)评分以及膝关节损伤和骨关节炎结果评分(KOOS)评分被认为是软骨修复患者中非常重要的3种评分。

这些基于患者的、经过验证的评分通常使用带有一系列问题的标准化问卷。根据患者的反馈，他们用以计算表明患者整体功能的数字分数。其中一些分数包括允许对体育相关活动进行更具体评估的子项分数。

除了一般分数外，还制定了特定活动分数，例如衡量特定体育活动的Tegner分数和每个分数可以达到的水平。同样，Marx活动评分量表使用患者进行运动中经常包含的活动能力来计算功能水平。

所有这些经过验证的分数都有助于比较和评估软骨修复手术后的患者。虽然它们提供了重要的科学信息，但这些评分并没有为患者提供有关其术后关节功能的实用测量值。例如，55分的国际软骨修复协会ICRS评分可能有助于临床医生比较术前和术后功能，但对于接受治疗的患者可能不是一个有意义的参数。

相比之下，为患者提供描述返回已知体育活动的可能性的百分比，甚至是与先前活动相比的预期体育参与水平，为运动患者提供了一个实用的工具，来评估他们对手术的现实期望。它还提供了有用的数据，可以帮助做出有关手术或非手术治疗的决策，以及评估恢复关节软骨的治疗策略的选择。

患者在软骨修复后的恢复和活动方面可以期待什么？

有几个因素使患者更有可能恢复运动或以前的活动。

重返运动的机会因人而异，例如，年龄是一个非常重要的参数。年轻患者往往做得更好，这主要是由于他们更活跃的细胞代谢以及在治疗的关节软骨缺损内产生新的软骨修复组织的更好能力。一些研究表明，无论使用哪种技术，30-40岁以下的患者在进行软骨修复手术后，都会有更高的活动水平和功能。

受伤前的活动水平也起着重要作用。多项研究表明，软骨损伤或软骨手术前较高的活动水平与之后的较高活动水平相关。与在不那么竞争或娱乐水平上进行相同运动的人士相比，更具竞争力的运动员有更高的运动回归率。这被认为是由不同程度的回归运动、社会状况和获得康复资源的动机引起的，这些可能因业余运动员和竞技运动员或职业运动员而异。

重要的是，在软骨修复手术后，更专业水平的运动员可以恢复充分的活动，并能够在各种运动中承受极高的冲击负荷，这一事实非常令人鼓舞，但同样，这可能更多是由于职业运动员整体（恢复的就好），而非对软骨手术的具体反应（在同样专业的软骨手术基础上，职业运动员恢复的整体要好一些）。

另一个非常重要的参数是患者在接受治疗前软骨损伤的时间（受伤后多久开始的治疗）。现在多项研究表明，如果患者受伤超过一年，恢复到相同活动水平的机会比受伤时间少于12个月的要低得多。这似乎与受影响关节中退化环境的发展有关，这抑制了新的软骨再生。此外，体育参与的长期减少也起到了一定的作用。

另一个起作用的因素是软骨缺损的大小。小缺损通常与更高概率的恢复正常体育活动有关。我们在一些研究中确定的临界水平是小于2-3厘米的软骨缺损有更好的成功修复机会。较大的缺陷不太可能允许重返运动，但较大缺陷的成功率仍然令人鼓舞。

此外，软骨修复技术的选择会影响恢复运动的能力和继续参加运动的可能性。据报道，运动人群恢复体育活动的平均比率分别是：自体软骨细胞植入(ACI)(74%)、微骨折(68%)、自体骨软骨移植(91%)和同种异体骨软骨移植(88%)。最近对软骨修复技术的系统评价表明，65%的运动员在软骨修复后恢复到受伤前的水平，不同技术之间没有显着差异。

已经开发了几种第二代技术，包括基质相关(MACI)或支架增强微骨折，并且已发现与第一代技术相比具有相似的运动恢复率。除了重返运动的能力之外，继续比赛的能力是另一个重要的结果参数。虽然在52个月后接受ACI治疗的运动员中有87%观察到出色的运动活动持久性，但在运动员使用微骨折或自体骨软骨移植治疗后，继续运动活动受到更多限制。

患者可以从康复计划中得到什么？

康复可能因所使用的修复技术以及是否单独进行软骨修复手术而异。通常，软骨修复技术与其他手术相结合，例如前交叉韧带(ACL)重建或截骨术，以解决相关的膝关节病变，例如不稳定或下肢力线异常。

如果最初导致软骨问题的相关病理因素没有得到纠正，软骨修复通常会受到限制并且不太成功。相关手术可能对患者康复产生影响。一般来说，如果患者有单纯的软骨缺损，最重要的方面是教育他们康复会很慢。

根据软骨缺损特征和修复技术，通常在手术后2到6周内会有一些负重限制。由熟悉软骨修复手术的经验丰富的物理治疗师指导的逐步增加也至关重要。

Injury to joint (articular) cartilage is often associated with a significant reduction in joint function, and frequently results in a decrease in function and activities, particularly in high-demand athletic patients participating in impact sports.

Articular cartilage injuries may develop acutely (quickly) or chronically (over a long period), but have been shown to cause symptoms and limitations more than twice as often in active patients compared to the general population.

For patients in general, but particularly for athletes, the ability to be active and return to sporting activities presents the most important functional outcome following articular cartilage repair.

Since activity demands are different between different sports and level of sports participation, a detailed understanding of the severity of the individual athlete’s injury and the potential success rate of the therapeutic intervention is critical to optimise the recovery potential and manage realistic expectations.

Intended audience

This article is intended for anyone suffering from damage to their articular cartilage and their families who would like to find out about activity levels after cartilage repair, as well as anyone interested in cartilage problems.

How is activity measured after cartilage repair?

Many outcome scores have been developed and validated for evaluating function after articular cartilage repair. Of the various available outcome measures, the ICRS score (https://www.cartilage.org/index.php?pid=223), the International Knee Documentation Committee (IKDC) score, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) score are considered the very important ones in cartilage repair patients.

These patient-based, validated scores typically use standardised questionnaires with a series of questions. Based on the patient’s response, they allow calculation of a numeric score that indicates the patient’s overall function. Some of these scores include sub-scores that allow more specific evaluation of sport-related activities.

Besides the general scores, specific activity scores have been developed, such as the Tegner score that measures specific sports activities and the level that can be achieved on each score. Similarly, the Marx activity rating scale uses a patient’s ability to perform activities that are frequently included in sports to calculate a level of function.

All these validated scores can be helpful to compare and evaluate patients after cartilage repair procedures. While they provide important scientific information, these scores do not provide the patient with a relevant and practical measure of their postoperative joint function. For example, an ICRS score of 55 can be helpful for the clinician in comparing preoperative and postoperative function, but may not be a meaningful parameter for the treated patient.

In contrast, providing the patient with a percentage rate describing the likelihood of returning back to a known athletic activity, and even the expected level of sports participation compared to prior activity, gives the athletic patient a practical tool to evaluate their realistic expectations for surgery. It also provides useful data that can help with decision-making regarding surgical or non-surgical treatment, and for the evaluation of options for restoring articular cartilage.

What can patients expect in terms of recovery and activity after cartilage repair?

There are several factors that make it more likely that a patient can return to sports or previous activities.

The chances of a return to sport can vary between individuals, and age is a very important parameter, for example. Younger patients tend to do better, which is mostly due to their more active cellular metabolism and resultant better ability to generate new cartilage repair tissue within the treated articular cartilage defects. Some studies have shown that patients younger than 30-40 years will have higher activity levels and function after cartilage repair procedures, regardless of which technique is being used.

Pre-injury activity level also plays a significant role. Several studies have shown that higher activity levels before cartilage injury or cartilage surgery are associated with higher activity levels afterwards. More competitive athletes have a higher rate of return to sports than people who perform those same sports at a less competitive or recreational level. This is felt to result from different levels of motivation for return to sport, social situation, and access to rehabilitation resources that may vary between amateur and competitive or professional athletes.

Importantly, the fact that athletes at the more professional level can return to full activity and are able to endure extremely high impact loads in a wide range of sports after cartilage repair procedures is very encouraging, but again, this may be more a result of the professional athlete as a whole than a specific response to cartilage surgery.

Another very important parameter is how long the patient has had the cartilage injury before it was treated. Multiple studies now have shown that, if a patient has been injured for more than a year, the chances of returning to the same activity level is much lower than if they have had the injury for less than 12 months. This seems to be related to the development of a degenerative environment in the affected joints, which inhibits new cartilage regrowth. In addition, a long-term reduction in sports participation also plays a role.

Another factor that comes into play is the size of the cartilage defect. Small defects often are associated with more frequent return to normal athletic activity. The cut-off level that we have identified in some of our studies is that a cartilage defect less than 2–3 cm has a much better chance of successful repair. Larger defects are less likely to allow return to sport, but the success rate for larger defects is still encouraging.

In addition, the choice of cartilage repair technique can affect the ability to return to sport and likelihood for continued sports participation. Average rates of return to sports activity in the athletic population have been reported after autologous chondrocyte implantation (ACI) (74%), microfracture (68%), osteochondral autologous transfer (91%) and osteochondral allograft transplantation (88%). A recent systematic review of cartilage repair techniques demonstrated that athletes returned to the pre-injury level in 65% of cases after cartilage repair, with no significant difference between the individual techniques.

Several second generation techniques have been developed, including matrix-associated (MACI) or scaffold-enhanced microfracture, and have been found to have similar rates for return to sport compared to the first generation techniques. Besides the ability to return to sport, the ability to continue to play presents another important outcome parameter. While excellent durability of athletic activity was observed in 87% of athletes treated with ACI after 52 months, continued sports activity was more limited after treatment using microfracture or osteochondral autograft in athletes.

What can patients expect from a rehabilitation programme?

Rehabilitation can vary depending on the repair technique used and whether a cartilage repair procedure is done alone. Often, cartilage repair techniques are combined with another procedure, such as an anterior cruciate ligament (ACL) reconstruction or an osteotomy, which address associated knee pathology such as instability or malalignment.

If the associated pathologic factors responsible for developing the cartilage problem in the first place are not corrected, the cartilage repair will often be limited and less successful. The associated procedures can have an effect on patient rehabilitation. In general, if a patient has an isolated defect, the most important aspect is to educate them that recovery will be slow.

Usually there will be some limitation of weight bearing for between 2 and 6 weeks after the procedure depending on the defect characteristics and repair technique. Gradual progression guided by an experienced physical therapist familiar with cartilage repair procedures is critical.

Further reading

· Flanigan DC, Harris JD, Trinh TQ, et al . Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc. 2010;42(10):1795-801.

· Gudas R, Gudaite A, Pocius A, Gudiene A, Cekanauskas E, Monastyreckiene E, Basevicius A. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012 Nov;40(11):2499-508.

· Kon E, Filardo G, Berruto M, Benazzo F, Zanon G, Della Villa S, Marcacci M. Articular cartilage treatment in high-level male soccer players: a prospective comparative study of arthroscopic second-generation autologous chondrocyte implantation versus microfracture. Am J Sports Med. 2011 Dec;39(12):2549-57

· Kreuz PC, Steinwachs M, Erggelet C, et al. Importance of sports in cartilage regeneration after autologous chondrocyte implantation: a prospective study with a 3-year follow-up. Am J Sports Med. 2007;35(8):1261-1268.

· Krych A, Robertson C, Williams, RJ. Return to Athletic Activity After Osteochondral Allograft Transplantation in the Knee. Am J Sports Med 2012 40:5: 1053-59

· McAdams T, Mithoefer K, Scopp J, Mandelbaum B, Articular Cartilage Repair in Athletes. Cartilage 2010, 1(3): 165-176.7.Mithoefer K. Complex articular cartilage restoration. Sports Med Arthrosc. 2013 Mar;21(1):31-7.

· Mithoefer K, Della Villa S, Silvers H, Ricci M, Hambly K. Current Concepts of Rehabilitation and Return to Sport after Articular Cartilage Repair in the Athlete. J Orthop Sports Phys Ther 2012; 3:254-273.

· Mithoefer K, Steadman R. Microfracture in the Football (Soccer) Player: A case series of professional athletes and systematic review. Cartilage 2012; 3:18S-24S.

· Mithoefer K, Peterson L, Saris D, Mandelbaum B. The Evolution and Current Role of Autologous Chondrocyte Transplantation for Treatment of Articular Cartilage Injury in Football Players. Cartilage 2012; 3:31S-36S.

· Mithoefer K, Gill TJ, Williams RJ, Cole BJ, Mandelbaum BR. Clinical Outcome and Return to competition after microfracture chondroplasty in the athlete’s knee. Cartilage 2010, 1:113-20.

· Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum, BR. Return to sports participation after articular cartilage repair in the knee. Am J Sports Med 2009, 37 Suppl 1:167S-176S.

· Mithoefer K, McAdams TR, Scopp J, Mandelbaum BR. Emerging Options for Treatment of Articular Cartilage Injury in the Athlete. Clin Sports Med 2009; 28:25-40

· Mithoefer K, Williams RJ, Warren RF, Wickiewicz TL, Marx RG. High-Impact Athletics after Knee Articular Cartilage Repair: A Prospective Evaluation of the Microfracture Technique. Am J Sports Med 34(9): 1413-1418; 2006.

· Mithöfer K, Minas T, Peterson L, Yeon H, Micheli LJ. Functional Outcome of Articular Cartilage Repair in Adolescent Athletes. Am J Sports Med 2005 33(8):1147-1153.

· Mithöfer K, Peterson L, Mandelbaum B, Minas T. Articular Cartilage Repair in Soccer Players with Autologous Chondrocyte Transplantation: Functional Outcome and Return to Competition. Am J Sports Med 2005, 33(11):1639-1646.