骨软骨损伤：软骨修复手术治疗的风险及并发症

Risks ＆ Complications in Cartilage Repair

骨软骨损伤：软骨修复手术治疗的风险及并发症

陶可(北京大学人民医院骨关节科)

图1: 膝关节外侧髁关节骨软骨损伤后可以采用如下的几种治疗方案：(a)采用特制的工具将制作骨软骨损伤部位进行充分的清理，深达软骨下骨板，(b)采用自体或异常具有增殖能力的间充质干细胞MSC移植，充填于上述骨软骨缺损区；或(c)采用混合有诱导因子（多为各种生长因子，如TGF-beta，IGF，FGF等）的间充质干细胞MSC移植于上述骨软骨缺损区；或(d)也可以采用将间充质干细胞MSC移植于预制好的生物支架材料，再添加诱导生长因子，最后充填于骨软骨缺损区。上述3种不同类型的骨软骨缺损的修复方法，最终的目的都是修复较大面积的全层骨软骨缺损，并且在临床上，均已经取得了良好的治疗效果。

图2: 膝关节内侧髁关节骨软骨损伤后可以采用如下的治疗方案：(a)将膝关节软骨组织收集，碎化，并消化成软骨微粒；(b)将上述软骨微粒与异体间充质干细胞MSCs混合，并移入预装号纤维蛋白胶的注射器，通过涂抹于骨软骨缺损部位，从而达到修复骨软骨缺损的目标。

图3: 通过向膝关节腔内注射scSOX9蛋白也是一种修复骨软骨缺损的策略。

图4: 膜片状的生物材料修复膝关节股骨髁骨软骨损伤的示意图。

图5: 柱状的生物材料修复膝关节股骨髁骨软骨损伤的示意图。

需要注意的是，一般来说，软骨修复是一种风险相对较低、安全的手术，并发症很少见。然而，与任何手术一样，了解风险——无论是一般性的还是特定个体的——都很重要，因为任何关于手术的决定都是一个充分知情的决定。

虽然并非详尽无遗，但以下信息是选择（计划）软骨手术都应考虑的一些风险情况。

但是，患者与其医专业人员进行积极对话非常重要（术前医患双方应该进行充分的、诚恳的针对手术治疗的沟通，包括但不限于：手术方式；应对突发状况的应急预案；术中可能的风险及并发症；术后可能遇到的恢复问题如伤口管理、疼痛等；康复锻炼指导方案；可能达到的恢复水平；回归正常生活的时间；可能的后遗症等等）。因此，此处的信息仅有助于形成患者与其医生之间讨论的基础，并为可能需要进一步思考的领域提供一些初步见解。

根据所讨论的特定部位的关节，软骨修复程序具有不同的风险和获益，每一个关节都需要仔细考虑。此外，在进行麻醉和手术时，需要考虑个别患者的情况，包括其他健康问题，例如长期疾病。

考虑到这一点，其中包含的一些信息可能会为患者提供他们向医疗专家提出任何疑虑的起点。

目标受众（阅读者）

本文适用于任何关节软骨受损的人及其家人，他们想了解手术后的软骨修复和物理治疗，以及任何对软骨问题感兴趣的人。

我应该知道哪些风险或并发症？

所有手术都可能遇到的风险或并发症

手术的一般风险（即，不特定于软骨修复）是讨论的第一个领域。出血和感染虽然不常见，但会显着影响结果，尤其是在老年患者中。

尽管由循环系统并发症引起的中风、血栓、肺部血栓和心脏病发作（心肌梗塞）在年轻且健康的患者中极为罕见，但在患有潜在疾病的患者中更为常见。

吸烟使用会增加感染和其他并发症（伤口愈合不良、溃烂等）的风险，并对任何类型的软骨修复结果产生严重的负面影响。

许多并存的健康问题，例如心脏病或肥胖症，可以在手术前将其对结果的影响降至最低，从而确保患者处于最佳状态。协作或“多学科”的方法将帮助手术团队将并发症的风险降至最低。

使用麻醉剂会带来一些风险，但其中大部分是与使用的药物、插管过程或使用神经阻滞有关的轻微、暂时的问题。据报道，严重过敏反应极为罕见，大约每100000名接受全身麻醉的患者中就有1人死亡。

软骨修复手术可能遇到的风险或并发症

拿软骨修复手术过程来看，可能需要不止一个手术操作。虽然大多数软骨手术是一步法技术，但软骨修复可能会在不同时间通过多个手术进行计划。在自体软骨细胞植入(ACI)等两阶段手术治疗中，从身体中采集软骨细胞（软骨细胞）（初始手术），在实验室中增殖，然后通过手术将其重新植入软骨缺损处（第二次手术）。

虽然很少见，但手术后的并发症（“术后并发症”）是另一个考虑因素。移植失败（例如分层或过度生长）可能需要进一步的操作。但是，如果采取适当的措施，可以将风险降到最低。

物理治疗师应与外科医生合作，以确保康复是适当的。手术后过早进行过度激进或要求苛刻的物理治疗，会导致移植并发症、并危及最佳结果。考虑到这一点，外科医生和物理治疗师都应该与患者讨论允许的运动范围和关节的负重限制。

还有一种可能是，尽管医疗团队尽了最大的努力，该手术治疗仍无法达到预期的结果。在这种情况下，患者和医生将讨论未来的治疗选择以及进一步治疗或手术的可能性。

软骨修复手术相对风险

由于软骨修复程序专注于关节，因此在手术过程中对主要器官或血管造成意外损伤的风险很小。但是，对周围结构（包括血管、神经或相邻软骨）造成损害的风险很小。

由于手术是计划好的或“选择性的”，因此可以提前权衡风险、收益和替代方案。同样，充足的术前护理时间，意味着同时存在健康问题的高风险患者可以为手术做好更好的准备。

重要的是，与整个外科手术程序相比，重要的是要记住，选择性软骨修复总体上是相对安全和低风险的。

常见问题(FAQ)

手术后多久可以回家？

在大多数情况下（国外），软骨手术是在门诊（手术室）进行的，或者可能只需要很短的住院时间。更复杂的手术治疗可能需要更长的住院时间。

从长远来看，手术解决软骨问题的机会有多大？

软骨修复手术治疗仍然是相对较新的领域。关于未经治疗的软骨病变的自然史或可以预测未来数年和数年手术结果的研究的长期数据很少。话虽如此，令人鼓舞的中期结果有望持续到长期（满意的骨软骨治疗效果）。

手术后我需要最少的休假时间吗？

在几乎所有软骨修复手术治疗后，通常您必须休息的最短时间是6周（6周以后，视恢复情况，决定复查以及康复锻炼指导意见）。

手术后我需要休息多久？

这将取决于个人手术方案和治疗结果。请咨询您的医疗专业人员以获得更具体的评估。

进一步阅读

目前，许多使用的软骨修复技术具有出色的中期结果，并且有充分的乐观情绪认为，随着时间的推移，将会有类似的令人鼓舞的长期结果数据。

目前有几种特定的技术和工具正在临床试验中，特别是，生物工程支架、基于细胞的疗法和辅助生长因子均处于临床前试验和其他临床应用中，预计将在可预见的未来推广。

关键词：软骨修复，并发症，临床疗效；风险

It is important to note that, in general, cartilage repair is a relatively low-risk, safe procedure, and complications are rare. However, as with any surgery, being aware of the risks – both in general and for a specific individual – is important as any decision made over surgery is a fully informed one.

While by no means exhaustive, the following information offers a background to some of the risks that should be considered for elective (planned) cartilage surgery.

However, it is very important that a patient engages with their healthcare professional in a proactive dialogue. The information here therefore merely helps to form the basis of a discussion between a patient and their doctor, and offer some initial insights into areas that may need further thought.

Depending on the joint in question, cartilage repair procedures carry different risks and benefits, each of which need to be considered carefully. In addition, individual patient circumstances, including other health concerns, such as long-standing disease, need to be factored in when undergoing anaesthesia and surgery.

With this in mind, some of the information contained within may provide a starting point for patients to bring up any concerns they have with their healthcare provider.

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 cartilage repair and physiotherapy following surgery, as well as anyone interested in cartilage problems.

What risks or complications should I know about?

Surgery in general

The general risks of surgery (i.e., not specific to cartilage repair) are the first area for discussion. Bleeding and infection, while uncommon, can significantly affect outcomes, especially in older patients.

Although strokes, blood clots, blood clots going to the lungs and heart attacks (myocardial infarction) caused by complications within the circulation are extremely rare in young and fit patients, they can be more common in those with underlying medical conditions.

Tobacco use increases the risk of infection and other complications, and has a serious negative effect on the outcome of any type of cartilage repair.

Many coexisting health concerns, such as heart disease or obesity, can have their impact on the outcome minimised before an operation, ensuring the best situation for the patient. A collaborative, or ‘multidisciplinary’, approach will help the surgical team to minimise the risk of complications.

The use of anaesthesia carries some risks, but most of these are mild, temporary issues related to the agents used, the process of intubation or the use of nerve blocks. Extremely rare instances of severe allergic reaction have been reported, and death is reported in approximately 1 in 100,000 patients undergoing general anaesthesia.

Cartilage repair

Looking at cartilage repair procedures in particular, more than one procedure may be required. While most cartilage procedures are single-stage techniques, cartilage repair may be planned over several procedures at different times. In two-stage procedures such as autologous chondrocyte implantation (ACI), cartilage cells (chondrocytes) are harvested from the body (initial operation), multiplied in a laboratory, and then surgically replanted into the cartilage defect (second operation).

While rare, complications after surgery (‘postoperative complications’) are another consideration. Graft failure (such as delamination or overgrowth) may make a further operation necessary. However, the risks can be minimised if due care is taken.

Physical therapists should work with surgeons to ensure that the rehabilitation is appropriate. Overly aggressive or demanding physical therapy too soon after the operation can cause graft complications and jeopardise optimal outcomes. With this in mind, both the both surgeon and physiotherapist should talk to the patient about the allowed ranges of motion and weight-bearing restrictions of the joint.

There is also the possibility that, despite the best efforts of the healthcare team, the procedure does not achieve the desired outcome. In such cases, the patient and the doctor will discuss future options and the potential for further treatments or procedures.

Relative risks

As cartilage repair procedures focus on the joints, the risk of accidental damage to major organs or blood vessels during surgery is minimal. However, there is a small risk of damage to surrounding structures, including vessels, nerves, or adjacent cartilage.

As the surgeries are planned, or ‘elective’, weighing the risks, benefits, and alternatives can be done well in advance. Similarly, ample time for pre-operative care means that higher risk patients with coexisting health concerns can be better prepared for surgery.

Importantly, when compared with the entire spectrum of surgical procedures, it is important to remember that elective cartilage repair is, overall, relatively safe and low-risk.

Frequently Asked Questions (FAQs)

How long after surgery will I be able to return home?

In most cases, cartilage procedures are performed on an outpatient basis, or might require only a very brief hospital stay. More complex procedures may require a longer length of stay.

What are the chances of an operation solving cartilage problems in the long-term?

Cartilage repair procedures are still relatively new field. There is little long-term data both on the natural history of untreated cartilage lesions or studies that can predict surgical results years and years into the future. That being said, encouraging mid-term results are hoped to carry on into the long-term.

Is there a minimum amount time off work I will need after the surgery?

After almost any cartilage repair procedure, the typical minimum amount of time that you will have to take off work is 6 weeks.

How much time off work will I need after the surgery?

This will depend on both the individual operation and the outcome. Ask your healthcare professional for more specific estimates.

Further reading

Many currently used cartilage repair techniques have excellent mid-term outcomes, and there is well-founded optimism that, as time progresses, there will be similarly encouraging long-term data on outcomes.

Currently there are several specific techniques and devices in the pipeline. In particular, bioengineered scaffolds, cell-based therapies, and adjuvant growth factors are both in pre-clinical trials and clinical use elsewhere, and are expected to be available in the foreseeable future.

Keywords

cartilage repair, complications, outcomes, Risks