Clinical Study on the Acupotomy for Iliotibial Band Release in the Treatment of Valgus Knee Osteoarthritis

Sanbing WU, Kui SUN, Yangchun SONG, Yang LIU, Dechun LIU

The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei 230061, China

Abstract [Objectives] To observe the clinical effect of acupotomy for iliotibial band release in the treatment of valgus knee osteoarthritis. [Methods] Sixty patients with mild valgus knee osteoarthritis who met the inclusion criteria were randomly divided into control group (n=30) and treatment group (n=30). The control group was treated with celecoxib capsule, and the treatment group was treated with acupotomy. The visual analogue score (VAS), modified American knee society score (KSS) and anatomic valgus angulation (AVA) were observed and compared between the two groups before and after treatment to evaluate the curative effect. [Results] Compared with those before treatment, there were significant differences in VAS and KSS between the two groups after treatment (P<0.05). There was no significant difference in AVA between the two groups before and after treatment. There were significant differences in the above-mentioned indexes between the two groups (P<0.05). The comprehensive curative effect of the treatment group was better than that of the control group (P<0.05), and there was significant difference between the two groups one month after treatment (P<0.05). [Conclusions] The acupotomy for iliotibial band release was effective in the treatment of valgus knee osteoarthritis, and it was found to delay the progression of knee valgus deformity through long-term observation.

Key words Valgus knee osteoarthritis, Acupotomy, Knee preservation

1 Introduction

Knee osteoarthritis, also known as knee proliferative arthritis, is a common degenerative articular cartilage disease[1]. It is characterized by joint pain and limitation of movement, and falls into the category of arthralgia syndrome in traditional Chinese medicine. The knee valgus deformity is often caused by the defect of lateral femoral condyle or lateral tibial plateau, which is a common complication of severe osteoarthritis of knee joint[2], and it is also a difficult point in knee preservation and surgical treatment of severe knee arthritis. According to the concept of acupotomy medicine and the key points of soft tissue release technique in joint surgery, acupotomy was used to release iliotibial bundle to treat mild valgus knee osteoarthritis, and its clinical effect was observed.

2 Data and methods

2.1 General informationFrom January 2019 to December 2021, 60 patients with mild valgus knee osteoarthritis were randomly divided into two groups: acupotomy group (n=30) and drug treatment group (n=30). There were 6 males and 24 females in the observation group, with an average age of (59±12) years. The average course of disease was (25.54±4.48) months. In the control group, there were 9 males and 21 females, with an average age of (61±11) years and an average course of (26.23±3.42) months. Comparing the general data of the two groups, there was no statistical difference between the two groups (P>0.05).

2.2 Inclusion criteria

2.2.1Diagnostic criteria. (i) Diagnostic criteria in Western medicine: refer to the diagnostic criteria of knee osteoarthritis intheGuidelinesfortheDiagnosisandTreatmentofOsteoarthritis(2007Edition)[3]. (ii) Diagnostic criteria in traditional Chinese medicine: refer to the diagnostic criteria of arthralgia syndrome in theStandardforDiagnosticandTherapeuticEffectofDiseasesandSyndromesinTraditionalChineseMedicine[4].

2.2.2Inclusion and exclusion criteria. (i) Inclusion criteria. (a) Meet the diagnostic criteria of Western medicine; (b) meet the diagnostic criteria of traditional Chinese medicine. (c) patients between the ages of 40 and 75; (d) with valgus deformity and tibial-thigh AVA<15°, no drug or other treatment was used recently; (e) those who have been examined by the hospital ethics committee and signed the informed consent form for study.

(ii) Exclusion criteria. (a) Those who do not meet the diagnostic criteria of osteoarthritis; (b) complications affecting joints, such as psoriasis, syphilitic neuropathy, brown yellow disease, metabolic osteopathy, acute trauma,etc.; (c) woman who is breastfeeding or preparing for pregnancy;(d) allergic constitution and allergy to multiple drugs;(e) patients with cardiovascular disease, cerebrovascular disease, liver disease, kidney disease, hematopoietic system disease, endocrine system disease and other severe primary diseases and mental illness; (f) those who are in such a critical condition that it is difficult to make an accurate assessment of the effectiveness and safety of treatment; (g) unable to adhere to this regimen or receive other treatment methods, affecting the observer of the curative effect; (h) ankylosis of the joint and history of vascular and nerve injury in the affected limb; (i) under the age of 40 years or over 75 years of age; (j) no valgus deformity or moderate and severe valgus deformity with AVA >15 °.

2.2.3Suspension and elimination criteria. (a) those who are unable to insist on treatment due to reasons such as going out in the course of treatment; (b) failure to follow the treatment plan; (c) subjects with serious adverse events/adverse reactions; (d) other serious concomitant diseases or worsening conditions in the course of clinical studies; (e) those who are cured early without the need for further treatment.

2.3 Treatment methods

2.3.1Acupotomy therapy. (i) Fixed point. 8 to 10 points were chosen each time from: both sides of patella, medial collateral ligament, lateral collateral ligament, knee point, proximal femoral trochanter point of iliotibial band, fibula head point of distal end of iliotibial band, ventral point of iliotibial band.

(ii) Operation. Patients were in the supine position, and the affected knee should be slightly padded with a pillow to be comfortable and natural. 4-8 tenderness points around the knee joint were selected, marked with gentian purple, skin was routinely disinfected and sterile hole towel was laid. Doctors wore disposable masks, aseptic gloves and chose Hanzhang I No.4 acupotomy. Acupotomy incision was parallel to the main ligaments, muscle fibers, blood vessels and nerves, and knife quickly penetrated into the skin, slowly reached the soft tissue nodes for vertical dredging and horizontal stripping until the operator’s hand felt loose and the patient felt sore. After taking out the knife, benzalkaniline was applied externally to the treatment point, and attention was paid to pressing to prevent bleeding. The patients were treated once a week and four times as a course of treatment.

2.3.2Drug treatment. Patients took 0.2 g of celecoxib capsules (Celebrex) orally, one capsule each time, once a day.

2.4 Observation indexes

2.4.1Security indexes. General physical examination, clinical symptoms, routine examination of blood, urine and stool, liver function and renal function examination.

2.4.2Therapeutic efficacy indexes. Related symptoms, American knee society score (KSS), anatomic valgus angulation (AVA).

2.4.3Evaluation criteria of curative effect. Refer to the standard score of curative effect stipulated in theGuidingPrinciplesforClinicalResearchofNewDrugsofTraditionalChineseMedicineintheTreatmentofOsteoarthritispublished by the Ministry of Health: clinical recovery: pain disappeared, joint activity was normal, total score ≥95%; markedly effective: pain and other symptoms disappeared, joint activity was not limited, total score ≥70, <95%; effective: pain and other symptoms basically disappeared, joint movement was slightly limited, and the total score was reduced by more than 30%<70%; ineffective: pain and other symptoms and joint activity did not significantly improve, and the total score was reduced by less than 30%.

3 Results and analysis

3.1 Comparison of the curative effect between the two groups before and after treatmentThe effective rate of treatment in the study group was 90% and the effective rate of the control group was 73%. The clinical treatment effect of the two groups was compared, and the difference was statistically significant (P<0.05), as shown in Table 1.

Table 1 Comparison of the curative effect between the two groups

3.2 VAS and KSS of patients in the two groupsThere was a significant difference in VAS and KSS between the two groups before and after treatment, as shown in Table 2.

Table 2 Comparison of VAS and KSS between the two groups (n=30)

According to the statistical description, VAS, KSS and AVA of the treatment group and the control group (data before treatment, after treatment and one month after treatment, and the difference between data one month after treatment and data after treatment) were in accordance with normal distribution and were tested by 2-samplet-test. Compared with those before treatment, there were significant differences in VAS and KSS between the two groups after treatment (P<0.05); there were significant differences in VAS, KSS and AVA between the treatment group and the control group after treatment and one month after treatment (P<0.05); the difference of VAS, KSS and AVA between the treatment group and the control group was statistically significant one month after treatment and after treatment(P<0.05); other indexes were compared (P>0.05), and there was no statistical difference.

4 Discussion

Knee osteoarthritis is a common degenerative articular cartilage disease. Severe knee osteoarthritis often complicated with knee valgus deformity usually needs surgical treatment, and the operation is difficult and there may be many complications. The valgus deformity of knee joint was graded according to tibial-thigh anatomic valgus angle (AVA): AVA 5°-7°—normal; AVA<15°—mild deformity; 15°30°—severe deformity. Moderate and severe valgus deformities with AVA > 15°are generally treated with joint replacement or osteotomy, but there is no unified surgical indication standard and effective conservative treatment for mild valgus deformities with AVA <15°.

There are many conservative treatment methods for knee osteoarthritis, and a large number of clinical studies have shown that acupotomy therapy has its unique advantages in the treatment of knee osteoarthritis[6]. Acupotomy therapy is a modern external treatment method of traditional Chinese medicine produced by the combination of traditional Chinese and Western medicine. In acupotomy medicine, bow-string theory holds that the relationship between bone and soft tissue is like "bow" and "string". The bone will shift only when the soft tissue changes and the bone is pulled, resulting in the pathological manifestation of knee valgus[7]. The root cause of the early pathology of knee valgus is not related to the bone, but related to the soft tissue around the knee joint. The force imbalance in one side of the inner soft tissue of the knee joint leads to the injury of the soft tissue, which in turn affects the force balance of the soft tissue inside and outside the knee joint and produces knee valgus. According to the above theory, acupotomy is used to release the high stress point of the soft tissue to eliminate the compression or traction of the nerves and blood vessels, so as to relieve the tension pain, relieve the imbalance of tensile stress and compressive stress, and finally restore the force balance inside the knee joint[7], thus treating the disease from the root cause.

Joint surgery studies have found that the iliotibial band plays an important role in knee valgus. According to Seebacheretal.[8], the iliotibial band is widely connected with the knee, which is an extracapsular structure and the active point is far from the joint line. The contracture and tension of the iliotibial band mainly cause valgus deformity in the extension position and cause external rotation of the proximal tibia during flexion, and the tension of the lateral patellar retinaculum during flexion affects the patellar trajectory. Whitesideetal.[9]believe that releasing and prolonging the iliotibial band during knee valgus correction plays an important role in improving the tension of the lateral straightening space. Therefore, acupotomy is used for the iliotibial band release to adjust the valgus knee soft tissue force balance to treat valgus knee osteoarthritis, which is a feasible idea.

The treatment methods of valgus knee osteoarthritis include corrective osteotomy and soft tissue release. Knee preservation is the focus of knee arthritis research. According to the medical principle of acupotomy, combined with the characteristics of soft tissue release technique in joint surgery, iliotibial band release was used to adjust the soft tissue tension of knee joint and force line of limb alignment to treat valgus knee osteoarthritis. Studies have shown that this method has a certain therapeutic effect in improving joint symptoms and delaying the progression of joint deformities, and has the advantages of small side effects, low cost, simple operation and suitability for clinical promotion. It is proved that acupotomy for release of soft tissue to adjust muscle force balance to treat valgus knee osteoarthritis is a feasible knee preservation idea. However, there are still some shortcomings in this study, such as small sample size, lack of unified standard for acupotomy operation, lack of long-term follow-up visit and so on. In the future study, it is necessary to further optimize the treatment scheme of acupotomy for knee protection and explore the therapeutic mechanism of acupotomy in knee preservation.