骨关节炎高研班OA

骨关节炎的现代概念,病因不同,但病理及临床结局相似关节软骨：有软骨变性、纤维化、裂隙、溃疡和全脱失,最终关节结构破坏和功能丧失全关节受累：如软骨下骨、韧带、关节囊、滑膜、关节周围肌肉,骨关节炎之“三高一低”,ScienceDaily (Aug. 27, 2009) Osteoarthritis (OA) and degenerative disc disease (DDD) are common, chronic musculoskeletal disorders. Both diseases cause joint pain, loss of function, and decreased quality of life for the more than 27 million OA and 59 million DDD suffers in the US. According to a 2003 Medical Expenditure Panel Survey, arthritis such as OA costs the U.S. economy nearly $128 billion per year in medical care and indirect expenses including lost wages and productivity.,骨关节炎的分类 -按范围,局限性骨关节炎:受累关节不同全身性骨关节炎:3个以上部位者,而且几乎均累及小关节,骨关节炎的分类 -按病因,原发性:病因不明者继发性:有明确病因先天性或遗传性外伤性其他骨关节病:类风湿关节炎,痛风性关节炎, 感染性关节炎等其他疾病内分泌病:糖尿病,甲亢,甲旁亢神经病性关节病大骨节病,局限性,全身性,继发性骨关节炎 -继发先天或遗传因素,局限性髋关节病:骨软骨病,先天性髋关节脱位,髋臼过浅机械和局部因素:肥胖,下肢不等长,内翻或外翻畸形,脊柱侧弯全身性骨发育不良:骨骺发育不良、脊柱骨骺发育不良代谢性疾病:血色病,褐黄病,血红蛋白病等钙沉积病:焦磷酸沉积病,羟磷灰石关节病,破坏性关节病,骨关节炎的分类 -按有无症状,症状性骨关节炎:不仅有X线表现而且有明显临床症状放射学性骨关节炎:只有X线骨性关节炎表现而无临床症状者,蛋白多糖聚合体为软骨基质的重要组成部分,骨关节炎,关节软骨丢失和软骨细胞代谢的变化,骨的再塑形增加 和成骨细胞表型的变化,软骨下骨,基质降解断裂,纤维化,软骨被腐蚀,基质降解,Modified from Clinical Symposia, 1996,骨关节炎的病理改变 -模拟图,骨关节炎,正常关节,关节囊增厚,囊性变,关节囊,软骨下硬化,纤维化软骨,骨赘形成,软骨,滑膜肥厚,骨轮廓异常,滑膜,骨,正常 骨关节炎,股骨髁,胫骨平台,软骨下骨,髌骨,触发因素,8,骨内压,5,畸形,Knee OA,Youd think thered be some sort of mechanism built in to counteract that, and indeed there is. There are a number of cytokines in articular cartilage that stimulate the cells to synthesize more proteoglycans, and here is an example of one of them that weve looked at, insulin-dependent growth factor-1 (IGF-1).,Here is that curve of the age-related decay and proteoglycan synthesis, but look what happens when we stimulate the cells with this anabolic cytokine. If we take a newborn cell, we can more than double the synthesis of proteoglycans. If we take it at age 6 months, we can still double it, and by the time we get to age 12 months, the cells just arent responding effectively to these cytokines.,骨关节炎发病的危险因素 -肥胖,肥胖患者的发生率为12%-43%,而骨关节炎患者伴肥胖者占12%-45%负重主要集中的膝关节内侧软骨正好是大多数肥胖者发生膝骨关节炎的常见部位肥胖引起姿势、步态及运动习惯发生改变,Arthritis-Attributable Activity Limitations Increase with WeightSource:MMWR2010;59(39):9991003,骨关节炎发病的危险因素 -损伤和过度使用,破坏软骨基质的拱形纤维网状结构和薄壳,进而破坏软骨细胞,形成恶性循环软骨微损伤加速钙化软骨重建,使非钙化带越来越薄,失去软骨功能软骨下骨板骨小粱微骨折后重建的骨小粱比正常骨小粱僵硬,对冲击力承受性差,使软骨更易受破坏,骨关节炎发病的危险因素 -遗传,伴Heberden结节的骨关节炎妇女的母亲和姐妹患病分别是普通人群的2倍和3倍最常见的遗传性骨关节炎是原发性全身性骨性关节炎,骨关节炎发病的危险因素 -软骨基质改变,因不同物质在软骨内沉积,直接或通过增加基质硬度而间接损伤软骨细胞,骨关节炎发病的危险因素 -骨内压增高,骨内压升高原因各种原因引起骨内静脉回流受阻动脉血流入过多关节内压明显升高骨内压升高后,影响骨组织的血液供应,导致关节软骨发生退行性变,bony enlargement骨质增生limitation of range of motion活动受限crepitus on motion骨擦音tenderness on pressure肿胀pain on motion活动疼joint effusion 关节渗出物malalignment and/or joint deformity关节畸形,Arthritis Rheum 1995;38(11):1535-1546,joint pain关节疼morning stiffness晨僵gel phenomenon 胶着感buckling or instability不稳定loss of function 功能丧失,Arthritis Rheum 1995;38(11):1535-1546,Narrowing of the joint space关节间隙狭窄Osteophytes 骨刺Subchondral sclerosis 软骨下硬化Cyst formation 囊变,最易受累的关节排序,美国国立研究院统计: 各年龄组手骨关节炎患病率最高,其次为足,膝和髋国内仁济医院调查:症状性骨关节炎患病率以颈椎最高,0.7%,0.48%,0.52%,0.41%,0.3%,骨关节炎,Figure 43-29 Osteoarthritis with cartilage narrowing shown to advantage on tunnel view.,骨关节炎,Figure 43-28 Osteoarthritis of the knee on MRI. A, coronal image of the knee. There are osteophytes at the joint margins. There are discrete areas of low signal replacing the subchondral marrow fat (open arrow) and more diffuse low signal extending into the tibial metaphysis. B, Inversion recovery image of the knee shows that most of the low signal area has become bright and is poorly marginated, consistent with edema. Bright joint fluid is adjacent to the bone medially, documenting complete absence of cartilage.,Notable Knuckles,不同部位骨关节炎的临床特点 -手部,远端指间关节,近端指间关节,掌指关节,拇指基底部,腕关节,右手,左手,不同部位骨关节炎的临床特点 -手部,远端指间关节受累(Heberden结节):常见,占70%,关节伸侧的内侧和外侧骨性膨大可伴结节局部轻度红肿、疼痛和压痛,持物或手部操作易诱发疼痛,不同部位骨关节炎的临床特点 -手部,蛇形指:远端指间关节增生及侧向半脱位可致蛇样畸形,不同部位骨关节炎的临床特点 -手部,近端指间关节(Bouchard结节):骨性膨大,占35%,不同部位骨关节炎的临床特点 -手部,第一腕掌关节受累:左手占60%,右手占40%,基底部骨质增生可引起方形手外观,特殊类型骨关节炎的临床特点 -侵蚀性炎性骨关节炎,多见于绝经后妇女,有家族聚集倾向及反复急性发作主要累及远端及近端指间关节和腕掌关节初期关节肿痛,最终关节畸形甚至强硬,此时关节疼痛反而缓解受累关节可发生冻胶状小囊,伴疼痛和触痛,常见骨性强直,特殊类型骨关节炎的临床特点 -侵蚀性炎性骨关节炎,左下图和右下图(双手X线片):远端和近端指间关节可见明显的骨赘生成,软骨下骨硬化和明显骨侵蚀,Figure 43-30 Gull wing deformities in erosive osteoarthritis. There is cartilage loss and bone remodeling at the middle and ring finger proximal interphalangeal joints, producing a gull wing appearance.,特殊骨关节炎的临床特点-侵蚀性炎性骨关节炎与银屑病关节炎X线对比,侵蚀性炎性骨关节炎(左下图):远端指间关节软骨下侵蚀,呈现“鸥翅”样,近侧关节面为中央性侵蚀银屑病关节炎(右下图): 远侧指间关节典型的裸 区侵蚀,引起“鼠耳”样, 侵蚀附近合并骨膜成 骨,引起杯口状表现,骨关节炎的影像学检查 -中晚期的X线特点,关节间隙狭窄,如在膝关节可小于3mm关节面硬化变形关节边缘骨赘关节鼠软骨下有边缘分 界清楚的囊性变骨变形或关节半脱位,骨关节炎的放射学分级,骨关节炎的影像学检查 -最有价值的X线片改变,手:软骨下骨硬化,骨关节炎的诊断标准 -手骨关节炎(1995年ACR修订),前月大多数时间有手痛10个指定的指间关节中有硬性膨大的2个掌指关节肿胀2个10个指定的指间关节中有畸形的手骨性关节炎1个,满足1+2+3+4条或1+2+3+5条,骨关节炎的诊断标准 -手骨关节炎(1995年ACR修订),10个指定关节:双侧第2、3指远端和近端指间关节及第一腕掌关节,骨关节炎与类风湿关节炎的鉴别,Arthritis MutilansExtensive joint destruction in RA is called arthritis mutilans. This severe chronic rheumatoid condition is characterized by reabsorption of bone, with consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as telescoping fingers.”(“套筒式”),Radiographs of OsteoarthritisThis OA radiograph shows joint-space narrowing and reactive bone (termed eburnation). OA radiographs may show erosive changes, indicating the more aggressive form termed erosive osteoarthritis. The momentum of OA therapy is changing to emphasize a more aggressive approach of early therapy, particularly in younger patients with this presentation.,MRIs for RAMRI can detect joint erosions in RA before they are apparent on routine radiographs. However, caution must be used in the interpretation of small cystic changes that can be overread as being due to erosive changes. In addition, caution in interpretation of office MRI scans is indicated. The small MRIs found in the offices of some orthopedic surgeons (or even rheumatologists) have a much weaker magnet and take a longer time to acquire images, so patients must hold their painful hand immobile for a longer period, resulting in motion artifacts that may appear as erosions.,Severe Gout Can Also Involve Both Hands.,骨关节炎的治疗 -治疗目的,缓解关节疼痛和僵直阻止和延缓疾病的发展保护关节的功能提高关节的活动能力改善患者的生活质量,骨关节炎的治疗方法,非药物治疗患者教育社会心理治疗物理/职业治疗减重 锻炼,药物治疗止痛剂 NSAIDs局部外用药关节内糖皮质激素 关节内透明质酸 慢作用药,手术关节镜灌洗和去除软骨碎片截骨术 关节置换,骨关节炎的治疗“金字塔”,对乙酰氨基酚,病人教育物理疗法和职业疗法减肥、运动、辅助器具,手术,局部用药,关节内注射激素或透明质酸或冲洗,骨关节炎的药物治疗 -分类,控制症状药:非甾类抗炎药,止痛剂,植物药帕歌斯,局部止痛药,激素关节腔内注射改善病情药及软骨保护剂:透明质酸的粘弹性补充疗法,氨基葡萄糖(维骨力,葡力),安必丁等,骨关节炎的药物治疗 -止痛剂,对乙酰氨基酚(扑热息痛)虽然止痛不及非甾类抗炎药,但从总体花费、有效性及毒性综合考虑,多数学者倾于首选剂量4000mg/d时,肝毒性低,但已有肝损害和常酗酒者慎用因延长华法令半衰期者,服 用华法令者应监测凝血酶 原时间,骨关节炎的药物治疗 -止痛剂,曲马多适合于对非甾类抗炎药有禁忌(如肾功不全)或疗效差的中重度疼痛患者成瘾性小,但副作用有恶心呕吐、便秘和瞌睡平均有效剂量200-300 mg/d,分4次用,骨关节炎的药物治疗 -氨基葡萄糖,生理状态的氨基单糖合成硫酸氨基葡聚糖和透明质酸的特异物质和刺激物抑制破坏关节软骨的酶及氧自由基,阻断病理过程不依赖抑制前列腺素抗炎止痛,骨关节炎的药物治疗 -氨基葡萄糖,两种药物维骨力(或称维固力,硫酸氨基葡萄糖): 250mg,一日3次,与饭同服,持续8周,间隔半年左右可重复1个疗程葡力(盐酸氨基葡萄糖):240mg,一日三次发挥疗效较慢,在开始服用的1-2周内,应同时服用一种非甾类抗炎药副作用小,主要是轻度恶心、便秘和 嗜睡,糖尿病或糖耐量异常者应注意 潜在影响,骨关节炎的改善病情药 -维固力对膝骨关节炎双盲对照(3年),组别 剂量 治后3年关节 P 间隙平均狭窄(mm)安慰(n=106) / 0.31 0.043维固力(Rotta) 1.5g/d 0.06 (n=106),Lancet,2001,27:251-6,骨关节炎的改善病情药 -维固力对202例膝骨关节炎双盲对照(3年),组别 关节间隙平均狭窄mm/3年 安慰剂组 0.19维固力组(1500mg/d) 0 P0.001,Arch Intern Med,2002,162:2113-2123,骨关节炎的药物治疗 -骨重吸收剂,双膦酸盐包括阿仑膦酸盐,羟已膦酸盐,氯屈膦酸盐,替鲁膦酸盐及利塞膦酸盐等品种阿仑膦酸盐:其中福善美为进口,固邦为国产,口服,5-10mg,每日1次,清晨空腹服,骨关节炎的药物治疗 -大剂量维生素C,可减缓膝骨性关节炎进展与合成型胶原发挥作用有关,骨关节炎的药物治疗 -非甾类抗炎药,有以下的上消化道出血危险因素者慎用非选择COX2抑制剂,而可选COX2特异性或倾向性抑制剂,或同时加胃粘膜保护剂及制酸剂年龄65 岁有其他内科疾病正在服皮质激素有消化道溃疡病史正用抗凝剂,骨关节炎的药物治疗 -非甾类抗炎药,选择对软骨合成无不良影响的药对软骨无不良影响:双氯芬酸钠,舒林酸及恶丙嗪等抑制软骨基质合成药:吲哚美辛,保太松等,骨关节炎的药物治疗 -非甾类抗炎药,不同时服用2种非甾类抗炎药疗效不增加,而不良反应增加但有一个例外,即具有心血管保护作用的小剂量阿司匹林(81-325mg/d)可与其他非甾类抗炎药合用最好为特异性COX2抑制剂与阿司匹林合用,其发生溃疡的几率比非选择性非甾类药单独或与阿司匹林联合应用者低,骨关节炎的药物治疗 -关节内注射皮质激素,只适用于伴发滑膜炎、有关节腔积液同一关节每年不超过3次2次之间的间隔时间不宜短于2个月,骨关节炎的药物治疗 -关节内注射皮质激素,得宝松(二丙酸倍他米松和倍他米松磷酸二钠的复合制剂)每支1ml,含倍他米松磷酸二钠2mg和二丙酸倍他米松5mg倍他米松磷酸二钠是可溶性的,快速起效二丙酸倍他米松为难溶性的, 维持疗效(2-4周),骨关节炎的药物治疗 -关节内注射皮质激素,去炎松(曲安奈德,Triamcinolone acetonide)原名曲安缩松每支1ml,含量40mg或10或5mg为混悬液,1-2天最大疗效,维持2-3周,骨关节炎的药物治疗 -分类,控制症状药:非甾类抗炎药,止痛剂,植物药帕歌斯,局部止痛药,激素关节腔内注射改善病情药及软骨保护剂:透明质酸的粘弹性补充疗法,氨基葡萄糖(维骨力,葡力),安必丁等,骨关节炎的药物治疗 -透明质酸关节内注射,保护滑膜细胞和软骨组织,保护疼痛感受器维持关节液动态平衡刺激生成新的透明质酸调节炎细胞活动,抑制前列腺素合成清除氧自由基,骨关节炎的药物治疗 -透明质酸关节内注射,施沛特(国产):2ml,每周1次,共5次,疗效可维持半年左右欣维可(美国):2ml,每周1次