膝骨性关节炎的注射治疗：指南系统回顾（五）

 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。

Platelet Rich Plasma Injections

The 2019 Osteoarthritis Research Society International (OARSI) international guidelines strongly recommended against Plateletrich plasma treatment in patients with knee OA: “there is concern regarding the heterogeneity and lack of standardization in available preparations of platelet-rich plasma, as well as techniques used, making it difficult to identify exactly what is being injected” (not recommended).

Also in the latest (2013) international guidelines of the American Academy of Orthopedic Surgeons, PRP is cited among the treatments that are not recommended for knee OA (not recommended).

PRP usage in the management of knee OA is taken into account in 2020 EULAR recommendations among the treatments that are not recommended for lack of evidence (not recommended) .

富含血小板血浆注射

2019年骨关节炎研究会国际（OARSI）国际指南强烈建议反对膝OA患者进行富含血小板血浆治疗："主要担心富含血小板血浆的制剂以及技术的异质性和缺乏标准化，以及所使用的技术，因此很难确切地确定注射的是什么"（不建议）。

此外，在美国骨科外科学会最新的（2013年）国际指南中，PRP被引用为膝盖OA不推荐的治疗（不推荐）。

2020年EULAR指南中， 因缺乏临床证据，不建议PRP用于治疗膝OA患者。

The Royal Australian College of General Practitioners in its Guidelines for the management of knee and hip osteoarthritis published in 2018 declare that they recommend against the use of PRP injection for people with knee OA due to a lack of high-quality evidence (not recommended).

This review is the first critical appraisal of guidelines for the injection-based therapy of knee OA. Of the 5 guidelines that were identified, 1 was excluded.

The heterogeneity and lack of standardization in available preparations of platelet-rich plasma, as well as techniques used, making it difficult to identify exactly what is being injected are the principal reason of ACR strong recommendation against PRP injection in KOA.

澳大利亚皇家全科医师协会在其2018年发布的《膝髋骨关节炎治疗指南》中提出，由于缺乏临床证据支持，不建议PRP注射用于治疗膝骨关节炎患者使用。

这篇文章是首次基于对膝OA注射的治疗指南进行客观性评估。在已查明的5项指南中，1项被排除在外。

富含血小板血浆的现有制剂的异质性和缺乏标准化，以及所使用的技术，使得难以确切地确定注射的是什么，是ACR强烈不建议在KOA注射PRP的主要原因。

DISCUSSION

An overall recommendation was provided according to the specific interventions across guidelines median calculation. These are presented as strongly recommended, recommended, recommended with caution, unsupported, and not recommended. None of the procedures were strongly recommended and recommended. Corticosteroid injection was recommended with caution. The use of hyaluronic injection was considered unsupported. The PRP injection was not recommended.

We observed a great discordance through guidelines on the recommendations for the use of corticosteroid injection and hyaluronic acid injection; the former was recommended with caution in one guideline, unsupported in one guideline, recommended in one guideline and recommended with caution in one guideline, the latter was recommended with caution in one guideline, explicitly not recommended in two guidelines and recommended in one guideline.

Instead, we noticed agreement in all retrieved guidelines PRP injections utilize in knee osteoarthritis; it was not recommended due to a lack of evidence.

讨论

根据指南中位数计算的具体干预措施进行了总结性推荐。分为强烈推荐、推荐、谨慎推荐、不支持、不推荐。没有一种方法是被强烈推荐和推荐的。谨慎推荐注射皮质类固醇。透明质酸注射被认为是不支持。不建议关节内 PRP 注射。

我们观察到指南中关于临床应用关节内注射皮质类固醇和透明质酸有争议，指南中前者为谨慎推荐，在一项指南中不予支持，在一项指南中建议，在一项指南中谨慎推荐，后者在一项指南中谨慎推荐，在两项指南中明确不建议，在一项指南中建议。

相反，我们注意到在所有检索到的指南均认为由于缺乏证据，不建议PRP注射用于膝盖骨关节炎。

Giving a closer look to the recommendations of the guidelines on the use of corticosteroid injection and analysing the studies considered, five mild quality trials that compared intraarticular corticosteroids to placebo were found. All the studies were considered valid for hypothesis, blinding, treatment integrity or measurement domains. All five studies were flawed in the cohort assignment domain, and one study were flawed in the cohort comparation and researcher bias domains. These studies assessed relief of pain for a 4 weeks period. Four of these studies didn’t find corticosteroid to be superior to placebo at any time. One study included 98 patients demonstrated after 1 week a considerable variation between intra-articular steroid and placebo.

Only one study found intra-articular corticosteroids to be superior to placebo on Western Ontario and Mc Master University (WOMAC) total subscale scores at 4 weeks.

仔细研究应用皮质类固醇注射的指南推荐，并就5项比较关节内注射皮质醇和安慰剂对照研究的临床实验进行研究分析。所有研究是随机、双盲都被认为随机、双盲、治疗完整或检测有效。所有五项研究在队列分配领域都有偏倚，一项研究在队列比较和研究人员存在偏倚。这些研究评估了4周的疼痛缓解程度。其中四项研究没有发现皮质类固醇在任何时点效果优于安慰剂。一项纳入98名患者的研究结果表明，关节内注射皮质醇和安慰剂1周后存在较大差异。

只有一项研究发现，关节内注射皮质醇4周的WOMAC总评分优于安慰剂。