基于下肢力线的膝骨关节炎“筋—骨”平衡体系研究
|
摘要
1、研究目的：
膝骨关节炎是在力学因素和生物学因素的共同作用下形成的一种慢性、进展性关节疾病。现在的研究多从生物学因素着眼,忽视了力学因素的重要作用。随着对膝骨关节炎病因病理研究的不断深入,我们提出：膝骨关节炎是膝关节筋骨平衡体系打破后,不断完善自身平衡状态的生物力学过程,正常的下肢力线是其平衡体系的基础。因此,基于下肢力线,探讨膝关节筋骨平衡体系之间的作用规律将有助于揭示力学因素在膝骨关节炎病程中的作用。本研究将通过影像学研究(X线、MR)探讨影响下肢力线的相关因素并筛选出临床中评价下肢力线简便有效的方法,同时运用中医经筋辨证的方法,为阐释膝骨关节炎筋骨平衡体系中“筋—骨”之间相互转化的病机构建联系的桥梁。
2、研究方法：
首先首先通过理论研究,从膝骨关节炎的解剖特点和生物力学模式入手,构建基于下肢力线的膝关节筋骨平衡体系的理论基础,同时结合中医经筋理论的研究,探讨运用经筋理论阐释膝骨关节筋骨病机的方法。然后通过对膝骨关节炎相关角度的测量,探索评价下肢力线畸形情况的简便有效地方法,为晚期膝骨关节炎患者行人工膝关节置换术时下肢力线的评估提供参考。通过人工膝关节置换术,评估晚期膝骨关节炎筋骨失衡状态,并积累人工膝关节置换术中重建基于下肢力线下的膝关节筋骨平衡体系的方法。最后通过对不同时期膝骨关节炎下肢力线的研究,运用磁共振的筛选出影响下肢力线的相关因素。并结合经筋辨证的方法,对膝骨关节炎经筋病变情况进行统计分析,初步总结膝骨关节炎经筋病变特点和筋骨之间相互转化的规律。
3、研究结果：
3.1通过理论研究,从膝骨关节炎的解剖特点和生物力学模式研究,我们认为膝关节的解剖特点和运动特点为膝关节筋骨平衡体系奠定了理论基础,下肢力线是膝关节筋骨平衡体系的根本。借助中医经筋辨证的方法能为膝骨关节炎“筋—骨”之间相互转化的病机提供联系的桥梁。
3.2人工膝关节置换患者影像学资料的测量术前患者机械轴(HKA)为186.7°土2.1°,胫股角(FTA)为183.8°土1.7°。通过HKA和FTA两项指标的相关度进行分析,发现FTA和HKA之间具有相关性(r=0.712,P<0.01)。
3.3人工膝关节置换术中对患者的半月板损伤情况进行了分析,其中内侧半月板损伤的有30例(前角损伤5例,体部损伤12例,后角部损伤13例),外侧半月板损伤的有8例(前角损伤2例,体部损伤3例,后角部损伤3例),外侧半月板的损伤情况远少于内侧。术中前交叉韧带都表现有一定的充血水肿,部分断裂的有8例,完全断裂的有2例。后交叉韧带相对比较完整,但多表现出不同程度的挛缩变性。内外侧副韧带都保存完好,内侧副韧带表现出不同程度的挛缩。通过对对膝关节内侧平台进行了区域划分,统计分析发现退变区域主要集中在3、4、6、7、8、2区,除了在6、7、8区发生软骨退变外,半月板保护下的2、3、4区同样发生较为严重的软骨退变。3.4人工膝关节置换术前膝骨关节炎患者的FTA角度为183.8°±1.7°,术后FTA角度为175.6°±2.1。,经统计分析P<0.01,差异有统计学意义。术前TS角度为8.6°±2.4°,术后TS角度为7.4°±3.8°,经统计分析P>0.05,差异无统计学意义。术前PT角度为83.7°±2.1°,术后为88.6°±2.0°,经统计分析P<0.01,差异有统计学意义。术前FC角度为80.3°±3.2°,术后为81.7°±2.6°,经统计分析P<0.05,差异有统计学意义。人工膝关节置换术前患者HHS评分为40.7±7.4,术后两周64.7±6.2,术后三个月84.7±6.8,术前术后评分经统计学分析P<0.01,差异有统计学意义。术后两次随访评分经统计学分析P<0.01,差异有统计学意义。术前疼痛评分7.8±3.3,术后两次随访评分分别为20.4±2.6,25.4±2.8,术前术后评分经统计学分析P<0.01,差异有统计学意义。术后两次随访评分经统计学分析P>0.05,差异无统计学意义。膝关节活动度为87°±8°,术后两次随访评分分别为98±6,110±6,术前术后评分经统计学分析P<0.05,差异有统计学意义。术后两次随访评分经统计学分析P<0.05,差异有统计学意义。
3.5运用影像学测量方法,对膝骨关节炎的三个角度进行测量,当K-L分级在Ⅱ级时,FTA角是177.5°±1.7°,当K-L分级在Ⅲ级时,FTA角是180.2°±1.2°,当K-L分级在Ⅳ级时,FTA角是182.7°±2.3°,三个级别之间经统计分析P<0.05,差异有统计学意义。当K-L分级在Ⅱ级时,PT角是85.5°±2.1°,当K-L分级在Ⅲ级时,PT角是84.1°±1.4°,当K-L分级在Ⅳ级时,PT角是83.2°±2.6°,三个级别之间经统计分析,Ⅱ级和Ⅲ级,Ⅲ级和Ⅳ级之间比较,P>0.05,差异无统计学意义。Ⅱ级和Ⅳ级之间比较,P<0.05,差异有统计学意义。说明胫骨结构性内翻是造成膝关节内翻畸形的重要因素。当K-L分级在Ⅱ级时,FC角是81.4°±0.9°,当K-L分级在Ⅲ级时,FC角是80.9°±1.2°,当K-L分级在Ⅳ级时,FC角是80.3°±0.7°,三个级别之间经统计分析,P>0.05,差异无统计学意义。说明股骨外翻角的改变在膝关节内翻畸形的过程中影响较小。
3.6运用磁共振检测技术对膝关节内侧室胫骨平台的骨赘和内侧半月板的信号改变进行统计,发现当半月板信号正常时时,有6例(66.67%)没有骨赘出现,当半月板发生信号改变时,有36例(81.82%)出现骨赘,当半月板发生破裂时,有42例(95.24%)出现骨赘,经统计学分析,P<0.05,差异有统计学意义。软骨下骨出现骨髓水肿的区域进行统计,发现共有40例患者出现有不同程度的骨髓水肿,其中内侧有34例,外侧有15例,内外侧都出现的有9例。半月板出现破裂时,半月板移位小于3mm的有19例(38%),半月板移位大于3mm的有23例(51.12%),通过对半月板信号的改变和半月板移位进行统计分析,P<0.05,差异有统计学意义。
3.7通过磁共振检测,结合疼痛VAS评分,在疼痛级别为1级时,有23例(57.5%)患者出现软骨下骨骨髓水肿,37例(67.27%)未出现骨髓水肿。在疼痛级别为2级时,有15例(37.5%)患者出现软骨下骨骨髓水肿,12例(21.82%)未出现骨髓水肿。进行统计分析,P<0.05,差异有统计学意义。在疼痛级别为1级时,有23例(51.11%)患者出现内侧半月板移位大于3mm,37例(67.27%)未出现内侧半月板移位小于3mm。在疼痛级别为2级时,有有20例(44.44%)患者出现内侧半月板移位大于3mm,7例(14%)出现内侧半月板移位小于3mm。进行统计分析,P<0.05,差异有统计学意义。在疼痛级别为1级时,有40例(65.57%)患者出现关节积液,20例(58.82%)未出现关节积液。在疼痛级别为2级时,有20例(32.79%)患者出现关节积液,7例(20.59%)未出现关节积液。进行统计分析,P<0.05,差异有统计学意义。在疼痛级别为1级时,有54例(68.35%)患者出现骨赘,6例(37.5%)未出现骨赘。在疼痛级别为2级时,有19例(24.05%)患者出现骨赘,8例(50%)未出现骨赘。进行统计分析,P<0.05,差异有统计学意义。
3.8通过经筋辨证,我们发现膝骨关节炎经筋辨证规律多呈现出复合证型。单一经筋病变的只有16条(16.84%),两条经筋病变的有54条(56.84%),三条同时病变的有25条(26.32%)。其中出现病变最多的是足三阴经筋70条(73.68%),足阳明经筋64条(67.37%),足太阳经筋58条(61.06%)。通过对三阴经筋的病位进行统计,我们发现病变位置主要集中在髎膝间、膝关次、髎骼次、阴陵上和血海次。
4研究结论
4.1膝骨关节炎筋骨平衡体系的理论基础是建立在膝关节解剖特点和生物力学基础上的。从膝骨关节炎的病理特点入手,从中医“整体观”和“平衡观”的角度出发,阐释了膝骨关节炎的筋骨病机及经筋辨证在膝骨关节炎中的应用价值。
4.2通过对下肢力线和膝关节相关角度的分析,我们认为FTA和HKA之间具有相关性,根据统计结果显示运用FTA角也能较好地反映下肢力线线情况,对制定术前计划及判断手术效果具有非常重要的作用,但FTA角的测量需要遵循严格的拍摄技术标准和测量方法。
4.3通过膝关节置换术中的研究我们认为下肢力线的异常和软骨磨损、软骨下骨的压缩以及韧带的挛缩都有重要的关系,下肢力线的矫正不仅依靠准确的截骨,膝关节周围软组织的松解也是调整下肢力线的关键。这也是膝关节炎筋骨平衡思想的重要体现。
4.4通过影像学研究(X线、MR),我们发现膝关节的疼痛和半月板的移位、软骨下骨髓水肿,滑膜积液,骨赘都有关系。半月板的退变和破裂在膝骨关节炎中发生率较高,半月板移位和骨髓水肿在膝骨关节病程中意义重要,它们是引起下肢力线改变的重要因素,提示关节在异常力线作用下的不平衡状态。
4.5通过经筋辨证研究,我们发现单一经筋病变较少,经筋病变主要是多条经筋同时病变,膝骨关节炎的发生多从阳明经筋和太阳经筋发生病变,或两经同时发病,后多转归为三阴经筋病变,其中出现病变最多的是足三阴经筋,我们发现病变位置主要集中在髎膝间、膝关次、髎髎次、阴陵上和血海次。从经筋辨证规律分析,三组主要经筋和下肢力线之间形成的筋骨平衡体系是膝关节稳定的基础。上述这些研究,可以为运用经筋理论和经筋疗法对膝骨性关节炎进行治疗提供重要参考。
1. Objective
Knee Osteoarthritis (KOA) is known as a chronic, progressing degenerative joint disease, involving a number of biomechanical and biological factors. However, researches are nowadays focused more on biological factors, other than biomechanical factors which play an important role in KOA. Along with the further investigation on the etiology and pathology of KOA, we proposed a theory:the equilibrium stationary system of soft-tissue and bone in KOA based on alignment of lower limb. We believed that KOA is a constantly biomechanical repair process of soft-tissue and bone (STB) when the equilibrium stationary system is broken, the normal alignment of lower limb is the fundament of the system. Therefore, based on alignment of lower limb, investigating the pathological mechanism of equilibrium stationary system (ESS)of STB may facilitate to reveal the pathogenesis of biomechanical factors in KOA. The study focused on factors influencing the alignment of lower limb and tried to explore a convenient and effective way to evaluate the alignment by tomography (X ray, MR) also applied traditional methods of syndrome differentiation in Meridian-Sinew to explain the pathogenesis of KOA concerning STB.
2. Methods
Firstly, by analyzing the anatomical characteristics and biomechanical model of knee,we founded the basis of the equilibrium stationary state of STB, and by combining the theory of Meridian-Sinew with our study, we explored a way to explain the pathogenesis of KOA concerning STB. Secondly, we evaluated alignment of lower limb by means of measuring the angles concerning KOA.That was a convenient and effective method which could provide an important basis to assess the alignment of lower limb in the process of total knee arthroplasty(TKA).By analysing the disequilibrated state of STB in the procedures of TKA, we conduct research to explore the way to equilibrate the relationshipe of STB in in the process of TKA for late KOA. Thirdly, we screened the factors influencing the alignment of lower limb in in different stages of KOA by means of MR. We also apply traditional methods of syndrome differentiation in Meridian-Sinew to analyze statistically the conditions of KOA so as to explain the pathogenesis of KOA and sum up the interacting patterns of STB.
3. Result
3.1 By analyzing the anatomical characteristics and biomechanical model of knee, we believe the equilibrium stationary system of STB in KOA is based on the anatomical characteristics and motion characteristics. The normal alignment of lower limb is the fundamental in the system. The theory of Meridian-Sinewcan in traditional Chinese medicine can provide a way to explain the pathogenesis of KOA concerning soft tissue and bone.
3.2 The HKA angle was 186.7°±2.1°, and the FTA angle was 183.8°±1.7°,there was a correlation between the FTA angle and HKA (r=0.712,P<0.01)
3.3 The patients in knee arthroplsty with meniscus injury was analyzed, including the medial meniscus in 30 cases (5 cases in the anterior horn,12 cases in body,13 cases in posterior corner), lateral meniscus injury in 8 patients (2 cases in the anterior horn,3 cases in body,3 cases in posterior corner), lateral meniscu injury was much lower than the medial meniscu. Anterior cruciate ligament surgery had shown a certain degree of congestion and edema, partial rupture in 8 patients, there were two cases of complete rupture. Posterior cruciate ligament was relatively intact,but show contracture.The lateral collateral ligament and medial collateral ligament Were well preserved, the medial collateral ligament showed contracture.Analysesing the degeneration zone in medial platform according to regional division, we found degeneration mainly in 3,4,6,7,8,2 zone. The 2,3,4 zone under the protection of the meniscus had the same cartilage degeneration as the 6,7,8, zone.
3.4 The FTA angle preoperative was 183.8°±1.7°,postoperative was 175.6°±2.1°, statistical study showed the curative effect of two groups had a significant difference (P<0.01).The TS angle preoperative was 8.6°±2.4°,postoperative was 7.4°±3.8°,there was no statistical significance between two groups (P>0.05).The PT angle was preoperative 83.7°±2.1°postoperative was 88.6°±2.0°, statistical study showed the curative effect of two groups had a significant difference (P<0.01). The FC angle preoperative was 80.3°±3.2°, postoperative was 81.7°±2.6°, statistical study showed the curative effect of two groups had a significant difference (P<0.05). After a follow-up of three months, the HSS score improved from 40.7±7.4 (preoperative) to 64.7±6.2 (2 weeks postoperative),84.7±6.8 (3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). The VAS score improved from 7.8±3.3(preoperative) to 20.4±2.6 (2 weeks postoperative),25.4±2.8 (3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). The ROM improved fom 87°±8°(preoperative) to 98°±6°(2 weeks postoperative), 110°±6°(3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). the ROM between 2weeks and 3months had a significant difference (P<0.05).
3.5 We measured three angles in KOA, when the KL grading was in gradeⅡ, the mean FTA angle was 177.5°±1.7°, when the KL grading was in gradeⅢ, the mean FTA angle was180.2°±1.2°, when the KL grading was in gradeⅣ, the mean FTA angle was182.7°±2.3°, statistical study showed the curative effect of three groups had a significant difference (P<0.01). When the KL grading was in gradeⅡ, the mean PT angle was 85.5°±2.1°, when the KL grading was in gradeⅢ, the mean PT angle was 84.1°±1.4°, when the KL grading was in gradeⅣ, the mean PT angle was 83.2°±2.6°, statistical study showed the curative effect inⅡandⅣgrade had a significant difference (P<0.01). There was no statistical significance between HandⅢ,ⅢandⅣ(P>0.05), which showed the PT angle in tibia was an important factor in aligmengt. When the KL grading was in gradeⅡ, the mean FC angle was 81.4°±0.9°,when the KL grading was in gradeⅢ, the mean PT angle was 80.9°±1.2°,when the KL grading was in gradeⅣ, the mean PT angle was 80.3°±0.7°, there was no statistical significance between three groups(P>0.05). which showed the FC angle in femur was not an important factor influencing aligmengt.
3.6 The research in MR showed when the signal was normal in meniscus, there were no osteophyte in medial tibial plateau in six cases (66.67%).when the signal was intrameniscus, there were osteophyte in medial tibial plateau in 36 cases (81.82%).When the signal was tear, there were osteophyte in medial tibial plateau in 42 cases(95.24%). There was statistical significance between three groups (P<0.05). There were 40 cases appear bone marrow edema(BME) in subchondral bone.34 cases in medial,15 cases in lateral,9 cases in medial and lateral. when the signal was tear,the medial meniscal displacement (MMD)<3mm was 19 cases(38%). the MMD>3mm was 23cases(51.12%). there was statistical significance between three groups (P<0.05).
3.7 Study on syndrome differentiation in Meridian-Sinew proves that osteorthritis is a kind of Meridian-Sinew diseases, which provides evidence for theoretical basis of Meridian-Sinew therapy. In clinical study,95 cases of patients with osteoarthritis were investigated on syndrome differentiation and frequency of focus along Meridian-Sinew region. A single Meridian-Sinew diseases type was 16(16.84%, two Meridian-Sinew diseases type were 54(56.84%), three Meridian-Sinew diseases type were 25 (26.32%), in which Foot Sanyin Meridian-Sinew Diseases were 70 (73.68%),Foot Yangming channel sinew were 64 (67.37%),Foot Taiyang channel sinew were 58 (61.06%).The frequency of focus in Foot Sanyin Meridian-Sinew was also measured statistically. We found the location mainly in Liaoxijian、Xiguanci、Liaoliaoci、Yinlingshang and Xuehaici
4.Conclusions
4.1 The theory of equilibrium stationary system of STB in KOA is established on the bases of anatomical characteristics of knee and biomechanical model of KOA. In view of the concept of Whole-view and Equilibrium-view in tradirional chinese medicine as well as pathological characteristics of KOA, the study apply traditional methods of syndrome differentiation in Meridian-Sinew to explain the pathogenesis of KOA concerning STB, so that the value of syndrome differentiation in Meridian-Sinew is verified.
4.2 It is concluded that there is a correlation between the FTA angle and HKA. The FTA angle, which can better reflect the alignment of lower limb is important both for preoperatively planning of total knee arthroplasty(TKA) and evaluating of surgical results. However, performing the measurement of FTA should follow the strict technical standards of radiographing and measuring.
4.3 It is concluded from the observation made in the procedures of TKA that the malalignment of lower limb is related closely to chronic wearing of cartilage,compression of subchondral bone, and ligament contracture in TKA.The correction of malalignment depends not only on accurate osteotomy, but also the releasing of soft-tissue surrounding the knee, which leads to optimizing the balance of the knee joint. Also, it demonstrates the importance of equilibrium stationary system of STB.
4.4 Analyzing the images of X-rays and MR of KOA reveals that MMD, BMD, synovial effusion and osteophyte contribute to the pain in knees. The incidence of degeneration and rupture of meniscuses is rather high in the cases of KOA. MMD and bone marrow edema, the major factors lead to the malalignment of lower limb, play an important role in the progress of KOA. These demonstrate the disequilibrium of knee joints under the action of the malalignment.
4.5 Study on standards of syndrome differentiation in Meridian-Sinew has proved that most cases of KOA involved more than one line of Meridian-Sinew simultaneously.The conditions usually initiate from Foot Yangming Meridian-Sinew or/and Foot Taiyang Meridian-Sinew and then transfer to Foot Sanyin Meridian-Sinew. We have noticed that Liaoxijian、Xiguanci、Liaoliaoci、Yinlingshang and Xuehaici are the mainly-affected points. The equilibrium stationary system of STB taken shape from the three groups of main Meridian-Sinews and the alignment of lower limb is the premise of a stable knee joint. The study we have done may be useful when we treat KOA with syndrome differentiation in Meridian-Sinew.
膝骨关节炎是在力学因素和生物学因素的共同作用下形成的一种慢性、进展性关节疾病。现在的研究多从生物学因素着眼,忽视了力学因素的重要作用。随着对膝骨关节炎病因病理研究的不断深入,我们提出：膝骨关节炎是膝关节筋骨平衡体系打破后,不断完善自身平衡状态的生物力学过程,正常的下肢力线是其平衡体系的基础。因此,基于下肢力线,探讨膝关节筋骨平衡体系之间的作用规律将有助于揭示力学因素在膝骨关节炎病程中的作用。本研究将通过影像学研究(X线、MR)探讨影响下肢力线的相关因素并筛选出临床中评价下肢力线简便有效的方法,同时运用中医经筋辨证的方法,为阐释膝骨关节炎筋骨平衡体系中“筋—骨”之间相互转化的病机构建联系的桥梁。
2、研究方法：
首先首先通过理论研究,从膝骨关节炎的解剖特点和生物力学模式入手,构建基于下肢力线的膝关节筋骨平衡体系的理论基础,同时结合中医经筋理论的研究,探讨运用经筋理论阐释膝骨关节筋骨病机的方法。然后通过对膝骨关节炎相关角度的测量,探索评价下肢力线畸形情况的简便有效地方法,为晚期膝骨关节炎患者行人工膝关节置换术时下肢力线的评估提供参考。通过人工膝关节置换术,评估晚期膝骨关节炎筋骨失衡状态,并积累人工膝关节置换术中重建基于下肢力线下的膝关节筋骨平衡体系的方法。最后通过对不同时期膝骨关节炎下肢力线的研究,运用磁共振的筛选出影响下肢力线的相关因素。并结合经筋辨证的方法,对膝骨关节炎经筋病变情况进行统计分析,初步总结膝骨关节炎经筋病变特点和筋骨之间相互转化的规律。
3、研究结果：
3.1通过理论研究,从膝骨关节炎的解剖特点和生物力学模式研究,我们认为膝关节的解剖特点和运动特点为膝关节筋骨平衡体系奠定了理论基础,下肢力线是膝关节筋骨平衡体系的根本。借助中医经筋辨证的方法能为膝骨关节炎“筋—骨”之间相互转化的病机提供联系的桥梁。
3.2人工膝关节置换患者影像学资料的测量术前患者机械轴(HKA)为186.7°土2.1°,胫股角(FTA)为183.8°土1.7°。通过HKA和FTA两项指标的相关度进行分析,发现FTA和HKA之间具有相关性(r=0.712,P<0.01)。
3.3人工膝关节置换术中对患者的半月板损伤情况进行了分析,其中内侧半月板损伤的有30例(前角损伤5例,体部损伤12例,后角部损伤13例),外侧半月板损伤的有8例(前角损伤2例,体部损伤3例,后角部损伤3例),外侧半月板的损伤情况远少于内侧。术中前交叉韧带都表现有一定的充血水肿,部分断裂的有8例,完全断裂的有2例。后交叉韧带相对比较完整,但多表现出不同程度的挛缩变性。内外侧副韧带都保存完好,内侧副韧带表现出不同程度的挛缩。通过对对膝关节内侧平台进行了区域划分,统计分析发现退变区域主要集中在3、4、6、7、8、2区,除了在6、7、8区发生软骨退变外,半月板保护下的2、3、4区同样发生较为严重的软骨退变。3.4人工膝关节置换术前膝骨关节炎患者的FTA角度为183.8°±1.7°,术后FTA角度为175.6°±2.1。,经统计分析P<0.01,差异有统计学意义。术前TS角度为8.6°±2.4°,术后TS角度为7.4°±3.8°,经统计分析P>0.05,差异无统计学意义。术前PT角度为83.7°±2.1°,术后为88.6°±2.0°,经统计分析P<0.01,差异有统计学意义。术前FC角度为80.3°±3.2°,术后为81.7°±2.6°,经统计分析P<0.05,差异有统计学意义。人工膝关节置换术前患者HHS评分为40.7±7.4,术后两周64.7±6.2,术后三个月84.7±6.8,术前术后评分经统计学分析P<0.01,差异有统计学意义。术后两次随访评分经统计学分析P<0.01,差异有统计学意义。术前疼痛评分7.8±3.3,术后两次随访评分分别为20.4±2.6,25.4±2.8,术前术后评分经统计学分析P<0.01,差异有统计学意义。术后两次随访评分经统计学分析P>0.05,差异无统计学意义。膝关节活动度为87°±8°,术后两次随访评分分别为98±6,110±6,术前术后评分经统计学分析P<0.05,差异有统计学意义。术后两次随访评分经统计学分析P<0.05,差异有统计学意义。
3.5运用影像学测量方法,对膝骨关节炎的三个角度进行测量,当K-L分级在Ⅱ级时,FTA角是177.5°±1.7°,当K-L分级在Ⅲ级时,FTA角是180.2°±1.2°,当K-L分级在Ⅳ级时,FTA角是182.7°±2.3°,三个级别之间经统计分析P<0.05,差异有统计学意义。当K-L分级在Ⅱ级时,PT角是85.5°±2.1°,当K-L分级在Ⅲ级时,PT角是84.1°±1.4°,当K-L分级在Ⅳ级时,PT角是83.2°±2.6°,三个级别之间经统计分析,Ⅱ级和Ⅲ级,Ⅲ级和Ⅳ级之间比较,P>0.05,差异无统计学意义。Ⅱ级和Ⅳ级之间比较,P<0.05,差异有统计学意义。说明胫骨结构性内翻是造成膝关节内翻畸形的重要因素。当K-L分级在Ⅱ级时,FC角是81.4°±0.9°,当K-L分级在Ⅲ级时,FC角是80.9°±1.2°,当K-L分级在Ⅳ级时,FC角是80.3°±0.7°,三个级别之间经统计分析,P>0.05,差异无统计学意义。说明股骨外翻角的改变在膝关节内翻畸形的过程中影响较小。
3.6运用磁共振检测技术对膝关节内侧室胫骨平台的骨赘和内侧半月板的信号改变进行统计,发现当半月板信号正常时时,有6例(66.67%)没有骨赘出现,当半月板发生信号改变时,有36例(81.82%)出现骨赘,当半月板发生破裂时,有42例(95.24%)出现骨赘,经统计学分析,P<0.05,差异有统计学意义。软骨下骨出现骨髓水肿的区域进行统计,发现共有40例患者出现有不同程度的骨髓水肿,其中内侧有34例,外侧有15例,内外侧都出现的有9例。半月板出现破裂时,半月板移位小于3mm的有19例(38%),半月板移位大于3mm的有23例(51.12%),通过对半月板信号的改变和半月板移位进行统计分析,P<0.05,差异有统计学意义。
3.7通过磁共振检测,结合疼痛VAS评分,在疼痛级别为1级时,有23例(57.5%)患者出现软骨下骨骨髓水肿,37例(67.27%)未出现骨髓水肿。在疼痛级别为2级时,有15例(37.5%)患者出现软骨下骨骨髓水肿,12例(21.82%)未出现骨髓水肿。进行统计分析,P<0.05,差异有统计学意义。在疼痛级别为1级时,有23例(51.11%)患者出现内侧半月板移位大于3mm,37例(67.27%)未出现内侧半月板移位小于3mm。在疼痛级别为2级时,有有20例(44.44%)患者出现内侧半月板移位大于3mm,7例(14%)出现内侧半月板移位小于3mm。进行统计分析,P<0.05,差异有统计学意义。在疼痛级别为1级时,有40例(65.57%)患者出现关节积液,20例(58.82%)未出现关节积液。在疼痛级别为2级时,有20例(32.79%)患者出现关节积液,7例(20.59%)未出现关节积液。进行统计分析,P<0.05,差异有统计学意义。在疼痛级别为1级时,有54例(68.35%)患者出现骨赘,6例(37.5%)未出现骨赘。在疼痛级别为2级时,有19例(24.05%)患者出现骨赘,8例(50%)未出现骨赘。进行统计分析,P<0.05,差异有统计学意义。
3.8通过经筋辨证,我们发现膝骨关节炎经筋辨证规律多呈现出复合证型。单一经筋病变的只有16条(16.84%),两条经筋病变的有54条(56.84%),三条同时病变的有25条(26.32%)。其中出现病变最多的是足三阴经筋70条(73.68%),足阳明经筋64条(67.37%),足太阳经筋58条(61.06%)。通过对三阴经筋的病位进行统计,我们发现病变位置主要集中在髎膝间、膝关次、髎骼次、阴陵上和血海次。
4研究结论
4.1膝骨关节炎筋骨平衡体系的理论基础是建立在膝关节解剖特点和生物力学基础上的。从膝骨关节炎的病理特点入手,从中医“整体观”和“平衡观”的角度出发,阐释了膝骨关节炎的筋骨病机及经筋辨证在膝骨关节炎中的应用价值。
4.2通过对下肢力线和膝关节相关角度的分析,我们认为FTA和HKA之间具有相关性,根据统计结果显示运用FTA角也能较好地反映下肢力线线情况,对制定术前计划及判断手术效果具有非常重要的作用,但FTA角的测量需要遵循严格的拍摄技术标准和测量方法。
4.3通过膝关节置换术中的研究我们认为下肢力线的异常和软骨磨损、软骨下骨的压缩以及韧带的挛缩都有重要的关系,下肢力线的矫正不仅依靠准确的截骨,膝关节周围软组织的松解也是调整下肢力线的关键。这也是膝关节炎筋骨平衡思想的重要体现。
4.4通过影像学研究(X线、MR),我们发现膝关节的疼痛和半月板的移位、软骨下骨髓水肿,滑膜积液,骨赘都有关系。半月板的退变和破裂在膝骨关节炎中发生率较高,半月板移位和骨髓水肿在膝骨关节病程中意义重要,它们是引起下肢力线改变的重要因素,提示关节在异常力线作用下的不平衡状态。
4.5通过经筋辨证研究,我们发现单一经筋病变较少,经筋病变主要是多条经筋同时病变,膝骨关节炎的发生多从阳明经筋和太阳经筋发生病变,或两经同时发病,后多转归为三阴经筋病变,其中出现病变最多的是足三阴经筋,我们发现病变位置主要集中在髎膝间、膝关次、髎髎次、阴陵上和血海次。从经筋辨证规律分析,三组主要经筋和下肢力线之间形成的筋骨平衡体系是膝关节稳定的基础。上述这些研究,可以为运用经筋理论和经筋疗法对膝骨性关节炎进行治疗提供重要参考。
1. Objective
Knee Osteoarthritis (KOA) is known as a chronic, progressing degenerative joint disease, involving a number of biomechanical and biological factors. However, researches are nowadays focused more on biological factors, other than biomechanical factors which play an important role in KOA. Along with the further investigation on the etiology and pathology of KOA, we proposed a theory:the equilibrium stationary system of soft-tissue and bone in KOA based on alignment of lower limb. We believed that KOA is a constantly biomechanical repair process of soft-tissue and bone (STB) when the equilibrium stationary system is broken, the normal alignment of lower limb is the fundament of the system. Therefore, based on alignment of lower limb, investigating the pathological mechanism of equilibrium stationary system (ESS)of STB may facilitate to reveal the pathogenesis of biomechanical factors in KOA. The study focused on factors influencing the alignment of lower limb and tried to explore a convenient and effective way to evaluate the alignment by tomography (X ray, MR) also applied traditional methods of syndrome differentiation in Meridian-Sinew to explain the pathogenesis of KOA concerning STB.
2. Methods
Firstly, by analyzing the anatomical characteristics and biomechanical model of knee,we founded the basis of the equilibrium stationary state of STB, and by combining the theory of Meridian-Sinew with our study, we explored a way to explain the pathogenesis of KOA concerning STB. Secondly, we evaluated alignment of lower limb by means of measuring the angles concerning KOA.That was a convenient and effective method which could provide an important basis to assess the alignment of lower limb in the process of total knee arthroplasty(TKA).By analysing the disequilibrated state of STB in the procedures of TKA, we conduct research to explore the way to equilibrate the relationshipe of STB in in the process of TKA for late KOA. Thirdly, we screened the factors influencing the alignment of lower limb in in different stages of KOA by means of MR. We also apply traditional methods of syndrome differentiation in Meridian-Sinew to analyze statistically the conditions of KOA so as to explain the pathogenesis of KOA and sum up the interacting patterns of STB.
3. Result
3.1 By analyzing the anatomical characteristics and biomechanical model of knee, we believe the equilibrium stationary system of STB in KOA is based on the anatomical characteristics and motion characteristics. The normal alignment of lower limb is the fundamental in the system. The theory of Meridian-Sinewcan in traditional Chinese medicine can provide a way to explain the pathogenesis of KOA concerning soft tissue and bone.
3.2 The HKA angle was 186.7°±2.1°, and the FTA angle was 183.8°±1.7°,there was a correlation between the FTA angle and HKA (r=0.712,P<0.01)
3.3 The patients in knee arthroplsty with meniscus injury was analyzed, including the medial meniscus in 30 cases (5 cases in the anterior horn,12 cases in body,13 cases in posterior corner), lateral meniscus injury in 8 patients (2 cases in the anterior horn,3 cases in body,3 cases in posterior corner), lateral meniscu injury was much lower than the medial meniscu. Anterior cruciate ligament surgery had shown a certain degree of congestion and edema, partial rupture in 8 patients, there were two cases of complete rupture. Posterior cruciate ligament was relatively intact,but show contracture.The lateral collateral ligament and medial collateral ligament Were well preserved, the medial collateral ligament showed contracture.Analysesing the degeneration zone in medial platform according to regional division, we found degeneration mainly in 3,4,6,7,8,2 zone. The 2,3,4 zone under the protection of the meniscus had the same cartilage degeneration as the 6,7,8, zone.
3.4 The FTA angle preoperative was 183.8°±1.7°,postoperative was 175.6°±2.1°, statistical study showed the curative effect of two groups had a significant difference (P<0.01).The TS angle preoperative was 8.6°±2.4°,postoperative was 7.4°±3.8°,there was no statistical significance between two groups (P>0.05).The PT angle was preoperative 83.7°±2.1°postoperative was 88.6°±2.0°, statistical study showed the curative effect of two groups had a significant difference (P<0.01). The FC angle preoperative was 80.3°±3.2°, postoperative was 81.7°±2.6°, statistical study showed the curative effect of two groups had a significant difference (P<0.05). After a follow-up of three months, the HSS score improved from 40.7±7.4 (preoperative) to 64.7±6.2 (2 weeks postoperative),84.7±6.8 (3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). The VAS score improved from 7.8±3.3(preoperative) to 20.4±2.6 (2 weeks postoperative),25.4±2.8 (3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). The ROM improved fom 87°±8°(preoperative) to 98°±6°(2 weeks postoperative), 110°±6°(3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). the ROM between 2weeks and 3months had a significant difference (P<0.05).
3.5 We measured three angles in KOA, when the KL grading was in gradeⅡ, the mean FTA angle was 177.5°±1.7°, when the KL grading was in gradeⅢ, the mean FTA angle was180.2°±1.2°, when the KL grading was in gradeⅣ, the mean FTA angle was182.7°±2.3°, statistical study showed the curative effect of three groups had a significant difference (P<0.01). When the KL grading was in gradeⅡ, the mean PT angle was 85.5°±2.1°, when the KL grading was in gradeⅢ, the mean PT angle was 84.1°±1.4°, when the KL grading was in gradeⅣ, the mean PT angle was 83.2°±2.6°, statistical study showed the curative effect inⅡandⅣgrade had a significant difference (P<0.01). There was no statistical significance between HandⅢ,ⅢandⅣ(P>0.05), which showed the PT angle in tibia was an important factor in aligmengt. When the KL grading was in gradeⅡ, the mean FC angle was 81.4°±0.9°,when the KL grading was in gradeⅢ, the mean PT angle was 80.9°±1.2°,when the KL grading was in gradeⅣ, the mean PT angle was 80.3°±0.7°, there was no statistical significance between three groups(P>0.05). which showed the FC angle in femur was not an important factor influencing aligmengt.
3.6 The research in MR showed when the signal was normal in meniscus, there were no osteophyte in medial tibial plateau in six cases (66.67%).when the signal was intrameniscus, there were osteophyte in medial tibial plateau in 36 cases (81.82%).When the signal was tear, there were osteophyte in medial tibial plateau in 42 cases(95.24%). There was statistical significance between three groups (P<0.05). There were 40 cases appear bone marrow edema(BME) in subchondral bone.34 cases in medial,15 cases in lateral,9 cases in medial and lateral. when the signal was tear,the medial meniscal displacement (MMD)<3mm was 19 cases(38%). the MMD>3mm was 23cases(51.12%). there was statistical significance between three groups (P<0.05).
3.7 Study on syndrome differentiation in Meridian-Sinew proves that osteorthritis is a kind of Meridian-Sinew diseases, which provides evidence for theoretical basis of Meridian-Sinew therapy. In clinical study,95 cases of patients with osteoarthritis were investigated on syndrome differentiation and frequency of focus along Meridian-Sinew region. A single Meridian-Sinew diseases type was 16(16.84%, two Meridian-Sinew diseases type were 54(56.84%), three Meridian-Sinew diseases type were 25 (26.32%), in which Foot Sanyin Meridian-Sinew Diseases were 70 (73.68%),Foot Yangming channel sinew were 64 (67.37%),Foot Taiyang channel sinew were 58 (61.06%).The frequency of focus in Foot Sanyin Meridian-Sinew was also measured statistically. We found the location mainly in Liaoxijian、Xiguanci、Liaoliaoci、Yinlingshang and Xuehaici
4.Conclusions
4.1 The theory of equilibrium stationary system of STB in KOA is established on the bases of anatomical characteristics of knee and biomechanical model of KOA. In view of the concept of Whole-view and Equilibrium-view in tradirional chinese medicine as well as pathological characteristics of KOA, the study apply traditional methods of syndrome differentiation in Meridian-Sinew to explain the pathogenesis of KOA concerning STB, so that the value of syndrome differentiation in Meridian-Sinew is verified.
4.2 It is concluded that there is a correlation between the FTA angle and HKA. The FTA angle, which can better reflect the alignment of lower limb is important both for preoperatively planning of total knee arthroplasty(TKA) and evaluating of surgical results. However, performing the measurement of FTA should follow the strict technical standards of radiographing and measuring.
4.3 It is concluded from the observation made in the procedures of TKA that the malalignment of lower limb is related closely to chronic wearing of cartilage,compression of subchondral bone, and ligament contracture in TKA.The correction of malalignment depends not only on accurate osteotomy, but also the releasing of soft-tissue surrounding the knee, which leads to optimizing the balance of the knee joint. Also, it demonstrates the importance of equilibrium stationary system of STB.
4.4 Analyzing the images of X-rays and MR of KOA reveals that MMD, BMD, synovial effusion and osteophyte contribute to the pain in knees. The incidence of degeneration and rupture of meniscuses is rather high in the cases of KOA. MMD and bone marrow edema, the major factors lead to the malalignment of lower limb, play an important role in the progress of KOA. These demonstrate the disequilibrium of knee joints under the action of the malalignment.
4.5 Study on standards of syndrome differentiation in Meridian-Sinew has proved that most cases of KOA involved more than one line of Meridian-Sinew simultaneously.The conditions usually initiate from Foot Yangming Meridian-Sinew or/and Foot Taiyang Meridian-Sinew and then transfer to Foot Sanyin Meridian-Sinew. We have noticed that Liaoxijian、Xiguanci、Liaoliaoci、Yinlingshang and Xuehaici are the mainly-affected points. The equilibrium stationary system of STB taken shape from the three groups of main Meridian-Sinews and the alignment of lower limb is the premise of a stable knee joint. The study we have done may be useful when we treat KOA with syndrome differentiation in Meridian-Sinew.
引文
[1]陈百成,张静.骨关节炎[M].人民卫生出版社,2004.1-3
[2]ATIK O.. Is the Bone and Joint Decade over?[J]. Eklem hastal klar ve cerrahisi= Joint diseases & related surgery,2010,21(3):123.
[3]JOHNSON K. A. Bone and joint decade extended[J]. Vet Comp Orthop Traumatol,2011,24(1):III.
[4]邱贵兴,王澍寰,卢世璧.骨关节炎诊治指南[J].中华骨科杂志,2007,27(10)：793-793.
[5]TAKAHASHI K., HASHIMOTO S., KUBO T., et al. Effect of hyaluronan on chondrocyte apoptosis and nitric oxide production in experimentally induced osteoarthritis[J]. J Rheumatol,2000,27(7):1713-1720.
[6]MCALINDON T.E., LAVALLEY M.P., GULIN J.P., et al. Glucosamine and chondroitin for treatment of osteoarthritis[J]. JAMA:the Journal of the American Medical Association,2000,283(11):1469.
[7]REICHENBACH S., STERCHI R., SCHERER M., et al. Meta-analysis: chondroitin for osteoarthritis of the knee or hip[J]. Annals of internal medicine,2007, 146(8):580.
[8]PELLETIER J.P., YARON M., HARAOUI B., et al. Efficacy and safety of diacerein in osteoarthritis of the knee:A double?blind, placebo?controlled trial[J]. Arthritis & Rheumatism,2000,43(10):2339-2348.
[9]FRISBIE DD, GHIVIZZANI SC, ROBBINS PD, et al. Treatment of experimental equine osteoarthritis by in vivo delivery of the equine interleukin-1 receptor antagonist gene[J]. Gene therapy,2002,9(1):12-20.
[10]陈泽文,喻友军.骨痹汤治疗膝关节骨性关节炎82例总结[J].湖南中医杂志,2002,18(3)：22-22.
[11]吴泳听,肖泓.补中桂枝汤治疗退行性骨关节病83例[J].四川中医,2002,20(2)：63-64.
[12]王敖明,邱德华.石氏调中保元汤治疗老年性膝关节病[J].上海中医药杂志,2001,35(7)：34-35.
[13]陈广祯,李心沁.从瘀血痰湿论治膝关节骨性关节炎58例[J].山东中医药大学学报,1998,22(1)：30-31.
[14]杜天信,韩新峰,高书图.寒湿痹颗粒治疗寒湿痹阻型风湿病的临床观察[J].中医正骨,2002,14(3)：10-12.
[15]李岩.理筋手法治疗退行性膝关节炎42例[J].中医外治杂志,2007,16(3)：39-39.
[16]许旺,陈玉辰,朱立国.提拿髌骨手法治疗膝关节骨性关节炎疗效观察[J].CHINA JOURNAL,2005,18(4).
[17]汪利合.点穴加旋转屈伸手法治疗膝关节骨性关节炎[J].中国民间疗法,2002,10(11)：29.
[18]李晓昊,黄清春,沈鹰,等.单刺曲池穴治疗膝关节骨关节炎68例[J].中国临床康复,2004,8(20)：4027-4027.
[19]戚耀,郝朝军.针灸治疗膝骨性关节炎临床疗效观察[J].陕西中医学院学报,2007,30(6)：43-44.
[20]张必萌,吴耀持,沈健.长针透刺治疗膝骨关节炎的临床研究[J].中国针灸,2004,24(9)：613-614.
[21]丁向荣,姚夏琦,蒋又祝.针罐并用治疗膝关节骨性关节炎51例[J].中国民间疗法,2004,12(9)：29-30.
[22]张琼,肖京,邓磊.麝香通痹巴布膏治疗骨性关节炎(肝肾不足,筋脉瘀滞证)的临床研究[J].中国临床药理学与治疗学,2005,10(8)：953-956.
[23]郭继锋,杜志谦,鲍铁周,等.芎芷痛瘀消散贴治疗膝骨陛关节炎膝关节痛临床研究[J].世界中西医结合杂志,2008,3(8)：468-470.
[24]尹建平,王海燕.活血通络凝胶剂合扶元乳膏剂治疗膝关节骨性关节炎60例疗效观察[J].新中医,2008,40(4)：69-70.
[25]王少山,张世华,邱红明.骨病中西医结合诊疗学[M].北京：中国中医药出版社.2002.
[26]娄玉钤.中国风湿病学[M].人民卫生出版社,2001.245-249
[27]HUNTER D. J., WILSON D. R. Role of alignment and biomechanics in osteoarthritis and implications for imaging[J]. Radiol Clin North Am,2009,47(4): 553-566.
[28]HUNTER D. J., SHARMA L., SKAIFE T. Alignment and osteoarthritis of the knee[J]. J Bone Joint Surg Am,2009,91 Suppl 1:85-89.
[29]FOROUGHI N., SMITH R., VANWANSEELE B. The association of external knee adduction moment with biomechanical variables in osteoarthritis:a systematic review[J]. Knee,2009,16(5):303-309.
[30]SHARMA L., SONG J., FELSON D. T., et al. The role of knee alignment in disease progression and functional decline in knee osteoarthritis[J]. JAMA,2001, 286(2):188-195.
[31]OGATA K., YASUNAGA M., NOMIYAMA H. The effect of wedged insoles on the thrust of osteoarthritic knees[J]. International orthopaedics,1997,21(5):308-312.
[32]VAN RAAIJ T.M., REIJMAN M., BROUWER R.W., et al. Medial knee osteoarthritis treated by insoles or braces:a randomized trial[J]. Clinical Orthopaedics and Related Research(R),2010,468(7):1926-1932.
[33]RANNOU F., POIRAUDEAU S., BEAUDREUIL J. Role of bracing in the management of knee osteoarthritis[J]. Curr Opin Rheumatol,2010,22(2):218-222.
[34]BENZAKOUR T., HEFTI A., LEMSEFFER M., et al. High tibial osteotomy for medial osteoarthritis of the knee:15 years follow-up[J]. Int Orthop,2010,34(2): 209-215.
[35]BROUWER RW, JAKMA TS, BIERMA-ZEINSTRA SM, et al. Osteotomy for treating knee osteoarthritis[J]. Cochrane database of systematic reviews (Online), 2005, (1):CD004019.
[36]B THIS H., PERLICK L., TINGART M., et al. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique[J]. The Journal of bone and joint surgery British volume,2004,86(5):682.
[37]STIEHL J.B. Knee kinematics and mobile bearings:new design considerations[J]. Current Opinion in Orthopaedics,2001,12(1):18-25.
[38]ASANO T., AKAGI M., TANAKA K., et al. In vivo three-dimensional knee kinematics using a biplanar image-matching technique[J]. Clinical orthopaedics and related research,2001,388:157-166.
[39]FREEMAN MAR, PINSKEROVA V. The movement of the knee studied by magnetic resonance imaging[J]. Clinical orthopaedics and related research,2003,410: 35-43.
[40]WRETENBERG P., RAMSEY D.K., N METH G Tibiofemoral contact points relative to flexion angle measured with MRI[J]. Clinical Biomechanics,2002,17(6): 477-485.
[41]DENNIS D.A., KOMISTEK R.D., HOFF W.A., et al. In vivo knee kinematics derived using an inverse perspective technique[J]. Clinical orthopaedics and related research,1996,331:107-117.
[42]STIEHL J.B., DENNIS D.A., KOMISTEK R.D., et al. In vivo kinematic analysis of a mobile bearing total knee prosthesis[J]. Clinical orthopaedics and related research, 1997,345:60-66.
[43]GEORGOULIS A. D., PAPADONIKOLAKIS A., PAPAGEORGIOU C. D., et al. Three-dimensional tibio femoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking[J]. Am J Sports Med,2003,31(1):75-79.
[44]TEICHTAHL AJ, MORRIS ME, WLUKA AE, et al. Foot rotation--a potential target to modify the knee adduction moment[J]. Journal of Science and Medicine in Sport,2006,9(1-2):67-71.
[45]LANDRY S.C., MCKEAN K.A., HUBLEY-KOZEY C.L., et al. Knee bio mechanics of moderate O A patients measured during gait at a self-selected and fast walking speed[J]. Journal of biomechanics,2007,40(8):1754-1761.
[46]王学谦,娄思权,侯筱魁.骨关节炎一诊断与治疗[M].天津：天津科技翻译出版公司.2005：296-297.
[47]黄国良,孙材江,黎志宏,等.正确认识和对待“骨质增生”的问题[J].中国现代实用医学杂志,2004,3(3)：43-45.
[48]王跃辉,韩清民,刘洪江,等.膝骨性关节炎影像学分析与经筋辨证关系研究[J].新中医,2008,40(5)：66-67.
[49]韩清民,王跃辉,黄旭东,等.膝骨关节炎从筋论治思路探讨[J].新中医,2009,41(1)：5-6.
[50]CEREJO R., DUNLOP D. D., CAHUE S., et al. The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease[J]. Arthritis Rheum,2002,46(10):2632-2636.
[51]TEICHTAHL AJ, CICUTTINI FM, JANAKIRAMANAN N., et al. Static knee alignment and its association with radiographic knee osteoarthritis[J]. Osteoarthritis and Cartilage,2006,14(9):958-962.
[52]FELSON D.T., MCLAUGHLIN S., GOGGINS J., et al. Bone marrow edema and its relation to progression of knee osteoarthritis[J]. Annals of internal medicine,2003, 139(5 Part 1):330.
[53]ROEMER F. W., ZHANG Y., NIU J., et al. Tibiofemoral joint osteoarthritis:risk factors for MR-depicted fast cartilage loss over a 30-month period in the multicenter osteoarthritis study[J]. Radiology,2009,252(3):772-780.
[54]BENNETT L. D., BUCKLAND-WRIGHT J. C. Meniscal and articular cartilage changes in knee osteoarthritis:a cross-sectional double-contrast macroradiographic study[J]. Rheumatology (Oxford),2002,41(8):917-923.
[55]黄加张,顾湘杰,潘哲尔,等.半月板突出在膝骨性关节炎关节间隙狭窄中的作用[J].中国临床康复,2005,9(002)：22-23.
[56]NAKAMURA M., SUMEN Y, SAKARIDANI K., et al. Relationship between the shape of tibial spurs on X-ray and meniscal changes on MRI in early osteoarthritis of the knee[J]. Magnetic Resonance Imaging,2006,24(9):1143-1148.
[57]KHAN F. A., KOFF M. F., NOISEUX N. O., et al. Effect of local alignment on compartmental patterns of knee osteoarthritis[J]. J Bone Joint Surg Am,2008,90(9): 1961-1969.
[58]KIJOWSKI R., STANTON P., FINE J., et al. Subchondral Bone Marrow Edema in Patients with Degeneration of the Articular Cartilage of the Knee Joint1[J]. Radiology,2006,238(3):943-949.
[59]刘涛.经筋实质初探[J].中国针灸,2007,27(4)：297-298.
[60]薛立功.经筋理论的探讨与发挥[J].中国针灸,1997,17(11)：698-699.
[61]骆书彦,马帅,崔瑾.十二经筋理论探析[J].江苏中医药,2004,25(1)：42-44.
[62]原林,钟世镇.人体自体检测与调控系统(筋膜学)——经络有关的解剖学基础[J].天津中医药,2004,21(5)：356-359.
[63]吴金鹏.中医“经筋”及“膜原”实质的筋膜理论探讨[J].北京中医,2007,26(5)：283-285.
[64]黄敬伟.经筋疗法[M].北京：中国中医药出版社.1996：65-85.
[65]MORELAND J. R., BASSETT L. W., HANKER G. J. Radiographic analysis of the axial alignment of the lower extremity[J]. J Bone Joint Surg Am,1987,69(5): 745-749.
[66]HSU R.W.W., HIMENO S., COVENTRY M.B., et al. Normal axial alignment of the lower extremity and load-bearing distribution at the knee[J]. Clinical orthopaedics and related research,1990,255:215-217.
[67]HINMAN R.S., MAY R.L., CROSSLEY K.M. Is there an alternative to the full?leg radiograph for determining knee joint alignment in osteoarthritis?[J]. Arthritis Care & Research,2006,55(2):306-313.
[68]COLEBATCH A.N., HART D.J., ZHAI G., et al. Effective measurement of knee alignment using AP knee radiographs[J]. The Knee,2009,16(1):42-45.
[69]INSALL JN, EASLEY ME. Surgical techniques and instrumentation in total knee arthroplasty[J]. Surgery of the knee 3rd ed New York:Churchill Livingstone,2001: 1584-1587.
[70]COOKE T.D.V., BRYANT J.T., SCUDAMORE R.A. Biomechanical factors in alignment and arthritic disorders of the knee[J]. Knee surgery Baltimore:Williams and Wilkins,1994:1061-1078.
[71]SNIEKERS Y. H., INTEMA F., LAFEBER F. P., et al. A role for subchondral bone changes in the process of osteoarthritis; a micro-CT study of two canine models[J]. BMC Musculoskelet Disord,2008,9:20.
[72]RADIN E. L., PAUL I. L., TOLKOFF M. J. Subchondral bone changes in patients with early degenerative joint disease[J]. Arthritis Rheum,1970,13(4): 400-405.
[73]RADIN E. L. Subchondral bone changes and cartilage damage[J]. Equine Vet J, 1999,31(2):94-95.
[74]DIEPPE P. Subchondral bone should be the main target for the treatment of pain and disease progression in osteoarthritis[J]. Osteoarthritis and cartilage/OARS, Osteoarthritis Research Society,1999,7(3):325-326.
[75]MROSEK E. H., LAHM A., ERGGELET C., et al. Subchondral bone trauma causes cartilage matrix degeneration:an immunohistochemical analysis in a canine model[J]. Osteoarthritis Cartilage,2006,14(2):171-178.
[76]KARSDAL MA, LEEMING DJ, DAM EB, et al. Should subchondral bone turnover be targeted when treating osteoarthritis?[J]. Osteoarthritis and Cartilage, 2008,16(6):638-646.
[77]SAKAO K., TAKAHASHI K. A., MAZDA O., et al. Enhanced expression of interleukin-6, matrix metalloproteinase-13, and receptor activator of NF-kappaB ligand in cells derived from osteoarthritic subchondral bone[J]. J Orthop Sci,2008, 13(3):202-210.
[78]BOYD S. K., MULLER R., ZERNICKE R. F. Mechanical and architectural bone adaptation in early stage experimental osteoarthritis[J]. J Bone Miner Res,2002,17(4): 687-694.
[79]PELLETIER J. P., BOILEAU C., BRUNET J., et al. The inhibition of subchondral bone resorption in the early phase of experimental dog osteoarthritis by licofelone is associated with a reduction in the synthesis of MMP-13 and cathepsin K[J]. Bone,2004,34(3):527-538.
[80]陆圣君,杨述华.降钙素对大鼠骨关节炎关节软骨和软骨下骨的影响[J].中国骨质疏松杂志,2008,14(3)：183-186.
[81]杨勇,吴世栋,张小钰,等.骨化三醇对大鼠骨性关节炎关节软骨及软骨下骨的影响[J].中国骨质疏松杂志,2009,15(5)：333-337.
[82]王跃辉,韩清民,李钊,等.生物力学因素在骨关节炎诊疗体系中的价值探讨—骨关节炎经筋诊疗思路浅谈[J].中国中医骨伤科杂志,2010,1.68-70
[83]ECKSTEIN F., BENICHOU O., WIRTH W., et al. Magnetic resonance imaging-based cartilage loss in painful contralateral knees with and without radiographic joint space narrowing:Data from the Osteoarthritis Initiative[J]. Arthritis Rheum,2009,61(9):1218-1225.
[84]TEICHTAHL A. J., DAVIES-TUCK M. L., WLUKA A. E., et al. Change in knee angle influences the rate of medial tibial cartilage volume loss in knee osteoarthritis[J]. Osteoarthritis Cartilage,2009,17(1):8-11.
[85]BROUWER GM, TOL AW, BERGINK AP, et al. Association between valgus and varus alignment and the development and progression of radio graphic osteo arthritis of the knee[J]. Arthritis & Rheumatism,2007,56(4):1204-1211.
[86]刘源,曾庆余.膝症状性骨关节炎X线特点及其意义[J].中华放射学杂志,1998,32(6)：425-426.
[87]叶永平,曾炳芳.膝骨关节炎病因,X线片及临床表现分析[J].临床骨科杂志,2000,3(3)：169-173.
[88]MUNDERMANN A., DYRBY C. O., ANDRIACCHI T. P. Secondary gait changes in patients with medial compartment knee osteoarthritis:increased load at the ankle, knee, and hip during walking[J]. Arthritis Rheum,2005,52(9):2835-2844.
[89]WEIDENHIELM L., SVENSSON O. K., BROSTROM L. A., et al. Adduction moment of the knee compared to radiological and clinical parameters in moderate medical osteoarthrosis of the knee[J]. Ann Chir Gynaecol,1994,83(3):236-242.
[90]WENHAM C. Y., CONAGHAN P. G. Imaging the painful osteoarthritic knee joint:what have we learned?[J]. Nat Clin Pract Rheumatol,2009,5(3):149-158.
[91]VAN DER KRAAN P. M., VAN DEN BERG W. B. Osteophytes:relevance and biology[J]. Osteoarthritis Cartilage,2007,15(3):237-244.
[92]MARSHALL J. L., OLSSON S. E. Instability of the knee. A long-term experimental study in dogs[J]. J Bone Joint Surg Am,1971,53(8):1561-1570.
[93]MOSKOWITZ R. W., GOLDBERG V. M. Studies of osteophyte pathogenesis in experimentally induced osteoarthritis[J]. J Rheumatol,1987,14(2):311-320.
[94]GALE DR, CHAISSON CE, TOTTERMAN SMS, et al. Meniscal subluxation: association with osteoarthritis and joint space narrowing[J]. Osteoarthritis and Cartilage,1999,7(6):526-532.
[95]FAIRBANK TJ. Knee joint changes after meniscectomy[J]. Journal of Bone and Joint Surgery-British Volume,1948,30(4):664-670.
[96]VEDI V., SPOUSE E., WILLIAMS A., et al. Meniscal movement:an in-vivo study using dynamic MRI[J]. Journal of Bone and Joint Surgery-British Volume,1999, 81(1):372-411.
[97]COSTA C., MORRISON W.B., CARRINO J.A. Medial meniscus extrusion on knee MRI:is extent associated with severity of degeneration or type of tear?[J]. American Journal of Roentgenology,2004,183(1):17-23.
[98]BREITENSEHER M. J., TRATTNIG S., DOBROCKY I., et al. MR imaging of meniscal subluxation in the knee[J]. Acta Radiol,1997,38(5):876-879.
[99]MASOUROS SD, MCDERMOTT ID, AMIS AA, et al. Biomechanics of the meniscus-meniscal ligament construct of the knee[J]. Knee Surgery, Sports Traumatology, Arthroscopy,2008,16(12):1121-1132.
[100]KENNY C. Radial displacement of the medial meniscus and Fairbank's signs[J]. Clin Orthop Relat Res,1997, (339):163-173.
[101]ENGLUND M., LOHMANDER LS. Risk factors for symptomatic knee osteoarthritis fifteen to twenty two years after meniscectomy[J]. Arthritis & Rheumatism,2004,50(9):2811-2819.
[102]BERTHIAUME MJ, RAYNAULD JP, MARTEL-PELLETIER J., et al. Meniscal tear and extrusion are strongly associated with progression of symptomatic knee osteoarthritis as assessed by quantitative magnetic resonance imaging[J]. Annals of the rheumatic diseases,2005,64(4):556-563.
[103]黄加张,顾湘杰,王旭,等.膝关节半月板半脱位的相关因素分析[J].复旦学报：医学版,2005,32(004)：433-435.
[104]LERER DB, UMANS HR, HU MX, et al. The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion[J]. Skeletal radiology,2004, 33(10):569-574.
[105]ISSA S. N., SHARMA L. Epidemiology of osteoarthritis:an update[J]. Curr Rheumatol Rep,2006,8(1):7-15.
[106]FELSON D. T., MCLAUGHLIN S., GOGGINS J., et al. Bone marrow edema and its relation to progression of knee osteoarthritis[J]. Ann Intern Med,2003,139(5 Pt 1):330-336.
[107]SCHWEITZER M.E., WHITE L.M. Does altered biomechanics cause marrow edema?[J]. Radiology,1996,198(3):851-853.
[108]KOO K.H., AHN I.O., KIM R., et al. Bone Marrow Edema and Associated Pain in Early Stage Osteonecrosis of the Femoral Head:Prospective Study with Serial MR Images1[J]. Radiology,1999,213(3):715-722.
[109]何伟,曾勤,张庆文,等.非创伤性股骨头坏死骨髓水肿与疼痛分级及坏死分期相关性的研究[J]Chinese Journal of Reparative and Reconstructive Surgery, 2008,22(3):299-302.
[110]CASTRO F. P., JR., BARRACK R. L. Core decompression and conservative treatment for avascular necrosis of the femoral head:a meta-analysis[J]. Am J Orthop (Belle Mead NJ),2000,29(3):187-194.
[111]NEOGI T., NEVITT M., NIU J., et al. Subchondral bone attrition may be a reflection of compartment-specific mechanical load:the MOST Study[J]. Annals of the rheumatic diseases,2010,69(5):841.
[112]ROEMER F. W., NEOGI T., NEVITT M. C., et al. Subchondral bone marrow lesions are highly associated with, and predict subchondral bone attrition longitudinally:the MOST study[J]. Osteoarthritis Cartilage,2010,18(1):47-53.
[2]ATIK O.. Is the Bone and Joint Decade over?[J]. Eklem hastal klar ve cerrahisi= Joint diseases & related surgery,2010,21(3):123.
[3]JOHNSON K. A. Bone and joint decade extended[J]. Vet Comp Orthop Traumatol,2011,24(1):III.
[4]邱贵兴,王澍寰,卢世璧.骨关节炎诊治指南[J].中华骨科杂志,2007,27(10)：793-793.
[5]TAKAHASHI K., HASHIMOTO S., KUBO T., et al. Effect of hyaluronan on chondrocyte apoptosis and nitric oxide production in experimentally induced osteoarthritis[J]. J Rheumatol,2000,27(7):1713-1720.
[6]MCALINDON T.E., LAVALLEY M.P., GULIN J.P., et al. Glucosamine and chondroitin for treatment of osteoarthritis[J]. JAMA:the Journal of the American Medical Association,2000,283(11):1469.
[7]REICHENBACH S., STERCHI R., SCHERER M., et al. Meta-analysis: chondroitin for osteoarthritis of the knee or hip[J]. Annals of internal medicine,2007, 146(8):580.
[8]PELLETIER J.P., YARON M., HARAOUI B., et al. Efficacy and safety of diacerein in osteoarthritis of the knee:A double?blind, placebo?controlled trial[J]. Arthritis & Rheumatism,2000,43(10):2339-2348.
[9]FRISBIE DD, GHIVIZZANI SC, ROBBINS PD, et al. Treatment of experimental equine osteoarthritis by in vivo delivery of the equine interleukin-1 receptor antagonist gene[J]. Gene therapy,2002,9(1):12-20.
[10]陈泽文,喻友军.骨痹汤治疗膝关节骨性关节炎82例总结[J].湖南中医杂志,2002,18(3)：22-22.
[11]吴泳听,肖泓.补中桂枝汤治疗退行性骨关节病83例[J].四川中医,2002,20(2)：63-64.
[12]王敖明,邱德华.石氏调中保元汤治疗老年性膝关节病[J].上海中医药杂志,2001,35(7)：34-35.
[13]陈广祯,李心沁.从瘀血痰湿论治膝关节骨性关节炎58例[J].山东中医药大学学报,1998,22(1)：30-31.
[14]杜天信,韩新峰,高书图.寒湿痹颗粒治疗寒湿痹阻型风湿病的临床观察[J].中医正骨,2002,14(3)：10-12.
[15]李岩.理筋手法治疗退行性膝关节炎42例[J].中医外治杂志,2007,16(3)：39-39.
[16]许旺,陈玉辰,朱立国.提拿髌骨手法治疗膝关节骨性关节炎疗效观察[J].CHINA JOURNAL,2005,18(4).
[17]汪利合.点穴加旋转屈伸手法治疗膝关节骨性关节炎[J].中国民间疗法,2002,10(11)：29.
[18]李晓昊,黄清春,沈鹰,等.单刺曲池穴治疗膝关节骨关节炎68例[J].中国临床康复,2004,8(20)：4027-4027.
[19]戚耀,郝朝军.针灸治疗膝骨性关节炎临床疗效观察[J].陕西中医学院学报,2007,30(6)：43-44.
[20]张必萌,吴耀持,沈健.长针透刺治疗膝骨关节炎的临床研究[J].中国针灸,2004,24(9)：613-614.
[21]丁向荣,姚夏琦,蒋又祝.针罐并用治疗膝关节骨性关节炎51例[J].中国民间疗法,2004,12(9)：29-30.
[22]张琼,肖京,邓磊.麝香通痹巴布膏治疗骨性关节炎(肝肾不足,筋脉瘀滞证)的临床研究[J].中国临床药理学与治疗学,2005,10(8)：953-956.
[23]郭继锋,杜志谦,鲍铁周,等.芎芷痛瘀消散贴治疗膝骨陛关节炎膝关节痛临床研究[J].世界中西医结合杂志,2008,3(8)：468-470.
[24]尹建平,王海燕.活血通络凝胶剂合扶元乳膏剂治疗膝关节骨性关节炎60例疗效观察[J].新中医,2008,40(4)：69-70.
[25]王少山,张世华,邱红明.骨病中西医结合诊疗学[M].北京：中国中医药出版社.2002.
[26]娄玉钤.中国风湿病学[M].人民卫生出版社,2001.245-249
[27]HUNTER D. J., WILSON D. R. Role of alignment and biomechanics in osteoarthritis and implications for imaging[J]. Radiol Clin North Am,2009,47(4): 553-566.
[28]HUNTER D. J., SHARMA L., SKAIFE T. Alignment and osteoarthritis of the knee[J]. J Bone Joint Surg Am,2009,91 Suppl 1:85-89.
[29]FOROUGHI N., SMITH R., VANWANSEELE B. The association of external knee adduction moment with biomechanical variables in osteoarthritis:a systematic review[J]. Knee,2009,16(5):303-309.
[30]SHARMA L., SONG J., FELSON D. T., et al. The role of knee alignment in disease progression and functional decline in knee osteoarthritis[J]. JAMA,2001, 286(2):188-195.
[31]OGATA K., YASUNAGA M., NOMIYAMA H. The effect of wedged insoles on the thrust of osteoarthritic knees[J]. International orthopaedics,1997,21(5):308-312.
[32]VAN RAAIJ T.M., REIJMAN M., BROUWER R.W., et al. Medial knee osteoarthritis treated by insoles or braces:a randomized trial[J]. Clinical Orthopaedics and Related Research(R),2010,468(7):1926-1932.
[33]RANNOU F., POIRAUDEAU S., BEAUDREUIL J. Role of bracing in the management of knee osteoarthritis[J]. Curr Opin Rheumatol,2010,22(2):218-222.
[34]BENZAKOUR T., HEFTI A., LEMSEFFER M., et al. High tibial osteotomy for medial osteoarthritis of the knee:15 years follow-up[J]. Int Orthop,2010,34(2): 209-215.
[35]BROUWER RW, JAKMA TS, BIERMA-ZEINSTRA SM, et al. Osteotomy for treating knee osteoarthritis[J]. Cochrane database of systematic reviews (Online), 2005, (1):CD004019.
[36]B THIS H., PERLICK L., TINGART M., et al. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique[J]. The Journal of bone and joint surgery British volume,2004,86(5):682.
[37]STIEHL J.B. Knee kinematics and mobile bearings:new design considerations[J]. Current Opinion in Orthopaedics,2001,12(1):18-25.
[38]ASANO T., AKAGI M., TANAKA K., et al. In vivo three-dimensional knee kinematics using a biplanar image-matching technique[J]. Clinical orthopaedics and related research,2001,388:157-166.
[39]FREEMAN MAR, PINSKEROVA V. The movement of the knee studied by magnetic resonance imaging[J]. Clinical orthopaedics and related research,2003,410: 35-43.
[40]WRETENBERG P., RAMSEY D.K., N METH G Tibiofemoral contact points relative to flexion angle measured with MRI[J]. Clinical Biomechanics,2002,17(6): 477-485.
[41]DENNIS D.A., KOMISTEK R.D., HOFF W.A., et al. In vivo knee kinematics derived using an inverse perspective technique[J]. Clinical orthopaedics and related research,1996,331:107-117.
[42]STIEHL J.B., DENNIS D.A., KOMISTEK R.D., et al. In vivo kinematic analysis of a mobile bearing total knee prosthesis[J]. Clinical orthopaedics and related research, 1997,345:60-66.
[43]GEORGOULIS A. D., PAPADONIKOLAKIS A., PAPAGEORGIOU C. D., et al. Three-dimensional tibio femoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking[J]. Am J Sports Med,2003,31(1):75-79.
[44]TEICHTAHL AJ, MORRIS ME, WLUKA AE, et al. Foot rotation--a potential target to modify the knee adduction moment[J]. Journal of Science and Medicine in Sport,2006,9(1-2):67-71.
[45]LANDRY S.C., MCKEAN K.A., HUBLEY-KOZEY C.L., et al. Knee bio mechanics of moderate O A patients measured during gait at a self-selected and fast walking speed[J]. Journal of biomechanics,2007,40(8):1754-1761.
[46]王学谦,娄思权,侯筱魁.骨关节炎一诊断与治疗[M].天津：天津科技翻译出版公司.2005：296-297.
[47]黄国良,孙材江,黎志宏,等.正确认识和对待“骨质增生”的问题[J].中国现代实用医学杂志,2004,3(3)：43-45.
[48]王跃辉,韩清民,刘洪江,等.膝骨性关节炎影像学分析与经筋辨证关系研究[J].新中医,2008,40(5)：66-67.
[49]韩清民,王跃辉,黄旭东,等.膝骨关节炎从筋论治思路探讨[J].新中医,2009,41(1)：5-6.
[50]CEREJO R., DUNLOP D. D., CAHUE S., et al. The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease[J]. Arthritis Rheum,2002,46(10):2632-2636.
[51]TEICHTAHL AJ, CICUTTINI FM, JANAKIRAMANAN N., et al. Static knee alignment and its association with radiographic knee osteoarthritis[J]. Osteoarthritis and Cartilage,2006,14(9):958-962.
[52]FELSON D.T., MCLAUGHLIN S., GOGGINS J., et al. Bone marrow edema and its relation to progression of knee osteoarthritis[J]. Annals of internal medicine,2003, 139(5 Part 1):330.
[53]ROEMER F. W., ZHANG Y., NIU J., et al. Tibiofemoral joint osteoarthritis:risk factors for MR-depicted fast cartilage loss over a 30-month period in the multicenter osteoarthritis study[J]. Radiology,2009,252(3):772-780.
[54]BENNETT L. D., BUCKLAND-WRIGHT J. C. Meniscal and articular cartilage changes in knee osteoarthritis:a cross-sectional double-contrast macroradiographic study[J]. Rheumatology (Oxford),2002,41(8):917-923.
[55]黄加张,顾湘杰,潘哲尔,等.半月板突出在膝骨性关节炎关节间隙狭窄中的作用[J].中国临床康复,2005,9(002)：22-23.
[56]NAKAMURA M., SUMEN Y, SAKARIDANI K., et al. Relationship between the shape of tibial spurs on X-ray and meniscal changes on MRI in early osteoarthritis of the knee[J]. Magnetic Resonance Imaging,2006,24(9):1143-1148.
[57]KHAN F. A., KOFF M. F., NOISEUX N. O., et al. Effect of local alignment on compartmental patterns of knee osteoarthritis[J]. J Bone Joint Surg Am,2008,90(9): 1961-1969.
[58]KIJOWSKI R., STANTON P., FINE J., et al. Subchondral Bone Marrow Edema in Patients with Degeneration of the Articular Cartilage of the Knee Joint1[J]. Radiology,2006,238(3):943-949.
[59]刘涛.经筋实质初探[J].中国针灸,2007,27(4)：297-298.
[60]薛立功.经筋理论的探讨与发挥[J].中国针灸,1997,17(11)：698-699.
[61]骆书彦,马帅,崔瑾.十二经筋理论探析[J].江苏中医药,2004,25(1)：42-44.
[62]原林,钟世镇.人体自体检测与调控系统(筋膜学)——经络有关的解剖学基础[J].天津中医药,2004,21(5)：356-359.
[63]吴金鹏.中医“经筋”及“膜原”实质的筋膜理论探讨[J].北京中医,2007,26(5)：283-285.
[64]黄敬伟.经筋疗法[M].北京：中国中医药出版社.1996：65-85.
[65]MORELAND J. R., BASSETT L. W., HANKER G. J. Radiographic analysis of the axial alignment of the lower extremity[J]. J Bone Joint Surg Am,1987,69(5): 745-749.
[66]HSU R.W.W., HIMENO S., COVENTRY M.B., et al. Normal axial alignment of the lower extremity and load-bearing distribution at the knee[J]. Clinical orthopaedics and related research,1990,255:215-217.
[67]HINMAN R.S., MAY R.L., CROSSLEY K.M. Is there an alternative to the full?leg radiograph for determining knee joint alignment in osteoarthritis?[J]. Arthritis Care & Research,2006,55(2):306-313.
[68]COLEBATCH A.N., HART D.J., ZHAI G., et al. Effective measurement of knee alignment using AP knee radiographs[J]. The Knee,2009,16(1):42-45.
[69]INSALL JN, EASLEY ME. Surgical techniques and instrumentation in total knee arthroplasty[J]. Surgery of the knee 3rd ed New York:Churchill Livingstone,2001: 1584-1587.
[70]COOKE T.D.V., BRYANT J.T., SCUDAMORE R.A. Biomechanical factors in alignment and arthritic disorders of the knee[J]. Knee surgery Baltimore:Williams and Wilkins,1994:1061-1078.
[71]SNIEKERS Y. H., INTEMA F., LAFEBER F. P., et al. A role for subchondral bone changes in the process of osteoarthritis; a micro-CT study of two canine models[J]. BMC Musculoskelet Disord,2008,9:20.
[72]RADIN E. L., PAUL I. L., TOLKOFF M. J. Subchondral bone changes in patients with early degenerative joint disease[J]. Arthritis Rheum,1970,13(4): 400-405.
[73]RADIN E. L. Subchondral bone changes and cartilage damage[J]. Equine Vet J, 1999,31(2):94-95.
[74]DIEPPE P. Subchondral bone should be the main target for the treatment of pain and disease progression in osteoarthritis[J]. Osteoarthritis and cartilage/OARS, Osteoarthritis Research Society,1999,7(3):325-326.
[75]MROSEK E. H., LAHM A., ERGGELET C., et al. Subchondral bone trauma causes cartilage matrix degeneration:an immunohistochemical analysis in a canine model[J]. Osteoarthritis Cartilage,2006,14(2):171-178.
[76]KARSDAL MA, LEEMING DJ, DAM EB, et al. Should subchondral bone turnover be targeted when treating osteoarthritis?[J]. Osteoarthritis and Cartilage, 2008,16(6):638-646.
[77]SAKAO K., TAKAHASHI K. A., MAZDA O., et al. Enhanced expression of interleukin-6, matrix metalloproteinase-13, and receptor activator of NF-kappaB ligand in cells derived from osteoarthritic subchondral bone[J]. J Orthop Sci,2008, 13(3):202-210.
[78]BOYD S. K., MULLER R., ZERNICKE R. F. Mechanical and architectural bone adaptation in early stage experimental osteoarthritis[J]. J Bone Miner Res,2002,17(4): 687-694.
[79]PELLETIER J. P., BOILEAU C., BRUNET J., et al. The inhibition of subchondral bone resorption in the early phase of experimental dog osteoarthritis by licofelone is associated with a reduction in the synthesis of MMP-13 and cathepsin K[J]. Bone,2004,34(3):527-538.
[80]陆圣君,杨述华.降钙素对大鼠骨关节炎关节软骨和软骨下骨的影响[J].中国骨质疏松杂志,2008,14(3)：183-186.
[81]杨勇,吴世栋,张小钰,等.骨化三醇对大鼠骨性关节炎关节软骨及软骨下骨的影响[J].中国骨质疏松杂志,2009,15(5)：333-337.
[82]王跃辉,韩清民,李钊,等.生物力学因素在骨关节炎诊疗体系中的价值探讨—骨关节炎经筋诊疗思路浅谈[J].中国中医骨伤科杂志,2010,1.68-70
[83]ECKSTEIN F., BENICHOU O., WIRTH W., et al. Magnetic resonance imaging-based cartilage loss in painful contralateral knees with and without radiographic joint space narrowing:Data from the Osteoarthritis Initiative[J]. Arthritis Rheum,2009,61(9):1218-1225.
[84]TEICHTAHL A. J., DAVIES-TUCK M. L., WLUKA A. E., et al. Change in knee angle influences the rate of medial tibial cartilage volume loss in knee osteoarthritis[J]. Osteoarthritis Cartilage,2009,17(1):8-11.
[85]BROUWER GM, TOL AW, BERGINK AP, et al. Association between valgus and varus alignment and the development and progression of radio graphic osteo arthritis of the knee[J]. Arthritis & Rheumatism,2007,56(4):1204-1211.
[86]刘源,曾庆余.膝症状性骨关节炎X线特点及其意义[J].中华放射学杂志,1998,32(6)：425-426.
[87]叶永平,曾炳芳.膝骨关节炎病因,X线片及临床表现分析[J].临床骨科杂志,2000,3(3)：169-173.
[88]MUNDERMANN A., DYRBY C. O., ANDRIACCHI T. P. Secondary gait changes in patients with medial compartment knee osteoarthritis:increased load at the ankle, knee, and hip during walking[J]. Arthritis Rheum,2005,52(9):2835-2844.
[89]WEIDENHIELM L., SVENSSON O. K., BROSTROM L. A., et al. Adduction moment of the knee compared to radiological and clinical parameters in moderate medical osteoarthrosis of the knee[J]. Ann Chir Gynaecol,1994,83(3):236-242.
[90]WENHAM C. Y., CONAGHAN P. G. Imaging the painful osteoarthritic knee joint:what have we learned?[J]. Nat Clin Pract Rheumatol,2009,5(3):149-158.
[91]VAN DER KRAAN P. M., VAN DEN BERG W. B. Osteophytes:relevance and biology[J]. Osteoarthritis Cartilage,2007,15(3):237-244.
[92]MARSHALL J. L., OLSSON S. E. Instability of the knee. A long-term experimental study in dogs[J]. J Bone Joint Surg Am,1971,53(8):1561-1570.
[93]MOSKOWITZ R. W., GOLDBERG V. M. Studies of osteophyte pathogenesis in experimentally induced osteoarthritis[J]. J Rheumatol,1987,14(2):311-320.
[94]GALE DR, CHAISSON CE, TOTTERMAN SMS, et al. Meniscal subluxation: association with osteoarthritis and joint space narrowing[J]. Osteoarthritis and Cartilage,1999,7(6):526-532.
[95]FAIRBANK TJ. Knee joint changes after meniscectomy[J]. Journal of Bone and Joint Surgery-British Volume,1948,30(4):664-670.
[96]VEDI V., SPOUSE E., WILLIAMS A., et al. Meniscal movement:an in-vivo study using dynamic MRI[J]. Journal of Bone and Joint Surgery-British Volume,1999, 81(1):372-411.
[97]COSTA C., MORRISON W.B., CARRINO J.A. Medial meniscus extrusion on knee MRI:is extent associated with severity of degeneration or type of tear?[J]. American Journal of Roentgenology,2004,183(1):17-23.
[98]BREITENSEHER M. J., TRATTNIG S., DOBROCKY I., et al. MR imaging of meniscal subluxation in the knee[J]. Acta Radiol,1997,38(5):876-879.
[99]MASOUROS SD, MCDERMOTT ID, AMIS AA, et al. Biomechanics of the meniscus-meniscal ligament construct of the knee[J]. Knee Surgery, Sports Traumatology, Arthroscopy,2008,16(12):1121-1132.
[100]KENNY C. Radial displacement of the medial meniscus and Fairbank's signs[J]. Clin Orthop Relat Res,1997, (339):163-173.
[101]ENGLUND M., LOHMANDER LS. Risk factors for symptomatic knee osteoarthritis fifteen to twenty two years after meniscectomy[J]. Arthritis & Rheumatism,2004,50(9):2811-2819.
[102]BERTHIAUME MJ, RAYNAULD JP, MARTEL-PELLETIER J., et al. Meniscal tear and extrusion are strongly associated with progression of symptomatic knee osteoarthritis as assessed by quantitative magnetic resonance imaging[J]. Annals of the rheumatic diseases,2005,64(4):556-563.
[103]黄加张,顾湘杰,王旭,等.膝关节半月板半脱位的相关因素分析[J].复旦学报：医学版,2005,32(004)：433-435.
[104]LERER DB, UMANS HR, HU MX, et al. The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion[J]. Skeletal radiology,2004, 33(10):569-574.
[105]ISSA S. N., SHARMA L. Epidemiology of osteoarthritis:an update[J]. Curr Rheumatol Rep,2006,8(1):7-15.
[106]FELSON D. T., MCLAUGHLIN S., GOGGINS J., et al. Bone marrow edema and its relation to progression of knee osteoarthritis[J]. Ann Intern Med,2003,139(5 Pt 1):330-336.
[107]SCHWEITZER M.E., WHITE L.M. Does altered biomechanics cause marrow edema?[J]. Radiology,1996,198(3):851-853.
[108]KOO K.H., AHN I.O., KIM R., et al. Bone Marrow Edema and Associated Pain in Early Stage Osteonecrosis of the Femoral Head:Prospective Study with Serial MR Images1[J]. Radiology,1999,213(3):715-722.
[109]何伟,曾勤,张庆文,等.非创伤性股骨头坏死骨髓水肿与疼痛分级及坏死分期相关性的研究[J]Chinese Journal of Reparative and Reconstructive Surgery, 2008,22(3):299-302.
[110]CASTRO F. P., JR., BARRACK R. L. Core decompression and conservative treatment for avascular necrosis of the femoral head:a meta-analysis[J]. Am J Orthop (Belle Mead NJ),2000,29(3):187-194.
[111]NEOGI T., NEVITT M., NIU J., et al. Subchondral bone attrition may be a reflection of compartment-specific mechanical load:the MOST Study[J]. Annals of the rheumatic diseases,2010,69(5):841.
[112]ROEMER F. W., NEOGI T., NEVITT M. C., et al. Subchondral bone marrow lesions are highly associated with, and predict subchondral bone attrition longitudinally:the MOST study[J]. Osteoarthritis Cartilage,2010,18(1):47-53.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |