骨软骨缺损：膝关节剥脱性骨软骨炎OCD的手术修复指南：你想知道的和你应该知道的医学知识

骨软骨缺损：膝关节剥脱性骨软骨炎OCD的手术修复指南：你想知道的和你应该知道的医学知识

译者：陶可（北京大学人民医院骨关节科）

摘要

剥膝关节脱性骨软骨炎OCD临床表现：股骨内侧髁软骨与软骨下骨一同从结构完整的膝关节表面剥离，形成形态不规则、大小不等的单一或多发的缺损区域：前后位视图

剥膝关节脱性骨软骨炎OCD临床表现：剥脱性骨软骨炎OCD常见位置：股骨内侧髁的侧位视图

介绍

剥脱性骨软骨炎(OCD)是一种影响膝关节的疾病，主要发生在股骨远端。OCD损坏的关节表面不会自然愈合。即使通过手术，OCD通常会导致未来的关节问题，包括骨关节炎。

解剖学

膝关节的哪个部位受到影响？

剥脱性骨软骨炎OCD主要影响膝关节的股骨髁。股骨髁是股骨远端圆形结构。每个膝关节有两个股骨髁，称为内侧股骨髁（在膝关节内侧）和外侧股骨髁（在外侧）。像大多数关节表面一样，股骨髁被关节软骨覆盖。关节软骨是一种光滑的橡胶状覆盖物，可让关节的骨骼平滑地相互滑动。

剥脱性骨软骨炎OCD问题发生在膝关节软骨附着在软骨下骨处。软骨表面正下方的骨骼区域受到损伤，导致骨骼血管受损。没有血流，受损骨骼区域实际上会发生坏死。这个死骨区域可以在X线上看到，有时被称为骨软骨炎病变。

病变通常发生在承受大部分体重的关节部分。这意味着问题区域一直处于压力之下，没有时间治愈。这也意味着病变会在走路和膝关节承受重量时引起疼痛和问题。病变多发生在股骨内侧髁，因为膝关节内侧承受的重量更大。

幼年剥脱性骨软骨炎

九岁或十岁的孩子可能会出现这种情况。但是这种疾病在儿童中的表现大不相同，因此被赋予了一个单独的名称，幼年剥脱性骨软骨炎(JOCD)，意思是儿童剥脱性骨软骨炎。

剥脱性骨软骨炎OCD和幼年剥脱性骨软骨炎JOCD对膝关节的伤害是相同的，但它们是不同的疾病。在仍在成长的孩子身上，问题更有可能自行痊愈。在成人中，骨骼没有生长。因此，剥脱性骨软骨炎OCD和幼年剥脱性骨软骨炎JOCD的治疗和预后可能有很大不同。

许多医生认为JOCD是由于对骨骼的反复应力造成的。大多数患有JOCD的年轻人从很小的时候就开始参与竞技运动。繁重的训练和比赛日程会给股骨带来压力，从而导致JOCD。在某些情况下，其他肌肉或骨骼问题可能会导致额外的应力并导致JOCD。

有时JOCD未得到治疗或未完全愈合。当这种情况发生时，JOCD会发展为剥脱性骨软骨炎OCD。剥脱性骨软骨炎OCD可以从成年早期开始的任何时间发生，但大多数患者是50岁以下的成年人。在成年早期首次诊断出的剥脱性骨软骨炎OCD病例可能始于JOCD。当一个人在以后的生活中患上剥脱性骨软骨炎OCD时，这可能是一个全新的问题。

医生不确定导致剥脱性骨软骨炎OCD的原因。剧烈、重复使用与剥脱性骨软骨炎OCD之间的联系较少。许多患有剥脱性骨软骨炎OCD的人没有任何特定的风险因素。

因为剥脱性骨软骨炎OCD会导致关节表面受损，这种情况会导致骨退化和骨关节炎的问题。关节面的损伤会影响关节的工作方式。就像一台失去平衡的机器，随着时间的推移，这种不平衡会导致关节软骨异常磨损。这是退行性关节炎和骨关节炎的原因之一。

患有剥脱性骨软骨炎OCD和幼年剥脱性骨软骨炎JOCD是什么感觉？

剥脱性骨软骨炎OCD和幼年剥脱性骨软骨炎JOCD引起相同的症状。症状开始时很轻微，随着时间的推移会加重。两个问题通常以轻微的疼痛开始。膝关节活动后会变得（较明显）疼痛，并且摸起来可能会肿胀和疼痛。最终，疼痛太大，无法将全部重量放在膝盖上。这些症状在运动员中相当普遍。它们类似于扭伤、拉伤和其他膝关节问题的症状。

随着情况变得更糟，受影响的骨骼区域可能会塌陷，导致在光滑的关节表面上形成一个凹口（缺损）。这个死骨部分（病变）上的软骨可能会受损。当膝关节在凹口（缺损）区域活动时，这可能会导致卡顿或别着的感觉。在某些情况下，死骨区域实际上可能会与股骨的其余部分分离，形成所谓的游离体。这个松散的游离体可能会漂浮在膝关节内部。如果松散的游离体挡住了膝关节，膝关节可能会在活动时时卡住或绞索。

剥脱性骨软骨炎OCD的严重程度分级：I软骨轻度损伤，表现为局部小的凹陷，裂隙或龟裂；II较大范围的软骨条带状软骨损伤；III软骨损伤范围扩大；IV软骨整块剥离，软骨下骨裸露，并可能形成游离体。

剥脱性骨软骨炎的诊断

你的医生是如何发现这个问题的？

你的医生会询问许多有关您病史的问题。您将被问及您当前的症状以及您过去曾遇到的其他膝关节或关节问题。然后，他将通过感觉和移动膝关节来检查你的膝关节疼痛。您可能会被要求走路、活动或伸展膝关节。这可能会受伤，但重要的是，你的医生确切地知道您的膝关节在何时何地受伤。

你的医生会为您的膝赶紧进行X线检查。大多数剥脱性骨软骨炎OCD病变会出现在膝关节的X线片上。如果没有，你的医生可能会建议进行MRI检查。

MRI检查使用磁波而不是X线来显示身体的软组织。使用这台机器，我们能够创建膝关节断面的图像，并且可以非常清楚地看到解剖结构和任何受伤情况。这些检测可能有助于确定剥脱性骨软骨炎OCD和幼年剥脱性骨软骨炎JOCD的损害程度，也有助于排除其他问题。

治疗

你的医生如何治疗这种疾病？

许多幼年剥脱性骨软骨炎JOCD病例可以通过精心治疗完全治愈。剥脱性骨软骨炎OCD可能永远不会完全治愈，但可以治疗。治疗幼年剥脱性骨软骨炎JOCD的方法有两种：帮助病变愈合的非手术治疗和手术治疗。手术通常是剥脱性骨软骨炎OCD的唯一有效治疗方法。

非手术治疗

非手术治疗有助于约一半的幼年剥脱性骨软骨炎JOCD病例。目标是在股骨停止生长之前帮助病变愈合。即使影像学检查显示生长已经停止，通常也值得尝试非手术治疗。当这些治疗奏效时，膝关节看起来和新的一样好，而且幼年剥脱性骨软骨炎JOCD似乎不会导致关节炎。

幼年剥脱性骨软骨炎JOCD的非手术治疗可能需要10到18个月。在此期间，停止做任何导致膝关节疼痛的事情是至关重要的。这意味着停止锻炼和运动。当出现症状时，可能需要使用拐杖或佩戴支架几个月。随着膝关节症状的缓解，可以开始进行不涉及通过脚部施加重量的运动（非负重锻炼）。练习应小心进行，不应引起任何疼痛。患者经常与物理治疗师合作制定锻炼计划。

你的医生可能想要重新评估膝关节，如果您的症状发生变化，可能会建议进行其他检查。如果您的症状需要额外检查，这可能包括新的X线、MRI扫描或骨扫描。即使在幼年剥脱性骨软骨炎JOCD中，最终也可能需要进行手术。当病变严重到完全或部分从股骨上脱落时，非手术治疗将不起作用。即使接受了治疗，一些患者仍然有症状，或者他们的骨扫描显示损伤正在恶化。

一些过于接近骨骼生长终点的患者可能无法从非手术治疗中受益。当这些问题出现时，你的医生可能会建议进行手术。

手术

如果病变完全或部分脱落，则需要手术切除游离体或将其固定到位你的医生需要在手术前收集大量关于您的膝关节病变的信息。

这可能需要额外的X线或MRI。你的医生也可能会使用关节镜，这是一个插入膝关节的微型相机，在进行手术以解决问题之前观察您的膝关节。这些测试很重要，因为你的医生需要知道病变的确切位置和大小才能确定哪种手术效果最好。

关节镜手术方式

在某些情况下，你的医生将能够使用关节镜进行手术。如果可以使用关节镜，则该过程需要比开放手术更小的切口。这可能会减少您恢复所需的时间。

开放手术方式

当你的医生无法获得整个病灶的照片、不清楚碎片如何最好地嵌入骨骼时，或者使用关节镜更换碎片太困难时，就需要进行开放式手术。开放式手术通常需要比关节镜手术更大的切口，以使你的医生能够看到膝关节并进行手术。

碎片修复方式

如果松散的骨碎片位于骨骼的承重区域，你的医生可能会尝试重新连接它。你的医生可能会使用微小的金属针或螺钉将碎片固定到原位。这有时被证明是困难的。受损的碎片通常不再完全适合骨骼。碎片周围的骨质经常发生变化，这意味着你的医生需要重建它。

剥脱性骨软骨炎骨软骨移植后图示

尽管困难重重，但重新连接碎片通常比移除它会产生更好的膝关节功能。您的膝盖不会像新的一样（功能）良好，但是认真的锻炼计划和后续随诊可以帮助您再次使用膝关节而不会感到疼痛。

同种异体移植

在极少数情况下，必须从负重区域移除病变。你的医生可能会尝试使用同种异体移植物来填补这个骨软骨缺损。同种异体移植是从供体将骨骼和软骨移植到您的膝关节。通常来自骨骼和组织库（捐献者的膝关节）。

在这种情况下，骨材料被移植到留在股骨髁上的预制的孔洞中。同种异体移植物存在风险，包括移植物排斥和感染。但他们可以非常成功地恢复膝关节的功能。

自体骨软骨移植柱

自体骨软骨移植是从患者自身骨软骨移植组织的过程。取移植物的地方称为供体部位。在这种情况下，你的医生会从供体部位移植少量骨骼（骨）和软骨（软骨）以放入病变部位。通常，该手术的供区位于受伤膝关节的关节面上。你的医生小心翼翼地从不会引起很多问题的膝关节部位取出移植物，通常是在膝关节软骨的顶部和外侧边缘。即便如此，人们有时也会在供体周围遇到问题。你的医生通过这种手术看到了极好的效果，并且已经看到许多运动员恢复到受伤前的活动水平。

自体软骨细胞移植

目前正在开发一种称为自体软骨细胞植入的新技术。它涉及使用软骨细胞（软骨细胞）来帮助再生关节软骨。这项技术看起来很有希望用于治疗剥脱性骨软骨炎OCD和幼年剥脱性骨软骨炎JOCD，但仍处于试验阶段。

康复

治疗后我应该期待什么？

非手术康复计划（具体请与你的就诊医生充分沟通，及时复查并调整康复锻炼计划）

非手术康复的目标是帮助您学习如何保护软骨受伤区域，同时改善膝关节运动和力量。可能会建议您在8周内避免剧烈运动或工作活动。在泳池中进行锻炼可以帮助您在此期间保持下肢柔软放松和康复，同时保护膝关节异常负荷。

你的医生将让您与物理治疗师一起工作4到6到12周。运动范围和伸展运动用于改善膝关节运动。您的治疗师可能会给你减震鞋垫，以减少冲击并保护您的膝关节。您还将看到加强髋关节和膝关节的锻炼，以帮助稳定膝关节并为其提供额外的保护，使其免受冲击和压力。

手术后康复锻炼计划（具体请与你的就诊医生充分沟通，及时复查并调整康复锻炼计划）

如果您进行了手术，你的医生可能会让您在手术后使用持续被动运动(CPM)机器来帮助膝关节开始屈伸活动并减轻膝关节僵硬。

除了关节镜下去除游离体外，患者被告知在站立或行走长达6周内，避免完全负重（将过多的重量放在脚上）。这使该区域有时间愈合。移植手术后，负重通常被限制长达4个月。

强烈建议患者遵循关于多少体重是安全的建议。他们可能需要助行器或拐杖长达6周，以避免在他们起身时对关节施加太大压力。

你的医生将让你在接受骨软骨炎损伤的膝关节手术后参加正式的物理治疗。最初的几种物理疗法旨在帮助控制手术引起的疼痛和肿胀。物理治疗师还将与患者合作，以确保他们只在受影响的腿上施加安全的重量。

选择练习来帮助改善膝关节运动，并再次恢复肌肉的张力和弹性。首先，重点是不会拉伤软骨愈合部分和运动锻炼中的膝关节。随着项目的发展，我们会选择更具挑战性的练习来安全地提高膝关节的力量和功能。

理想情况下，患者将能够恢复他们以前的生活方式活动。可能会鼓励一些患者修改他们的活动选择，特别是如果使用了同种异体移植物。

康复治疗师的目标是帮助您控制疼痛，确保安全负重量，并改善您的力量和运动范围。当您进展顺利时，您的康复治疗师定期访问将结束。你可以继续在康复治疗师指导下继续进行居家康复锻炼。

A Patient’s Guide to Osteochondritis Dissecans of the Knee

Osteochondritis Dissecans

Introduction

Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD usually leads to future joint problems, including osteoarthritis.

Anatomy

What part of the knee is affected?

OCD mostly affects the femoral condyles of the knee. The femoral condyle is the rounded end of the lower thighbone, or femur. Each knee has two femoral condyles, referred to as the medial femoral condyle (on the inside of the knee) and the lateral femoral condyle (on the outside). Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial femoral condyle, because the inside of the knee bears more weight.

Juvenile Osteochondritis Dissecans

Children as young as nine or ten can develop this condition. But the disease behaves much differently in children and for this reason is given a separate name, juvenile osteochondritis dissecans (JOCD), meaning osteochondritis dissecans of children.

OCD and JOCD cause the same kind of damage to the knee, but they are separate diseases. In the child who is still growing, the problem is much more likely to heal itself. In the adult, the bones are not growing. For this reason, the treatment and prognosis of OCD and JOCD can be very different.

Many doctors think that JOCD is caused by repeated stress to the bone. Most young people with JOCD have been involved in competitive sports since they were very young. A heavy schedule of training and competing can stress the femur in a way that leads to JOCD. In some cases, other muscle or bone problems can cause extra stress and contribute to JOCD.

Sometimes JOCD is not treated or does not heal completely. When this happens, JOCD develops into OCD. OCD can occur any time from early adulthood on, but most patients are adults under age 50. The cases of OCD that are first diagnosed in early adulthood probably began as JOCD. When a person gets OCD later in life, it is probably a brand new problem.

Doctors aren’t sure what causes OCD. There is less of a link between strenuous, repetitive use and OCD. Many people who develop OCD don’t have any particular risk factors.

Because OCD leads to damage to the surface of the joint, the condition can lead to problems with bone degeneration and osteoarthritis. The damage to the joint surface affects the way that the joint works. Like a machine that is out of balance, over time this imbalance can lead to abnormal wear and tear on the joint. This is one cause of degenerative arthritis and osteoarthritis.

What do OCD and JOCD feel like?

OCD and JOCD cause the same symptoms. The symptoms start out mild and grow worse with time. Both problems usually start with a mild aching pain. Moving the knee becomes painful, and it may be swollen and sore to the touch. Eventually, there is too much pain to put full weight on that knee. These symptoms are fairly common in athletes. They are similar to the symptoms of sprains, strains, and other knee problems.

As the condition becomes worse, the area of bone that is affected may collapse, causing a notch to form in the smooth joint surface. The cartilage over this dead section of bone (the lesion) may become damaged. This can cause a snapping or catching feeling as the knee joint moves across the notched area. In some cases the dead area of bone may actually become detached from the rest of the femur, forming what is called a loose body. This loose body may float around inside of the knee joint. The knee may catch or lock when it is moved if the loose body gets in the way.

Diagnosis of Osteochondritis Dissecans

How does your doctor identify this problem?

Your doctor will ask many questions about your medical history. You will be asked about your current symptoms and about other knee or joint problems you have had in the past. He will then examine the painful knee by feeling it and moving it. You may be asked to walk, move, or stretch your knee. This may hurt, but it is important that your doctor knows exactly where and when your knee hurts.

Your doctor will order an X-ray of your knee. Most OCD lesions will show up on an X-ray of the knee. If not, your doctor may suggest an MRI.

The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. With this machine, we are able to create pictures that look like slices of the knee and see the anatomy, and any injuries, very clearly. These tests may help determine the extent of damage from OCD and JOCD, and they also help rule out other problems.

Treatment

How does your doctor treat the condition?

Many cases of JOCD can be completely healed with careful treatment. OCD will probably never completely heal, but it can be treated. There are two methods of treating JOCD: nonsurgical treatment to help the lesions heal, and surgery. Surgery is usually the only effective treatment for OCD.

Nonsurgical Treatment

Nonsurgical treatments help in about half the cases of JOCD. The goal is to help the lesions heal before growth stops in the thighbone. Even if imaging tests show that growth has already stopped, it is usually worth trying nonsurgical treatments. When these treatments work, the knee seems as good as new, and the JOCD doesn’t seem to lead to arthritis.

Nonsurgical treatment of JOCD can take from 10 to 18 months. During that time, it is crucial to stop doing everything that causes pain to the knee. This means stopping exercise and sports. It may require using crutches or wearing a brace for a couple of months when symptoms are present. As knee symptoms ease, exercises can be started that don’t involve placing weight through your foot. The exercises should be done carefully and should not cause any pain. Patients often work with physical therapists to develop an exercise program.

Your doctor may want to reevaluate the knee and may suggest additional tests if your symptoms change. This may include new X-rays, MRI scan or a bone scan if your symptoms warrant additional testing. Even in JOCD, surgery may eventually be required. When the lesion has become so bad that it detaches totally or partially from the bone, nonsurgical treatment will not work. Even with the treatment, some patients continue to have symptoms or their bone scans show signs that the damage is getting worse.

Some patients who are too near the end of bone growth may not benefit with nonsurgical treatment. When these problems develop, your your doctor may suggest surgery.

Surgery

If the lesion becomes totally or partially detached, surgery is needed to remove the loose body or to fix it in place. Your doctor will need to gather lots of information about your knee and your problem before surgery.

This may require additional X-rays, or MRIs. Your doctor may also use an arthroscope, a tiny camera inserted into the knee to look at your knee before doing surgery to fix the problem. These tests are important because your doctor needs to know the exact location and the size of the lesion to determine what kind of surgery will work best.

Arthroscopic Method

In some cases, your doctor will be able to use the arthroscope to do the surgery. If the arthroscope can be used, the procedure requires smaller incisions than for an open surgery. This may reduce the time needed for your recovery.

Open Method

Open surgery is needed when your doctor can’t get a picture of the entire lesion, when it is unclear how the fragment would best fit into the bone, or when it would be too difficult to replace the fragment using the arthroscope. Open surgery usually requires larger incisions than arthroscopic surgery to allow the your doctor to see into the knee and perform the operation.

Fragment Repair

If the loose bone fragment is in a weight-bearing area of your bone, your doctor may try to reattach it if possible. Your doctor may use tiny metal pins or screws to hold the fragment in place. This sometimes proves difficult. The damaged fragment often doesn’t fit perfectly into the bone anymore. And the bone around the fragment has often changed in ways that mean your doctor will need to rebuild it.

Osteochondritis Dissecans

Despite the difficulties, reattaching the fragment generally results in much better knee function than removing it. Your knee will not be as good as new, but a careful plan of exercise and follow-up care can help you use your knee again without pain.

Allograft Transplant

In rare cases, the lesion must be removed from a weight-bearing area. Your doctor may try to fill in the hole using an allograft. An allograft is an actual transplant of bone and cartilage from a donor into your knee. The bone is usually obtained from a bone and tissue bank.

In this case, bone material is transplanted into the hole left in the bone. Allografts have risks, including graft rejection and infection. But they can be very successful in returning function to the knee.

Osteochondral Autograft

An autograft is a procedure for grafting tissue from the patient’s own body. The place where the graft is taken is called the donor site. In this case, your doctor grafts a small amount of bone (osteo) and cartilage (chondral) from the donor site to put into the lesion. Usually, the donor site for this procedure is on the joint surface of the injured knee. Your doctor is careful to take the graft from a spot that won’t cause a lot of problems, usually on the top and outside border of the knee cartilage. Even then, people sometimes end up with problems around the donor site. Your doctor has seen excellent results with this surgery and has seen many athletes return to their pre-injury level of activity.

Autologous Chondrocyte Implantation

A new technology called autologous chondrocyte implantation is currently being developed. It involves using cartilage cells (chondrocytes) to help regenerate articular cartilage. This technology looks promising for treating JOCD and OCD but is still very much experimental.

Related Document: A Patient’s Guide to Articular Cartilage Problems of the Knee

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

The goal of nonsurgical rehabilitation is to help you learn ways to protect the injured area of cartilage while improving knee motion and strength. You may be advised to avoid heavy sport or work activities for up to eight weeks. Doing exercises in a pool can help you stay limber and fit while protecting the knee during this period.

Your doctor will have you work with a physical therapist for four to six to twelve weeks. Range-of-motion and stretching exercises are used to improve knee motion. Your therapist may issue shock-absorbing shoe insoles to reduce impact and protect your knee joint. You will also be shown strengthening exercises for the hip and knee to help steady the knee and give it additional protection from shock and stress.

After Surgery

If you have surgery, your doctor may have you use a continuous passive motion (CPM) machine after surgery to help the knee begin to move and to alleviate joint stiffness.

With the exception of arthroscopic removal of a loose body, patients are instructed to avoid putting too much weight on their foot when standing or walking for up to six weeks. This gives the area time to heal. Weight bearing is usually restricted for up to four months after transplant procedures.

Patients are strongly advised to follow the recommendations about how much weight is safe. They may require a walker or pair of crutches for up to six weeks to avoid putting too much pressure on the joint when they are up and about.

Your doctor will have his patients take part in formal physical therapy after knee surgery for osteochondritis lesions. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. Physical therapists will also work with patients to make sure they are only putting a safe amount of weight on the affected leg.

Exercises are chosen to help improve knee motion and to get the muscles toned and active again. At first, emphasis is placed on exercising the knee in positions and movements that don’t strain the healing part of the cartilage. As the program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function.

Ideally, patients will be able to resume their previous lifestyle activities. Some patients may be encouraged to modify their activity choices, especially if an allograft was used.

The therapist’s goal is to help you keep your pain under control, ensure safe weight bearing, and improve your strength and range of motion. When you are well under way, regular visits to your therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

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