踏腳石 - 退化性膝關節炎患者的棲息地

孤寂的先行者，期盼著2009的第一道曙光。




2008 對我來說，是值得珍惜的一年，
年初即接獲 JBJS 對我努力了五年的創新手術方法相關論文的接受信函：

Dear Dr Lyu,

Log no. 20584 'Arthroscopic medial release for medial compartment osteoarthritis of the knee'

Thank you for sending us your resubmission.  I am very pleased to tell you that we would now like to publish your article, subject to the usual in-house editing.

We shall send you edited proofs for approval in due course. Please note that we may remove any figures that the Editor feels are unnecessary at this stage.

Please could you also confirm your address, telephone, email and fax numbers for correspondence and communication during editing. If you are planning on being away for any length of time over the next few months, it would also be helpful if you could let us know.

With best wishes

James Scott, MA, FRCS
Editor
Journal of Bone and Joint Surgery
22 Buckingham Street
London, England

這也加強了我在六月於荷蘭 Amsterdam 第54屆北歐骨科醫學會發表口頭報告的信心。

54th Nordic Orthoapaedic Federation Congress
(第54屆兩年一次的北歐骨科醫學會)




此次會議，最大的收穫是，透過口頭報告引發熱烈討論，首度讓“膝關節健康促進方案“在國際曝光，也種下了讓此方案走入國際舞台的種子。
果然，抓住機緣後，回國不到一個月，就接到如下的邀請函：

Dear Mr. Michael SR Lyu,
 
Let me introduce myself. I am the Project Manager of the Conference Management in charge of the organisation of IMUKA 2009.

In the view of the Organising Committee your published papers are very interesting and it pleases the Organising Committee that you are willing to contribute to the value of the IMUKA 2009 conference.
 
Your participation as a speaker at the IMUKA 2009 conference would be highly appreciated.
We are looking forward to welcoming you as a speaker at the IMUKA 2009 conference.
 
If you have any further questions, please do not hesitate to contact me or Dr. Nanne Kort, Course Director. His email is n.kort@imuka.eu.
Have a nice day.
 
Met vriendelijke groet / with best regards,
CONFERENCE AGENCY MAASTRICHT
 
Janine Coenen
Project Manager




IMUKA (International Meeting on early intervention for Unicompartmental Knee Arthritis) 是全球首度針對單腔室的早期膝關節炎治療方式的國際研討會，由荷蘭醫師 Nanne P. Kort 發起，將於今年二月4～6 日在荷蘭南端的小城 Maastricht 舉辦，三天的議程，將邀請五十餘位國際專家發表專題演講，深入探討單腔室的早期膝關節炎的相關議題，預估將有骨科、運動醫學科、一般內科、風溼免疫科、復健科、及相關醫療專業人士共500人參與。很意外的，我是唯一受邀的亞洲學者，真是受寵若驚。
   
會議所在地


小城 Maastricht

                                                                                   
對於這次邀約，當然是誠惶誠恐，近十年的研究成果，要在短短的一刻鐘表達清楚，確實須費心準備。
不過，孤寂已久，期待知音的心情還是愉快的！

以下是我剛完成的演講摘要：

Arthroscopic Medial Release for Medial Abrasion Syndrome
- A Novel Concept of Treatment for Early and Moderate OA Knee

Shaw-Ruey Lyu, MD, PhD
Joint Center
Tzu-Chi Dalin General Hospital
Chiayi, Taiwan

Arthroscopic techniques for the management of degenerative conditions of the knee include joint lavage, debridement, abrasion arthroplasty and microfracture. Nevertheless, their effectiveness has not been proven in prospective trials and the mechanism by which they improve the course of degenerative conditions of the knee has not been established.

A new concept of arthroscopic medial release has been developed in our center based on the conceptualization of a possible pathogenesis process drawn out by “medial abrasion syndrome”, which might be the consequence of chronic inflammation of the medial plica in many primary medial compartment OA knees.

According to our observation, medial plica was more commonly found in patients with osteoarthritic knees. Cartilaginous degeneration on the surface of the medial femoral condyle could be found in most of the knees with a medial plica. The severity of the degeneration was positively correlated with the severity of the medial plica and patients’ age.¹

The experimental study on the tensile strength of the medial plica using high precision micro-force tensile tests indicated that as patients get older, the fiber content of the medial plica and the Young’s modulus of the plica will increase accordingly. We have also demonstrated that the Young’s modulus of the medial plica was positively correlated with the severity of the plica lesion.²

In another study, we have observed and disclosed the kinematic relationship of different type of medial plica with the medial femoral condyle during knee motion in vivo. This pattern of medial–lateral motion may generate some shearing force acting on the cartilage of the medial femoral condyle. This finding may draw more attention to the role of medial plica in the pathogenesis of degeneration of the cartilage on the medial femoral condyle of the knee joint.³

Based on these sentinel studies, we have established a biomechanics based finite element model to study the stress elicited by the medial plica on the medial femoral condyle. In response to the degree of fibrosis and the size of the plica tissue, the stress produced on the medial femoral condyle was shown to be between 4.75 and 20.13 MPa, which is high enough to cause cartilage damage.⁴

Moreover, according to our recent studies, we’ve found  pannus-like tissue located around the degeneration area of the medial femoral chondyle related to the abrasion caused by medial plica  in early stage OA knee. This pannus-like tissue has been reported to have some role in the pathogenesis of  knee OA.⁵ In an immunohistochemical study for the detection of MMP-3 we performed recently, MMP-3 is highly expressed in pannus-like and medial plica tissues of the OA knee patients. The RT-PCR and Western blot analysis also disclosed that IL-1β is a potent stimulus for MMP-3 mRNA and MMP-3 in the cells isolated from both pannus-like tissue and medial plica.

The results of these studies encourage us to develop a new arthroscopic treatment option to eliminate the “medial abrasion syndrome” caused by the chronically inflamed medial plica and the adjacent medial capsule. This procedure, which we called arthroscopic medial release (AMR), has been proven to be an effective treatment for osteoarthritis of the medial compartment of the knee joint and can be expected to reduce the pain in the majority of patients for at least four years post-operatively.⁶ The preliminary results of a more encouraging radiographic follow-up study which is undertaken will also be presented.

In conclusion, all of the information we’ve got pleads us that the life long interplay between the medial plica and the medial femoral condyle might be an important etiologic factor for the pathogenesis of the so called “primary” medial compartment OA knee. Arthroscopic medial release, if performed in time, might change the natural course of OA knee.


Reference:

1. Lyu SR, Hsu CC, Medial plicae and degeneration of the medial femoral condyle. Arthroscopy. 2006 Jan;22(1):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. Shaw-Ruey Lyu, Relationship of medial plica and medial femoral condyle during flexion. Clinical Biomechanics, 2007, Volume 22, Issue 9, Pages 1013-1016
4. Loening AM, James IE, Levenston ME, Badger AM, Frank EH, Kurz B, Nuttall ME, Hung HH, Blake SM, Grodzinsky AJ, Lark MW, Injurious mechanical compression of bovine articular cartilage induces chondrocyte apoptosis. Arch Biochem Biophys. 2000 Sep 15;381(2):205-12.
5. Shibakawa A, Aoki H, Masuko-Hongo K, Kato T, Tanaka M, Nishioka K, Nakamura H, Presence of pannus-like tissue on osteoarthritic cartilage and its histological character. Osteoarthritis Cartilage. 2003 Feb;11(2):133-40.
6. Shaw-Ruey Lyu, Arthroscopic medial release for medial compartment osteoarthritis of the knee, J Bone Joint Surg Br, September, 2008, Vol 90-B, issue 9, Pages 1186-1192