Clinical Effects of Ultrasound-Guided Acupotomy in Knee Osteoarthritis Treatment

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 data^2,3 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 knee^5,6, 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 individuals^7,8. 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 lesions^11,12, improving the accuracy and safety of acupotomy¹³. Currently, it is primarily used to treat joint pain in the neck, shoulder, waist, and leg^14,15. 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 study after obtaining and signing informed consent either from the patients or their families. The surgeon was familiar with the anatomy of the knee joint and acupotomy treatment.

1. Patient recruitment

1. Diagnostic criteria
   1. Use the following diagnostic criteria to diagnose knee osteoarthritis, according to the Chinese Society of Osteology's guidelines for the diagnosis and treatment of osteoarthritis (GDTO)¹⁶. Check the affected knee for pain within the last month, and if any two of the following four criteria exist, diagnose as knee osteoarthritis: (1) radiographs (standing or weight-bearing) showing joint space narrowing, joint margin osteophyte formation, subchondral osteosclerosis, or cystic change; (2) age ≥ 60 years; (3) morning stiffness of ≤ 30 min; (4) bone grinding sound during activity.
2. Inclusion criteria
   1. Use the following inclusion criteria to enroll patients in this study: (1) conform to the diagnostic criteria of KOA; (2) age between 40-75 years; (3) body mass index ≤ 25 kg/m²; (4) no cognitive dysfunction; (5) no previous knee surgery or acupotomy within 1 month; (6) understands the relevant contents of the study in detail, and have good medical compliance and a high degree of cooperation; (7) agree and sign the informed consent.
3. Exclusion criteria
   1. Use the following exclusion criteria to not include patients in this study: (1) pregnant and lactating women; (2) patients with infection and muscle necrosis or deep abscess at the treatment site (knee); (3) patients with a history of fainting with the use of needles; (4) patients with a severe meniscus tear, anterior or posterior cruciate ligament tear, medial or lateral collateral ligament injury; (5) patients with knee joint pain caused by neurological diseases; (6) patients with severe cardiovascular, liver, kidney or hematopoietic system disease; (7) patients receiving other treatment options; (8) lidocaine hydrochloride allergy; (9) patients who do not want to be followed up.
4. Dropout criteria
   1. Use the following exit criteria to allow patient dropout in this study: (1) voluntary withdrawal by the patient; (2) occurrence of other complications.

2. Acupotomy treatment

1. Preoperative preparation
   1. Material preparation (Figure 1): sterilize disposable medical plastic cups, forceps, absorbent cotton balls, self-adhesive dressing, ultrasonic instruments (portable color ultrasound system), sterile ultrasound coupler, sterile protective cover for probe, 40 mm small disposable sterile needle knife, marker pen, disposable medical mask, hygiene hat, type II skin disinfectant, disposable sterile towel, 2% lidocaine hydrochloride, sterile water for injection, 10 mL disposable sterile syringe, sterile needle for injection, and surgical rubber gloves.
   2. Operation site: Prepare a treatment room with air disinfectant capabilities.
   3. Check patient information: check all basic patient information like name, age, and treatment site. Explain the needle-knife therapy procedure, including the possible risks and benefits of treatment. Ensure that the patient understands needle-knife treatment and remains relaxed during the procedure.
   4. Patient position: Ask the patient to lie down in a supine position, with the affected knee joint fully exposed and a thin pillow placed under the affected knee joint to place the joint in a relaxed state. Abduct the contralateral knee slightly, providing more room for the surgeon.
2. Positioning (Figure 2)
   1. Tenderness points positioning: Mark the point where significant pain occurred in the affected knee joint due to the operator's finger pressure, such as the 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 bursa point.
   2. Ultrasound positioning¹⁷: Use the ultrasound probe (frequency 8-15 MHz, depth 1-4 cm) to scan along the short and long axis of the quadriceps tendon, the long axis of the knee tibial collateral ligament, the long axis of the fibular collateral ligament of the knee, the long axis of the patellar tendon and the tenderness point. Mark the points of local thickening, reduced echo, and loss of lamellar structure in ultrasound on the body surface.
3. Operative steps (Figure 3)
   1. Following aseptic procedures, wear masks, hats, and sterile gloves.
   2. Ask the surgical assistant to open a 5 mL 2% lidocaine and 5 mL sterile water vial. Place a 10 mL syringe, a 25G needle, and a 40 mm disposable small sterile needle knife into a sterile plastic cup.
   3. Ask the surgical assistant to use cotton balls and type II skin disinfectant to disinfect the 15 cm area around the marked point on the knee. Place a sterile towel so that the mark point is in the middle of the sterile towel.
   4. Extract 5 mL of 2% lidocaine and 5 mL of sterile water with a 10 mL syringe to prepare 10 mL of working 1% lidocaine solution. Replace the 22G needle with a 25G needle (using a thinner needle for pain control).
   5. Fit the sterile protective cover over the probe. Hold the ultrasound probe in the left hand and the syringe in the right hand. Extrude the sterile ultrasonic gel and apply it to the probe.
      NOTE: The surgical assistant assists the surgeon with this.
   6. Place the probe in the marked position. Confirm the target in the ultrasound image. Insert the syringe needle into the skin from the probe side so that the syringe needle and the target are in the same field of view. Make sure no blood returns upon aspiration. Inject each target with 1-2 mL of 1% lidocaine working solution.
   7. Hold the needle knife in the right hand. Insert the needle knife into the lidocaine injection site. The needle knife insertion direction is parallel to the direction of muscle and ligament fibers to avoid cutting muscle fibers and ligament fibers. Make sure the needle knife and the target are in the same field of view. Avoid touching blood vessels and nerves.
   8. Perform a longitudinal incision, stripping, and release the adhesion¹⁸. The patient will feel local soreness and pain, and the surgeon will feel resistance under the knife needle. Remove the knife needle when the surgeon feels a sense of looseness under the knife.
4. Postoperative care (Figure 3)
   1. Press the injection site with a dry sterile cotton ball for 1 min. Cover the surgical area with a sterile self-adhesive dressing. Help the patient get dressed and leave the operating room.
   2. Ask the patient to sit quietly at the door of the operating room for approximately 15 min to avoid postoperative discomfort. Ask the patient to remove the dressing after 24 h and avoid contact with water for 3 days to avoid infection¹⁹.
5. Perform ultrasound-guided acupotomy once a week for a total of three acupotomy treatments.

3. Follow up evaluation

1. Parameters for evaluation^{10,11,12,13,14,15,16,17,18,19,20,21,22}
   1. Use the synovial thickness of the suprapatellar bursae, the Visual analog scale (VAS), the Hospital for Special Surgery Knee Score (HSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to assess the outcome. Take measurements before treatment and 1 week after the 3 treatments were completed.
2. Ultrasound-based evaluation
   1. Use the ultrasound to measure the synovial membrane thickness of suprapatellar bursae.
   2. Press the Power button to turn on the ultrasound machine. Press the Patient button, click on New Patient, and enter the patient's name.
   3. Ask the patient to lie in a supine position. Place a thin pillow under the popliteal fossa of the affected knee joint to fully expose it.
   4. Use the head end of the probe to find the superior edge of the patella. Place the tail end on the quadriceps tendon. Adjust the direction of the probe. Make sure that the acoustic beam is made perpendicular to the tendon and located on the synovial membrane of the suprapatellar bursae.
   5. Press the Freeze button to save the ultrasound image. Press the Caliper button to test the synovial thickness of the suprapatellar bursa. Record the measurement results.

4. Statistical analysis

1. Use a statistical analysis software. Express the measurement data as mean ± standard deviation (SD). Use a T-test to compare the differences before and after treatment. Consider p <0.05 as statistically significant.

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 ...

Materials

Name	Company	Catalog Number	Comments
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