关节炎性疼痛综合征骨关节炎

　　Osteoarthritishastraditionallybeendescribedas“wearandtear”jointdegenerationattributabletotheagingprocess.Painduetoosteoarthritisconstitutesthemostcommonjointcomplanintforwhichpatienisseekmedicalattention.Primaryosteoarthritisaffectsthearticularcartilageofotherwisenormaljoints.Secondaryosteoarthritisoccursasasequelaoftrauma，jointdiseasesuchasLegg-Perthesdisease，orsubtleanomaliessuchasmildacetabulardysplasiaresultinginlong-standingjointincongruity.

　　骨关节炎被传统地描述为由于老年化过程而出现的磨损性关节变性。由骨关节炎引起的关节能疼痛是病人就医时最多的主诉。原发性骨关节炎犯其他正常侵犯其他正常的骨关节软骨面。继发性骨关节炎是作为创伤、关节病（如Legg-Perthe病）或轻微畸形（如轻度髋臼发育不良导致长期关节不交合）的后遗症而发生的。

　　Osteoarthritisisthemostcommonofallarthropathies，affectingroughly30-50%oftheentirepopulation.Heritabilityhasnotbeendemonstrated.Womenaremoreoftenaffectedthanmen，thoughvirtuallyallpersonsoverage55havesomex-rayevidenceofthisdisease.Fortunately，lessthanhalfofpatientswithx-raychangeswillexperiencejointsymptoms.Onsetofsymptomaticdiseaseisusuallyinthesixthdecade.

　　骨关节炎是所有骨关节病中最常见，整个人群中约有30~50%受累。遗传性未得到证实。女性较男性患者多。事实上超过55岁的人都有一点患此病的X线证据，幸而只有不到一半有X线证变化的病人感到有关节症状，通常是在60岁开始出现。

　　Thoughthespecificincitingagentremainsunclear，theearliesthistopathologicchangeinosteoarthriticjointsislossofmucopolysaccharidegroundsubstanceintheoutermostlayersofarticularcartilage.Asaresultthemechanicalpropertiesofthecartilagearealteredandresistancetodeformationislowered.Theweakenedsuperficiallayersofcartilagedevelopfissuresinresponsetoincreaseddeformationbynormalloads.Thisresultsinunevendistributionofstresstransmissiontodeeperlayersofcartilageandtotheunderlyingsubchondralbone.Thisconcentrationofstressfurtheracceleratescartilagewearwiththinningofouterlayersandpropagationofcracksandfissuresinthedeeperlayers.Cartilagedebriswithinthejointresultsinlow-gradechronicinflammatorysynovitisandjointeffusion.

　　虽然特异性刺激因素尚不清楚，但是在骨关节炎关节中最早的组织病理学变化是在关节软骨的最外层中丧失粘液多糖基质。结果是软骨的机械性能发生改变，对变形的耐受力下降。变弱的表层软骨因对正常负荷增加变形而发生裂隙。这导致应力分布不均匀地传导至深层软骨及其下面的软骨下骨。集中的应有尽有力进一步加速外民支软骨磨损及变薄，也加速深层碎裂和裂隙的扩布。在关节内软骨碎片导致低度慢性囊炎和关节积液。

　　Ifweightbearingorstressloadingoftheaffectedjointcontinues，thinningofthecartilagemayprogresstoeventualfull-thicknesscartilageloss.Thesubchondralbonebearsprogressivelygreaterloadsascartilagedestructionevolves.Increasedloadingofbonestimulatesboneremodelingandnewbonedeposition，manifestedbymarginalosteophyteformationandsclerosiswithintheoverloadedsubchondralboneinciteachronicinflammatoryresponseReplacementofnercroticbonebyfibroustissueresultsinsubchondralcystformation.

　　如果受损的关节持续负重或承受应力，软骨变薄可进行下去，直到最后全层软骨消失。软骨破坏过程中，软骱下骨胳的负荷逐渐加重，骨负荷加重刺激骨胳重新塑和新骨沉积，表现为边缘的骨赘形成和软骨下骨质硬化。过度负荷的软骨下骨质中的细微骨折激起慢性炎症反应，坏死的骨骼被纤维组织替代导致软骨下囊肿形成。

　　ClinicalFindings

　　a.SympomsandSigns：Osteoarthritisisalocalconditionwithoutsystemicmanifestations.Asymptomaticdegenerativejointchangesinthehandsandspinearecommon，butweight-bearingjointssuchasthekneeandhipareoftenstiffandpainful，particularlyfollowingtheactivitiesoftheday.Symptomsmaybeepisodic，withlongperiodsofspontaneousremission，orslowlybutsteadilyprogressive，resultinginprofounddisabilityandintractablepain.Discomfortischaracteristicallymoresevereatnight，andmorningstiffnessisminimal.Monarticularosteoarthritisisunusual.Bothkneesaretypicallyinvolved，thoughoneusuallymoreextensivelythantheother.Osteoarthritisofthehipoccursslightlylessfrequentlybutisstillquitecommon，Nodularswellingofthedistaljointsofthefingers（Heberden'snodes）ispainfulinoverhalfofaffectedindividuals.andpainfuldegenerationofthecarpometacarpaljointofthethumbandthemetocarpophalangealjointofthegreattoeiscommon，theankle，shoulder，andelbowarerarelyinvolved，andthewristleastfrequentlyofall.

　　临床表现

　　a.症状与体征：骨关节炎是一局部病变无全身症状。无症状的退行性关节变化常见于手和脊柱，而在负重的膝及髋关节等常是僵凝和疼痛的。特别是在一在活动之后更是如此。症状可以是发作性的。可长期自行缓解或缓慢地稳步发展，导至严重的残废和难治的疼痛，不适的特征是夜间较重，而早上僵硬程度最轻。单关节骨关炎不多见。典型的为侵犯双侧膝关节，不过一侧较另一侧严重。髋关节骨关节炎发生得轻些少些，但仍不少见。半数以上患者的手指远端关节出现结节性肿胀（Heberden's结节），拇指腕骨关节及大趾的，跖趾关节疼痛性变性最常见。踝，肩及肘关节很少受到侵犯，在所有关节中腕关节受累最少。

　　Examinationofosteoarthriticjointsisremarkablefortheabsenceofinflammatorysigns.Effusion，whenpresent，isslight，andrednessandwarmthareusuallyabsent.Painwithmotionisthepredominantfinding，andcrepitationmaybepalpatedwithpassivemotion.Rnage-of-motiontestingrevealslimitationofterminalflexionandextensionintheinvolvedkneejointsandinternalrotationininvolvedhips.Moreseverelimitationischaracteristicofmoreadvanceddisease.Varusorvalgusdeformityofthekneemaybepresent，dependinguponthepredominanceofinvolvementofthemedialorlateraljointcompartment.Heberden'snodesofthedistalinterphalangealjointsofthehandareclassicfindings.Thesedorsalbonyprominencesrepresentmarginalosteophytes，SimilardegenerativechangesoftheproximalinterphalangealjointsmaybepresentandareknoiwnasBouchard’snodes.

　　引入注意的是检查骨关节炎性关节时无炎症性体征。如有渗出液，一般都很轻微。通常无发红和发热现象。最突出的表现是活动时疼痛，被动活动可触到磨擦感。活动范围试验显示受累膝关节不能完全屈曲和伸直，髋关节内旋受限。病情越发展，活动范围更严重受限。随着关节内侧和外侧明显受累，可出现膝内翻或外翻畸形。手远侧指间关节的Heberden's结节是典型的表现。这些前侧骨突起表明有边缘性骨赘。近侧指间关节可出现类似的退行性变。这种病变称为Bouchard氏结节。

　　b.LaboratoryFindings：Laboratorystudiesareusuallynormal.

　　b.实验室检查：实验室检查通常正常。

　　c.X-RayFindings：X-rayfindingsareconsistentwiththehistopathologicstageofdegeneration.Earlychangesconsistofmildjointspacenarrowingandminimalosteophyteformation（“spurring”）。oftheperipheryofinvolvedjoints.Moreadvanceddiseaseismanifestedbyseverejointspacenarrowing，markedosteophyteformationatthejointmargins，densesclerosisofsubchondralbone，andsubchondralcysts.Subluxationandjointspacenarrowingareoftenapparentonlyonweight-bearingfilms，whichshouldbeobtainedforbothkneesandhips.]

　　c.X线表现：X线所见与组织病理的变性期一致，早期变化有轻度关节间隙窄狭窄，受累关节周围有很轻的骨赘形成（骨刺）。更严重的疾病，表现为关节间隙更窄狭，在关节边缘有明显骨赘形成，软骨下骨坚实硬化以及软骨下囊肿。不完全脱位和关节间隙狭窄只是在关节承受重力时所拍的片中常是明显的但两侧的膝及髋关节都应拍片。

　　Treatment

　　a.ExternalSupportMeasures：Managementofosteoarthritisdependsuponthestageofdisease.Whendegenerationinaweight-bearingjointismild，symptomsaresignificantlyrelievedbyuseofexternalsupportssuchasacane，crutches，orawalker.Thoughactualhealingofosteoarthriticcartilageisdifficulttodemonstrate，remissionofjointpainissometimesdramaticwhenstressisdiminishedbyuseofexternalaida.

　　a.外支撑法：骨关节炎的处理方法取决于疾病处于何阶段，当一负重的关节变性较轻时，使用外支撑物如手杖，拐杖或步行器可使症状明显缓解。虽然骨关节炎的软骨实际愈合很难证实，但通过支架减轻压力，关节疼痛的缓解有时是很明显的。

　　b.Medication：Anti-inflammatorydrugsarelesseffectiveinosteoarthritisthaninrheumatoidarthritisorgout.Atrialofnonsteroidalantiinflammatorydrugsiswarranted，however，assomepatientsreportconsiderablereliefwiththeiruse.Analgesics，hotpacks，ultrasound，andmassagemayalsoprovidesymptomaticrelief.Physicaltherapyforjointstrengtheningexercisesmayoccasionallybywarranted，andweightreductionisbeneficial.

　　b.药物治疗：抗炎药物对骨关节炎的作用比起类风湿性关节炎或痛风要小些。试用非类固醇类抗炎药物是有根据的，正如某些病人所言，在使用后有一定缓解。止痛药，热敷法，超声及按摩亦可使症状缓解。增强关节的运动等物理疗法，偶尔有用，减轻负重是有利的。