通常，越接近日落，心境與 Vincent 的共鳴越強；
一早起來，精神抖擻，又有 Braveheart 中 Mel Gibson 的鬥志了！
以下的申覆陳述，就是在這樣的清晨完成的 .......

（又有兩筆 ACRFP 的手術被健保局核刪！）

該說得都說了，接下來就  Let it be 囉！

等待這項治療或是已接受治療的病患應是最能體會我們的心境了 .......


複審委員，您好，辛苦了！

誠摯的請您在下判斷前，先看完以下的陳述及相關資料，謝謝：

退化性膝關節炎，跨越數十世紀，深深影響著人類的健康生活。十年前，以美國為首的西方先進國家，將之納入【2000~2010 – The Bone and Joint Decade】的五大標的骨關節疾病，欲結合各領域專家，傾力研究，尋求解決之道。

如今，十年時光已逝。遺憾的是，在 AAOS (American Academy of Orthopaedic Surgeon)、OARSI (Osteoarthritis Research Society International) 以及 EULAR (European League Against Rheumatism)  相繼提出的退化性膝關節炎治療指引之中，並無法找到足以振奮人心的訊息，充其量只是將大家所熟知的各種治療方式以實證醫學的角度重新整理，仍然無法找到真正的病因以及根本的治癒之道。

在 AAOS 提出的退化性膝關節炎治療指引之中，已將Arthroscopic Debridement for OA knee 列入沒有積極療效的手術，而反對它的執行！

AAOS OA Knee Guideline No. 18 ( 22項中的第18項 )：
    We recommend against performing arthroscopy with debridement or lavage in patients
    with a primary diagnosis of symptomatic OA of the knee
           Level of Evidence: I and II
           Grade of Recommendation: A

其實，我們對這樣的看法也深表同意，也就是說，初審委員希望我們申報的 64243B 關節鏡清創手術，在我們的認知是沒有意義的手術（我們對 64244B 鑽孔磨骨手術的看法也是如此） ，十幾年來，我們已未曾施行這類手術。更何況，若果真是執行這項手術，病人根本就不須住院，也沒有必要使用 HemoVac 引流，懇請複審委員明察。

再次強調，我們執行的手術，並非 64243B，也不是 64244B，我們所稱的 ACRFP (Arthroscopic Cartilage Regeneration Facilitating Procedure) 乃是十幾年來，一步步結合基礎研究，為了移除病因的創新手術觀念及方法。依每個膝關節的不同病情，執行以下各種單一術式的不同組合： AMR (Arthroscopic Medial Release, 見 Reference 4 ); ALR (Arthroscopic Lateral Release) ; APM (Arthroscopic Partial Meniscectomy); Arthroscopic Synovectomy; Arthroscopic Loose Body Removal 以及 Arthroscopic Chondroplasty。

若以現有的手術碼申報，事實上是包括： 64055B，64218B 及 64244B 的混合組成，為了單純化，乃決定以 64244B 申報。若精算我們實際執行的項目，絕對超過 64244B 給付的金額！也就是說，我們並非計較收益的多少，而是想要強調這項新的手術觀念及做法對病人的長期治療價值。

Voltaire（1694~1778, Philosopher, French）曾有以下頗富哲理的看法：

          Whenever something is new,
               people say it is not true.

          As time goes on and it is proven to be true,
               people say it is not important.

          As time goes on and it is proven to be important,
               people say it is not new anymore!

我們深知，新的觀念，要被同儕接受，是難上加難而曠日費時的。然而，過去十年的臨床經驗，實際參與見證的病患已累積有四、五千人，對於他們及周遭的親朋好友而言，這項治療觀念早已不是新的，可是，他們若想在就近的醫院得到相同的治療，至今仍無法如願。

過去幾年，我們努力想藉由雜誌、學會發表，吸引國內外同儕的興趣，期待能改變醫界對這重要疾病的看法，可是，得到的成效，相較於 【Glucosamine】 及 【Hyaluronic Acid】 的大行其道，實為我們醫療及社會體制的最大諷刺！難道我們醫界永遠都要故步自封，沈浸於早已腐爛而不自知的榮耀中嗎？

為了讓醫界能慢慢接受並共享我們多年來的研究成果，我們除了繼續在學會發表，
今年開始，更積極籌辦“膝關節健康促進研習課程”，預計每半年舉辦一次研討會，期待慢慢有更多專業醫師投入。

以下是今年初已經圓滿完成的第一期研習課程及將在半年後舉行的第二期課程表， 非常歡迎  委員屆時能撥冗蒞臨指教！


（膝關節健康促進專業研習社群網頁：http://www.joint.idv.tw/plc/）

Current Status of our Ongoing Studies
Shaw-Ruey Lyu

    In previous study, two distinguished foci of chondral lesions were noticed over the medial femoral condyle facing the pathologic medial plica in OA knee (1). The lesion over the marginal region (focus A) has been demonstrated be caused by the abrasion phenomenon between medial plica and the cartilage during daily activities (2,3,5). The eradication of the abrasion phenomenon and the inflammatory synovium in this area by arthroscopic medial release could effectively reduce pain in the majority of patients with medial compartment osteoarthritis of the knee and might reduce or arrest the degenerative process in the medial compartment (4). Recent studies have demonstrated high expression of IL-1β and MMP-3 in the medial plica and pannus-like tissue related to this abrasion phenomenon (6,7). Total protein and interleukin-1β concentrations were also found higher in the medial compartment of medial compartment osteoarthritic knee (8).
    In further studies, we plan to examine the histomorphologic presentation and the IL-1β and MMP-3 expressions of the chondral lesions shown in Figure 1 (9,10). We postulated that these lesions might have correlation with the matrix degradation enzymes produced by the facing inflamed medial plica or the marginal pannus-like tissue.  Therefore, surgical eradication of these inflammatory tissues might have benefits and change the natural course of the degenerative knees.
Figure 1
(Fig. 3 from Ref 1)

References

1.    Lyu SR, Hsu CC. Medial plicae and degeneration of the medial femoral condyle. Arthroscopy 2006, 22:17-26.
2.    Shaw-Ruey Lyu, Jeh-En Tzeng, Chia-Yuan Kuo, Ai-Ru Jian, De-Shin Liu, Mechanical strength of mediopatellar plica - The influence of its fiber content. Clinical Biomechanics, Volume 21, Issue 8, October 2006, Pages 860-863
3.    Lyu SR. Relationship of medial plica and medial femoral condyle during flexion. Clin Biomech 2007, 22:1013-16.
4.    Lyu SR. Arthroscopic medial release for medial compartment osteoarthritis of the knee: the result of a single surgeon series with a minimum follow-up of four years. J Bone Joint Surg Br 2008, 90:1186-92.
5.    Shaw-Ruey Lyu, Jui-Kun Chiang, Chih-En Tseng, Medial plica in patients with knee osteoarthritis: a histomorphological study. Knee Surg Sports Traumatol Arthroc, published online: 14 October 2009
6.    Hwai-Shi Wang, Pei-Yin Kuo, Chih-Chang Yang, Shaw-Ruey Lyu, Matrix metalloprotease-3 expression in medial plica and pannus-like tissue in knees with medial compartment osteoarthritis , submitted
7.    Hwai-Shi Wang, Chih-Chang Yang, Shaw-Ruey Lyu, MMPs and ADAMTS-4 are highly expressed in pannus-like tissue in knees with early medial compartment osteoarthritis, submitted
8.    Shaw-Ruey Lyu, Jong-Yuh Cherng, Chang-Yue Chiang, Lai-Kwan Chau, Total protein and interleukin-1β concentrations are higher in the medial compartment of medial compartment osteoarthritic knee, submitted
9.    Chih-En Tseng, Shaw-Ruey Lyu, Medial plica related chondral lesions in medial compartment osteoarthritis of the knee: a histomorphological study, undergoing
10.  Hwai-Shi Wang, Chih-Chang Yang, Shaw-Ruey Lyu, IL-1β and MMP-3 expressions in medial plica related chondral lesions in early medial compartment osteoarthritis of the knee, undergoing



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踏腳石 - 退化性膝關節炎患者的棲息地

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