膝骨性关节炎的注射治疗：指南系统回顾（六）

 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。

In conclusion, the authors affirm that there are some proofs that intra-articular steroids are successful, but their advantage may be quite short lived (<4 weeks). However additional findings are necessary to consider the use of corticosteroid injection as a standard therapy. We strongly encourage the develop of study protocol and randomized clinical trials.

Regarding the recommendations on the use of hyaluronic acid injection, on reviewing the 10 studies taken into account in the guidelines that compared HA injection vs. placebo, we found that there is some proofs to sustain the utilization of high molecular weight viscosupplementation, while for other agents the evidence is weak or absent. Even if our analysis revealed that benefit was limited to the experiments with higher risk of bias: when restricted to experiments with low risk of bias, meta-analysis has demonstrated that the impact size of hyaluronic acid injections compared to saline injections approaches zero. Most of the positive outcome were limited to the studies or part of the studies that considered the injection of high molecular weight viscosupplementation and a course of two to four injections a year.

因此，本文认为，有一些证据表明，关节内注射皮质醇类固醇是有效的，但可能维持时间较短（<4周）。然而，如果将皮质醇注射作为标准疗法尚需进一步研究。我们提倡建议大力进行更多的随机临床试验。

关于使用透明质酸注射的建议，研究分析了10项研究比较HA注射与安慰剂临床指南研究，我们发现有一些证据支持应用高分子量粘性剂，而其他证据是薄弱或缺失的。即使我们的分析结果表明，疗效仅限于偏倚度较高的实验：偏倚度较低的实验meta分析结果表明，透明质酸注射的疗效与盐水无明显差别。仅有部分研究结果表明每年两到四次注射高分子量粘性剂有较好的疗效。

In summary, there is some findings to sustain the efficiency of hyaluronic acid in the managing of knee OA for pain decrease, but quality of the evidence is still inadequate and the positive outcome are limited to high molecular weight hyaluronic acid.

These projections even more underscore the need to know and understand the guidelines for injection-based treatment, since that pain associated with OA often leads to inactivity and loss of mobility, resulting in deconditioning, weight gain, loss of independence, and decreased quality of life; while a good injection-based management of OA of the knee can foster more physical activity and exercise that can modify several biohumoral indicators having a positive effect on the health of elderly. Furthermore, even if joint substitution is an efficient intervention to relieve pain and enhance quality of life for those with advanced OA. However, despite a increasing amount of joint replacements undertaken each year, many people are still included on a waiting list often for a significant time and a large number of patients affected with knee OA do not like to undergo surgery for associated comorbidity.

综上所述，一些研究表明，注射透明质酸对于缓解膝骨关节炎疼痛有一定疗效，但临床证据仍然不足，且疗效仅限于高分子量透明质酸。

本研究旨在研究注射关节注射的治疗指南，因为与OA相关的疼痛往往导致活动量减少和丧失活动能力，导致体重增加、失去独立性和生活质量下降：而正确的膝OA注射治疗可以促进更多的体育活动和锻炼，减少生物性伤害指标，对老年人的健康有积极的影响。此外，即使关节置换是一种有效的干预措施，能够减轻疼痛和提高生活质量，尤其是老龄化OA患者。然而，尽管每年进行关节置换的数量不断增加，许多人仍需要等待很长时间才能进行手术，并且许多膝关节OA患者不能接受外科手术相关的并发症。

Study Limitation

Only guidelines published in English were reviewed, leading to a potential publication bias.

The objective of this appraisal was to examine the accessible guidelines and offer the treatment recommendations for the injection-based management of OA in a format that was helpful to the physician. EULAR Guidelines are collection and adapted/translated the data local National Societies version summery. The guideline reflect the main clinical practice in Europe.

研究局限性

本研究只研究了英文发表的指南，有潜在的出版偏倚。此评估的目的是检索可获取的指南，并对OA的临床注射治疗提供建议和依据。EULAR 指南是收集和改编/翻译国家协会数据摘要。该指南反映了欧洲的主要临床实践标准。

CONCLUSION

In conclusion, there are some proofs that intra-articular steroids are efficacious, but their advantages may be relatively short lived (<4 weeks). Most of the positive outcome were limited to the studies or part of the studies that considered the injection of high molecular weight as visco-supplementation, with a course of two to four injections a year. In this critical appraisal we assessed the quality of the guidelines, synthesized, rated, and meticulously offered all the significant recommendations for the injectionbased treatment of OA of the knee. It is expected that this will advise health care providers on the best findings interventions accessible for the injection-based therapies of the knee OA.

结论

总之，有一些证据表明，关节内注射类固醇是有效的，但可能维持时间较短（<4周）。部分研究结果表明每年注射2-4次高分子量粘性剂有较好的疗效。在指南的客观性评价研究中，我们评估了指南的质量，并加以汇总、分级，并较为严谨地提出了膝OA注射治疗的重要建议。一丝不苟地提供了所有重要的建议，以注射为基础的治疗OA的膝盖。希望本研究能够为膝OA患者关节注射治疗提供最佳干预措施。