• 中国科技论文统计源期刊
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Volume 44 Issue 12
Dec.  2019
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Effect of the arthroscope combined with Bushenjiangu decoction in the treatment of osteoarthritis of ankle joint in middle and old age

  • Received Date: 2017-07-24
    Accepted Date: 2018-06-17
  • ObjectiveTo study the effects of arthroscopic surgery combined with Bushenjiangu decoction on the ankle joint pain, swelling and activity in middle and old age patients with osteoarthritis.MethodsNinety-six elderly patients with osteoarthritis of the ankle joint were randomly divided into the control group and observation group(48 cases in each group).The control group was treated with arthroscopic surgery, and the observation group was treated with Bushenjiangu decoction on the basis of control group.The curative effect was compared between two groups, and the scores of ankle joint pain, swelling and activity in two groups were compared between before and after treatment.All cases were followed-up for 1 year.The improved McGuire, Mazur and AOFAS scores were compared.ResultsThe total effective rates of treatment in observation group and control group were 97.91% and 83.33%, respectively, and the difference of which was statistically significant(P < 0.01).The joint pain, swelling and activity scores in two groups after treatment were significantly higher than those before treatment(P < 0.01), and the joint pain, swelling and activity scores in observation group after treatment were significantly higher than those in control groups(P < 0.01).After 1 year of following-up, the improved McGuire, Mazur and AOFAS scores in two groups were significantly higher than before treatment(P < 0.01), and the improved McGuire, Mazur and AOFAS scores in observation group were significantly higher than those in control group(P < 0.01).ConclusionsThe curative effect of arthroscopic surgery combined with Bushenjiangu decoction on senile osteoarthritis of the ankle joint is significant, which can significantly improve the ankle pain, swelling and other symptoms, promote the recovery of ankle function, and is highly secure and worthy of promotion in clinic.
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  • [1] NAKAJIMA A, NAKAGAWA K, AOKI Y, et al.Changes in synovial fluid biochemical markers following arthroscopic surgery in patients with knee osteoarthritis[J].Rheumatol Int, 2013, 33(1):209. doi: 10.1007/s00296-012-2374-8
    [2] 任珩, 杨益民, 袁学峰, 等.关节镜结合补肾坚骨汤治疗中老年踝关节骨性关节炎35例临床观察[J].中医药导报, 2014, 19(14):74.
    [3] AKALAN N E, APTI A, KUCHIMOV S, et al.Does clinically measured ankle plantar flexor muscle strength or weakness correlate with gait velocity, ankle kinematics and kinetics during walking for healthy individuals?[J].Gait Post, 2015, 42(13):25.
    [4] 杨益民, 任珩, 袁学峰, 等.关节镜结合中药治疗老年人髌股关节炎的临床研究[J].华南国防医学杂志, 2014, 28(10):976.
    [5] 任珩, 袁学峰, 杨益民.踝关节镜在中老年骨性关节炎中的临床应用[J].西部医学, 2014, 26(8):1051. doi: 10.3969/j.issn.1672-3511.2014.08.032
    [6] DELCO ML, KENNEDY JG, BONASSAR LJ, et al.Post-traumatic osteoarthritis of the ankle:a distinct clinical entity requiring new research approaches.[J].J Orthop Res, 2016, 24(17):829.
    [7] 蒋逸秋, 桂鉴超.老年性踝关节骨性关节炎的外科干预[J].实用老年医学, 2015, 20(9):715.
    [8] WIKSTROM EA, ANDERSON RB.Alterations in gait initiation are present in those with posttraumatic ankle osteoarthritis:a pilot study.[J].J Appl Biomech, 2013, 29(3):245. doi: 10.1123/jab.29.3.245
    [9] 任珩, 袁学峰, 刘雅静, 等.关节镜下手术治疗踝关节骨性关节炎的临床疗效观察[J].安徽医药, 2014, 18(3):517. doi: 10.3969/j.issn.1009-6469.2014.03.038
    [10] FIGUEROA D, CALVO R, VILLALÓN IE, et al.Clinical outcomes after arthroscopic treatment of knee osteoarthritis[J].Knee, 2013, 20(6):591. doi: 10.1016/j.knee.2012.09.014
    [11] PIHL K, ENGLUND M, LOHMANDER LS, et al.Signs of knee osteoarthritis common in 620 patients undergoing arthroscopic surgery for meniscal tear[J].Acta Orthopaedica, 2017, 16(25):1.
    [12] 段小军, 杨柳.踝关节重度骨关节炎行关节镜下踝关节融合术的临床研究[J].第三军医大学学报, 2015, 37(3):220.
    [13] 袁奇亮, 王明君, 李振威, 等.关节镜下综合治疗踝关节骨关节炎28例临床分析[J].中华实用诊断与治疗杂志, 2013, 17(4):403.
    [14] NVESCH C, HUBER C, PAUL J, et al.Mid-to-Long-term clinical outcome and gait biomechanics after realignment surgery in asymmetric ankle osteoarthritis.[J].Foot Ankle Int, 2015, 36(8):908. doi: 10.1177/1071100715577371
    [15] 夏卿, 王凌椿.关节镜清理术联合活血消肿汤辨证治疗膝关节骨性关节炎的疗效分析[J].四川中医, 2013, 31(10):79.
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Effect of the arthroscope combined with Bushenjiangu decoction in the treatment of osteoarthritis of ankle joint in middle and old age

  • 1. Department of Orthopedics, Tangshan Union Hospital, Tangshan Hebei 063000, China
  • 2. Electromyogram Room, Tangshan Union Hospital, Tangshan Hebei 063000, China

Abstract: ObjectiveTo study the effects of arthroscopic surgery combined with Bushenjiangu decoction on the ankle joint pain, swelling and activity in middle and old age patients with osteoarthritis.MethodsNinety-six elderly patients with osteoarthritis of the ankle joint were randomly divided into the control group and observation group(48 cases in each group).The control group was treated with arthroscopic surgery, and the observation group was treated with Bushenjiangu decoction on the basis of control group.The curative effect was compared between two groups, and the scores of ankle joint pain, swelling and activity in two groups were compared between before and after treatment.All cases were followed-up for 1 year.The improved McGuire, Mazur and AOFAS scores were compared.ResultsThe total effective rates of treatment in observation group and control group were 97.91% and 83.33%, respectively, and the difference of which was statistically significant(P < 0.01).The joint pain, swelling and activity scores in two groups after treatment were significantly higher than those before treatment(P < 0.01), and the joint pain, swelling and activity scores in observation group after treatment were significantly higher than those in control groups(P < 0.01).After 1 year of following-up, the improved McGuire, Mazur and AOFAS scores in two groups were significantly higher than before treatment(P < 0.01), and the improved McGuire, Mazur and AOFAS scores in observation group were significantly higher than those in control group(P < 0.01).ConclusionsThe curative effect of arthroscopic surgery combined with Bushenjiangu decoction on senile osteoarthritis of the ankle joint is significant, which can significantly improve the ankle pain, swelling and other symptoms, promote the recovery of ankle function, and is highly secure and worthy of promotion in clinic.

  • 踝关节骨性关节炎属于关节退行性疾病,一般多在50岁左右中年或者老年人群体中发生,特征表现为关节软骨退变、畸形以及关节周骨质增生[1]。研究[2]显示,关节炎发病踝关节是膝关节的1/12~1/10。该病病人主要表现为关节疼痛及功能障碍,踝关节无法正常行使负重功能。目前,保守治疗和手术治疗是踝关节骨性关节炎最常用的治疗手段,其中保守治疗包括理疗、减轻负重、抗炎药物及透明质酸钠等方法[3],多用于疾病早期病人中,但无法彻底根治疾病。而中晚期病人多采用手术进行治疗,传统手术包括游离体去除、骨赘清理、关节置换或融合等,其创伤较大[4],存在较高并发症风险,影响术后预后质量。近年来微创外科不断获得进步,各种类型腔镜手术在临床中得到大范围推广和应用。自1981年关节镜用于探查踝关节的首次报道以来,踝关节镜病灶清理术得到显著进展,已逐步取代传统切开术,成了踝关节骨性关节炎治疗之第一选择[5]。中医治疗踝关节骨性关节炎有着悠久历史,中药配合踝关节镜术能够提升这一病症整体治疗效果。本文就选用补肾坚骨汤对中老年踝关节骨性关节炎治疗效果进行研究证实,旨在为临床提供指导。现作报道。

1.   资料与方法
  • 选择2014年12月至2016年2月在我院接受治疗的中老年踝关节骨性关节炎病人96例;纳入标准[6]:(1)符合《临床常见病诊疗手册》诊断标准;(2)X线检查提示关节间隙小且边缘骨质增生;(3)踝关节弹响、疼痛。排除标准:(1)生活不能自理;(2)心、肾、肺功能严重不健全及糖尿病病人;(3)不能坚持配合内服中药的病人。采用随机数字法分为对照组和观察组,各48例。对照组男29例,女19例;年龄41~79岁;病程6~27个月。观察组男30例,女18例;年龄40~79岁;病程5~29个月。2组病人性别、年龄、病程等一般资料均具有可比性。

  • 所有病人都行关节镜下病灶清理术治疗。手术方法:保持病人仰卧姿势位于手术床,给予椎管内麻醉处理,常规消毒铺巾,气囊止血带止血。关节镜由Ackermann Instrumente GmbH生产,手术选取前内、前外侧入路,行长约5 mm切口,经关节镜下均可见关节滑膜出现不同程度充血、增生、软骨剥脱,术中清除明显增生滑膜、清理软骨创面使其边缘平缓,同时将游离软骨及脱落碎屑清除。采用髓核钳或者磨钻将踝关节内骨赘清除,同时使用射频汽化烧灼骨创面使其保持平滑。手术完成后不留置引流管,采用厚棉垫常规加压包扎处理,同时服用抗生素抗感染3 d。

  • 观察组病人实施关节镜下病灶清理术后第2天开始口服补肾坚骨汤联合治疗,方中成分:当归、赤芍、熟地黄、杜仲、川断以及桑寄生各12 g,独活、秦艽、桂枝、川芎以及威灵仙各10 g,细辛5 g;于沸水煎熬后口服,每天1剂,分2次服用; 1个月为1个疗程,1个疗程后休息3~5 d; 共服用4个疗程。

  • 对2组病人治疗总有效率进行比较;比较2组病人治疗前和术后1年踝关节疼痛、肿胀及活动度评分;术后随访1年,对比2组病人治疗前和治疗后改良McGuire、Mazur及美国矫形外科足踝协会(AOFAS)评分。根据AOFAS踝-后足评分系统对踝关节肿胀、疼痛、活动度及各项功能指标评分开展治疗效果评价[7],可分为:显效,总分>80分;有效,总分65~80分;无效,总分 < 65分。治疗总有效率=(显效率+有效率)/总例数×100.0%。踝关节疼痛、肿胀及活动度均分为0分、1分、2分及3分4个计分等级,分数越高表示症状越轻。

  • 采用t检验和秩和检验。

2.   结果
  • 观察组与对照组治疗总有效率分别为97.91%和83.33%,差异有统计学意义(P < 0.01)(见表 1)。

    分组 n 显效 有效 无效 总有效率/% uc P
    对照组 48 17 23 8 83.33
    观察组 48 31 16 1 97.91 3.17 < 0.01
    合计 96 48 39 9 90.63
  • 2组病人治疗前踝关节疼痛、肿胀及活动度评分比较差异均无统计学意义(P>0.05);治疗后,2组治疗后关节疼痛、肿胀及活动度评分均显著高于治疗前(P < 0.01),且观察组病人的踝关节疼痛、肿胀及活动度评分均明显高于对照组(P < 0.01)(见表 2)。

    分组 n 疼痛 肿胀 活动度
    治疗前
        对照组 48 0.87±0.16 1.30±0.68 1.07±0.61
        观察组 48 0.89±0.17 1.34±0.71 1.05±0.58
          t 0.59 0.28 0.16
          P >0.05 >0.05 >0.05
    治疗后
        对照组 48 1.47±0.58** 1.72±0.65** 2.13±0.75**
        观察组 48 2.43±0.71** 2.16±0.54** 2.51±0.66**
          t 7.25 3.61 2.64
          P < 0.01 < 0.01 < 0.01
        组内配对t检验:**P < 0.01
  • 2组病人治疗前改良McGuire、Mazur及AOFAS评分差异均无统计学意义(P>0.05);随访1年后,2组病人的改良McGuire、Mazur及AOFAS评分均显著高于治疗前(P < 0.01),且观察组病人的改良McGuire、Mazur及AOFAS评分均显著高于对照组(P < 0.01)(见表 3)。

    分组 n 改良McGuire Mazur AOFAS
    治疗前
        对照组 48 52.16±12.35 56.34±10.75 52.53±11.80
        观察组 48 51.87±11.96 56.73±11.02 53.12±12.35
          t 0.12 0.18 0.24
          P >0.05 >0.05 >0.05
    治疗一年后
        对照组 48 73.18±9.58** 72.95±9.48** 72.15±8.81**
        观察组 48 84.26±8.74** 85.10±8.67** 83.46±8.34**
          t 5.92 6.55 6.46
          P < 0.01 < 0.01 < 0.01
        组内配对t检验:**P < 0.01
3.   讨论
  • 踝关节是人体负重之重要部位,通过胫腓下端关节面以及距骨滑车组成,其承受重量较膝以及髋这些关节更高,且距离地面较近,承重无法有效缓冲。当踝关节长期过度负重,导致关节滑车摩擦增大,出现软骨纤维变形及关节软骨丢失,磨损软骨的碎屑、微结晶以及降解物质堆积于关节腔内,进而介导继发性慢性滑膜炎发生,并能刺激白细胞介素、肿瘤坏死因子等炎症因子释放,导致关节腔内环境变化,出现滑膜充血、血管增生、软骨破坏,易诱发踝关节骨性关节炎发生[8]。疼痛、肿胀及活动受限是踝关节骨性关节炎最主要的表现特征,与关节滑膜充血、炎症细胞浸润所致滑膜绒毛增生、肥厚、软骨边缘骨赘脱落、断裂在关节腔内形成的游离体有关[9]。因此,有效改善关节腔内环境、清除受损软骨、脱落碎屑,是改善踝关节疼痛、肿胀及功能的关键。目前,临床治疗踝关节骨性关节炎相关办法较多,大致包含保守治疗与手术两大类。药物、理疗等保守治疗手段无法做到有效改善关节腔内环境,清除关节内软骨碎屑等致痛因子,其治疗疗效有限,且后期易出现复发,加重病人身心负担[10]。传统切开术主要以清除炎性滑膜和骨赘、游离体、清理病变软骨为主,但其手术创伤较大,易损伤周围血管和神经,存在较高并发症风险,严重影响其手术综合效果。

    近年来,踝关节镜在踝关节骨性关节炎中得到广泛应用,具有损害性小、手术以后恢复迅速、并发症低等多种优势,可以完全清除关节腔内受损害软骨及其碎屑,同时去除影响关节正常功能的骨赘和游离体,使关节腔内致痛因子得以清除,同时能够清除关节内炎症因子,阻断炎症反应恶性循环,从而减轻疼痛、肿胀等症状[11]。且研究[12]证实,其还能够调节关节腔内酸碱平衡、酶活性以及抑制自由基释放,改善关节腔内环境,从而促进病情康复。关节镜术在踝关节骨性关节治疗中所体现出的治疗效果已得到一致认可,但其虽能一定程度改善病人踝关节疼痛、肿胀及活动度,但仍无法做到彻底治愈。关节镜手术配合中药内服可增强手术治疗效果,促进疾病的治愈[13]。祖国中医对骨性关节炎有着独特治疗优势,其认为肝肾亏损发虚、气血停滞凝聚是其主要病因,因此,滋养补充肝肾、疏通血液脉络是中医治疗该病症的主要原则。药理学研究[14]表明,补肾坚骨汤同时具有补养肝肾和强健筋骨之功效,可明显增强病人抗炎症、抗敏感能力,并能促进软骨的修复,抑制滑膜炎症所致的增生、肥厚,进而实现消肿止痛、恢复关节功能的效果。本研究结论显示,2组疗效比较差异有统计学意义,同时观察组治疗后踝关节疼痛、肿胀以及活动度评分同样显著高于对照组,证实配合补肾坚骨汤能够提高关节镜手术治疗效果,与相关报道[15]基本一致。且术后随访1年发现,观察组病人在改良McGuire、Mazur以及AOFAS评分均显著高于对照组,表明补肾坚骨汤同样能帮助并加快踝关节远期功能恢复。

    综上所述,关节镜手术联合补肾坚骨汤对中老年踝关节骨性关节炎的疗效显著,可明显改善踝关节疼痛、肿胀等症状,加快踝关节功能恢复,并且治疗安全性较高,适合在临床中进行广泛推广。

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