膝骨性关节炎的注射治疗：指南系统回顾（四）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Pavone V, Vescio A, Turchetta M, et al. Injection-Based Management of Osteoarthritis of the Knee: A Systematic Review of Guidelines. Front Pharmacol. 2021;12:661805.本次学习由林小雯副主任医师主讲。

Hyaluronic Acid Injections

The knee OA IAHA clinical benefit on may depend on two mechanisms: joint mechanical viscosupplementation (permitting lubrication and shock absorption), and the re-creation of joint homeostasis by encouraging endogenic HA production, which endures long after the exogenous injection has left the joint.

The latest Osteoarthritis Research Society International (OARSI) international guidelines published in 2019 conditionally recommended (recommended with caution) hyaluronic acid injections in individuals with knee OA in all groups. A Good Clinical Practice Statement applying to intraarticular (IA) treatments for all comorbidity subgroups was added, noting that intra-articular hyaluronic acid (IAHA) may have beneficial effects on pain at and beyond 12 weeks of treatment.

透明质酸注射

膝关节腔HA注射的疗效机制可能有两种：补充关节粘性剂（润滑和减震），以及通过促进内源性HA的生成而重建关节的稳态平衡，且该作用疗效持久。

国际骨关节炎研究协会（OARSI）于 2019 年发布的最新国际指南有条件地建议（谨慎推荐）在膝OA患者中关节腔注射透明质酸。一项关于膝骨关节炎所有疾病亚组关节内治疗的临床研究表明，关节内透明质酸（IAHA）能够有效缓解疼痛，且维持12周以上。

In the 2013 international guidelines the American Academy of Orthopedic Surgeons doesn’t recommend (not recommended] using hyaluronic acid for individuals affected by symptomatic knee OA: “Meta-analysis in meaningfully important difference (MID) units showed that the over effect was less than 0.5 MID units, indicating a low likelihood that an appreciable number of patients achieved clinically important benefits in the outcomes. Although meta-analyses of WOMAC pain, function, and stiffness subscales scores all found statistically significant treatment effects, none of the improvements met the minimum clinically important improvement thresholds. When we differentiated high- vs. low- molecular weight viscosupplementation, our analyses did show that most of the statistically significant outcomes were associated with high-molecular cross linked hyaluronic acid but when compared to mid-range molecular weight, statistical significance was not maintained” .

2020 EULAR recommendations for the management of knee osteoarthritis support the use (recommended) of hyaluronic acid injections: “there is evidence to support the efficacy of hyaluronic acid in the management of knee OA both for pain reduction and functional improvement”.

在 2013 年的国际指南中，美国骨科外科学会不建议对临床症状型膝骨关节炎患者应用透明质酸："MID meta分析表明，MID小于 0.5表明较多数量的患者取得临床疗效的可能性很低。尽管对膝关节疼痛、功能和活动度WOMAC评分进行的meta分析结果具有统计学意义，但没有一项疗效改善达到了临床阈值。我们关于比较高分子量与低分子量粘性剂的分析结果表明，大多数统计学上显著的结果都与高分子量透明质酸有关，但中低分子量则没有统计学意义。

2020年EULAR关于膝盖骨关节炎管理的建议支持使用（推荐）透明质酸注射："有证据表明透明质酸在膝OA管理中对减轻疼痛和功能改善疗效确切。

The Royal Australian College of General Practitioners in its Guidelines for the management of knee and hip osteoarthritis published in 2018 states that “We suggest not offering viscosupplementation injection for people with knee OA”, giving to the practitioners a conditional recommendation against the procedure (not recommended).

In 2020, ACR recommended a limited use of IAHA, especially for glucocorticoid injections or in cases of interventions fail in reducing local joint symptoms. The restricted IAHA benefit findings, when other alternatives have been exhausted or failed to provide satisfactory benefit, is the main reason of conditional recommendation against.

澳大利亚皇家全科医师学院在其2018年发布的《膝髋骨关节炎管理指南》中指出，"我们不建议膝OA患者提供粘性剂注射"，谨慎推荐。

2020年，ACR建议限制性使用IAHA，特别是用于糖皮质激素注射或局部关节症状不明显时。当其他治疗方案疗效不佳时时，可限制性使用IAHA。