超音波顯示膝蓋積水可以預測骨關節炎的關節置換


  June 13, 2008(巴黎) — 歐洲多中心的研究團隊在EULAR 2008-歐洲抗風濕年度研討會中報告指出,超音波檢查積水,在膝蓋骨關節炎(OA)超音波檢查的滑囊發炎期特徵,可以作為需要關節置換手術的獨立預測因子。
  
  主要研究者、英國Leeds大學肌肉骨骼醫學教授Phillip Conaghan醫師向Medscape Rheumatology表示,在600名膝蓋骨關節疼痛的病患中,超音波膝蓋積水深度4mm以上者需要全膝置換手術的風險,是積水深度小於4mm者的將近3倍。
  
  Conaghan醫師表示,這是首次提出一個客觀發炎標記作為關節置換的預測因子;這不令人驚訝,因為我們知道發炎與軟骨損傷呈些許比率,或許是膝蓋內的其他構造損傷,現在我們有了現代的工具可以偵測這些。
  
  不過,他們很快停止研究,他們表示研究發現已展現因果關係,也就是說,滑囊發炎引起滑囊和/或構造惡化導致關節置換。
  
  Conaghan 醫師表示,這或許是偶發症狀,沒有人可以相當確定地指出OA的滑囊會造成疾病惡化,這著實是另一個有趣的問題,因為我們改變整個如何治療OA的要素。
  
  研究者前溯式探究OA疼痛病患的膝蓋,為期3年,病患有一部分是一個歐洲多中心的大型EULAR贊助試驗,所有病患在研究開始時接受臨床評估、X光以及超音波檢查。
  
  研究者在3年的追蹤期間,使用Kaplan-Meier存活資料分析確認膝蓋置換手術的比率,他們也進行單一變項指數系列法,和使用Cox比例危險回歸模型(Cox proportional hazards regression model)進行多變項分析,以釐清關節置換的預測因子;潛在的基礎預測因子,如人口統計學和臨床因子,以及放射線和超音波特徵都被檢視。
  
  共有531名病患接受分析,平均年紀為67 ± 10歲,平均疾病期間為6.1 ± 6.9 年,在平均3年的追蹤期間,94名病患接受或者判定需要膝置換手術,計算得到事件發生比率為17.7%。
  
  在這個多變項分析中,研究人員確認關節置換的預測因子如下:
  * Kellgren和Lawrence放射線分級大於等於3相較於小於3 (風險比 [HR], 4.08; 95% 信心區間 [CI], 2.34 – 7.12; P < .0001)
  * 超音波證實膝蓋積水深度至少4mm相較於不到4mm(HR, 2.63; 95% CI, 1.70 – 4.06; P < .0001)
  * 膝蓋疼痛強度在0-100mm的視覺類比量表中,大於等於60相較於不到60 (HR, 1.81; 95% CI,1.15 – 2.83; P = .01)
  * 疾病期間至少5年相較於不到5年(HR, 1.63; 95% CI, 1.08 – 2.47; P = .02)。
  
  Conaghan 醫師指出,不論是臨床偵測積水或者是超音波檢視滑囊,都與單一變項分析的關節置換有關。
  
  匹茲堡大學醫學流行病學教授C. Kent Kwoh醫師對Medscape Rheumatology提出有關此研究的建議時表示,我認為這很有意義,我們在OA探究的議題是,是否有發炎成分、其影響度為何,這幫助我們思考或許有顯著的發炎成分可以用積水測量,可幫助預測人們的長期結果是否惡化、以及是否需要關節置換。
  
  該研究接受EULAR贊助。Conaghan 醫師和 Kwoh醫師宣稱沒有相關資金上的往來。
  
  EULAR 2008:歐洲抗風濕年度研討會:摘要Thu0299.。發表於2008年6月12日。

Knee Effusion on Ultrasound Predicts Joint Replacement in Osteoarthritis

By Neil Osterweil
Medscape Medical News

June 13, 2008 (Paris) — Ultrasound effusion, a feature of synovial inflammation seen on ultrasound studies in knee osteoarthritis (OA), is an independent predictor of the need for joint replacement, a multicenter team of European investigators reported here at EULAR 2008, the European League Against Rheumatism Annual Congress.

Of 600 patients with painful OA of the knee, ultrasonographic knee effusion depth of 4 mm or greater was associated with a nearly 3-fold risk for total knee replacement surgery compared with effusion depths of less than 4 mm, said lead investigator Phillip Conaghan, MD, a professor of musculoskeletal medicine at the University of Leeds, United Kingdom, in an interview with Medscape Rheumatology.

"What's new is that for the first time, an objective marker for inflammation is a predictor of joint replacement," Dr. Conaghan said. "It's not so surprising, because we know that the inflammation is roughly proportional to the amount of, at least, cartilage damage, but probably other structural damage within the knee, but now that we've got modern tools, we can detect these things."

He and his colleagues stop short, however, of saying that their findings constitute cause and effect; that is, that synovial inflammation causes synovial and/or structural deterioration leading to joint replacement.

"This is probably an epi-phenomenon," Dr. Conaghan said. "Nobody has really conclusively shown that the synovitis of OA contributes to the progression of the disease, and that's another really interesting question, because then we change a whole lot of stuff, how we treat OA."

The investigators prospectively looked at patients with painful OA of the knee for 3 years. The patients were part of a large EULAR-sponsored trial conducted in centers across Europe. All of the patients in the substudy had clinical evaluation, X-ray studies, and ultrasonography at entry.

The investigators determined the rate of knee replacement surgery during the 3-year follow-up period using Kaplan-Meier survival data analyses. They also conducted univariate log-rank tests and multivariate analysis using a Cox proportional hazards regression model to tease out data on predictors for joint replacement. Potential baseline predictors such as demographic and clinical factors, as well as radiographic and ultrasound features, were also examined.

A total of 531 patients who were a mean age 67 ± 10 years, with a mean disease duration of 6.1 ± 6.9 years, were available for the analysis. During the median 3-year follow-up, 94 patients either underwent or were determined to be in need of knee replacement surgery, yielding an estimated event rate of 17.7%.

In the multivariate analysis, the investigators determined that predictors of joint replacement were the following:

  • Kellgren and Lawrence radiographic grade greater than or equal to 3 compared with a grade of less than 3 (hazard ratio [HR], 4.08; 95% confidence interval [CI], 2.34 – 7.12; P < .0001)
  • Ultrasound evidence of knee effusion of at least 4 mm depth compared with effusion of less than 4 mm (HR, 2.63; 95% CI, 1.70 – 4.06; P < .0001)
  • Knee pain intensity on a 0- to 100-mm visual analog scale of 60 or greater compared with intensity of less than 60 (HR, 1.81; 95% CI,1.15 – 2.83; P = .01)
  • Disease duration of at least 5 years compared with duration of less than 5 years (HR, 1.63; 95% CI, 1.08 – 2.47; P = .02).

Dr. Conaghan noted that neither clinically detected effusion nor synovitis seen on ultrasound were associated with joint replacement in the univariate analysis.

"I think this is very promising," said C. Kent Kwoh, MD, professor of medicine and epidemiology at the University of Pittsburgh, Pennsylvania, who commented on the study for Medscape Rheumatology. "The issue that we're looking for in OA is whether there's an inflammatory component and what the significance of that is, and this helps us see that perhaps a significant inflammatory component as measured by effusion in this study might help to predict which people are going to have worse long-term outcomes, such as the need for joint replacement."

The study was funded by EULAR. Dr. Conaghan and Dr. Kwoh have disclosed no relevant financial relationships.

EULAR 2008: The European League Against Rheumatism Annual Congress: Abstract Thu0299. Presented June 12, 2008.

    
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