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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]




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.


He is not alone

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

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.


TKR is a successful treatment for his condition, but there are concerns given his younger age

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


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.



He will golf and ski again

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.


The TKR procedure is becoming easier and safer

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


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.



Knee replacement is the definitive treatment for osteoarthritis of the knee, but it is the last resort

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.


TKR remains the “gold standard” for the definitive treatment of osteoarthritis of the knee.


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.


Basis for Autologous Cell Treatment

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).


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.


Addressing Barriers to Treatment

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.


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


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.


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



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.


Recommendation to Patients

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.


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.


由MediCool医库软件 王露黔 编译

原文来自PM R

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