关节挛缩的发病机制及治疗进展

Research advances in pathomechanism and treatment of joint contracture

关节挛缩是目前临床常见问题,严重影响患者的日常生活,其发病机制尚不明确。目前认为关节囊增厚纤维化是主要原因,成纤维细胞与肌成纤维细胞过度增殖,细胞外基质沉积,胶原增生且排列紊乱,其病理过程可能涉及转移生长因子β、结缔组织生长因子、肿瘤坏死因子-α、基质金属蛋白酶和基质金属蛋白酶组织抑制剂等多种细胞因子。目前临床上治疗关节挛缩的方法主要包括两大类:牵伸疗法、物理因子治疗、运动疗法、肉毒素注射等非手术治疗,关节镜下松解术、开放式松解术等手术治疗,常规先进行非手术治疗,当非手术治疗方法难以取得进一步改善时,则选择手术治疗。对于轻中度关节挛缩有较好效果,但是对于较为严重的关节挛缩则难以使关节活动完全恢复。虽然临床上的治疗方法多种多样,但临床效果参差不齐,其治疗的有效性也存在争议。关节挛缩是骨科与康复科医师、治疗师及患者所面临的重要挑战,现对关节挛缩的发病机制及治疗等现状进行总结,为临床诊疗提供理论基础。

Joint contracture is one of the common musculoskeletal disorders.It has seriously disturbed patients’activities of daily living in various aspects.The pathogenesis of it is eager to explore to distinct degree.Nowadays the thickeness and fibrosis of joint capsular is redarded as the major reason to joint contracture.It is reported that excessive fibroblasts and myofibroblasts activity,collagen hyperplasia,and extracellular matrix(ECM)deposition in these fibrotic condtions lead to the contracture.In addition,upregulators of myofibroblast and collagen synthesis,transforming growth factor beta 1(TGF-β1),and connective tissue growth factor(CTGF)were shown to be increased.Altered levels of cytokines were also thought to play a role in this process as elevated levels of tumor necrosis factorα(TNF-α),matrix metalloproteinases(MMPs)and abnormal distribution tissue inhibitors of MMPs(TIMPs)were demonstrated in contracted capsules.At present,the methods for clinical treatment of joint contracture mainly include two major categories:stretching therapy,physical factor therapy,exercise therapy,botulinum toxin injection and other non surgical treatments,arthroscopic lysis,open lysis,and other surgical treatments.Surgical treatment is performed when non surgical treatment is difficult to achieve further improvement.It has a good effect on mild to moderate joint contracture,but it is difficult to completely restore joint activity for serious joint contracture.Although clinical treatment methods are diverse,the clinical effects are staggered and the effectiveness of their treatment is controversial.Joint contracture is an important challenge faced by orthopedics and rehabilitation physicians,therapists and patients.The review summarized the pathogenesis and treatment of joint contracture and provided a theoretical basis for clinical diagnosis and treatment.