十字韌帶斷裂或膝關節退化，是不是一定要開刀？

文：劉仁凱

隨著運動人口的字韌增加和平均壽命的增加，膝蓋疼痛的帶斷定開刀問題變得越來越常見。不論是裂或年輕人的十字韌帶斷裂或是年長者的膝關節退化，如果發生了就一定要開刀嗎？如果不開刀，膝關是節退不是就不會好呢？

為什麼膝蓋痛？

我們的膝蓋由肌肉、韌帶和硬軟骨共同提供活動與穩定，字韌因此當我們有膝蓋疼痛的帶斷定開刀問題時，自然就會聯想到是裂或不是這些地方出了問題。十字韌帶斷裂是膝關年輕及運動族群最常見的運動傷害，由於前十字韌帶斷裂後會在被動的節退穩定測試出現陽性反應，因此通常會建議藉由開刀進行人工重建。字韌而膝關節退化則是帶斷定開刀被認為是年長者族群膝蓋疼痛的主因，雖然我們的裂或肌力、活動力等都會隨著年紀的膝關增長而衰退，進而增加膝蓋痛的節退機會，但是通常要經過X光檢查判定退化嚴重度達重度至重度時，才會建議接受人工關節置換術。

十字韌帶與重建術

究竟十字韌帶斷裂是否需要開刀，這就要看開刀的目的為何？

從研究看來，韌帶重建手術能有效改善關節穩定度及減少半月板磨損，但是在日常生活功能的改善及重回運動場的部分，和單純只做復健訓練的結果是相同的，也就是不論有沒有開刀，日後的生活品質和運動表現是一樣的。 另外 60%半月板磨損的人完全沒有症狀外， 65%的青少年在未接受十字韌帶重建手術下，仍舊可以重回原來的運動強度，而且這些青少年中，也只有9.5%的人因此出現半月軟骨磨損。

所以在考量是否要開刀時，應該先評估自己是否因為十字韌帶斷裂而持續地感受到膝蓋痠痛或軟腳，或是因此無法工作或運動。若出現：

1. 運動時有不穩定感（軟腳）。
2. 因膝蓋的不穩定感嚴重影響日常生活。
3. 合併出現多條韌帶斷裂時

會建議接受韌帶重建術，反之，則會建議先以物理治療作為優先選擇。

膝關節退化與人工關節

Photo Credit: Depositphotos

根據骨科的臨床指引，（1）膝關節達到中度到嚴重的退化或（2）疼痛等症狀嚴重影響到生活品質時，就會建議進行人工關節置換。而通常被診斷有關節退化問題的族群，通常會伴隨肌肉力量不足或肌肉控制的問題，所以在手術前後搭配物理治療，關節置換後的成效都會比單純開刀來的有效。

不過目前研究發現，膝蓋疼痛等問題並不全然來自於關節退化或半月軟骨受損。而且16-67%半月板破損的人，透過合適的活動訓練，即使沒有開刀依然能達到疼痛減少與生活功能改善的成效。因此，懷疑有膝蓋退化導致疼痛的話，不妨先接受復健治療囉！

物理治療能做什麼？

簡單的說，就是用非侵入式的方法（例如開刀或吃藥）改善疼痛的問題。以髖和膝關節退化的人來說，經過物理治療的介入後，可以有效：

1. 改善疼痛和相關的行動障礙。
2. 減少因為疼痛和活動障礙而衍生的憂鬱和焦慮。
3. 促進日常生活功能。

也就是說現在物理治療師們不再倚靠電療、熱敷或拉腰等儀器。轉而是透過一對一的訪談與評估，來解決活動與疼痛的問題。所以當膝蓋的治療遭遇瓶頸時，也許可以檢視一下是不是目前為止，都只是坐在椅子上利用電療和熱敷在「復健」呢？

結論

十字韌帶斷裂和膝關節退化究竟需不需要開刀，目前仍是個未定論。但是透過結合適當的活動訓練，不論有沒有開刀，都能為膝蓋帶來正向的結果。也就是說除了開刀之外，我們依然有其他的選擇來幫助我們跨越活動的藩籬！

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責任編輯：潘柏翰
核稿編輯：翁世航