ACL重建为何无法预防创伤后骨关节炎：力学与生物学视角的叙述性综述
简介
ACL重建虽能恢复膝关节稳定性，但无法可靠预防术后创伤性骨关节炎（PTOA），长期随访中发生率常超过50%。本综述整合临床与实验证据，阐明其多因素机制：残余旋转不稳导致的异常关节负荷、手术本身引发的继发性“炎症打击”以及软骨下骨重塑与骨髓脂肪组织的生化力学串扰。临床含义：术后关节保护需针对不同阶段，同时干预力学不稳、炎症反应及软骨下骨改变，而非依赖单一因素。
英文摘要
Anterior cruciate ligament (ACL) injury markedly increases the risk of post-traumatic osteoarthritis (PTOA), and anterior cruciate ligament reconstruction (ACLR), despite restoring knee stability and function, does not reliably prevent long-term cartilage degeneration. This narrative review aims to integrate current clinical and experimental evidence to clarify the multifactorial mechanisms responsible for PTOA development after ACLR, with particular emphasis on the interactions between mechanical, inflammatory, and subchondral bone-related factors. Recent epidemiological studies consistently demonstrate a high and time-dependent prevalence of PTOA following ACLR, frequently exceeding 50% at long-term follow-up. Residual anterior and rotatory instability and resulting altered joint loading remain important mechanical contributors, and emerging evidence suggests that lateral extra-articular tenodesis may reduce long-term PTOA risk by improving rotational control. Beyond biomechanics, ACLR itself induces a postoperative inflammatory response that acts as a secondary "inflammatory hit," re-triggering the degenerative pathways initiated by the primary injury, even when joint kinematics are restored. Increasing attention has also been directed toward subchondral bone remodeling and bone marrow adipose tissue, which actively mediate biochemical and biomechanical crosstalk within the osteochondral unit. In addition, patient age, concomitant meniscal or cartilage injury, surgical timing, and early postoperative loading conditions are known to critically influence PTOA progression. PTOA after ACLR arises from the temporal interplay between mechanical instability, surgery-induced inflammation, and subchondral bone alterations rather than from a single isolated factor. Effective long-term joint preservation will likely require an integrated strategy that addresses both mechanical and biological processes across different postoperative stages.