Erggelet Christoph, Vavken P
alphaclinic Zurich, Switzerland; Department for Orthopaedic Surgery and Traumatology, Albert-Ludwigs-University Medical Center, Freiburg, Germany.
alphaclinic Zurich, Switzerland; Division of Sports Medicine, Children's Hospital, Harvard Medical School, Boston, United States.
J Clin Orthop Trauma. 2016 Jul-Sep;7(3):145-52. doi: 10.1016/j.jcot.2016.06.015. Epub 2016 Jun 28.
The evidence for the effectiveness of the microfracture procedure is largely derived from case series and few randomized trials. Clinical outcomes improve with microfracture for the most part, but in some studies these effects are not sustained. The quality of cartilage repair following microfracture is variable and inconsistent due to unknown reasons. Younger patients have better clinical outcomes and quality of cartilage repair than older patients. When lesion location was shown to affect microfracture outcome, patients with lesions of the femoral condyle have the best clinical improvements and quality of cartilage repair compared with patients who had lesions in other areas. Patients with smaller lesions have better clinical improvement than patients with larger lesions. The necessity of long postoperative CPM and restricted weight bearing is widely accepted but not completely supported by solid data. Maybe new developments like the scaffold augmented microfracture(6) will show even more consistent clinical and biological results as well as faster rehabilitation for the treatment of small to medium sized cartilage defects in younger individuals. All in all there is limited evidence that micro fracture should be accepted as gold standard for the treatment of cartilage lesions in the knee joint. There is no study available which compares empty controls or non-surgical treatment/physiotherapy with microfracture. According to the literature there is even evidence for self regeneration of cartilage lesions. The natural history of damaged cartilage seems to be written e.g. by inflammatory processes, genetic predisposition and other factors. Possibly that explains the large variety of the clinical outcome after micro fracture and possibly the standard tools for evaluation of new technologies (randomized controlled trials, case series, etc.) are not sufficient (anymore). Future technologies will be evaluated by big data from international registries for earlier detection of safety issues, for detection of subtle but crucial co-factors for failure and osteoarthritis as well as for lower financial burdens affecting industry and healthcare systems likewise.
微骨折手术有效性的证据主要来自病例系列研究，随机试验较少。在大多数情况下，微骨折手术能改善临床结果，但在一些研究中，这些效果无法持续。由于未知原因，微骨折术后软骨修复的质量参差不齐且不稳定。年轻患者的临床结果和软骨修复质量优于老年患者。当病变位置被证明会影响微骨折结果时，与其他部位有病变的患者相比，股骨髁有病变的患者临床改善情况和软骨修复质量最佳。病变较小的患者比病变较大的患者临床改善情况更好。术后长期使用持续被动运动（CPM）和限制负重的必要性已被广泛接受，但尚未得到确凿数据的充分支持。也许像支架增强微骨折技术（6）这样的新进展将在治疗年轻个体中小到中等大小的软骨缺损时显示出更一致的临床和生物学结果以及更快的康复效果。总而言之，仅有有限的证据表明微骨折应被视为膝关节软骨损伤治疗的金标准。目前尚无研究将空白对照或非手术治疗/物理治疗与微骨折进行比较。根据文献，甚至有证据表明软骨损伤可自我修复。受损软骨的自然病程似乎由炎症过程、遗传易感性和其他因素所决定。这可能解释了微骨折术后临床结果的巨大差异，也可能说明评估新技术的标准工具（随机对照试验、病例系列等）已不再足够。未来的技术将通过国际注册机构的大数据进行评估，以便更早地发现安全问题，检测导致失败和骨关节炎的细微但关键的辅助因素，以及减轻同样影响产业和医疗系统的经济负担。
