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病例漫谈111:一例活动量大的男性晚期膝关节骨性关节炎患者:生物疗法或全膝关节置换术 [复制链接]

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CASE SCENARIO

病例简介

A healthy 54-year-old man presents to your office for your opinion regarding his progressively worsening right knee pain. At age 24, he underwent a primary anterior cruciate ligament reconstruction as a result of a skiing injury. He subsequently has had 2 arthroscopic surgeries, the first a partial resection undergone 15 years ago for a degenerative tear, followed 5 years later by a complete medial meniscus resection. His pain now interferes with his ability to complete a full round of golf, and he does not want to resort to using a cart. During the previous 2 years, he has tried a variety of treatments, including nonsteroidal anti-inflammatory medications, physical therapy with home exercises, unloader and patellar bracing, 2 corticosteroid injections, and 2 hyaluronic acid injections. He has experienced some temporary relief, but none of these treatments have allowed him to fully engage in golfing. Knee radiographs demonstrate Kellgren-Lawrence Grade 3 osteoarthritis, predominately affecting the medial compartment, but there is tricompartmental involvement. He consulted with anorthopedic surgeon, who recommended a total knee replacement (TKR). A second physician suggested he trystem cell therapy for osteoarthritis. He would like to re-engage in golfing and even skiing, and he seeks your advice regarding whether the total knee replacement (TKR) or stem cell treatment would provide the optimal treatment for his knee pain and function. Dr. Wayne Colizza will argue that a TKR will offer the best possible outcomes. Dr. Victor Ibrahim will argue that stem cell therapy is a viable treatment option for this patient.

一名54岁健康男性,因右膝疼痛逐渐恶化来诊。24岁时,他因滑雪受伤,接受过原位前交叉韧带重建术,随后,接受了2次关节镜手术。15年前,因退行性撕裂第一次行部分切除术,5年后,接受了内侧半月板全切除术。目前的疼痛会影响完成一轮完整的高尔夫球赛,但患者又不想依靠手推车助步。过去2年,他已经尝试了多种治疗方法,包括非甾体类抗炎药治疗、物理治疗和家庭体育锻炼、消除负荷和髌骨支撑、2次糖皮质激素注射和2次透明质酸注射。疼痛暂时得到了缓解,但这些治疗都没有让他能完全参与高尔夫球赛。膝关节X线片显示Kellgren-Lawrence分级为3级骨性关节炎,主要影响内侧间室,但累及三个间室。他向一名矫形外科医生咨询,医生建议其接受全膝关节置换术(TKR)治疗。另一名医生则建议他可尝试干细胞疗法治疗骨性关节炎。他希望重新进行高尔夫运动,甚至可以滑雪,于是咨询全膝关节置换术(TKR)或干细胞治疗哪种治疗膝关节疼痛和功能障碍的方法疗效最佳。Wayne Colizza博士认为,TKR的治疗结果可能最佳。Victor Ibrahim博士则认为,对于这名患者,干细胞疗法治疗是一种可行的治疗方案。


Wayne A. Colizza, MD, FACS, Responds
Wayne A. Colizza, MD, FACS的回答

Given his history, presentation, and goals, I would provide the following information and advice.

根据患者的病史,介绍和目标,我给出以下信息和建议。


He is not alone
此类患者并不少见

The patient is among the estimated 20%-30% of U.S. adults living with osteoarthritis, according to the National Arthritis Data Workgroup, with hips, knees, and hands being the most commonly affected joints. The increase in the prevalence of osteoarthritis is attributable to the increase in life expectancy, obesity, and sports-related joint trauma in our society.

根据美国国家关节炎数据中心(National Arthritis Data Workgroup)的数据显示,全美大约有20%-30%的成年人患有骨性关节炎,受累关节最常见于髋部、膝部和手部。骨性关节炎的发病率随年龄、肥胖和运动相关关节创伤的增加而增加。


He has not responded to any nonoperative management for his condition
保守治疗无效

This patient has tried nonsteroidal anti-inflammatory medications, physical therapy, bracing, intra-articular corticosteroid injections, and 2 series of visco-supplementation. Unfortunately, these treatments have failed to bring him to his goal of comfortably playing golf and skiing. It is my opinion that he now needs a TKR to reach this goal.

此患者已尝试了非甾体类抗炎药治疗、物理治疗、支撑、关节内皮质类固醇激素注射和2种黏弹性补充疗法。遗憾的是,这些治疗方法未能使他轻松地进行高尔夫运动和滑雪。我认为患者现在需要接受全膝关节置换术才能达到治疗目标。


TKR is a successful treatment for his condition, but there are concerns given his younger age
TKR能成功治疗此病患,但鉴于患者较年轻给出了一些注意事项

Joint replacement is a well-established surgical treatment for osteoarthritis with documented results in improvements in function, pain reduction, correction of deformity, and return to activity

依据功能改善、疼痛减轻、畸形矫正以及活动恢复的记录结果,关节置换术是治疗骨性关节炎行之有效的一种手术治疗方法。  


In a younger patient, the greater worry is the survivorship of the prosthesis. Medical practitioners have expressed concern about early loosening and failure of the implant when TKR is performed in younger and more active patients. These risks would be discussed with the patient before proceeding with surgery.

年轻患者中,较担忧的是假体的使用寿命。医生表示年轻和活动较多的患者行TKR时应注意植入物的早期松动和植入失败。在进行手术之前,应与患者讨论这些风险。

    

He will golf and ski again
他又可以进行高尔夫和滑雪运动

Our patient wants to golf and ski. Fortunately, he does not want to run a marathon. There is a paucity of orthopedic literature addressing return to sport after TKR. In 2007, members of the American Association of Hip and Knee Surgeons were polled as to their preferences for the return to sporting activity after TKR. There was strong consensus toward allowing patients to return to skiing (if the patient had preoperative experience) and golfing. Other studies support a return to golf but recognize the greater stress on the target-side knee, which will not be an issue if our patient is right-handed. Unfortunately, unlike his golf partners who have under gone a total hip replacement, he will notice a loss of 12 yards on his drive.

患者希望打高尔夫和滑雪。目前TKR术后恢复运动的骨科类文献较缺乏。2007年,美国髋膝外科医师学会成员认为全膝关节置换术可使患者恢复体育运动,并因此接受了采访。他们对于可以使患者重新滑雪(如果患者术前有经验)和打高尔夫球形成了高度共识。另一些研究对重新打高尔夫表示支持,但承认手术侧膝盖会承受更大压力,不过,如果患者是右撇子,那么就不存在这一问题。患者的队友接受了全髋关节置换术,遗憾的是与队友相比,患者会注意到自己驱动力损失了12码。


The TKR procedure is becoming easier and safer
TKR疗程正变得更容易、更安全

Compared with 15 years ago, the TKR procedure is becoming easier and safer for the patient.

与15年前相比,TKR手术过程变得更容易且更安全。


It has been shown to decrease surgical bleeding in patients undergoing total hip and TKR without increasing the risk of deep venous thrombosis. Patients no longer have to donate autologous blood preoperatively, and perioperative heterologous transfusion rates have decreased, eliminating the risk of transfusion reactions and blood-borne infection.

接受全髋关节和全膝关节置换术患者已被证实在不增加深静脉血栓形成风险的同时,可以减少手术出血。患者术前不需要自体血储备,围手术期异种输血率降低,输血反应和血液传播感染的风险降低。

    

Knee replacement is the definitive treatment for osteoarthritis of the knee, but it is the last resort
膝关节置换术是膝关节骨性关节炎的决定性疗法,但应是最后的手段
          

In caring for any patient with knee arthritis, it is important to exhaust all therapeutic measures short of TKR before considering this operation. This is particularly true in the younger patient, in whom survivorship of the prosthesis is paramount.

膝关节炎患者的治疗过程中,在考虑此项手术之前,应已经用完TKR以外的所有治疗措施。年轻患者尤其如此,考虑假体的寿命尤为重要。


TKR remains the “gold standard” for the definitive treatment of osteoarthritis of the knee.
TKR仍是膝关节骨性关节炎治疗的“金标准”。

  

Victor Ibrahim, MD, Responds
Victor Ibrahim博士的回答

The advent of modern-day stem cell science and its clinical applications poses a potential paradigm shift in how clinicians evaluate and treat such pathologies. The current method of “watch and wait” has been supplanted by cellular based therapies that may offer patients improved function with minimal risk. Because of these new treatment options, it is first important to outline the limitation of modern-day joint replacement and compare it with these novel cell-based interventions. When one compares safety, efficacy, and cost, stem cell therapy appears to be areasonable and potentially superior option.

现代干细胞科学的出现及其临床应用为如何评估和治疗骨性关节炎带来了潜在的模式转变。以细胞为基础的疗法已取代了现有的“观望”方法,此疗法可改善患者功能,且风险最小。针对这些新型治疗方法,首先要做的是列出现代关节置换术的局限点,并将此方法与以细胞为基础的介入治疗相比较。通过比较安全性、疗效和成本,干细胞治疗似乎是更具合理性和潜在优越性的选择。

Basis for Autologous Cell Treatment
自体细胞治疗的基础  

Autologous cell-based therapy is based on harnessing the body’s physiologic self-regulation of cartilage repair. Accessing this physiologic pathway to facilitate healing has been a primary goal of using cell-based therapies, including stem cell therapy and platelet-rich plasma (PRP).

自体细胞为基础的治疗是以人体软骨修复的生理自我调节为基础。以细胞为基础的治疗包括干细胞疗法和富血小板血浆(PRP),主要目标是通过生理途径促进愈合。


Both stem cell therapy and PRP involve procuring progenitor cells from the patient. PRP is performed simply via a blood draw, whereas stem cell therapy is usually via a bone marrow aspiration. These cells are then concentrated and injected into the affected issues.

干细胞治疗和PRP涉及从患者自身获取祖细胞。PRP可简单通过抽血进行手术,而干细胞疗法通常是通过骨髓穿刺,随后,集中这些细胞,并注入到受累部位。


Addressing Barriers to Treatment
解除治疗障碍

Common barriers to recommending cellular-based therapies include safety concerns, efficacy, and cost. Concerns for safety are of course most paramount when considering new treatments. To date, there have been no reportable incidents of significant adverse reaction to stem cell intra-articular injection reported in the literature.

基于细胞进行治疗的常见障碍包括安全问题、疗效和成本。考虑新治疗方法时,需重点关注安全问题。到目前为止,尚无文献报道干细胞关节内注射的严重不良反应事件。

Given its good safety profile thus far, the effectiveness of the treatment must then be considered.

鉴于一直以来的良好安全性,需考虑该疗法的有效性。


According to Centeno et al, the majority of patients undergoing stem cell injection for knee arthritis reported significant improvement in both pain and function. In the author’s experience in sports medicine, several hundred patients have returned to high-impact sports activities after receiving cell-based treatments.

根据Centeno等人的报道,多数以干细胞注射治疗膝骨性关节炎的患者在疼痛和功能上得到了明显改善。鉴于作者在运动医学上的经验,数百名接受细胞治疗的患者已恢复高强度体育运动。  


Finally, the issue of cost has been of increasing concern.

最后,成本问题已经越来越多受到关注。

    

As determined by a simple internet search, the average cost of a stem cell treatment appears to range from $2000 to $5000, and may be less for a simpler treatment such as PRP. This of course is a very real barrier for any therapy. The average cost of a total joint replacement, however, is reportedly $50,000. The cost to a patient of a stem cell treatment, therefore, becomes more comparable.

通过互联网进行简单搜索,干细胞治疗的平均费用为2000-5000美元,PRP等简单治疗费用可能少一些。当然,这对于任何治疗都是很现实的障碍。然而,据报道,全关节置换术的平均成本是50000美元。因此,干细胞治疗的成本更具可比性。  


Recommendation to Patients
给患者的建议

When providing a clinical treatment plan for a patient, it is prudent that the practitioner adequately explain alternative treatment options. In a healthy 54-year- old man, the likelihood of a revision surgery is very high. This surgery would be performed at a later age, in which risk of complications would undoubtedly be greater and whose risks are truly unknown. Considering the low risk of autologous cellular therapy, it is reasonable and prudent to raise such a possibility to patients. In contrast, stem cell therapy has a low reported rate of immediate complications.

医生在为患者设计临床治疗计划时应谨慎,需向患者充分解释替代治疗方案。54岁健康男性行翻修手术的可能性非常高,这一手术会在患者年龄较大时实施,此时诱发并发症的风险无疑会加大,且充满未知性。考虑到自体细胞治疗的低风险性,针对这些患者提出这一可能的治疗方法是合理和谨慎的。据报道,相比之下,干细胞治疗引起即刻发生并发症的机率较低。


In addition to a discussion of risks, the success rate and costs of the proposed treatment must be discussed. Outcomes after a TKR may be improved if the patient lives a sedentary lifestyle, but high-impact activities and a limited shelf life of 15 years remain concerning limitations. Also, given the greater costs to patients, insurance companies, and society associated with a TKR, stem cell therapy is a more attractive option. The weight of the clinical decision ultimately lies in the informed consent of a patient. Given this patient’s age and level of function, stem cell therapy provides a relatively safe, effective, and relatively low-cost method in treating osteoarthritis in a 54-year-old active individual. Given the known risks associated with a TKR, stem cell treatment for this patient is very reasonable and may be in the best interest of the patient.

除对风险进行讨论外,推荐治疗方法的成功率和费用也是必须考虑的。如果患者的生活方式是久坐不动,那么行全膝关节置换术后,病情可能得到改善。但是,患者存在高强度运动,且此疗法仅有15年有效期,因此仍存在局限性。此外,患者、保险公司和社会耗费的成本更高,因此干细胞疗法较TKR更具吸引力。临床决策最终取决于患者的知情同意书。这名骨性关节炎患者54岁,运动多,鉴于其年龄和功能水平,干细胞治疗是相对安全、有效和低成本的疗法。


由MediCool医库软件 王露黔 编译

原文来自PM R

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