Osteoarthritis of the knee (knee osteoarthritis) requires significant personal and social financial resources. In the elderly, the risk of losing the ability to work because of knee OA is equal to or greater than that of any other medically necessary disorder. Therefore, early diagnosis and appropriate treatment of osteoarthritis of the knee can slow the progression of the disease and reduce the heavy burden of knee disorders on patients. This review will summarize the progress of Chinese and Western medical diagnostic methods and treatment options for early osteoarthritis of the knee.
I. Accepted definition of osteoarthritis
During the 20th century, the definition of OA evolved from “hypertrophic osteoarthritis (hypertrophic arthritis)” to the now generally recognized definition: OA disease is the interaction of mechanical and biological factors, so that the normal synthesis and degradation of articular chondrocytes, extracellular matrix and subchondral bone is out of balance. OA can be triggered by a variety of factors, including genetic, developmental, metabolic, and traumatic factors, and OA disease can involve all tissues of all movable joints. , osteoid formation and subchondral bone cysts. When the clinical manifestations of OA are evident, OA has joint pain, pressure pain, limitation of motion, twisting pronation, occasional joint exudate and varying degrees of joint inflammation without systemic reaction [2].
Second, the epidemiological study of the knee joint
The disease is more prevalent after middle age. Preliminary domestic surveys have shown that the overall prevalence of osteoarthritis is about 4%, 10-17% in people aged 40 years, and up to 50% in people aged 60 years or older, while 80% of people aged 75 years or older have osteoarthritis. The disability rate of the disease is 53%. Clinically, swollen and painful joints, osteophytes and restricted movement are most common. The incidence of osteoarthritis and the type and number of joints involved may be related to race, age, occupation, lifestyle, and genetics. Sase et al. reported that the cervical spine was the most affected, followed by the lumbar spine, distal phalanges, sacral joints, wrist joints, and wobbly toe joints. A survey conducted at Renji Hospital in China showed that the cervical spine was the most frequent among symptomatic osteoarthritic joints, followed by the lumbar spine, knee, hand and wrist, with prevalence rates of 0.7%, 0.48%, 0.52%, 0.4%, and 0.03%, respectively. The knee and lumbar spine are the most common, followed by the cervical spine, which is also the most common patient in orthopedic clinics.
The etiology of osteoarthritis
Western medical research on the etiology of osteoarthritis of the knee is mainly based on age, genetics, gender, trauma, repetitive stress load, obesity, mechanical and traumatic injury, intraosseous hypertension theory, cytokines and growth factors, cartilage enzyme degradation theory, bone density (osteoporosis and osteosclerosis), estrogen deficiency, nutritional deficiency, immune factors, and immune response theory.
Chinese medicine mainly believes that the development of knee osteoarthritis is broadly divided into: liver, spleen and kidney deficiency, kidney deficiency, liver yin, liver and blood deficiency, spleen and stomach weakness, qi stagnation, blood stasis, phlegm clotting, wind, cold and damp external evil invasion, paralysis and obstruction of meridians.
IV. Pathogenesis of osteoarthritis of the knee joint
Existing theories suggest that: a. chondrocytes are less responsive to growth factors that promote repair; b. laxity of joint ligaments increases, resulting in relative instability of the joint and ease of injury; c. joint shock absorption and protection are weakened; d. thinning of non-calcified cartilage edges increases the shear force of the cartilage basal layer, increasing cartilage vulnerability. e. with age, the quality and quantity of molecules such as collagen and PGS in the cartilage matrix This, combined with the dysregulation of the chondrocyte reconstruction mechanism, results in progressive changes in cartilage: f . Patients with knee OA have varying degrees of decreased knee flexion and extension muscle strength. The decrease in muscle strength in knee OA includes both arthogenous muscle inhibition (AMI) and muscle atrophy factors. The pathogenesis of knee OA is closely related to the decrease in knee stability.
V. Current diagnostic modalities of osteoarthritis of the knee
1, the application of clinical symptoms to the diagnosis of KOA
KOA symptoms are invasive development, although there is a clear progression of imaging. In the early stage, pain may be felt during walking, and in the late stage, pain may be felt at rest, especially at night in bed. Pain on active and passive activity is a distinctive feature of joint involvement. Knee pain can be widespread or limited to the patella, both sides of the joint, the posterior knee, the distal femur, and the proximal tibia. Patients may experience some relief from joint stiffness with activity, followed by progressively more pronounced pain with weight bearing. Pressure points in the knee joint are often asymmetrical and may change in location over time. Roughness and friction of the joint may be felt with active movement, and exudate may be more or less frequent. Mild quadriceps atrophy is often seen. As the disease progresses, there may be inversion and occasionally valgus deformity of the knee, as well as lateral or anterior-posterior instability. The American Rheumatism Association’s criteria for diagnosing KOA require knee pain and radiographic changes that meet at least one of the following criteria: (1) age greater than 50 years; (2) morning stiffness of less than 30 minutes; and (3) a sensation of joint friction during activity. Therefore, for some patients with early KOA, early diagnosis is possible. However, considering the patient’s pain tolerance and the importance of the disease, under the current national conditions, some patients may have already reached the middle and late stages of OA at the time of consultation.
2.Imaging examination
2.1 The application of X-ray plain film in the diagnosis of KOA
2.1.1 Kellgren and Laerence grading criteria of X-ray plain film
Grade Ⅰ
Suspicious narrowing of joint space, possible bony flab
Grade Ⅱ
There is obvious bone redundancy and suspicious narrowing of the joint space
Grade III
Moderate amount of bone fat, clear narrowing of joint space, and sclerotic changes
Grade IV
A large amount of bone, joint space narrowing and severe sclerotic lesions and obvious deformities
2.1.2 Ancillary diagnostic features of conventional X-ray for osteoarthritis of the knee
Osteosclerosis, subsurface cystic changes and bone redundancy formation are characteristic, but have become advanced.
Articular cartilage is mainly evaluated based on whether the joint space is narrowed, with poor specificity and sensitivity.
Recently Buckland-Wright [10,11] proposed a new radiographic technique for the quantification of radiographic changes using magnified X-ray images. This technique uses micron-level X-ray focusing, with the joint being examined close to the X-ray bulb and a distance of 1-2 m between the bulb and the film. This results in a magnified image with high spatial resolution. X-ray imaging procedures have been proposed for different joints, with this technical standard. Moreover, methods have been proposed for the precise interpretation of standardized and quantified examination results. The most sensitive radiographic signs used to determine the presence of OA are osteophytes, subchondral osteosclerosis and translucent areas close to the articular surface. According to their recommendations, the only credible and sensitive parameters for evaluating the progression of OA are changes in the number and size of bone redundancies, and joint space narrowing. However, summarizing the current X-ray imaging principles and early KOA changes, X-ray has no diagnostic significance.
2.2 Application of MRI in the diagnosis of KOA
As soon as MIR was introduced in the early 2008s, it showed its outstanding advantages in the diagnosis of musculoskeletal lesions such as bone tumors and osteonecrosis. With the advent of special limb-matched radiofrequency coils, high-field intensity MRI systems, and other MR imaging techniques, MRI has greatly broadened its application to the knee, making it one of the most widely accepted methods of knee imaging. MRI is a cost-effective method of knee examination that can reduce the need for unnecessary surgical or arthroscopic procedures.
According to the Yulish MRI grading method, cartilage degeneration is classified into four grades. Grade I: abnormally low signal in the articular cartilage, but smooth articular surface; Grade II: mild irregularity of the articular surface and/or articular cartilage loss, but less than 50% of the articular cartilage thickness; Grade III: severe irregularity of the articular surface cartilage, with cartilage loss of more than 50% of the thickness, but less than 100%; Grade IV: complete loss of the articular Complete cartilage loss, exposing subchondral bone.
In recent years, many researchers have used and developed various MRI sequences to study normal and pathological articular cartilage, but there is still an academic debate as to which MR sequence is the best method to evaluate articular cartilage. The current study concluded that conventional MRI techniques are difficult to obtain cartilage images with high contrast resolution, and gradient-echo sequence 3D imaging and fat suppression techniques are of higher value in imaging articular cartilage, but the evaluation of the optimal scan parameters of different gradient-echo techniques for articular cartilage display has not been clearly reported. Lei et al. showed that FS 3D FAST and FS
3D RF-spoiled FAST had good agreement with pathological and arthroscopic controls for the detection and grading of articular cartilage degeneration. Therefore, when MR examination is performed in patients with knee pain, a cartilage-sensitive sequence should be added in addition to the conventional MR sequence to provide accurate and effective imaging information of articular cartilage degeneration for clinical purposes.
3. The application of ultrasound in the diagnosis of KOA
After more than 50 years of development, ultrasound plays a special role in medical diagnosis compared with CT, MR and PECT. This is because ultrasound has the following significant advantages: First, ultrasound can rapidly provide real-time tomographic images of human organs, which can obtain rich and dynamic anatomical diagnostic information. Second, ultrasound scanning has a high degree of flexibility, by changing the direction of the probe can obtain any cross-sectional images. Third, the outstanding advantages are excellent cost performance, convenience and practicality, no radiation, more easily accepted than CT, MR, more popular and repeated application.
Ultrasound as a non-invasive examination method applied to the study of KOA has received widespread attention. This method is also recognized by more and more clinicians. Ultrasound also has its own advantages compared to other imaging methods, but at the same time ultrasound examination has its own limitations.
Jiang et al. showed that using high-resolution color Doppler diagnostic instrument with energy Doppler (CDE) function to diagnose KOA shows advantages: (1) bone cortex is impermeable to strong reflection of sound waves, which can produce clear surface sonograms; (2) cartilage is partially transmissive, which can obtain complete section images; (3) periarticular soft tissue has good transmissibility, which can be displayed layer by layer; (4) ultrasound is most valuable for tendon injury (4) ultrasound is the most valuable for the diagnosis of tendon injury, and there is no significant difference between the identification of tendon injury and tendinitis and MRI; (5) ultrasound shows no significant difference between joint effusion and MRI.
Injury or inflammation of the knee joint can involve the synovium to varying degrees and result in congestion and edema, inflammatory cell infiltration, joint effusion and synovial hyperplasia. Inflammation spreads to the articular cartilage, leading to inflammatory destruction of the articular surface and granulation formation, eventually leading to fibrous or bony adhesions and fusion of the joint. The complex structure of the injured cartilage tissue in and around the knee joint makes diagnosis more difficult. Therefore ultrasound has a better imaging advantage for early KOA examination and is inexpensive and simple to perform, but it is not commonly used at present. The effect of late stage is not good.
4.Laboratory examination
KOA is a disease that involves a series of clinical, radiological and synovial fluid examinations. Unfortunately, there are no specific laboratory abnormalities. Blood and urine tests are generally normal, and synovial fluid tests show nonspecific changes. However, body fluid tests can screen for other arthritis and differentiate metabolic disorders associated with secondary OA. Other diagnostic modalities, including synovial biopsy, radionuclide bone scan, arthroscopy, and interosseous venography, provide a limited and selective assessment of KOA.
4.1 Blood tests
4.1.1 Cellular composition
In the absence of complications, the blood cell count and morphology of primary KOA are normal.
4.1.2 Acute phase reactants
The ESR is normal in the vast majority of patients and may increase transiently with more severe clinical symptoms. Since ESR increases nonspecifically and mildly with age, and the incidence of KOA increases with age, a mild increase in the patient’s hematocrit may not be meaningful for the diagnosis of KOA. However, for significant ESR elevation (50 mm/h or more), inflammatory or neoplastic diseases unrelated to KOA but coexisting should be taken into account.
Studies have shown that C-reactive protein (CRP) is associated with the clinical severity of hip and knee OA, and ESR is not significantly correlated.
In conclusion, ESR increases mildly with age, but is not associated with OA. However, new more sensitive assay techniques demonstrate a slight but definite increase in CRP in people with OA. the significance of CRP in the diagnosis or monitoring of OA activity has not been established. Therefore, in the early diagnosis of KOA, we can assist in the diagnosis of KOA with the help of monitoring CRP.
4.1.3 Serum chemistry
4.1.3.1 Glucose
KOA does not affect glucose tolerance, but conversely, diabetes can accelerate the course of OA. In an epidemiological survey of 1026 patients, fasting glucose levels were significantly higher in patients with OA than in controls. Therefore, a hyperglycemic screening test should be performed in patients with OA with early onset or overly severe joint lesions. However, it should not be used as a diagnostic indicator for early KOA.
4.1.3.2 Insulin-like production factor
Serum concentrations of insulin-like production factor (IGF-1) are associated with the presence and growth of bone fragments in patients with KOA, and with the overall progression of OA. Data from the Chingoford study suggest that serum IGF-1 concentrations are associated with the development of OA of the distal interphalangeal joint and more severe bilateral KOA in women. No studies have shown significance in the early diagnosis of KOA process.
4.1.3.4 Insulin
Hyperinsulinemia may be an independent risk factor for the development or progression of OA. In a study of 48 overweight patients, serum insulin levels were statistically higher in patients with KOA than in those without KOA.
4.1.3.4 Calcium, phosphorus and alkaline phosphatase
In primary OA, the routine biochemistry of bone metabolism is normal. When abnormalities are present, secondary osteoarthritis due to other diseases should be considered.
4.1.3.5 Cholesterol
Investigations conducted for the U1m osteoarthritis Study (U1m osteoarthritis study) reported that serum cholesterol may be an independent risk factor for OA. Excess blood cholesterol and high serum cholesterol levels were associated with systemic OA (1:3). It may help in the diagnosis of early osteoarthritis of the knee.
4.1.4 Cartilage matrix composition
Sensitive and specific tests for cartilage proteolytic components and degradation products have been obtained. Due to a number of metabolic factors, including the dilution of individual joint dysfunction reflected in serum and the unknown effects of renal and hepatic disease, it appears that despite the importance of serological tests, their potential value is less than that of synovial fluid analysis.
In humans, keratan sulfate, a unique sugar, is derived essentially (95%) from articular cartilage and disc cartilage. Elevated serum keratan sulfate levels have been found in patients with OA, but their significance varies significantly. A retrospective study found a transient decrease in keratan sulfate in those who underwent hip arthroplasty for OA. The decrease in serum keratine levels was thought to be associated with arthroplasty; the subsequent elevation on could not be explained.
Plasma hyaluronate was measured by ELISA in patients with OA and RA. Compared to non-arthritic controls, patients with OA had two times more hyaluronate and those with RA had seven times more. Moreover, elevated hyaluronate was found to correlate with the functional status of the patients. However, a radiometric study of serum hyaluronate in 50 patients with OA of the hip or knee failed to show any association between hyaluronate levels and Lepuense index, time to symptom onset, CRP or severity of radiological changes. Still, we can foresee that hyaluronate may serve as an important indicator in the future as a predictor of early knee osteoarthritis. However, further studies are still needed.
Cartilage oligomeric matrix protein (COMP), a marker of disease progression in KOA patients, was also investigated. 81 patients were followed for 5 years, and progressive patients were defined as those who had radiographic evidence of a 2 mm or greater reduction in joint space and who required surgical treatment during the 5-year period. Serum COMP was elevated to a mean of 6.42ug/ml in progressive OA and a mean of 0.07ug/ml in non-progressive, indicating that there is diagnostic significance for COMP in progressive KOA and no significant significance for non-progressive KOA. There is no clear significance for early diagnosis of KOA.
A protein, chondex, secreted by human chondrocytes and synovial fibroblasts is elevated in the serum of patients with joint and cartilage disease. Chondex levels measured by ELISA are elevated in both active RA and OA. It has diagnostic significance for progressive OA.
4.1.5 Metalloproteinases
Serum mesenchymolysin 1 [matrix metalloproteinase 3 (MMP-3)] is elevated in patients with OA and correlates strongly with joint index. The levels of collagenase (MMP-1) or tissue inhibitor of matrix metalloproteinase (TIMP-1) were normal.
4.1.6 Sex hormones
Testing of sex hormones in patients with OA revealed that endogenous estrogen levels were not associated with OA and its severity.
4.1.7 Other components
Abnormalities in other components within plasma, such as substance P, serum iron, serum copper, and plasma copper cyanogen, are not clearly relevant for the early diagnosis of KOA.
4.1.8 Immunological examination
Osteoarthritis has been reported to be associated with HLA I AI, B8 and al I antitrypsin phenotypes, suggesting the possibility of the presence of autoimmune factors. The qualitative and quantitative alterations of collagen and proteoglycan in cartilage are directly responsible for the loss of normal biomechanical properties of cartilage. Modern studies have suggested the presence of cellular and humoral immunity in the pathology. Guo Qinen et al. applied monoclonal antibody immunohistochemical staining to investigate the presence of not only type II collagen but also a large amount of type III and type IV collagen in the cartilage of patients with OA, but did not find overlap in the distribution of type I collagen, type X collagen and type II and III collagen, while type 1 collagen was limited to the subchondral bone. Guerassimov [et al. found significant cellular immunity in patients, with 42.4% against proteoglycans and 45.8% against core proteins, compared to 13.8% and 7.7%, respectively, in healthy controls. Recently Onuma et al. detected the expression of C5a complement receptor (C5aR) in human chondrocytes, which is frequently seen in patients with arthritis.
4.2 Urine examination
Patients with primary OA have normal urine findings. Urine and phosphorus levels were highly variable depending on food intake. Urinary u-proline is normal and usually ranges from 14-38 mg/24 h by age group. urinary estrogen and gonadotropin secretion are the same in menopausal women, with and without OA.
4.3 Other cytokine examinations
The normal structure and function of the cartilage matrix depends on the balance between anabolism and catabolism, and this balance is regulated by cytokines. The balance between the two maintains the balance between anabolic and catabolic cartilage matrix, and the imbalance between the two is the basic cause of degradation and destruction of cartilage matrix in osteoarthritis. In addition, there is a secondary involvement of synovial inflammation and excessive apoptosis of chondrocytes, which ultimately leads to loss of articular cartilage integrity. Cytokines are known to be involved in each of these processes, mainly interleukin-1 (IL-1), tumor necrosis factor (TNF), and interleukin-1 (IL-1), which promote the catabolism and progression of OA lesions.
The main factors that promote catabolism and inhibit the progression of OA lesions are interleukin-1 (IL-1), tumor necrosis factor (TNF), interleukin-6 (IL-6), and insulin-like growth factors (IGF), transforming growth factor-β (TGF-β).
factor-β (TGF-β), etc.
4.3.1 Interleukin-1 (inrerleukin-1, IL I-1)
In a study on bovine articular chondrocytes, Mendes AFI et al. found that chondrocytes treated with IL-1 alone induced NF a kappaB activity and expression of iN0s, promoting apoptosis in chondrocytes. il-lβ was also found to increase the expression of MMP-3 with a concomitant decrease in proteoglycan concentration. il-1 has two common receptors (IL- IRI, IL-1RII), and IL-1 acts by binding to receptors on target cells. The number of receptors on the surface of OA chondrocytes is twice that of the normal cell surface, making OA cartilage and synovial cells highly sensitive to IL-1. Pan Haille quantified the changes of IL-1 levels in serum and joint fluid of OA model animals, and the results showed that IL-1 levels in blood and joint fluid of experimental group animals were significantly elevated, which were significantly different from normal control group. It showed that the increase of IL-1 was parallel to the degree of OA lesion, and the two were highly positively correlated.
4.3.2 Tumor necroie factor (TNF)
Scholaak JF et al. found that high concentrations of TNF-α were present in the synovial fluid of OA patients, and high concentrations of TNF-α were also present in OA synovial cell cultures, while TNF-α was not detected in normal synovial cell cultures.Shimei used immunohistochemistry to detect cartilage tissue, and OA cartilage was positive for TNF-α, while normal cartilage was negative, suggesting that TNF -α may be an important link in the pathogenesis of OA. The mechanism of action of TNF-α is gradually understood, and its role in inhibiting cartilage synthesis and aggravating the inflammatory response has gradually become clear.
4.3.3 Interleukin-6 (IL-6)
IL-6, also known as B-cell differentiation factor, acts in association with B-cell function. IL-6 is not detected by immunohistochemistry in normal human synovial membranes. but its presence can be detected in OA synovial lining cells and infiltrating mononuclear macrophages. It has been observed in the synovial fluid that the level of IL- 6 in OA synovial fluid tends to decrease gradually with the progression of the disease, which may be the result of the diminished ability of IL-6 to maintain the balance of MMPs and TIPM and its inability to inhibit cartilage matrix degeneration. Serum IL- 6 levels in patients with osteoarthritis peaked in the middle of OA and decreased in the late stage, and were significantly higher in the early and middle stages compared with normal subjects.
4.3.4 Insulin-like growth factors (IGF)
IGF-1 plays a key role in regulating chondrocyte proteoglycan synthesis in the development of OA, and is a mediator of cartilage synthesis, increasing proteoglycan synthesis and decreasing cartilage degradation.One of the basic causes of OA pathological manifestations of articular cartilage surface roughness and unevenness, protofibrous changes of cartilage matrix, chondrocyte swelling, disintegration and hyperplasia is the abnormal increase of insulin One of the basic reasons for these manifestations is that the abnormal increase of Insulin-like growth factor binding protein (IGFBP) impedes the binding between IGF-1 and the receptor, thus making OA chondrocytes insensitive to IGF-1 and reducing the ability of OA chondrocytes to synthesize PG using u-proline, and the formation of OA bone redundancy and serum ICf-1 level was positively correlated.
4.3.5 Transforming growth factor-β (TGF-β)
TGF-β is a large class of multifunctional cytokines that is widely involved in the proliferation and differentiation of chondrocytes and has a dual role in regulating collagen synthesis. When cell division is active and the proportion of S-phase cells is high, TGF-β stimulates proliferation; conversely, when cell division is slow and the proportion of GI-phase cells is high, TGF-β inhibits proliferation. in vitro articular cartilage culture, Morales et al. found that TGF-β increased chondrocyte synthesis of proteoglycan PG, inhibited its degradation, and maintained a relatively stable PG concentration in the ECM.
4.4 Free radicals
Free radicals are highly reactive groups containing one or more unpaired electrons, which can chemically modify amino acids, peptides and proteins, alter their structure and function, increase their sensitivity to protein hydrolases, promote their degradation, and cause lipid peroxidation in cell membranes, which is the basis for the development of many diseases. The role of free radicals in damage to articular cartilage has begun to be appreciated. Free radicals act on the amino acids and lipid chains of collagen, altering the primary structure of collagen and destroying its secondary and tertiary structures; they react directly with hyaluronic acid, attacking the chemical bonds that bind polysaccharides in it, causing depolymerization and degradation of hyaluronic acid. Free radicals can cause changes in the morphology, growth state and function of chondrocytes through damage to cellular biofilms, proteins and nucleic acids. It promotes apoptosis of chondrocytes, inhibits the synthesis of proteoglycans, and changes the secretion of collagen from type II to type I. This suggests that biological free radicals can not only damage cartilage matrix but also damage chondrocytes, thus accelerating the damage and degeneration of articular cartilage, and may also play a more important role in the pathogenesis of 0A.
NO is a highly reactive cytotoxic free radical, an endolipophilic and highly reactive mediator of gaseous transmission and regulation. Studies have shown that NO levels in serum and synovial fluid of OA patients are higher than normal, and chondrocytes in the superficial layer of articular cartilage can produce more NO than chondrocytes in the deeper layer.
4.5 Apoptosis
Apoptosis (APO) refers to the natural death process of nucleated cells of multicellular organisms under genetic control, dependent on ATP for energy supply and following their own program, also known as programmed death (PCD), to remove non-functional cells, damaged cells, senescent cells or cells harmful to themselves, so as to make sure that the number of cells in a specific area does not exceed the physiological needs and maintain the stability of the internal environment of the organism. APO is a physiological phenomenon necessary to ensure the maturation of the body and to maintain normal physiological functions. The presence of chondrocyte AP0 in articular cartilage has also drawn attention to its role in OA. The incidence of APO in normal articular chondrocytes is low, 0%-5%, while the occurrence of APO in OA articular chondrocytes is significantly higher. This suggests that chondrocyte APO is involved in the development of OA. The results of studies on the percentage of chondrocyte APO vary widely, from 0-10% in normal cartilage specimens to 22-51% in patient specimens. While AP0 in normal chondrocytes was mainly located in the superficial layer, in addition to a significantly higher number in the superficial layer, cellular APO was present in the migratory and radial layers in OA affected patients, and these are the regions with the highest expression of IN08 and NO and the highest loss of proteoglycans. Programmed death gene 5 (PDCD5), an apoptosis-related gene identified by the Human Disease Genetic Research Center of Peking University, plays an important role in apoptosis. It was found that PDCD5 expression was significantly upregulated in OA articular chondrocytes, which may be involved in the apoptotic process of OA chondrocytes and play a role in the pathogenesis of OA. This suggests that abnormal chondrocyte apoptosis is one of the important causes of OA and is one of the important links in the pathogenesis of OA.
4.6 The theory of intraosseous hypertension
The concept of intraosseous hypertension was first proposed by Carsen in 1893. Later studies have shown that the near joint bone marrow microcirculation disorders, intraosseous venous return obstruction, increased intra-articular pressure, reduced blood flow, increased oxygen consumption, causing the release of enzymes, degradation of articular cartilage, but whether the hemodynamic metabolic changes are only the pathological phenomena accompanying the pathogenesis of OA at a certain stage, coupled with the hemodynamic study of the bone methods, each with its own limitations, so further research is needed to confirm. The maximum joint pressure was shifted from the normal lateral tibial plateau to the medial tibial plateau and the internal femoral ship joint, and the weight-bearing surface of the joint was reduced and the compressive stress on the local articular cartilage was relatively increased. The results suggest that the increased intraosseous pressure is the pathological basis for the development of OA.
Through laboratory tests, KOA can be diagnosed early and clearly, but because the rationality of the data requires further research, the laboratory diagnosis of KOA has a long way to go.
5, Chinese medicine identification
At present, the evidence-based treatment of knee in Chinese medicine is reported more often in various medical journals, but the following problems exist.
1, the various schools of Chinese medicine on the etiology and pathology of knee OA recognized differently, there is no scientific and unified criteria for identification and typing, resulting in the diversity of identification and typing, affecting the clinical research and promotion of Chinese medicine in the treatment of knee OA.
2, Chinese medicine for the treatment of knee OA does not have a unified efficacy assessment standards, can not be a statistical analysis of clinical treatment research.
3, Chinese medicine treatment of knee OA although there is clinical efficacy, but the lack of treatment during the disease location, lesion improvement, and the degree of improvement of the overall observation.
Chinese medicine diagnosis can be referred to the “Chinese medicine industry standard of the People’s Republic of China? Chinese medicine disease diagnosis and efficacy standards? Bone paralysis”. The diagnosis of TCM is based on: (1) Mostly seen in middle-aged people. (2) Initially, it is mostly seen in the lumbar leg, lumbar spine, knee joint “1,P vague pain, flexion and extension? Tenderness? The pain is slightly relieved by light activity, aggravated by climate change, and repeatedly lingering. (3) The onset of the disease is insidious and slow. (4) There may be mild swelling of local joints, and the joints may have a clicking or rubbing sound when moving. Severe muscle atrophy, joint deformity and back hunch can be seen. (5) X-ray examination shows irregularity of joint surface, narrow joint space, subchondral bone sclerosis, and lip-like changes at the edges, and bone redundancy formation. (6) Blood sedimentation, anti-“0” mucin, rheumatoid factor, etc. should be checked to differentiate from rheumatic disease and rheumatoid arthritis. Zeng Yilin believes that osteoarthritis belongs to kidney deficiency bone paralysis. The common clinical symptoms can be classified as follows: (1) Kidney deficiency and marrow deficiency type: vague pain in the joints, soreness and weakness of the waist and knees, and unfavorable back and legs. Accompanied by dizziness, tinnitus and dizziness. Pale red tongue, thin white coating and thin pulse. (2) Yang deficiency and cold condensation: pain in the joints of the limbs, heaviness, unfavorable flexion and extension, aggravated by weather changes, light day and heavy night, increased pain when cold, slightly reduced by heat. Pale tongue. White fur, sunken and slow pulse. (3) Fatigue and blood obstruction type: tingling pain in the joints, fixed pain, deformed joints, unfavorable movement, or stooping back, dull complexion, purple lips and tongue, sunken or thin pulse.
VI. Treatment of early KOA
1.Modern medical treatment
1.1 Non-pharmacological treatment
Non-pharmacological treatment measures for osteoarthritis of the knee include patient education, aerobic exercise, bracing, physical therapy, etc. Doctors need to explain to patients with osteoarthritis:Sometimes non-pharmacological treatment alone can help patients improve their current quality of life. Patients should be aware of OA disease, raise awareness of risk factors, and promote a healthy lifestyle. Exercises such as walking and swimming are beneficial not only for patients with mild to moderate OA, but also for those with severe disease. Decreased quadriceps muscle strength can lead to reduced knee stability, which is a risk factor for the formation of knee osteoarthritis, so strengthening the quadriceps muscle strength can significantly improve the subjective symptoms and the degree of functional limitation.
Weight control Obesity is known to be an avoidable and modifiable risk factor, and a weight loss of only 5 kg can reduce a woman’s risk of developing OA by 50% over the next 10 years. Weight loss alone or in combination with exercise can reduce pain and dysfunction and improve walking ability.
Physiotherapy plays an important role in the treatment of OA [53]. Physiotherapy is usually used to increase or maintain the range of motion and muscle strength of the joints and reduce pain using heat-transfer therapy such as shortwave and microwave. Because the weight of the human body in water is only 1/8 of that on land, hydrotherapy may be used to improve joint function by reducing joint pain and relaxing muscles.
1.2 Medication
Now the drug treatment of knee osteoarthritis is divided into two categories according to the nature of treatment: drugs to improve symptoms and drugs to change the condition, and according to the treatment mode, oral, intra-articular injection, and local surface medication, which can be used alone or in combination. With the in-depth understanding of the pathogenesis of OA, some new therapeutic drugs have been introduced, especially those that delay the onset of OA and modify its condition by specifically blocking the metabolic process of one or more OA [54].
1.2.1 Treatment with drugs to improve joint symptoms
The purpose is mainly analgesic, anti-inflammatory, improve the function of the knee joint, improve the quality of life of patients, however, can not block the progress of OA, but also can not improve the pathological state of joint cartilage and other tissues, plus this drug may cause some adverse reactions, so it is generally not recommended for long-term continuous application.
1.2.1.1 Oral drugs
Generally, there are ethanolaminophen, non-kicker anti-inflammatory drugs (NSAIDs), etc. Aspirin has been on the market for more than a century, and still today ethaqualaminophen is the drug of choice for the treatment of osteoarthritis [55], which has no significant anti-inflammatory effect, but has good antipyretic and analgesic effects. NSAIDs, of which there are about a hundred varieties, are currently one of the best-selling drugs in the world. This shows that NSAIDs have a significant short-term effect on patients with osteoarthritis of the knee. The commonly used drugs in clinical practice are isobutylpropionic acid (ibuprofen), methoxypropionic acid (nephelene), and diclofenac.NSAIDs have at least two COX isozymes:COX21 and COX22 [57], and the anti-inflammatory effect of NSAIDs is related to the inhibition of COX22 [58].NSAIDs are indicated for moderate to severe osteoarthritis and are more effective than ethanolaminophen [59 ]. complications of NSAIDs include gastrointestinal bleeding, perforation, hypertension, and congestive heart failure epidemiology has shown that 20-30% of patients hospitalized for peptic ulcers in people older than 65 years of age have applied NSAIDs drugs, and the risk of serious gastrointestinal events in older adults taking NSAIDs correlates with the dose used [60].
1.2.1.2 Intra-articular injection class
Generally glucocorticoids. Intra-articular glucocorticoid injections can relieve acute knee pain and promote the regression of joint effusion. When the joint is painful and swollen and other drugs are ineffective, aspiration of joint fluid and intra-articular injection of hormones can relieve pain and improve function. However, glucocorticoids may inhibit cartilage glycoprotein synthesis, which may aggravate cartilage damage and even degenerate normal cartilage.
1.2.1.3 Local surface medication
Generally capsaicin, lidocaine, non-steroidal anti-inflammatory drugs, etc.. Capsaicin is applied to the skin surface to produce a burning sensation to reduce the sensitivity of the skin to pain, thus achieving analgesic effects. The use of NSAID emulsions in patients with osteoarthritis has become common in the United States, and it has much fewer side effects than oral preparations. Research on the application of lidocaine to osteoarthritis has been rarely reported at home and abroad, but it still has some analgesic effect for KOA in local block treatment of knee joint.
1.2.2 Drugs to improve the condition
These drugs can not only improve the joint function and reduce the pain of patients. And they can target the pathological changes of knee osteoarthritis into treatment, protect the cartilage surface, eliminate inflammatory factors, promote cartilage repair, and effectively stop the further development of osteoarthritis.
1.2.2.1 Oral
Glucosamine sulfate is a normal component of the soft stomach matrix and synovial fluid, and it has been studied that it may have various pharmacological effects in cartilage and joint tissues.
First of all, glucosamine sulfate has anti-inflammatory effects; interleukin (ILl-β) is one of the important pro-inflammatory cytokines, which can cause joint destruction and inflammatory responses through a series of cascade reactions. Glucosamine sulfate inhibits ILl-β activity, especially nuclear factor KB (NF KB) activity, which contains inhibitory industry groups (a member of the l KB family) and is an important regulator of tissue inflammation, existing in an inactive form in the cytoplasm, which activates transcription of pro-inflammatory cytokines, regulates cyclooxygenase (COX) inducible nitric oxide synthase (iNos) , matrix metalloproteinase (MMP) synthesis, etc., and promotes inflammatory responses in joints. Amino glucosamine sulfate inhibits the activation of NF KB and reduces pro-inflammatory cytokines and other factors involved in osteoarthritis.
Secondly, glucosamine sulfate is beneficial to cartilage metabolism:Glucosamine sulfate can approach chondrocytes in the extracellular matrix in a diffuse manner, transport through glucose transport carriers, synthesize ammonia tomb glucose polysaccharide in chondrocytes, and further synthesize proteoglycan, which is a proteoglycan colloid complex attached to the matrix collagen reticulum, and together with the collagen reticulum structure forms an elastomer that plays the role of bearing pressure, conduct and cushion stress, and protect cartilage structures and subchondral bone. After the degeneration of OA chondrocytes, the synthesis of this proteoglycan is altered, causing degeneration of the extracellular matrix and leading to further progression of OA. Supplementation with exogenous glucosamine can better stimulate chondrocyte synthesis of proteoglycans, increase the level of proteoglycan mRNA, significantly reduce the activity of chondrocyte phosphodiesterase A2 (PLA 2) and collagenase, increase PKC production, and inhibit metalloproteinase activity, which can better prevent further progression of OA and repair cartilage. Therefore, glucosamine sulfate can be combined with NSAIDs (such as diclofenac, anti-inflammatory pain, and viroxicam) and can reduce the dose of NSAIDs by 2-2.7 times, which significantly reduces the incidence of side effects of NSAIDs.
Supplementation of exogenous glucosamine for the treatment of OA originated in the 1960s, but there has been a very intense controversy in 1982, Vaz published an article that oral glucosamine on OA patients with significant symptom relief, followed by the application of glucosamine in OA has become increasingly prevalent in recent years, especially in Europe, the results of a large number of clinical trials have shown that it has a significant effect on symptomatic osteoarthritis. Reginaste et al. conducted a study on 212 patients with osteoarthritis treated with glucosamine sulfate for 3 years.
In a 3-year clinical trial of 212 patients with osteoarthritis treated with glucosamine sulfate, patients in the treatment group showed significant improvement in symptoms and imaging according to the combined efficacy assessment criteria of structural improvement and symptom improvement. At present, glucosamine has been introduced and produced in China, and clinical application trials have also yielded better evaluation of joint function. Hu Tongyu et al. in Hebei randomly divided OA patients into meloxicam control group and meloxicam plus glucosamine sulfate treatment group for 6 weeks, and the pain decrease in the treatment group was significantly higher than that in the control group, which was statistically significant. Zuochuan et al. in Sichuan randomly divided 108 patients with knee OA into nitrogen sulfate glucose group and diclofenac group, taking the drug for 5 weeks and observing 8 weeks after stopping the drug, the results of the study showed that there was no significant difference in the total efficiency of the two groups, but the diclofenac group had a rapid onset of effect, and the effect was maintained for a limited time after stopping the drug, while the efficacy of the amino glucose sulfate group appeared about 3 weeks, and the efficacy could still be sustained 8 weeks after the end of the course of treatment, and the adverse effects of the diclofenac group The adverse reactions in the diclofenac group were significantly higher than those in the glucosamine sulfate group, with gastrointestinal reactions being the most important. Thus, it is concluded that glucosamine sulfate is an ideal drug for the treatment of knee osteoarthritis because of its long-term effect on improving joint structure and relieving symptoms, and its clinical application is promising.
1.2.2.2 Joint injection drugs
Mainly sodium hyaluronate, which is the main component of synovial fluid, is synthesized in joints mainly by synovial cells and meganuclear phagocytes. The synthetic hyaluronic acid first enters and fills the stroma of synovial cells, then is extruded into the synovial fluid by joint movement, distributed on the surface of cartilage and ligaments, partially penetrating into the cartilage layer, and forming proteoglycan polymers together with proteoglycans and connexins. It has the following physiological functions:
Lubrication and stress cushioning: The hyaluronic acid and glycoproteins in synovial fluid make the synovial fluid lubricious and carrier elastic. Radin et al. concluded that the resistance to joint movement is mainly generated by friction between soft tissues and that increased frictional resistance is the main cause of joint stiffness, so hyaluronic acid in synovial fluid plays an important role in the physiological function of joints. When the joint is at a low impact frequency, the synovial fluid containing hyaluronic acid is a saline solution that lubricates the synovial membrane, various tissue planes, ligaments and collagen structures in the joint to reduce friction; when the joint is at a high impact frequency, the synovial fluid has a gel-like elastic characteristic and acts as a cushion in the joint space to cushion the impact of stress on the joint and protect the articular cartilage.
Acts as a filler and diffusion barrier: Under normal conditions, the movement of the joint cavity is maintained by the flow of hyaluronic acid. The size of the joint cavity volume is controlled by the hydrostatic and osmotic pressures of the fluid in the cavity and surrounding tissues. Hyaluronic acid plays an important role in the regulation of the volume of the joint cavity by regulating the transport of other macromolecules within the joint, thereby regulating the hydrostatic pressure and flow rate of the fluid. The concentration of hyaluronic acid in synovial fluid is sufficient to form a macromolecular network that acts as a diffusion barrier within the joint, regulating the movement of water and other nutrients into and out of the cartilage matrix.
Scavenging function: It has been found that free radicals, especially light radicals, can cause breaks in the hyaluronic acid molecular chain. Hyaluronic acid can scavenge free radicals in the body through this reaction. It has also been suggested that the rapid metabolism of hyaluronic acid in the joint may facilitate the removal of cellular debris, which can be embedded in its polymeric meshwork and removed with its metabolism, as well as assist in the excretion of metabolites and excretion from chondrocytes. This suggests that hyaluronic acid plays an important role in the nutrition and metabolism of cartilage.
Intra-articular injection of exogenous sodium hyaluronate can increase the sodium hyaluronate content in the synovial fluid, allowing it to
In animal experiments, Ryrdell et al. found that sodium hyaluronate formed a viscoelastic protective film on the articular cartilage surface and saw a gradual recovery of damaged cartilage beneath the film. It improves the physiological function of the synovial fluid in pathological conditions, allowing it to play a lubricating role, reducing friction from joint movements and tissue sliding, and increasing the range of motion of the joint. It has a strong inhibitory effect on the excitability of nociceptive receptors and sensory fibers located in the synovial membrane and subsynovial membrane.1 Chatter can relieve joint pain. Nonaka et al. observed that sodium hyaluronate inhibited the production of urokinase-type fibrinogen activator, urokinase-type fibrinogen activator inhibitor, and urokinase-type fibrinogen activator receptor by synovial fibroblasts isolated from OA and RA patients. receptors and other substances, thereby inhibiting the development of local inflammation. It can be seen that intra-articular injection of sodium hyaluronate has a very good therapeutic effect on knee osteoarthritis, and the application prospect is very broad.
1.2 Surgical treatment of early osteoarthritis of the knee
Early KOA surgery is mainly based on knee arthroscopic cleanup. Knee OA usually begins with the weakening or impairment of the hydrostatic lubrication of the joint fluid, resulting in nutritional impairment of the articular cartilage, softening and fibrosis due to degeneration of the cartilage, resulting in impaired integrity of the articular cartilage and eventual exposure of the subchondral bone, also involving the synovial membrane and the supporting structures around the joint, causing hyperplasia and hypertrophy of the synovial membrane, formation of periarticular bone, intraarticular This results in clinical symptoms such as joint swelling, pain, and limitation of movement.
Arthroscopic debridement is gaining prominence in the treatment of knee osteoarthritis, as it is the gold standard for the potential diagnosis of knee osteoarthritis. S.P. Oakley et al. established a model of early osteoarthritis in sheep by intraoperatively removing cartilage for
Arthroscopic surgery was found to have high sensitivity (91%-100%), specificity (62%-88%) and accuracy (55%-93%) for osteoarthritis of the knee. Secondly, arthroscopic cleaning of the knee joint removes various inflammatory mediators and inflammatory proteins, lowers intra-knee pressure, adjusts osmotic pressure and pH of the knee joint, and replenishes electrolytes by irrigating the joint cavity with a large amount of saline; at the same time, it removes various necrotic tissues, removes bone redundancy, levels the joint, loosens intra-articular fibrous adhesions, trims the meniscus, and shaves the hyperplastic synovial membrane to relieve joint pain and increase joint mobility. The aim is to relieve joint pain and increase joint mobility.
Patients with osteoarthritis of the knee must be detected and treated early. First, they must have a complete and systematic understanding of the disease, avoid activities that damage the joints, strengthen quadriceps exercises, reduce body weight, and provide appropriate physical therapy. At the same time, you must be careful in choosing treatment options, try to choose drugs and methods that can improve the condition, and use less drugs that only reduce symptoms but damage the joints. Pay attention to the contraindications of drugs and indications for surgery. To achieve the purpose of avoiding knee artificial joint replacement surgery or delaying the time of artificial joint replacement surgery.
2.Traditional medicine treatment
Chinese traditional medicine has a unique advantage in this regard, and through evidence-based treatment, it has the advantage of precise efficacy and good long-term results. The following is a review of the literature from recent years.
2.1 Internal treatment method
Tu Yangmao et al. divided this disease into three types. (1) Qi stagnation and blood stasis type: the treatment is to activate blood circulation and eliminate blood stasis, move Qi and relieve pain. The formula is based on the following formula: Angelica sinensis 9g, Chuanxiong rhizome 12g, Chuan Niu Knee 12g, Di Long 9g, Su Mu 9g, Red Peony 9g, Safflower 9g, Yan Hu Suo 9g, Yu Jin 9g, Citrus aurantium 9g, Tao Ren 10g; (2) Wind-cold and damp paralysis type: the treatment is to disperse cold and remove dampness, warm the meridians and open the channels. The formula is based on the following formula: 12g of Doklam, 12g of Mulberry, 9g of Radix Gentiana, 9g of Bupleurum, 3g of Radix Sinensis, 12g of Radix Achyranthes, 12g of Radix Angelicae Sinensis, 10g of Radix Paeoniae Alba, 9g of Osmanthus, 12g of Poria, 30g of Coix Coix seeds, 10g of Eucommia; (3) Liver and kidney deficiency type: the treatment is to tonify the liver and kidney and strengthen the muscles and bones. The formula uses Six Flavors Dihuang Tang plus reduction: Duzhong 9g, Wolfberry 9g, Shu Dihuang 12g, Yam 10g, Huai Niu Knee 12g, Cornus Officinalis 9g, Wine Conjugate 9g, Poria 12g, Dog’s Backbone 9g, Epimedium 9g, Ze Di 12g, Cuscuta 10g; (4) Decoction method and course of treatment: 1 dose per day, decoction taken 2 times continuously, divided into 2 oral doses, for 7 days for a course of treatment. The treatment was also given by fumigation with Chinese herbal medicine. The dregs of the decoction of 2 juices of Chinese herbal medicine taken internally were added to 3,000mL of water and boiled for 20min, and the affected knee was fumigated for 20min each time, twice a day for 7 days. A total of 98 cases were treated, with a total efficiency of 94.9%. Li Xiaoxian also divided the disease into Qi stagnation and blood stasis type, cold and damp paralysis type, and liver and kidney deficiency type. According to the symptoms, the following drugs were added: Cang Zhu and Huang Bai for damp-heat; Huang Qi for qi deficiency; Agaricus blazei and Chicken Blood Vine for blood deficiency; Bai Hua Snake for severe joint pain; Pieces of Radix et Rhizoma Pseudostellariae and Gui Zhi for cold joint pain; Yuan Shen and Dan Pi for burning joint pain; Ligustrum lonicum for blood stasis and heat; Er Chen Tang for swollen and hard joints with interlocking phlegm and stasis. It activates blood stasis and relieves pain; Wu Ling Li and Di Long dispel blood stasis and open the ligaments; Qiang Wu and Gentiana Macrophylla dispel wind and remove dampness, open the ligaments and relieve pain; Niubizi invigorates blood and strengthens tendons and bones; Licorice harmonizes all the herbs to activate blood stasis, open the ligaments and remove paralysis. Clinically, it is combined with massage, local puncture and bloodletting, and TDP irradiation. If the blood viscosity is high and triglyceride is high, ShuXinNing injection and other drugs should be used to unblock blood vessels, and DanShen drops with ester are more effective. The total efficiency of the three types was about 87.25% after treatment. Duan Junying et al. used self-formulated Yi kidney bone building soup (12g of mulberry, 12g of Chuanjian, 12g of Huaiyu Knee, 10g of Shu Dihuang, 10g of bone crushed tonic, 10g of bone marrow, 15g of keel bone, 15g of stretching tendon grass, 5g of papaya, 5g of blood exhaustion), plus and minus: 10g of Pueraria lobata for cervical spondylosis, 10g of Duzhong for lumbar spondylosis, 10g of dog’s spine, 10g of Chuanniu Knee and 10g of Dilong for knee arthritis, 15g of mulberry for frozen shoulder. (15g) orally and externally treated with fumigant and black ointment. The total effective rate was 97.2%. Wang Shibiao et al. treated osteoarthritis mainly with kidney tonic method, and made homemade Bone Paralysis Wei Ling Wan (Wei Ling Xian, Wu Zhi Snake, Angelica Sinensis, Dog’s Backbone, Bone Shredder, Bonesetter, Bonesetter, Fan Feng, Blood exhaustion, Du Zhong, Sang Sang Sang, Chuan Gui, Turtleworm, and Piercing Nail), 2~3g/time, 3 times/day, with 15mL of yellow wine and boiled water, treating 160 cases of osteoarthritis, with a total effective rate of 98.125%.
2.2 External treatment methods
2.2.1 Acupuncture treatment
Gu Mingshi took the foot Sanli, knee eye, Yanglingquan, Yinlingquan and Blood Sea points, and used a 2-inch, 0.3-mm diameter stainless steel milli-needle to stab the foot Sanli, Yanglingquan and Yinlingquan points straight for 1.5 inches, and the Blood Sea was stabbed obliquely for 1 inch, and the inner and outer knee eyes were stabbed obliquely for 1.5 inches at an angle of 80° along the knee joint gap toward the intercondylar augmentation, stopping and retreating slightly when resistance was encountered (to avoid damaging the meniscus), adjusting the direction and then slowly entering the joint. After entering the joint cavity, use the method of swinging the tail of the needle with a left and a right, and perform the nine numbers. The needles were left in place for 20 min after obtaining Qi in Yanglingquan, Yinlingquan and Blood Sea points, and 3 strokes of warm needle in each of the Foot Sanli and Knee Eye after obtaining Qi. The treatment was carried out once every other day, 10 times as a course of treatment, a total of 3 courses of treatment. Treatment of 80 cases, the total effective rate of 72%. Zhang Xiaoling et al. took the calf nose, hedge, blood sea, liangqiu, yinlingquan, yanglingquan, foot yangguan, foot sanli, knee guan, ququan, and ayurveda points. Operation: The 0.30 mm diameter, 40 mm length milli-needle was used to pierce the acupuncture point and perform the twisting and turning technique. After acupuncture, the acupuncture is followed by medium-frequency treatment (advanced computerized medium-frequency treatment instrument YK-2000B/C type).
The treatment is given once a day, 10 times for a course of treatment, 2 consecutive courses of treatment, with 3 days of rest between courses. Patients were instructed to take rest during the treatment period. The total effective rate of treatment was 96% in 80 cases. Zhu Xiuping used warm acupuncture with Chinese herbal fumigation to treat acupuncture points: the inner and outer knee eyes, the foot three li, and the ayurvedic point. For the type of blood stasis blockage, Yanglingquan and Blood Sea were added; for the type of spleen deficiency and dampness blockage, Yinlingquan and Sanyinjiao were added. Operation: Have the patient sit with both knees flexed to 70°-90°; or have the patient lie flat on the bed with both knees flexed to 70°-90°, fully exposing the affected knee. Set the acupuncture point, and disinfect the point with 75% medical alcohol routinely. Use 0.30mm×50mm disposable milli-needle to enter the needle vertically, carry out twisting and twisting, flattening and flattening the diarrhea, and retain the needle after obtaining the qi. During the needle retention period, insert a 3 cm long lighted moxa stick into the needle handle of each acupuncture point, and burn out the needle. Chinese herbal prescription: Wei Ling Xian 30g, Chicken Blood Vine 50g, Gui Zhi 15g, Dou Wu 30g, Niubizi 30g, Boswellia 15g, Safflower 15g, etc. The total effective rate was 92.65%.
2.2.2 Tuina treatment
Lu Guizhong used Tui-Na with acupuncture and herbal fumigation to treat osteoarthritis. Acupuncture points: He Ding, Inner Knee Eye, Calvary, Yanglingquan, Yinlingquan. Operation: The massage is performed with gentle and mild techniques, which promotes the normal synovial fluid secretion in the knee joint and achieves the mechanical balance of the knee joint by flicking and grinding the patella and shaking the knee flexion and extension. In the control group, the acupuncture operation was the same as that of the treatment group. The efficiency of the treatment group was 94.2%, and that of the control group was 82.2%. Some experts reported 62 cases of osteoarthritis treated with Chinese herbal ironing, in which the massage technique was used to push the calf nose, inner knee eye, blood sea, Liangqiu, Yinlingquan, Yanglingquan, feet three li and the ayurvedic point around the knee, with an excellent rate of 78.42%.
2.2.3 Acupuncture treatment
Gao Nan et al. used acupuncture treatment. ① Position: generally supine, with the affected knee flexed 70°~80° or in passive knee position. ②Positioning: 4~6 points at a time were selected for the peripatellar region of the knee, abnormal pressure nodules and striae in the internal and external joint spaces, etc., and marked with gentian violet. ③Operation: routine iodine disinfection of the surgical part, laying sterile cave towel, wearing sterile gloves, fixing the skin limb of the surgical part with the left hand, holding the knife with the right hand, with the knife line in the same direction as the ligament, entering the needle knife perpendicular to the patellar margin or the skin limb surface of the joint gap, and performing longitudinal sparing and transverse stripping of tough abnormal nodules and cords (for particularly tough or large range, cut transversely again 1~3 times), feeling loose and soft under the knife that the needle knife is released. Compression to stop bleeding for a moment, after no bleeding covered with a band-aid. 7 days once, usually 2-5 times. Note that when entering the needle knife to the bone surface, lift the needle knife slightly and be careful and precise to prevent injury to the periosteum or surrounding normal tissues. Joint cavity injection with 2mL of Spironolactone is given once every 7 days for a total of 5 times. In case of obvious fluid accumulation in the joint cavity, the fluid will be pumped out first and then injected. The total effective rate was 85.6%.
Osteoarthritis is not only a common and frequent disease, but also a difficult disease to treat. According to the Chinese medicine, this disease belongs to the category of “bone paralysis”. The treatment of this disease mainly focuses on relieving pain symptoms, improving joint function and protecting joint structure. Combined with the holistic concept of Chinese medicine, the treatment is based on evidence, and the combined use of Chinese medicine, acupuncture, massage and acupuncture is an effective way to improve the symptoms of patients.
In summary, there are various diagnostic and treatment modalities for early KOA. Early diagnosis and reasonable treatment for KOA will greatly relieve patients and save medical resources. However, the diagnostic and treatment modalities suitable for the existing national conditions in China still need to be studied.