冲击波联合富血小板血浆对骨关节炎软骨损伤的疗效

doi:10.3877/cma.j.issn.1674-134X.2023.03.006

目的

探讨对股骨内侧髁软骨损伤的膝骨关节炎患者行关节镜微骨折术后，采用冲击波联合富血小板血浆(PRP)治疗的临床疗效。

方法

按照2018年中华医学骨科骨关节炎标准纳入内侧髁软骨损伤的门诊患者，且年龄≥45岁。排除标准包括：膝关节外翻畸形或外侧间隙狭窄的患者，膝关节镜检查过程中发现膝关节外侧间室内出现软骨损伤，自身免疫疾病关节炎，膝关节内韧带损伤，凝血功能障碍及血液系统疾病，严重心脑血管疾病及依从性较差患者，既往膝关节手术史。行关节镜下损伤软骨区域微骨折术，术后给予冲击波联合富血小板血浆治疗。手术前及术后2、3、6个月对患者临床症状及功能改善程度通过视觉模拟评分法(VAS)、Lequesne功能演算指数(Lequesne评分)、西安大略麦克马斯特大学关节炎指数(WOMAC)及步态分析进行评估。方差分析及LSD-t检验对数据进行统计学分析。

结果

术后2个月VAS疼痛评分、Lequesne评分、WOMAC评分均较术前明显改善(t＝20.35、23.39、27.49，均为P<0.05)，WOMAC评分中疼痛、功能、僵硬评分也较术前明显减低(t＝10.44、8.00、19.96，均为P<0.05)；术后3个月VAS疼痛评分、Lequesne评分、WOMAC评分较术前(t＝16.76、27.38、40.98，均为P<0.05)及术后2个月(t＝6.27、11.52、24.76，均为P<0.05)明显降低；术后6个月VAS疼痛评分、Lequesne评分、WOMAC评分较术前(t＝－17.97、－18.82、－33.65，均为P<0.05)及术后2个月(t＝－7.1、－7.7、－28.56，均为P<0.05)、术后3个月(t＝－3.19、－1.68、－6.99，均为P<0.05)明显降低；术后2、3、6个月步速较术前明显提升(t＝5.26、52.66、32.52，均为P<0.05)；术后3个月步长与术前及术后2个月比较明显增大(t＝34.68、8.81，P<0.05)，术后6个月步长与术前、术后2、3个月比较患者步长增大(t＝13.22、9.17、2.54，均为P<0.05)。术后3个月步幅较术前及术后2个月提升明显(t＝33.94、18.82，均为P<0.05)。术后6个月步幅与术前及术后2个月比较步幅度增大(t＝18.39、13.98，均为P<0.05)。

结论

冲击波联合PRP对因膝骨关节炎股骨内侧髁软骨损伤行关节镜下微骨折手术的患者可以有效缓解疼痛、改善功能，值得进一步临床研究。

关键词: 骨关节炎，膝, 体外冲击波疗法, 富血小板血浆, 关节镜检查, 康复

Objective

To investigate the clinical efficacy of shock wave combined with platelet-rich plasma(PRP)following arthroscopic microfractures treatment on osteoarthritis patients with medial condylar cartilage injury.

Methods

In accordance with the 2018 Chinese Medical Orthopedic Osteoarthritis Standards, outpatient patients with medial condyle cartilage injury and age over 45 years were included. Exclusion criteria were: patients with knee valgus deformity or narrowing lateral space of knee, cartilage damage in the lateral compartment of the knee during knee arthroscopy, autoimmune disease arthritis, ligament injury inside knee joint cavity, coagulopathy and hematologic disorders, severe cardio- and cerebrovascular diseases and poor compliance, history of knee surgery. Arthroscopic micro-fractures in the cartilage injury area was performed, and shock waves combined with platelet-rich plasma were given after surgery. The clinical symptoms and functional improvement of patients before and after treatment were evaluated by visual analogue scale(VAS), Lequesne index, the Western Ontario & McMaster Universities osteoarthritis index(WOMAC )and gait analysis. The data were analyzed by analysis of variance and LSD-t test.

Results

VAS pain scores, Lequesne scores, and WOMAC scores at two months after surgery improved remarkably compared with those before surgery(t=20.35, 23.39, 27.49, all P<0.05). The pain, function and stiffness scores in WOMAC scores were also significantly lower than those at preoperative (t=10.44, 8.00, 19.96, all P<0.05). VAS pain scores, Lequesne scores, and WOMAC scores at the three months after surgery were significantly lower than the data before operation(t=16.76, 27.38, 40.98, all P<0.05)and data of two months after operation(t=6.27, 11.52, 24.76, all P<0.05). VAS pain scores, Lequesne scores, and WOMAC scores were significantly lower at postoperative six months than the data before operation(t=-17.97, 18.82, -33.65, all P<0.05)and data of two months(t=-7.1, -7.7, -28.56, all P<0.05)and three months after operation (t=-3.19, -1.68, -6.99, all P<0.05). The stride rate at two, three and six months after surgery significantly improved compared with the rate before surgery (t=5.26, 52.66, 32.52, all P<0.05). The step length at two and three months after surgery were significantly longer than those before surgery (t=34.68, 8.81, P<0.05). The step length at postoperative six month also significantly improved compared with those before operation at two months and three months after operation (t=13.22, 9.17, 2.54, P<0.05). The stride length at three months after surgery was significantly higher than that at two months after surgery (t=33.94、18.82P<0.05). The stride length obviously increased at six months compared with the data before operation and the data of two months after operation (t=18.39, 13.98, P<0.05).

Conclusion

Shock wave combined with PRP can effectively relieve pain and improve function in knee osteoarthritis patients with medial femoral condylar cartilage injury after arthroscopic microfractures, which is worthy of further clinical research.

Key words: Osteoarthritis, knee, Extracorporeal shock wave therapy, Platelet-rich plasma, Arthroscopy, Rehabilitation

表1 不同随访时间点VAS评分、Lequesne评分、WOMAC评分(±s)

Table 1 VAS, Lequesne score, WOMAC score at different follow-up time points

时间Time	VAS评分	Lequesne评分	WOMAC评分
时间Time	VAS评分	Lequesne评分	疼痛Pain	功能Function	僵硬Stiffness	总分Total score
术前	4.5±1.0	7.7±2.1	9.0±2.1	29.4±7.8	3.6±1.0	42.0±1.9
术后2个月	2.8±1.2^a	4.6±2.3^a	6.6±2.3^a	20.5±6.1^a	2.5±1.2^a	29.7±1.5^a
术后3个月	2.1±1.2^ab	2.5±1.7^ab	4.5±2.5^ab	16.8±1.0^ab	1.6±1.0^ab	22.8±1.4^ab
术后6个月	1.8±0.9^abc	2.1±1.1^abc	3.5±2.1^abc	20.1±1.3^abc	1.3±0.9^abc	20.1±1.3^abc
F值	183.40	302.87	140.34	210.51	51.19	587.10
P值	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表1 不同随访时间点VAS评分、Lequesne评分、WOMAC评分(±s)

Table 1 VAS, Lequesne score, WOMAC score at different follow-up time points

时间Time	VAS评分	Lequesne评分	WOMAC评分
时间Time	VAS评分	Lequesne评分	疼痛Pain	功能Function	僵硬Stiffness	总分Total score
术前	4.5±1.0	7.7±2.1	9.0±2.1	29.4±7.8	3.6±1.0	42.0±1.9
术后2个月	2.8±1.2^a	4.6±2.3^a	6.6±2.3^a	20.5±6.1^a	2.5±1.2^a	29.7±1.5^a
术后3个月	2.1±1.2^ab	2.5±1.7^ab	4.5±2.5^ab	16.8±1.0^ab	1.6±1.0^ab	22.8±1.4^ab
术后6个月	1.8±0.9^abc	2.1±1.1^abc	3.5±2.1^abc	20.1±1.3^abc	1.3±0.9^abc	20.1±1.3^abc
F值	183.40	302.87	140.34	210.51	51.19	587.10
P值	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表2 患者治疗前后步态结果

Table 2 Gait outcomes before and after treatment at different times

时间Time	步速(m/s)Stride rate(m/s)	步长(m)Step length(m)	步幅(m)Stride length(m)
术前	0.489±0.123	0.199±0.028	0.422±0.056
术后2个月	0.491±0.119^a	0.205±0.031	0.426±0.054
术后3个月	0.506±0.124^ab	0.234±0.030^ab	0.459±0.056^ab
术后6个月	0.512±0.123^abc	0.242±0.033^abc	0.462±0.059^ab
F值	1 095.11	383.81	362.42
P值	<0.001	<0.001	<0.001

表2 患者治疗前后步态结果

Table 2 Gait outcomes before and after treatment at different times

时间Time	步速(m/s)Stride rate(m/s)	步长(m)Step length(m)	步幅(m)Stride length(m)
术前	0.489±0.123	0.199±0.028	0.422±0.056
术后2个月	0.491±0.119^a	0.205±0.031	0.426±0.054
术后3个月	0.506±0.124^ab	0.234±0.030^ab	0.459±0.056^ab
术后6个月	0.512±0.123^abc	0.242±0.033^abc	0.462±0.059^ab
F值	1 095.11	383.81	362.42
P值	<0.001	<0.001	<0.001

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Efficacy of shock wave combined with platelet-rich plasma treatment on cartilage injury in osteoarthritis

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Efficacy of shock wave combined with platelet-rich plasma treatment on cartilage injury in osteoarthritis