膝关节骨性关节炎的分型进展及临床意义

Knee osteoarthritis phenotypes and their clinical relevance: a review of literature

膝关节骨性关节炎(KOA)是常见的临床疾病。目前有多种治疗方法,疗效很不一致,其中重要的原因之一在于KOA是多因素导致的关节软骨退变,已知的各个病理因素虽有其各自的致病特点,但最终发生的KOA有相同的影像学特征和临床表现,因此临床上一致认为KOA是一个多因素导致的综合征,且KOA应该存在不同的类型。对引起KOA的病理因素研究比较充分,主要依此进行分型。KOA初步分为原发性和继发性两大类别。原发性KOA包括:基因决定型,雌激素缺乏相关型和衰老型。继发性KOA包括:(1)炎症型;(2)慢性疼痛型,这一类型较高概率合并痛觉敏感和神经病理性疼痛;(3)代谢综合征型,和糖尿病、肥胖、高脂血症等相关;(4)骨软骨代谢异常型;(5)力学负荷异常型,力线异常导致相应间室退变;(6)微小关节病型,这一类型临床症状轻,进展缓慢。虽然目前还没有获得广泛认可的分型标准,但是进行科学的分型很有必要,在此基础上予以对症治疗,才能获得好的疗效,比如针对力线异常的矫正术非常成功,消炎止痛药物治疗炎症型效果较好,对慢性疼痛型应予镇静、抗抑郁及心理疏导健康教育,对代谢综合征型这一型需要对相关的危险因素干预,调节成骨细胞和破骨细胞代谢的药物对骨软骨代谢异常型有效。本文对KOA的分型进展作一综述。

Knee Osteoarthritis(OA)is the most common form of arthritis,which is treated by many therapies with varied consequence due to the heterogeneity in pathogenesis of KOA.It has been suggested that a multitude of underlying mechanisms leading to similar clinical presentations,including joint damage,pain,stiffness and loss of physical function,are responsible for the development and progression of KOA.Different approaches to phenotype identification in the KOA population have been advocated,though there is no a consensus.Osteoarthritis may occur due to a wide variety of factors.Several authors have attempted to identify meaningful clinical phenotypes of the disease based on the risk factors.The primary OA is classified into 3 categories:the genetically determined,the estrogen hormone dependent and the aging related,whereas the secondary KOA is classified into 6 phenotype,including the chronic pain type which the central mechanisms,such as central sensitization,are prominent,the inflammatory type with high levels of inflammatory biomarkers,metabolic syndrome type with diabetes,obesity and hyperlipidemia,one and cartilage metabolism type with alteration in local tissue metabolism,mechanical overload type characterized primarily by varus malalignment and medial compartment disease,minimal joint disease type characterized as minor clinical symptoms with slow progression over time.The use of phenotypes in KOA research can help us to understand variations in disease progression,and response to therapy.Patients with malalignment respond well to biomechanical interventions,such as wedged insoles,knee braces,rather than to drug treatments aiming to protect the cartilage.Treatments targeting the inflammation process may be particularly effective in the inflammatory phenotype.Cognitive-behavioral therapy and pain education can be worthwhile in the chronic pain phenotype.Drugs aiming to influence bone and cartilage metabolism may see their effect improved if tested in the bone and cartilage metabolism phenotype.