老年膝关节骨性关节炎患病危险因素的调查

背景：膝关节骨性关节炎是老年人最常见的一种关节疾病,可引起老年人下肢残疾,严重影响着老年人的日常活动和生活质量,了解老年人膝关节骨性关节炎的患病因素对预防疾病的发生起到积极作用。目的：通过调查佛山市高明区老年人膝关节骨性关节炎的患病情况,探讨老年人膝关节骨性关节炎的相关危险因素。方法：在佛山市高明区内采用分层多阶段整群抽样方法,抽取2250名60岁及以上老年人进行膝关节骨性关节炎的流行病学问卷调查,男女各1125名,对1064名有症状者进行膝关节正侧位X射线检查,老年人膝关节骨性关节炎诊断标准为临床症状阳性和X射线Kellgren＆Lawrence分级2级及以上者。采用SPSS13.0软件对调查问卷结果进行多因素非条件Logistic回归分析,筛选出膝关节骨性关节炎的危险因素。结果与结论：文化程度、饮食习惯、吸烟、饮酒、出入爬楼梯习惯、蹲位排便习惯、骨质疏松病史并不是老年人膝关节骨性关节炎的危险因素（均OR〈1）。性别、年龄、肥胖、居住环境潮湿阴暗、站姿工作习惯、重体力劳动职业、膝关节外伤史、骨性关节炎家族史是老年人膝关节骨性关节炎的危险因素（均OR〉1）。     

Correlation between single limb support phase and self-evaluation questionnaires in knee osteoarthritis populations

Purpose.?To investigate the correlation between single limb support (SLS) phase (%% of gait cycle) and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 Health Survey) in patients with knee osteoarthritis (OA).

Method.?A prospective observational study was employed with 125 adults with bilateral medial compartment symptomatic knee OA who underwent a physical and radiographic evaluation. Velocity, step length and SLS were assessed by a computerised mat (GAITRite). Patients completed the WOMAC and SF-36 Health Survey questionnaires.

Results.?Statistical analysis examined the correlations between SLS and both questionnaires, between Kellgren & Lawrence (K&L) scores and both questionnaires and between SLS correlations and K&L correlations. We found significantly stronger correlations between SLS and WOMAC-pain, WOMAC-function, the SF-36 pain sub-category, velocity and step length than between K&L scores and these parameters (Pearson's r == 0.50 vs. 0.26, 0.53 vs. 0.34, 0.50 vs. 023, 0.81 vs. 0.33, 0.77 vs. 0.37, respectively; all p < 0.05). Significant differences in SLS were found over WOMAC-pain, WOMAC-function and SF-36 overall score quartiles (p < 0.05 for all).

Conclusion.?We recommend integrating SLS as an objective parameter in the comprehensive evaluation of patients with knee OA.     

国内六大行政区域六城市中老年人群膝关节骨性关节炎患病危险因素比较

目的：了解中国不同地区间中老年人群膝关节骨性关节炎患病危险因素。方法：调查时间为2005—07／08。①从中国六大行政区（西北，华北，华东。中南，东北，西南）选出六城市（西安，石家庄，上海。广州，哈尔滨市，成都），用分层多阶段整群抽样方法，抽取6218名40岁及以上具有正式户口常住男女人群进行膝关节骨性关节炎的流行病学问卷调查（包括一般情况、现病史、既往史、体格检查、X射线片检查情况和疾病诊断6个方面，共计94个问题141个变量指标），并对其中4808名有症状者进行X射线平片膝正侧位投照。②膝关节骨性关节炎诊断标准为临床症状阳性加X射线Kellgren ＆ Lawrence分级二级及以上者。③计算患病率，并采用Epilnf06．0和SPSS 10．0软件对其中83个变量进行多因素非条件Logistfc回归分析，表示疾病与暴露因素之间联系强度的指标用比值比（OR），若OR〉1，说明疾病发生危险性增加，与暴露因素呈正关联；若OR〈1，说明疾病发生危险性减少，与暴露因素呈负关联。 结果：①六城市膝关节骨性关节炎总患病率为15．6％，其中西安7．7％，石家庄11．2％，上海9．8％。广州30．5％，哈尔滨16．9％，成都17．5％，各城市患病率比较差异显著（P〈0．01）。②Logistic回归分析膝关节骨性关节炎在大部分城市有共同的危险因素如年龄大（OR=1．032—1．181），使用蹲坑排便年限长（OR=1．021-1．077），体质量高（OR=1．048—1．073），和开始饮酒年龄大（OR=1．008～1．028）；而从事专职体育运动（OR=1．651，西安），骨质疏松病史（OR=3．311，石家庄），吸烟（OR=2．654，石家庄），类风湿关节炎病史（OR=4．964，上海），文化程度高（OR=2．593，上海），女性（OR=2．510，广州），姐妹骨关节炎史（OR=13．251，哈尔滨），母亲骨关节炎史（OR=5．683，成都）等危险因素分别在不同地区出现． 结论：年龄大、使用蹲坑排便年限长、体质量高和开始饮酒年龄大是中国六地区膝关节骨性关节炎患病的共同危险因素，同时，不同地区主要危险因素又有一定差异。     

Disability in end-stage knee osteoarthritis

Objective. To examine the attributes of disability in end-stage knee osteoarthritis (OA) by analyzing the relationships between self-reported disability and objectively measured physical function after controlling pain, personal characteristic factors, and pathophysiological factors.

Methods. The present study adopted a cross-sectional design. The subjects (n=88, aged 60–80 years) were scheduled for primary unilateral total knee arthroplasty (TKA) due to knee OA. Self-reported disability and pain were measured with the Western Ontario and McMaster Universities OA Index (WOMAC) and the RAND 36-item Health Survey 1.0 (RAND-36). Physical performance tests included a 15-m walk test and stair performance. Knee isometric muscle strength was measured. A clinical examination included analyses of comorbidity, body mass index (BMI), and a detailed knee examination: The flexion range of motion (ROM) was measured; the presence of varus/valgus malalignments and antero-posterior laxity was assessed. Radiographs were analyzed with the Kellgren-Lawrence grading scale.

Results. In the linear regression model the WOMAC pain score, antero-posterior laxity of the knee, age, and BMI accounted for 54.8% of the variance in the WOMAC function score. In the bivariate analyses the WOMAC function score had a positive correlation with the 15-m walk (r_s=0.32, p=0.003), stairs up (r_s=0.40, p=0.001), and stairs down (r_s=0.38, p=0.001) tests, and a negative correlation with RPT extension (r_s=?0.45, p < 0.001) and RPT flexion (r_s=?0.39, p=0.001) of the affected side and RPT flexion (r_s=?0.39, p <0.001) of the contralateral side. The results of the physical performance tests also correlated with the RAND-36 Physical function (PF) score. Comorbid diseases and pain deteriorated the results of the physical performance tests and self-reported disability. Female gender deteriorated the results of the physical performance tests and the RAND-36 PF, but not the WOMAC function score. Malalignments, restriction in the flexion ROM of the knee, and the radiologic severity of knee OA did not affect self-reported disability.

Conclusion. Pain, BMI, and antero-posterior laxity of the knee joint were major attributes of self-reported disability. The negative effect of comorbid diseases and female gender on health-related quality of life was significant. The results of objectively measured physical performance tests correlated with self-reported disability.     

Treatment of knee osteoarthritis

Knee osteoarthritis is a common disabling condition that affects more than one-third of persons older than 65 years. Exercise, weight loss, physical therapy, intra-articular corticosteroid injections, and the use of nonsteroidal anti-inflammatory drugs and braces or heel wedges decrease pain and improve function. Acetaminophen, glucosamine, ginger, S-adenosylmethionine (SAM-e), capsaicin cream, topical nonsteroidal anti-inflammatory drugs, acupuncture, and tai chi may offer some benefit. Tramadol has a poor trade-off between risks and benefits and is not routinely recommended. Opioids are being used more often in patients with moderate to severe pain or diminished quality of life, but patients receiving these drugs must be carefully selected and monitored because of the inherent adverse effects. Intra-articular corticosteroid injections are effective, but evidence for injection of hyaluronic acid is mixed. Arthroscopic surgery has been shown to have no benefit in knee osteoarthritis. Total joint arthroplasty of the knee should be considered when conservative symptomatic management is ineffective.     

川芎嗪关节腔内注射治疗膝关节骨性关节炎的临床观察

目的探讨川芎嗪关节腔内注射治疗膝关节骨性关节的临床效果。方法将60例膝关节骨性关节炎患者随机分成治疗组和对照组,每组30例。治疗组行关节镜下关节清理术并腔内注射川芎嗪;对照组关节镜下关节清理术并腔内注射透明质酸钠。采用13本整形协会（JOA）制定的评定标准,于术后1周、3个月、6个月、12个月做疗效评定;并检测术前、术后1、10、20d血清C-反应蛋白（CRP）的含量。结果术后1周两组无显著差异（P〉0．05）;术后3个月、6个月、12个月治疗组疗效明显优于对照组,差异非常显著（P〈0．01）;治疗组术后10dCRP含量明显低于对照组,有非常显著差异（P〈0．01）。结论川芎嗪关节腔内注射是治疗膝关节骨性关节炎的有效方法。     

膝关节骨关节炎手术治疗进展

膝关节骨关节炎是中老年人常见的关节疾病,目前治疗方案主要分为保守治疗与手术治疗。手术治疗常常用于保守治疗无效的膝关节骨关节炎患者。手术治疗方式主要有关节镜手术,关节软骨修复术,膝关节周围截骨术和膝关节置换术。本文主要对不同手术方式的发展、研究进展及适应证进行阐述。     

State-of-the-Art management of knee osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis found in the United States’ population and is also the most common disease of joints in adults throughout the world with the knee being the most frequently affected of all joints. As the United States’ population ages along with the increasing trends in obesity prevalence in other parts of the world, it is expected that the burden of OA on the population, healthcare system, and overall economy will continue to increase in the future without making major improvements in managing knee OA. Numerous therapies aim to reduce symptoms of knee OA and continued research has helped to further understand the complex pathophysiology of its disease mechanism attempting to uncover new potential targets for the treatment of OA. This review article seeks to evaluate the current practices for managing knee OA and discusses emerging therapies on the horizon. These practices include non-pharmacological treatments such as providing patient education and self-management strategies, advising weight loss, strengthening programs, and addressing biomechanical issues with bracing or foot orthoses. Oral analgesics and anti-inflammatories are pharmacologicals that are commonly used and the literature overall supports that some of these medications can be helpful for managing knee OA in the short-term but are less effective for long-term management. Additionally, more prolonged use significantly increases the risk of serious associated side effects that are not too uncommon. Disease-modifying osteoarthritis drugs are being researched as a treatment modality to potentially halt or slow disease progression but data at this time is limited and continued studies are being conducted to further investigate their effectiveness. Intra-articular injectables are also implemented to manage knee OA ranging from corticosteroids to hyaluronans to more recently platelet-rich plasma and even stem cells while several other injection therapies are presently being studied. The goal of developing new treatment strategies for knee OA is to prolong the need for total knee arthroplasty which should be utilized only if other strategies have failed. High tibial osteotomy and unicompartmental knee arthroplasty are potential alternatives if only a single compartment is involved with more data supporting unicompartmental knee arthroplasty as a good treatment option in this scenario. Arthroscopy has been commonly used for many years to treat knee OA to address degenerative articular cartilage and menisci, however, several high-quality studies have shown that it is not a very effective treatment for the majority of cases and should generally not be considered when managing knee OA. Improving the management of knee OA requires a multi-faceted treatment approach along with continuing to broaden our understanding of this complex disease so that therapeutic advancements can continue to be developed with the goal of preventing further disease progression and even potentially reversing the degenerative process.     

Topical therapies for knee osteoarthritis

Background: Symptomatic knee osteoarthritis (OA) involves millions of adults around the world.

Purpose: To analyze the effectiveness and tolerability of topical therapies and their contemporary placement in knee OA management criteria.

Methods: A Cochrane Library and PubMed (MEDLINE) search related to the role of topical therapies in knee OA was carried out.

Results: Many types of local therapy have been reported, including nonsteroidal anti-inflammatory drugs (NSAIDs) like diclofenac and ketoprofen; capsaicin, cream containing glucosamine sulfate, chondroitin sulfate, and camphor; nimesulide; civamide cream 0.075%; menthol; drug-free gel containing ultra-deformable phospholipid vesicles (TDT 064); 4Jointz utilizing Acteev technology; herbal therapies; gel of medical leech (Hirudo medicinalis) saliva extract; and gel prepared using Lake Urmia mud. One systematic review showed that topical diclofenac and topical ketoprofen can alleviate pain. However, another systematic review found that topical diclofenac and ketoprofen had limited efficacy in knee OA at 6 to 12 weeks. Many studies with a low level of evidence have reported some pain mitigation using the rest of aforementioned topical therapies.

Conclusions: Although some controversy exists on the role of topical NSAIDs, current management guidelines advise topical NSAIDs as an option and even first-line therapy for knee OA treatment, particularly among elderly patients. Topical NSAIDs may be contemplated as similar options to oral NSAIDs and are associated with fewer gastrointestinal complications when compared with oral NSAIDs. Caution should be taken with the use of both topical and oral NSAIDs, including close adherence to dosing regimens and monitoring, especially for patients with previous complications of NSAIDs. The role of other topical therapies needs further research.     

Pedobarographic findings in patients with knee osteoarthritis

OBJECTIVE: The aim of this study was to evaluate pedobarographic findings and balance in knee osteoarthritis. DESIGN: A total of 48 patients with knee osteoarthritis and 30 controls were included in this study. Pedobarographic measures were obtained from all patients and controls. Pain intensity of patients was measured using the Visual Analog Scale. The percentage of pressure on forefoot and hindfoot was measured using static pedobarography, and the peak pressures at forefoot, midfoot, and hindfoot were measured using dynamic pedobarography. The center-of-pressure sway length and width were measured for evaluation of balance. RESULTS: The percentage of right hindfoot pressure (P < 0.05) and peak pressure of the right forefoot during walking were lower in the osteoarthritic group than in the controls (P < 0.05). The sway width in the patient group was higher than in the control group (P < 0.05). The Visual Analog Scale score at rest was negatively correlated with peak pressures of both right and left hindfeet in the osteoarthritic group (P < 0.05). The grade of osteoarthritis was positively correlated with sway length and sway width (P < 0.05). CONCLUSION: Pedobarography may become a useful technique to determine foot pressures that change because of disturbed weightbearing and balance problems in knee osteoarthritis.     

Objective measurement of stiffness in knee osteoarthritis

PURPOSE: The purpose of this study was to evaluate an objective measure of knee joint stiffness in older adults with and without knee osteoarthritis. DESIGN: Methodological study of the modified pendulum test. SAMPLE: A convenience sample of community-dwelling older adults (n = 41). METHODS: Knee angle oscillation data were collected with a VICON motion analysis system and were used to calculate stiffness and damping coefficients and measures of joint stiffness. FINDINGS: Although some testing problems were encountered early in the study, useable data were obtained from 29 participants. Within-participant variability for calculated stiffness and damping coefficients was low (0.55% and 8.92%, respectively), whereas the between-participant variability was high for both the stiffness (99.45%) and damping (91.08%) coefficients. DISCUSSION: The modified pendulum test is a reliable method for evaluation of knee joint stiffness. This method can be used in collection of outcome data for future intervention studies addressing joint stiffness.     

Sensitization in patients with painful knee osteoarthritis

Pain is the dominant symptom in osteoarthritis (OA) and sensitization may contribute to the pain severity. This study investigated the role of sensitization in patients with painful knee OA by measuring (1) pressure pain thresholds (PPTs); (2) spreading sensitization; (3) temporal summation to repeated pressure pain stimulation; (4) pain responses after intramuscular hypertonic saline; and (5) pressure pain modulation by heterotopic descending noxious inhibitory control (DNIC). Forty-eight patients with different degrees of knee OA and twenty-four age- and sex-matched control subjects participated. The patients were separated into strong/severe (VAS ? 6) and mild/moderate pain (VAS < 6) groups. PPTs were measured from the peripatellar region, tibialis anterior (TA) and extensor carpi radialis longus muscles before, during and after DNIC. Temporal summation to pressure was measured at the most painful site in the peripatellar region and over TA. Patients with severely painful OA pain have significantly lower PPT than controls. For all locations (knee, leg, and arm) significantly negative correlations between VAS and PPT were found (more pain, more sensitization). OA patients showed a significant facilitation of temporal summation from both the knee and TA and had significantly less DNIC as compared with controls. No correlations were found between standard radiological findings and clinical/experimental pain parameters. However, patients with lesions in the lateral tibiofemoral knee compartment had higher pain ratings compared with those with intercondylar and medial lesions. This study highlights the importance of central sensitization as an important manifestation in knee OA.     

膝关节骨性关节炎的运动疗法

目的：了解运动疗法在治疗膝关节骨性关节炎中的作用。方法：选取膝关节骨性关节炎患者40例,分成运动疗法组和对照组,每组各20例。使用日本整形外科学会的《膝关节功能评定表》进行评测,运动疗法组进行规范的肌力训练,对照组采用物理疗法。结果：训练后,运动疗法组患者膝关节功能比训练前明显改善,疗效优于对照组。结论：规范的运动疗法可减轻膝关节骨性关节炎的症状,改善其功能。