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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2021, Vol. 15 ›› Issue (05) : 586 -595. doi: 10.3877/cma.j.issn.1674-134X.2021.05.010

综述

膝骨关节炎与膝关节周围骨密度的相关性研究进展
郭子瑊1, 毛兴佳1, 高英杰1, 高振中1, 向川1,†()   
  1. 1. 030001　太原，山西医科大学第二医院骨科
  • 收稿日期:2020-09-03 出版日期:2021-10-01
  • 通信作者: 向川
  • 基金资助:
    国家自然科学基金项目(81972075)

Research progress on relationship between knee osteoarthritis and bone mineral density around knee joint

Zijian Guo1, Xingjia Mao1, Yingjie Gao1, Zhenzhong Gao1, Chuan Xiang1,†()   

  1. 1. Department of Orthopedics, The Second Affiliated Hospital of Shanxi Medical University, Taiyuan 030001, China
  • Received:2020-09-03 Published:2021-10-01
  • Corresponding author: Chuan Xiang
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郭子瑊, 毛兴佳, 高英杰, 高振中, 向川. 膝骨关节炎与膝关节周围骨密度的相关性研究进展[J]. 中华关节外科杂志(电子版), 2021, 15(05): 586-595.

Zijian Guo, Xingjia Mao, Yingjie Gao, Zhenzhong Gao, Chuan Xiang. Research progress on relationship between knee osteoarthritis and bone mineral density around knee joint[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2021, 15(05): 586-595.

膝骨关节炎(KOA)是以软骨退变及关节间隙变窄为主要特征的慢性、退行性疾病。骨密度(BMD)是指单位体积或面积的骨矿物质含量，是临床上用于反映骨质量的重要指标。全身BMD和膝关节BMD与KOA的分级，疼痛，生活质量及术后效果都有很密切的联系。尤其是膝关节BMD对于KOA的早期诊断、发展和预后都具有更为重要的意义，且二者的关系十分复杂，并成为近年来的研究热点，但目前膝关节BMD测量方法尚未统一，成为制约研究二者关系的瓶颈。本文对膝关节BMD与KOA的关系重点阐述，简要回顾并对比了近年来有关膝关节BMD测量方法，对今后相关研究提供参考和指导。

关键词: 骨关节炎，膝, 骨密度, 骨质疏松

Knee osteoarthritis (KOA) is a chronic and slowly progressive joint disease characterized by cartilage degeneration and narrowing of joint space. It is the type with the highest incidence of osteoarthritis (OA). Bone mineral density (BMD) refers to the bone mineral content per unit volume or surface, which is an important index to reflect bone quality in clinic. There is a close relationship between whole body BMD and knee joint BMD and KOA grade, pain, quality of life and postoperative effect. In particular, knee joint BMD plays a more important role in the early diagnosis, development and prognosis of KOA, and the relationship between them is very complex and has become a research hotspot in recent years. But the measurement methods of knee joint BMD have not been unified. This paper focused on the relationship between knee joint BMD and KOA, briefly reviewed and compares the measurement methods of knee joint BMD in recent years, so as to provide reference and guidance for related research in the future.

Key words: Osteoarthritis, knee, Bone mineral density, Osteoporosis
表1 各个研究主要特征及结果
第一作者 研究类型 测量部位 测量方法 例数 重要结果
Clarke [10] 前瞻性研究 胫骨近端内外侧软骨下骨骨密度 DXA 112 胫骨近端内侧软骨下骨密度高于外侧。内侧骨密度与患者性别、身高、体重、最小内侧关节间隙宽度显著相关。男性和女性的平均外侧骨密度随着进入年龄的增加而下降，但内侧骨密度没有下降。
Lo [31] 横断面研究 胫骨近端内外侧骨密度 DXA 436 髋-膝-踝角度(hip-knee-ankle, HKA)与内外侧BMD的相关系数大于任何其他骨测量。内翻对齐程度越高，内侧BMD越低。内侧和外侧的BMD占HKA变异的40%。当仅对那些影响诊断OA的膝关节进行分析时，内侧和外侧的BMD占HKA变异的47%。
Lo [6] 横断面研究 胫骨近端内侧 DXA 482 通过评估内侧BMD和MRI骨小梁测量的总体比较具有统计学意义。结果显示在内侧关节间隙狭窄评分较高的膝关节(2/3级)中，骨密度、骨小梁体积、骨小梁数量和骨小梁厚度在统计学上大于内侧关节间隙不狭窄患者(0/1级)。
Lo [23] 纵向观察性队列研究 胫骨近端内外侧骨密度 DXA 444 M/L BMD、表观骨体积分数、骨小梁数量和骨小梁厚度的增加与关节内侧进展相关。M/L BMD从最低到最高四分位数的变化，每组经历内侧关节突进展者的比例分别为5%、5%、11%和18%。并且M/L BMD是与外侧关节间隙狭窄相关的唯一测量量。
Omoumi[20] 回顾性病例对照研究 股骨远端及胫骨近端 CT 32 无论是总承重区还是非承重亚区，内侧的BMD均显著高于外侧。当比较总承重区时，KOA和非KOA膝关节BMD差异无统计学意义，但KOA患者胫骨外侧BMD明显低于非KOA。OA膝关节的胫骨外侧区BMD较低。股骨内侧有较高的BMD，而股骨外侧有较低的BMD。在胫骨亚区方面，KOA患者的内侧外侧亚区BMD均显著高于非KOA患者，在外侧中央亚区和前亚区显著低于非OA膝。在股骨和胫骨总承重区，KOA膝关节的M/LBMD明显高于非OA膝关节。
Sannmann[32] 前瞻性研究 股骨远端及胫骨近端 QCT 67 骨骺下部和骨骺中部的内侧骨密度高于外侧骨密度，但低于骨骺毗邻区的外侧骨密度。半月板覆盖和非半月板覆盖区之间的骨密度差异也有相似的影响。骨骺下半月板非覆盖区BMD高于覆盖区BMD。骨骺中区骨密度无明显差异。而骨骺毗邻区半月板覆盖区BMD高于非覆盖区BMD。
Burnett [22] 前瞻性研究 股骨远端、髌骨、胫骨近端，以及胫骨远端终板近端66%的胫骨干 QCT 42 有"剧烈疼痛"的参与者比"无疼痛"的参与者有更高的胫骨平台外侧BMD。在距软骨下表面2.5 mm处，或在整个胫骨内外侧平台，局灶性骨密度在各组之间差异无统计学意义。然而，在疼痛增加的各组中，胫骨平台内侧骨密度降低的趋势差异并无统计学意义。胫骨干皮质横截面积和密度差异无统计学意义。
Ishii [33] 前瞻性研究 股骨内外侧髁及胫骨内外侧 DXA 156 采用多元线性回归分析和逐步变量选择进行多因素分析，股骨M/L BMD比值只有胫骨角有显著影响，而胫骨M/LBMD比值只有机械轴角度有显著影响。
Burnett [34] 前瞻性研究 股骨远端、髌骨、胫骨近端和胫骨远端终板近端66%的胫骨干 QCT 42 夜间卧床疼痛与距胫骨软骨下表面2.5~5 mm处的侧位骨密度显著相关。股骨远端，髌骨，胫骨近端都与患者疼痛感觉密切相关。
Huang [3] 前瞻性队列研究 股骨远端 DXA 50 线性回归分析显示vBMD与术后疼痛呈正相关。vBMD与"疼痛"和"症状"领域得分的变化呈负相关。术后2个月膝关节骨密度与"日常生活能力"呈负相关。
Shiraishi [35] 前瞻性研究 胫骨近端软骨下骨 HR-pQCT 20 内侧平台和外侧平台之间的骨显微结构有显著差异。内侧平台软骨下骨微结构由密度较大、厚度较厚的骨小梁组成，其骨小梁排列各向异性结构明显多于外侧平台。内侧平台的vBMD、骨小梁体积、与K & L分级呈正相关。胫骨平台内侧的vBMD与骨小梁体积和机械轴偏差呈正相关，而骨小梁间距与机械轴偏差呈负相关。此外内侧平台的vBMD、骨小梁数量、体积、间距、厚度与K & L分级和股胫角呈正相关。
Bruyere [29] 前瞻性研究 胫骨近端软骨下骨 DXA 56 软骨下骨密度与关节间隙宽度的1年变化呈显著负相关。当以年龄、性别、体重指数和基线的最小关节扭力为伴随变量进行多元回归分析时，软骨下骨的骨密度和基线的关节扭力是关节扭力1年变化的独立预测因子。
Akamatsu [36] 前瞻性研究横断面 股骨内外侧髁及胫骨内外侧 DXA 192 股骨内侧髁骨密度随年龄增加而显著增加，而胫骨内侧髁骨密度无明显变化。股骨和胫骨内、外侧髁骨密度比值均与年龄呈正相关，而股骨外髁和胫骨髁骨密度与年龄呈负相关。随着疼痛程度的增加，股骨和胫骨内髁BMD均显著增加，而股骨和胫骨外髁BMD无明显变化。股骨和胫骨内、外侧髁骨密度比值随疼痛程度的增加而显著增加。股骨和胫骨髁内侧骨密度与股胫角、内侧和外侧骨赘、内侧关节间隙狭窄程度、腰椎和股骨颈骨密度、疼痛程度呈显著正相关，与膝关节疼痛和功能评分呈显著负相关。
Thorp [37] 前瞻性研究 胫骨近端内外侧骨密度 DXA 84 M/L BMD与身高、体重、BMI、年龄或疼痛之间没有显著关系。M/L BMD与终末站立时膝关节内收角动量的相关性最强，与其他一些动态负荷步态指标(如总体峰值，总角动量等)以及膝关节对齐角也有相关性。M/L BMD与自选正常步行速度呈负相关。
图1 下肢HKA(髋-膝-踝)角及双下肢长度测量
图2 患者接受膝关节BMD(骨密度)检查时采取的体位，图中箭头所指向为头部
图3 测量胫骨平台BMD(骨密度)时设置的胫骨平台内外侧ROI(感兴趣区)
图4 使用MRI测量时选取的ROI(感兴趣区)
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