给药位点差异对透明质酸在膝关节软骨表面覆盖范围的影响

Injection site diversity influences sodium hyaluronate distribution on knee cartilage surface： a cadaveric study

目的 观察给药位点差异对透明质酸（hyaluronic acid, HA）在膝关节软骨表面覆盖范围的影响。方法 2014年9月至2014年12月, 收集32例膝关节大体标本, 按股骨髁宽从小到大排列, 并从1~32赋予编号, 奇数编号采用髌骨下给药组（16例, 以髌骨内侧中点为穿刺点）, 偶数编号为关节线给药组（16例, 以髌骨内侧缘与下极连线交点为穿刺点）。使用质量浓度为5%的亚甲蓝示踪HA注射液2.5 ml按不同给药位点注射, 完成后将膝关节大体标本固定于Electro Force平台做5°~45°反复屈伸运动, 2 h后切开关节腔观察HA在膝关节软骨表面的覆盖范围。将膝关节表面分为8个区域（髌骨区、股骨滑车区、股骨内侧髁前区、股骨外侧髁前区、股骨内侧髁后区、股骨外侧髁后区、胫骨平台内侧区、胫骨平台外侧区）, 按照HA在各区域的覆盖面积赋分, 记录HA在膝关节表面各区域的范围；分析不同给药位点对HA在膝关节表面覆盖范围的影响。结果 股骨髁宽≤7.0 cm时, 髌骨下给药组在胫骨平台外侧区的药物覆盖评分低于关节线给药组, 其他各区域两组间差异无统计学意义。股骨髁宽〉7.0 cm时, 髌骨下给药组在髌骨区、滑车区的药物覆盖评分显著高于关节线给药组, 在股骨外髁前区、股骨内髁后区、股骨外髁后区和胫骨平台外侧区的药物覆盖评分则显著低于关节线给药组。结论 从不同位点给药, HA在小体型（股骨髁宽≤ 7.0 cm）人群膝关节腔内具有相似的分布特征, 但在大体型（股骨髁宽 〉7.0 cm）人群膝关节腔内的分布则显著不同。股骨髁宽 〉7.0 cm时, 髌骨下给药的HA主要分布于髌股关节及前关节腔；关节线给药的HA则主要分布于胫股关节及后关节腔。

Objective To elucidate whether and how injection site diversity influences on the sodium hyaluronate （HA） distribution on cartilage surface of the knee joint. Methods From September 2014 to December 2014, 32 human cadaveric knees were sorted from small to large based on femoral condyle width （FCW） and divided into group I （n=16, odd number, the patella medial approach） and group II （n=16, even number, injected through the medial joint line approach）. Knees of both groups were interfused with a 5% （mg∶ml） methylene blue tracer. Each specimen was then simulated a 5°-45° alternating walking for 2 h in the Electro Force platform. Afterwards, all the knee cavities were cut open to examine the range of HA distribution. Based on the eight-zoning classification law for the knee cartilage surface, the coverage area of HA in each zone was scored and the characteristics of HA distribution was depicted, as well as HA zonal distribution diversity between groups were statistically analyzed. Results HA of both patella medial and medial joint line subgroups showed analogical distribution in all zones except the lateral tibial plateau at the time of FCW ≤ 7.0 cm. However, HA coverage through the patella medial approach showed significantly higher distribution scores in the patella zone and the femoral trochlear zone, but significant lower distribution scores in the antero-lateral/postero-lateral femoral condyle, the medial posterior femoral condyle zone and the lateral tibial plateau zone compared with medial joint line approach at the time of FCW 〉 7.0 cm. Conclusion When delivered through different injection approaches, HA showed analogical distribution characteristics in most zones of the knee cavity in population with a small bodily shape （FCW ≤ 7.0 cm）, but significant diverse distribution characteristics in population with a big bodily shape （FCW 〉7.0 cm）. When FCW 〉 7.0 cm, HA injected through the medial-patellar approach tended to be distributed mainly over the patella-femoral articulation and the anterior knee cavity, while HA injected through the joint line approach tended to be distributed mainly over the tibio-femoral articulation and the posterior knee cavity.