In our daily orthopedic clinics, there are many patients with knee pain, of which osteoarthritis is the most common cause of knee pain. Osteoarthritis of the knee is most common in the elderly population and can develop in both men and women. Due to increased life expectancy in the population, the incidence of osteoarthritis has increased significantly during the 20th century, especially in the obese elderly population.
According to the literature, 50% of people over 60 years of age have osteoarthritis on X-ray, of which 35% to 50% have clinical manifestations; 80% of people over 75% have osteoarthritis symptoms. Osteoarthritis is a chronic arthritic disease characterized by degeneration and loss of articular cartilage and regeneration of bone at the joint edges and subchondral bone. The disease begins in the cartilage.
The etiology of knee arthritis is complex and includes chronic injury, obesity, aging, overload exercise, diet, gender, race, environment, cytokines, and immune factors, among others.
Pathogenesis of knee osteoarthritis.
Knee osteoarthritis belongs to the scope of “paralysis”, “bone paralysis” and “knee paralysis” in Chinese medicine, and its etiology is mainly due to old age and physical weakness, combined with the onset of external evil; external evil refers to wind, cold, humidity, heat and other natural climate changes. The external evil refers to wind, cold, dampness, heat and other natural climate changes. According to Chinese medicine, when a person is nearly 50 years old, the liver and kidney qi and blood decline, and the liver is the master of tendons, the kidney is the master of bones, and the relationship with the tendons and bones is very close, the liver blood can not nourish the tendons, the kidney essence can not fill the bones, and the positive qi is weak, can not resist the wind, cold, damp and other external evil, wind, cold, damp three qi mixed to take advantage of the weakness, resulting in the onset of disease.
According to Western medicine, the normal knee joint has six degrees of freedom of movement, namely three translational movements (forward and backward, internal and external, up and down) and three rotational movements (flexion and extension, internal and external rotation, internal retraction and abduction). Normally these six degrees of freedom of motion are controlled by the ligaments, the joint capsule, the bony match, the meniscus and the associated neuromuscles. Injury to one of these tissues and loss of kinetic action can result in abnormal stresses on the knee joint and lead to osteoarthritis.
Prolonged immobilization of the knee joint is also a type of joint stress abnormality that can cause cartilage to degenerate due to loss of nutrients, ligament shortening, and osteoarthritis. Because the cartilage in osteoarthritis loses the lubricating effect of synovial fluid that can be squeezed out by normal cartilage under pressure, and because the subchondral bone is sclerotic and cystic, the uniform stress distribution and shock absorption of the subchondral bone are destroyed, so the cartilage is vulnerable to wear and tear.
This repair phenomenon can mean an increase in the weight-bearing area of the joint and a decrease in the pressure per unit area. The cause of osteochondral hyperplasia can be due to vascularization under the area of cartilage destruction, healing of microfractures in the subchondral bone, and increased intraosseous venous stasis and bone pressure.
The cause of osteoarthritis of the knee is not yet fully understood by Western medicine. Most cases of osteoarthritis of the knee lack a known cause and are referred to as primary osteoarthritis of the knee. Primary osteoarthritis of the knee is closely related to age and occurs most often in older adults. Less frequently, it is a consequence of joint trauma, infection or some genetic, developmental, metabolic or neurogenic disorder known as secondary knee osteoarthritis, which can occur in young adults and even children.
It is becoming clear that a variety of factors, including biological factors (e.g., genetics, age, inflammation, etc.) and mechanical injury, cause the destruction of articular cartilage. This causes a series of pathophysiological changes, resulting in structural damage and further biomechanical disorders that lead to more pronounced manifestations of osteoarthritis.
The clinical manifestations of knee osteoarthritis include four major symptoms: pain, swelling, deformity, and movement disorders, each of which has different symptoms and characteristics, such as fluid accumulation in the knee cavity, morning stiffness, and popping sounds.
In fact, the diagnosis of osteoarthritis of the knee is not difficult, and patients can make a preliminary diagnosis of their knee pain against the following diagnostic points to see if it is caused by osteoarthritis of the knee.
The diagnosis of osteoarthritis of the knee can be made if the following conditions are met; clinical manifestations of osteoarthritis of the knee can be diagnosed if 1, 2, 3, 4 or 1, 2, 3, 5 are met.
1. Frequent recurrent knee pain within the last month.
2.There is friction sound when moving.
3.Morning stiffness of the knee joint ≤ 30 min.
4, middle-aged and elderly people (≥ 40 years old).
5, hypertrophy of the bony end of the knee joint with osteophytes.
4 types of knee osteoarthritis
Chinese medicine has long accumulated rich experience in the treatment of knee osteoarthritis, and according to the different types, methods such as internal Chinese medicine, external application, acupuncture, cupping, tui-na and medicinal food conditioning can be used to achieve certain results.
Chinese medicine generally classifies knee osteoarthritis into four types: cold-damp obstruction type, damp-heat accumulation type, qi-blood deficiency type and liver-kidney deficiency type, depending on which external evil is prevalent and the choice of medicine, each type may be intermingled with each other, the patient is mostly accompanied by physical deficiency, because Chinese medicine believes that physical deficiency is the key to the disease, if “shall not be deficient, evil can not hurt alone”.
Acupuncture treatment is more effective
Chinese medicine treatment: Commonly used formulas include Douwu Yaisheng Tang, Ermiao San, Danggui Qixian Tang, Dafengfeng Tang, Ma Gui Wenjing Tang, San Qi Drink, etc. Commonly used herbs include Douwu, Qiangwu, Bai Shao, Danggui, Huangqi, Duzhong, Hossein, Chuanxiong, Gui Zhi, Jihaodian, Cangzhi, Niu Knee, Haitongpi, Coix Seed and Licorice, etc. Physicians will add or subtract drugs according to different types of symptoms. In addition to internal medication, some of the above herbs can also be used, placed in a cloth bag and heated and then applied externally to the affected area, or the dregs of the decoction can be wrapped in a cloth bag and applied to the affected area while it is still hot. Acupuncture and cupping treatment: Acupuncture is more effective in the treatment of knee osteoarthritis. According to research, acupuncture has the effect of anti-inflammatory and pain relief, swelling reduction, and promotion of blood circulation, etc. By changing the blood flow and blood flow rate of the affected area, some pathogenic inflammatory factors are taken away to improve the symptoms. Commonly used acupuncture points are: Yanglingquan point, Yinlingquan point, the nasal point, the foot three li point, Liangqiu point, the sea of blood point, the commission point, Chengshan point, etc. Electric acupuncture can be used, or moxibustion can be added, or cupping can be added. According to research, electro-acupuncture and warm moxibustion have the best effect and can generally relieve the symptoms after several treatments.
Tui na treatment: properly applied, tui na treatment is also very effective for knee arthritis. It is best not to use the massage method during the acute inflammation period, or to use caution in using light manipulation to avoid exacerbation of inflammation.
Herbal diet: 15 grams of dulcimer, 20 grams of hyssop, 15 grams of pepper root, and about 200 grams of pig’s feet. The pig’s trotters will be cleaned, add the herbs and the right amount of water and boil until the pig’s trotters are cooked and soft, drink the soup and eat the meat of the trotters, this recipe can also be used instead of the pig’s trotters, which has the effect of strengthening the tendons and bones, dispelling the wind and blood, moistening the joints.
Exercise: to develop the habit of exercise exercise, must start from a young age, exercise according to the strength, do not overdo it. The knee is the most weight-bearing joint in the body, and overload is likely to cause arthritis, once the onset of the disease should not stop exercising completely, as long as the amount of exercise is adjusted according to the situation, or do swimming, cycling and other non-weight-bearing exercise, or more benefits than disadvantages of knee arthritis.
The most common question asked by patients and friends is that knee osteoarthritis is a degenerative lesion of the joints and so far, there are no drugs or other methods to stop or reverse the disease.
Western medical treatment.
(i) Drug therapy
The current treatment of osteoarthritis of the knee is divided into two types of drugs to improve the symptoms and improve the condition. Treatment of osteoarthritis of the knee joint is still dominated by anti-inflammatory analgesics and non-steroidal anti-inflammatory drugs (NSAID) for symptomatic treatment: anti-inflammatory analgesics preferred to acetyl amino acids (paracetamol, acetaminophon) have good pain-relieving effects. COX-2 inhibitors (such as rofecoxib, cemetaxib) or non-selective NSAID non-steroidal anti-inflammatory drugs (diclofenac, meloxicam) can also be used. If still ineffective, tramadol may be used. Glucosamine sulfate is an anti-inflammatory and pain-relieving agent that can be taken for long periods of time to slow the development of osteoarthritis of the knee. Sodium hyaluronate can be given intra-articularly as a viscous supplement to relieve joint pain and increase joint slippage.
(B) Non-surgical treatment
1. Reducing joint weight bearing, physiotherapy, and physical therapy to reduce symptoms and maintain joint stability are the main treatment strategies for osteoarthritis of the knee. The drug treatment strategy for osteoarthritis of the knee should focus on early diagnosis, early treatment and a long course of treatment. Prophylaxis and comprehensive treatment should be started before symptoms appear, before significant articular cartilage lesions are detected, and before the joint space is narrowed. Patients should rest appropriately and minimize weight bearing on the knee within the limits of normal life and work, and complete rest is generally not required.
Reduce or avoid harmful movements in daily activities, and hold the handrail when going up and down stairs. When standing up from a sitting position, support the armrest of the chair with your hand to reduce the pressure on the joint cartilage. In severe cases, walking with a cane is recommended. Some people advocate the use of lower limb braces, but they are often not accepted by patients. In severe cases of knee effusion, bed rest and knee physiotherapy should be used.
2. In order to maintain knee stability and reduce quadriceps atrophy, appropriate muscle exercises should be performed daily. 15 min of straight leg raising exercises can be performed daily.
(C) Surgical treatment
1.Joint washout cleanup The excellent result rate is about 65%~75%.
Since the role of joint cleaning is to remove mechanical irritants in the joint, it is a palliative surgery, so arthroscopic joint cleaning has the advantages of less surgical damage and faster postoperative recovery. Arthroscopic debridement or grinding of the free cartilage surface and removal of the synovial membrane that has invaded the cartilage surface are possible. Bone spurs and free bodies that impede joint movement are removed, the torn meniscus is occluded, and the knee is flushed with large amounts of saline (2000 ml or more). This treatment is still considered by many doctors as a successful palliative treatment. It is more effective for those without significant deformity (internal and external rotation). It is less effective in cases with excessive disease and pain after rest.
Secondary osteoarthritis mostly originates from traumatic cartilage damage, and repairing cartilage damage is a means to prevent and treat osteoarthritis.
2.Osteotomy The purpose of femoral or tibial osteotomy for knee osteoarthritis with heavy knee pain and poor alignment is to improve the balance of joint forces and keep the femoral and tibial joints in a 5°~7° valgus position. This shifts the load on the knee joint from the damaged joint space cavity to a more normal joint space cavity.
The knee osteotomy must be essentially normal in the joint space corresponding to the diseased joint space, and the knee must be stable, (collateral and collateral ligaments, cruciate ligaments) and have a near normal range of joint motion.
Therefore, treatment can only improve the symptoms, reduce pain and improve the quality of life, and must be adhered to in order to achieve more desirable results, such as serious cases can be considered for Western medicine surgery, such as knee fusion for a single serious osteoarthritis of the knee joint for young patients engaged in manual labor; artificial knee replacement for more bone and joint destruction, pain serious elderly patients. Our department has carried out hundreds of artificial knee joint replacement surgeries independently, with excellent skills, and has been well received by patients.