Clinical Effects of Ultrasound-Guided Acupotomy in Knee Osteoarthritis Treatment

Published: April 26, 2024

doi:

Chen Chen, Dan Liu, Su Xia Guo, Bo Chen, Shi Yun Wang, Ping Hua Chen, Pan Li, Fang Fang Li, Qian Chen, Xue Fei Li, Fangyu Li, Zhi Jun Hu

¹Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine, ²Shanghai Pudong New Area Guangming Hospital of Traditional Chinese Medicine

Summary

This paper introduces the operation method of ultrasound-guided acupotomy for knee osteoarthritis, which can reduce synovial thickness and improve knee joint function. It has the advantages of precise target, low treatment risk, few complications, and high safety.

Abstract

The protocol presented here demonstrates the operation method of ultrasound-guided acupotomy for knee osteoarthritis (KOA), including patient recruitment, preoperative preparation, manual operation, and postoperative care. The purpose of this protocol is to relieve pain and improve knee function in patients with KOA. A total of 60 patients with KOA admitted between June 2022 and June 2023 were treated with ultrasound-guided acupotomy. Pathological changes and knee function scores were compared before and after the treatment. After 1 week of treatment, the synovial thickness of the suprapatellar bursae was significantly lesser than before treatment (p < 0.05), the Hospital for Special Surgery Knee Score (HSS) was significantly higher than before treatment (p < 0.05), the Visual analogue scale (VAS) was significantly lower than those of the control group (p < 0.05) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were significantly lower than those of the control group (p < 0.05). Therefore, ultrasound-guided acupotomy for the treatment of KOA can reduce synovial thickness, relieve pain, improve knee joint function, and have a remarkable curative effect.

Introduction

Knee osteoarthritis (KOA) is the most common degenerative disease of the knee joint, causing knee pain, bony enlargements, morning stiffness, knee activity limitations, and other symptoms. Knee pain and limited function are the primary factors affecting daily life and work in patients with KOA. Most people with KOA experience a partial or complete loss of the ability to work and self-care, which is the primary cause of chronic disability¹. Epidemiological data²^,³ show that the prevalence of KOA is positively correlated with age. With the aging Chinese population, the incidence of KOA is increasing every year. Globally, approximately 250 x 10⁶ patients have osteoarthritis, and its incidence is increasing annually. By 2030, osteoarthritis will be one of the main causes of disability⁴, with approximately 85% of osteoarthritis cases of the knee⁵^,⁶, which seriously affects the quality of life of patients and causes pain in their life and work, leading to a heavy economic burden to the country and individuals⁷^,⁸. Therefore, finding safe and minimally invasive treatments for patients with KOA is an area of intense research in orthopedics.

The main treatments for KOA include conservative therapies like patient education, lifestyle adjustments, physical therapy, orthopedic aids and orthotics, and medication and surgery. The vast majority of intra-knee surgery is performed through arthroscopic surgery with little trauma and a low infection rate. However, arthroscopic surgery still has some traumatic effects. Patients with KOA often undergo surgery after conservative treatment has failed⁹.

Acupotomy is a less invasive surgery than arthroscopy. Acupotomy can be performed in conjunction with conservative treatment. The needle knife is generally about 10-15 cm long and 0.4-1.2 mm in diameter. The needle knife consists of three parts: handle, needle body, and blade. The blade is thin and sharp. Its width is equal to the diameter of the needle body. Traditional acupotomy refers to the treatment of tendon pain points by a surgeon under the condition that the internal tissue structure of the human body cannot be directly observed; the interventional treatment is carried out according to his/her own experience and knowledge of the local anatomical tissue, combined with the symptoms and tender points of the patient. Due to the high risk of the procedure, including damage to the surrounding soft tissues, nerves, and blood vessels, infection, uncertain effects, and the possibility of multiple procedures, the use of traditional acupotomy is quite limited. With the development of imaging technology, the use of visualization has become a developing trend in acupotomology¹⁰ and has broadened the clinical application of acupotomy. Ultrasound can be used to visualize muscle and fascial lesions in real-time, allowing complete identification of the relative anatomy and the lesions¹¹^,¹², improving the accuracy and safety of acupotomy¹³. Currently, it is primarily used to treat joint pain in the neck, shoulder, waist, and leg¹⁴^,¹⁵. Ultrasound-guided acupotomy has the advantages of being a precisely targeted therapy, low risk, few complications, and high safety. Therefore, this study evaluated ultrasound-guided acupotomy as a new therapeutic approach for KOA.

Protocol

All patients with KOA were evaluated in the outpatient Department of TCM Rehabilitation at Guangming Hospital of Shanghai Pudong New Area from June 2022 to June 2023 for a total of 60 cases. This study was approved by the ethics review committee at Guangming Hospital of Traditional Chinese Medicine of Shanghai Pudong New Area (Ethics number: GMEC-KY-2020034). Doctors informed patients and their families regarding the clinical significance, risks, and follow-up requirements of the study. Patients were included in the stud…

Representative Results

During the study, one patient received additional other treatments (intra-articular steroid injection) due to increased pain. In one patient, the synovial thickness of the suprapatellar bursae could not be detected on ultrasonography. One patient developed swelling and subcutaneous stasis around the wound after treatment, which improved after ice application without affecting normal treatment and follow-up. Two patients terminated the experiment, and the remaining 58 patients were included in the final statistical analys…

Discussion

There are three aspects of the treatment procedure that need special attention. The first is tenderness point localization. The surface of the total knee joint should be pressed to mark the location of the patient's pain response through the patient's complaint and the doctor's palpation. Peroneal collateral ligament and iliotibial band point, patellar lateral retinaculum point, quadriceps tendon and suprapatellar bursa point, patellar medial retinaculum point, tibial collateral ligament point, pes anserinus …

Divulgations

The authors have nothing to disclose.

Acknowledgements

We are grateful to Shanghai Three-year Action Plan to Further Accelerate the Inheritance and Innovation of Traditional Chinese Medicine (ZY(2021-2023)-0201-01); Pudong New Area Health System Pudong Famous TCM Training Program (PWRzm2020-15); Chinese Medicine Rehabilitation Service Enhancement Project (Medical 032); Innovation project of Longhua Hospital: Clinical study of acupotomy combined with knee balance exercise in the treatment of knee osteoarthritis (CX202045); Clinical study of acupotomy combined with Mulligan dynamic joint loosening in the treatment of periarthritis of shoulder (PKJ2020-Y76); Pudong New Area Health Commission Pudong Famous Chinese Medicine Successor Training Plan (PWRzj2020-21); TCM special disease Brand Construction Doubling Plan – Small acupotomy Special Disease (PDZY-2021-0304).

Materials

Disposable sterile injection needle	Shanghai Mishava Medical Industry Co., Ltd	601900973	Type specification:0.5 x 38 RWLB
Disposable medical mask	Shanghai Honglong Medical Supplies Equipment Co., LTD	20162140493	Type specification: 17.5 x 9.5cm
Disposable sterile small needle-knife	Wujiang Yunlong Medical equipment Co., Ltd	PR-4040	Type specification:40 mm x 40 mm
Disposable sterile syringe	Shandong Weigo Group Medical polymer Products Co., Ltd	601909174	Type specification:10 mL
Disposable sterile towel	Xinxiang Huakang Medical Material Co., LT	20182140517	Type specification: 80x100cm
Hygiene hat	Shanghai Honglong Medical Supplies Equipment Co., LTD	20150071	Type specification: 21x14cm
Lidocaine hydrochloride	Shanghai Hefeng Pharmaceutical Co., Ltd	6904996104121	Type specification:5 mL
Marker pen	Zebra Trading (Shenzhen) Co., Ltd	4901681518111	Type specification:1.0 mm/0.5 mm
Sterile absorbent cotton ball	Shanghai Honglong Medical Supplies Equipment Co., Ltd	601905637	Type specification:0.3 25 g
Sterile disposable medical plastic cup	Shanghai Honglong Medical Supplies Equipment Co., Ltd	709008633	Type specification:Waist-shaped disc
Sterile dressing block	Ningbo Haishu Shenyuan Medical Materials Co., Ltd	601909470	Type specification:7.5 cm x 7.5 cm x 8 floors
Sterile medical tweezers	Shanghai Honglong Medical Supplies Equipment Co.,Ltd	603917444	Type specification:Small size
Sterile protective cover for probe	Yangzhou Puen Medical Technology Co., LTD	20200046	Type specifications: 20x150cm
Sterile rubber surgical gloves	Guilin Hengbao health protection Co., Ltd	6971787071320	Type specification:6.5
Sterile self-adhesive dressing	Shanghai ISO Medical Products Co., Ltd	601909414	Type specification:10 cm x 15 cm
Sterile ultrasonic coupler	Jiangsu Huadong Medical Equipment Industrial Co., LTD	6972830280430	Type Specifications: 20g
Sterile water for injection	Shanghai Xinyi Jinzhu Pharmaceutical Co., Ltd	6938493300953	Type specification:5 mL
Type II skin disinfectant	Shanghai Likang Disinfection high-tech Co., Ltd	6909157000359	Type specification:500 mL/ bottle
Ultrasound	Suzhou Daer Medical Equipment Co., Ltd	100018857	uSmart3300 portable color ultrasound system

References

Joo, P. Y., Borjali, A., Chen, A. F., Muratoglu, O. K., Varadarajan, K. M. Defining and predicting radiographic knee osteoarthritis progression: A systematic review of findings from the osteoarthritis initiative. Knee Surg Sports Traumatol Arthrosc. 30 (12), 4015-4028 (2022).
Tan, X. F., Guo, Y. X. Research progress of predisposing factors of knee osteoarthritis. Rheumatism Arthritis. 11 (1), 60-64 (2022).
Alrowali, L. M. G. Magnetic resonance evaluation of knee osteoarthritis among the Saudi population. Pak J Med Sci. 35 (6), 1575-1581 (2019).
Thomas, E., Peat, G., Croft, P. Defining and mapping the person with osteoarthritis for population studies and public health. Rheumatology. 53 (2), 338-345 (2014).
Primorac, D., et al. Knee osteoarthritis: A review of pathogenesis and state-of-the-art non-operative therapeutic considerations. Genes. 11 (8), 854 (2020).
Tang, X., et al. The prevalence of symptomatic knee osteoarthritis in China: Results from the China health and retirement longitudinal study. Arthritis Rheumatol. 68 (3), 648-653 (2016).
Hunter, D. J., Schofield, D., Callander, E. The individual and socioeconomic impact of osteoarthritis. Nat Rev Rheumatol. 10 (7), 437-441 (2014).
Wang, B., et al. Systematic review of the epidemiology and disease burden of knee osteoarthritis in China. Chin J Evid-Based Med. 18 (2), 134-142 (2018).
Michael, J. W., Schlüter-Brust, K. U., Eysel, P. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int. 107 (9), 152-162 (2010).
Zhou, Q. Y., et al. Opportunities and challenges in the development of visual acupotomies. Chinese J Tradl Chinese Med. 35 (10), 4801-4804 (2019).
Gao, G. X., Zhang, S. Clinical study of musculoskeletal ultrasound-guided knife-needle relaxation in treatment of Cervical radiculopathy. Hebei Chinese Med. 43 (4), 662-665 (2021).
Wang, J., et al. Clinical study of musculoskeletal ultrasound-guided acupotomy in the treatment of greater occipital nerve entrapment syndrome. South China J Def Med. 34 (8), 527-530 (2019).
Ren, S., et al. Ultrasound-guided acupotomy combined with ozone in the treatment of 40 cases of subacromial bursitis. Chinese J Orthoped Traumatol Tradl Chinese Med. 29 (6), 71-73 (2021).
Dai, M., Li, K. P., Wu, X. L. Research status and application advantages of ultrasonic visualization acupotomology. J Liaoning Uni Tradl Chinese Med. 22 (6), 170-173 (2020).
Zeng, X., et al. Research progress of ultrasound acupotoma visualization. J Acupunct Res. 46 (6), 546-548 (2019).
Joint Surgery Group of the Orthopedic Branch of the Chinese Medical Association. Guidelines for the diagnosis and treatment of osteoarthritis (2021 edition). Chin J Orthop. 41 (18), 1291-1314 (2021).
Malanga, G., Mautner, K. . Atlas of ultrasound-guided musculoskeletal injection. , (2014).
Hu, Z. J. . Clinical practice of practical small needle knife. , (2018).
Chinese society of acupuncture and moxibustion minimally invasive acupotomology professional committee. . Acupotomology clinical diagnosis, treatment and operation norms. , (2012).
He, S., Renne, A., Argandykov, D., Convissar, D., Lee, J. Comparison of an emoji-based visual analog scale with a numeric rating scale for pain assessment. JAMA. 328 (2), 208-209 (2022).
Whittaker, J. L., et al. OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis. Br J Sports Med. 56 (24), 1393-1405 (2022).
Alrawashdeh, W., et al. Effectiveness of total knee arthroplasty rehabilitation programmes: A systematic review and meta-analysis. J Rehabil Med. 53 (6), jrm00200 (2021).
Xu, Y., et al. Discussion on the treatment strategy of knee osteoarthritis based on the theory of transfascia and myofascia. Chinese J Tradl Chinese Med. 35 (7), 3293-3296 (2019).
Liang, C., et al. Effects of acupotomy intervention on the biodynamics of medial collateral ligament and the expression of Integrin β1, Col-II genes in KOA rabbits. Chinese J Tradl Chinese Med. 30 (5), 1689-1693 (2015).
Zhang, L., Liu, H., Xiu, Z. Meta-analysis of the therapeutic effect of acupotomy on knee osteoarthritis based on the theory of transtendon. Chinese Ethnic Folk Med. 29 (8), 54-57 (2020).
Zhang, T. M., Du, Y. J. A brief introduction to the mechanical anatomical system of human bowstring. China Med Rev. 14 (3), 164-168 (2017).
Zhao, Y., Fang, W., Qin, W. Mechanism of small acupotomy in closed treatment of myofascitis. Chinese J Acupuncture Moxibustion. 34 (9), 907-909 (2014).
Shi, X., Liu, Y. Short-term effect of acupotomy on improving symptoms of knee osteoarthritis. J Guangzhou Uni Chinese Med. 36 (1), 74-78 (2019).
Zhou, S., et al. Effect of acupotomy on surface electromyography and biomechanical behavior of tendons of tibial anterior muscle in rabbits with knee osteoarthritis. J Beijing Uni Chinese Med. 41 (8), 675-680 (2018).
Geng, W., et al. Meta-analysis of musculoskeletal ultrasound in the diagnosis of soft tissue injury. J Naval Med. 43 (1), 78-83 (2022).
Liu, Q., et al. Visualization development of acupotomy with ultrasonic-assisted means. J Hubei Uni Tradl Chinese Med. 18 (4), 117-120 (2016).
Xu, D. H., et al. Tiaohe Yinyang acupotomy for knee osteoarthritis: a randomized controlled trial. Zhongguo Zhen Jiu. 42 (12), 1351-1356 (2022).
Zhao, L., et al. Zhuifeng Tougu capsules in the treatment of knee osteoarthritis (cold dampness obstruction syndrome): a randomized, double blind, multicenter clinical study. Chin Med. 19 (1), 18 (2024).