体外冲击波联合关节镜治疗膝骨关节炎的临床研究

doi:10.3877/cma.j.issn.1674-134X.2019.06.003

目的

观察体外冲击波联合关节镜手术治疗早中期膝关节骨关节炎的临床疗效，以及对关节液中单核细胞趋化蛋白-1(MCP-1)、超氧化物歧化酶(SOD)和一氧化氮(NO)水平的影响。

方法

根据随机对照原则，严格按照本研究的纳入标准(K-L分期属于Ⅱ、Ⅲ级，能耐受麻醉、关节镜手术及体外冲击波治疗(ESWT)与排除标准关节感染、活动性关节结核、类风湿性关节炎或局部有伤口；严重膝关节畸形、严重骨质疏松)，选取2013年02月至2016年12月于广西壮族自治区人民医院就诊的膝关节骨关节炎(KOA)患者285例分为3组，体外冲击波联合关节镜手术治疗组、单纯体外冲击波治疗组、单纯关节镜手术治疗组。分别在治疗前及治疗后3个月、6个月、12个月行Lysholm膝关节功能评分(Lysholm评分)和疼痛视觉模拟评分(VAS评分)，并检测患者关节液中MCP-1、SOD和NO的水平。计量资料采用重复测量资料的方差分析，多均数两两比较采用SNK-q检验，计数资料比较采用卡方检验。

结果

治疗后3个月时：3组VAS评分及Lysholm评分均显著优于治疗前，联合组评分优于冲击波、关节镜治疗组(q₁＝4.091，q₂＝5.562，P<0.05)。3组治疗后6个月时联合组及关节镜组评分仍优于治疗前，联合组评分明显优于其他两组(q₁＝6.194，q₂＝6.064，P<0.05)，冲击波组与治疗前比较，差异无统计学意义(P>0.05)。治疗后12个月时，联合组评分仍优于治疗前，冲击波及关节镜组评分与治疗前比较，差异无统计学意义(P>0.05)；联合组VAS评分及Lysholm评分明显优于其他两组，冲击波组与关节镜组比较，差异无统计学意义(P>0.05)。治疗后3个月，3组MCP-1和NO水平均明显低于治疗前，SOD高于治疗前，联合组各水平与冲击波及关节镜组比较，差异有统计学意义(q₁＝4.065，q₂＝5.046，q₃＝5.556, P<0.05)。治疗后6个月，3组MCP-1和NO水平较治疗后3个月升高，SOD较治疗后3个月降低，联合组MCP-1和NO水平明显低于冲击波及关节镜组，SOD水平高于冲击波及关节镜组(q₁ ＝4.929，q₂ ＝6.284，q₃＝5.061，P<0.05)，关节镜组MCP-1和NO水平与治疗前比较，差异无统计学意义(P>0.05)。治疗后12个月，联合组MCP-1和NO水平仍低于治疗前，SOD水平高于治疗前，冲击波及关节镜组与治疗前比较，差异无统计学意义(P>0.05)；联合组MCP-1和NO水平低于冲击波及关节镜组，SOD水平高于冲击波及关节镜组，冲击波及关节镜组两组间MCP-1、NO和SOD水平比较，差异无统计学意义(P>0.05)。

结论

体外冲击波联合关节镜手术能有效缓解膝关节骨关节炎关节疼痛症状，改善关节功能，有效降低关节液中炎性介质MCP-1和NO水平，提高SOD水平，其近期和远期疗效均显著优于单纯应用体外冲击波或关节镜手术治疗。

关键词: 冲击波, 关节镜, 膝, 骨关节炎

Objective

To observe the clinical effect of extracorporeal shock wave combined with arthroscopy in the treatment of osteoarthritis of knee joint in early and middle stage, and to observe the effect of extracorporeal shock wave combined with arthroscopy on the levels of monocyte chemoattractant protein-1 (MCP-1), superoxide dismutase (SOD) and nitric oxide (NO) in articular fluid.

Methods

According to the principle of random control, 285 patients with knee osteoarthritis were divided into three groups: extracorporeal shock wave combined with arthroscopic surgery group (combining group), extracorporeal shock wave group (shock wave group) and arthroscopic surgery group (arthroscopic group). Lysholm score and visual analogue scale (VAS) score were measured before treatment and three, six, 24 months after the treatment. The levels of MCP-1, SOD and NO in articular fluid of the groups were measured. The scores of Lysholm and VAS were statistically analyzed by repetitive measure analysis of variance, SNK-q test or chi-square test.

Results

Three months after the treatment, the Lysholm and VAS scores in the three groups were significantly better than those before treatment, and the scores in the combining group were significantly better than those in the shock wave group and the arthroscopic group (q₁=4.091, q₂=5.562, P<0.05). The scores of the three groups six months after the treatment compared to the data three months after the treatment showed statistically significant differences. The scores of the combining group and shock wave group were still better than before the treatment (q₁=6.194, q₂=6.064, P<0.05), while the arthroscopic group was not significantly different compared to the scores before treatment (P>0.05). At 12 months after treatment, the scores of Lysholm and VAS in the combining group were still better than those before treatment, and the scores in the combining group were significantly better than the other two groups. There was no significant difference in the score of shock wave and arthroscopy group compared with that before treatment (P>0.05). Three months after treatment, the levels of MCP-1 and NO in the three groups were significantly lower than those before treatment, and SOD was higher than that before treatment. There was significant difference between the combining group and the shock and arthroscopy group (q₁=4.065, q₂=5.046, q₃=5.556, P<0.05). At six months after treatment, the levels of MCP-1 and NO in the three groups were higher than those in three month after treatment, and the levels of SOD in the combining group were significantly lower than those in the shock wave and arthroscopy group, the levels of MCP-1 and NO in the combining group were significantly lower than those in the shock wave and arthroscopy group, and the SOD level was higher than that in the shock wave group and arthroscopy group (q₁ =4.929, q₂ =6.284, q₃=5.061, P<0.05). The levels of MCP-1 and NO in arthroscopy group were not significantly different from those before treatment (P>0.05). Twelve months after treatment, the levels of MCP-1 and NO in the combined group were still lower than those before treatment, the level of SOD was higher than that before treatment, the levels of MCP-1 and NO in the combined group were lower than those in the shock wave and arthroscopy group, and the level of SOD was higher than that of shock wave and arthroscopy. The levels of MCP-1, NO and SOD in shock wave and arthroscopy group were not significantly different from those before treatment (P>0.05).

Conclusions

Extracorporeal shock wave combined with arthroscopy can effectively relieve the joint pain, improve joint function, reduce the levels of inflammatory mediators MCP-1 and NO, and increase the level of SOD in articular fluid. The short-term and long-term results of combining the two methods are better than that of extracorporeal shock wave or arthroscopy alone.

Key words: High-energy shock waves, Arthroscopes, Knee, Osteoarthritis

表1 两组一般资料比较

?	性别(例)		年龄(岁)	病程(月)	K-L分级(例)
?	男	女	年龄(岁)	病程(月)	Ⅱ级	Ⅲ级
联合组	23	67	62±8	26±6	54	41
ESWT组	24	65	64±8	27±7	59	36
关节镜组	20	67	60±8	26±7	61	34
统计值	χ²＝1.164		F ＝0.993	F ＝1.269	χ²＝1.375
P值	>0.05		>0.05	>0.05	>0.05

表1 两组一般资料比较

?	性别(例)		年龄(岁)	病程(月)	K-L分级(例)
?	男	女	年龄(岁)	病程(月)	Ⅱ级	Ⅲ级
联合组	23	67	62±8	26±6	54	41
ESWT组	24	65	64±8	27±7	59	36
关节镜组	20	67	60±8	26±7	61	34
统计值	χ²＝1.164		F ＝0.993	F ＝1.269	χ²＝1.375
P值	>0.05		>0.05	>0.05	>0.05

表2 各组VAS评分比较[分，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	6.5±1.5	3.9±0.6^a	4.7±1.2^a	6.1±1.4^a	5.956	<0.05
ESWT组	89	6.6±1.8	4.7±1.2^{b d}	5.8±1.4^{b d}	6.5±1.9^d	2.011	>0.05
关节镜组	87	6.4±1.5	4.9±1.1^{c d}	6.3±1.6^d	6.5±1.4^d	1.816	>0.05
q值	?	0.395	4.091	6.194	1.811	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表2 各组VAS评分比较[分，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	6.5±1.5	3.9±0.6^a	4.7±1.2^a	6.1±1.4^a	5.956	<0.05
ESWT组	89	6.6±1.8	4.7±1.2^{b d}	5.8±1.4^{b d}	6.5±1.9^d	2.011	>0.05
关节镜组	87	6.4±1.5	4.9±1.1^{c d}	6.3±1.6^d	6.5±1.4^d	1.816	>0.05
q值	?	0.395	4.091	6.194	1.811	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表3 各组Lysholm膝关节评分比较[分，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	46±9	81±15^a	79±16^a	63±11^a	6.265	<0.05
ESWT组	89	48±8	72±14^{b d}	61±13^{b d}	49±8^d	1.891	>0.05
关节镜组	87	48±9	70±12^{c d}	50±7^d	46±7^d	2.035	>0.05
q值	?	0.216	5.562	6.064	1.122	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表3 各组Lysholm膝关节评分比较[分，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	46±9	81±15^a	79±16^a	63±11^a	6.265	<0.05
ESWT组	89	48±8	72±14^{b d}	61±13^{b d}	49±8^d	1.891	>0.05
关节镜组	87	48±9	70±12^{c d}	50±7^d	46±7^d	2.035	>0.05
q值	?	0.216	5.562	6.064	1.122	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表4 各组MCP-1比较[μg/L，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	0.66±0.12	0.45±0.07^a	0.50±0.08^a	0.60±0.11^a	5.069	<0.05
ESWT组	89	0.68±0.13	0.51±0.09^bd	0.62±0.12^bd	0.67±0.13^d	2.902	>0.05
关节镜组	87	0.65±0.13	0.51±0.08^cd	0.64±0.11^d	0.68±0.14^d	2.032	>0.05
q值	?	0.626	4.065	4.929	1.358	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表4 各组MCP-1比较[μg/L，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	0.66±0.12	0.45±0.07^a	0.50±0.08^a	0.60±0.11^a	5.069	<0.05
ESWT组	89	0.68±0.13	0.51±0.09^bd	0.62±0.12^bd	0.67±0.13^d	2.902	>0.05
关节镜组	87	0.65±0.13	0.51±0.08^cd	0.64±0.11^d	0.68±0.14^d	2.032	>0.05
q值	?	0.626	4.065	4.929	1.358	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表5 各组SOD比较[μU/L，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	86±17	129±21^a	110±20^a	97±16^a	6.358	<0.05
ESWT组	89	85±18	117±21^bd	104±20^bd	86±18^d	1.994	>0.05
关节镜组	87	85±17	114±17^cd	88±17^d	84±15^d	0.902	>0.05
q值	?	0.924	5.046	6.284	0.916	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表5 各组SOD比较[μU/L，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	86±17	129±21^a	110±20^a	97±16^a	6.358	<0.05
ESWT组	89	85±18	117±21^bd	104±20^bd	86±18^d	1.994	>0.05
关节镜组	87	85±17	114±17^cd	88±17^d	84±15^d	0.902	>0.05
q值	?	0.924	5.046	6.284	0.916	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表6 各组NO比较[μmol/L，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	78±18	54±10^a	66±15^a	73±17^a	5.968	0.028
ESWT组	89	80±18	604±13^bd	72±17^bd	79±18^d	2.113	0.066
关节镜组	87	81±21	62±14^cd	80±20^d	83±21^d	1.091	>0.05
q值	?	0.718	5.556	5.061	0.719	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

表6 各组NO比较[μmol/L，(±s)]

组别	例数	治疗前	治疗后3个月	治疗后6个月	治疗后12个月	q值	P值
联合组	90	78±18	54±10^a	66±15^a	73±17^a	5.968	0.028
ESWT组	89	80±18	604±13^bd	72±17^bd	79±18^d	2.113	0.066
关节镜组	87	81±21	62±14^cd	80±20^d	83±21^d	1.091	>0.05
q值	?	0.718	5.556	5.061	0.719	?	?
P值	?	>0.05	<0.05	<0.05	>0.05	?	?

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Clinical efficacy of extracorporeal shock wave combined with arthroscopy for treatment of knee osteoarthritis

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Clinical efficacy of extracorporeal shock wave combined with arthroscopy for treatment of knee osteoarthritis