Study on the relation between tissues pathologies and traditional chinese medicine syndromes in knee osteoarthritis: Medical image diagnostics by preoperative X-ray and surgical arthroscopy

Abstract

OBJECTIVE: This study aims to investigate whether integration of traditional Chinese medicine and modern medicine has advantage in achieving the improved diagnosis and treatment of knee osteoarthritis.

METHODS: 90 patients with knee osteoarthritis were selected from The Department of Minimal Invasive Joint of The Third Affiliated Hospital of Beijing University of Chinese Medicine from June 2013 to June 2015. They were divided into 3 groups with 30 cases per group in accordance to the syndrome differentiation of traditional Chinese medicine. The patients underwent arthroscopic surgery, and we categorized the patients having the same characterization in each group, and those having distinct difference into the three groups. Based on the arthroscopic analysis, we performed analysis of statistical data in order to analyze the relation between knee osteoarthritis under arthroscope and traditional Chinese medicine syndromes.

RESULTS: There are three syndromes according to traditional Chinese medicine that can be categorized into various different groups. The synovial proliferation can be seen mostly in the syndrome of stagnation of blood stasis. The slight damage of knee joint cartilage can be seen in the syndrome of yang deficiency and cold stagnation, the severe one in the syndrome of kidney-marrow deficiency. We found that there are different pathological expressions with the various degree of the tissues damage at the knee and we categorized the knee according to their syndrome.

CONCLUSION: For knee osteoarthritis, different syndromes of traditional Chinese medicine presents different tissues pathological changes at the knee joint under arthroscopy, which will provide objective basis for the diagnosis of this medical condition.

Keywords

Knee osteoarthritis arthroscopic surgery traditional Chinese medicine syndromes orthopedic diagnosis

1 Introduction

1.1 Modern medical perspective of knee osteoarthritis

Osteoarthritis (OA) is a common articular disease that causes chronic disability, mostly as a consequence of the knee osteoarthritis (KOA) [1]. Osteoarthritis (OA) is highly prevalent and increasing in frequency; the number of patients with OA has increased by nearly 30% over the past 10 years [2], and to financially pay for its treatment, every patient and his/her family underwent great sacrifice to the disease, and many lost work productivity due to it. Knee osteoarthritis is a common age-related degenerative joint disease that is characterized by articular cartilage degradation, subchondral bone sclerosis, osteophyte formation and synovial membrane inflammation [3]. Old age, over-weight and obesity, knee injury, repetitive use of joints, bone density, muscle weakness, and joint laxity all play roles in the development of KOA [4]. Previous knee trauma increases the risk of KOA 3.86 times [5]. It is a painful and disabling disease that affects millions of patients [6]. Despite its severe consequences, most patients with KOA can manage it well with the help of good community care [7].

Approximately 13% of women and 10% of men aged 60 years and older have symptomatic KOA [8]. Prevalence of KOA in men is lower compared with women [9]. The prevalence of pain in the knee was age-dependent in women but not in men [10]. Middle-aged women had a high prevalence of moderate-to-severe knee osteoarthritis [11]. In a recent review, it is concluded that in Asia, the prevalence of KOA or knee pain is as high as or higher than other Caucasian populations [12]. For instance, in a Chinese population aged above 60 years, the prevalence of KOA was 22% in men and 43% in women, and this prevalence was 45% higher than in the US white population [13]. In a Japanese rural population, the prevalence of knee OA was 30% in women and 11% in men [14]. In Vietnam, which is a country with a population of 90 million, the prevalence of KOA has not been studied, but the prevalence of knee pain was 18% for those aged 16 and above [15].

In knee osteoarthritis, all structures at the joint undergo pathological change leading to joint failure [16]. The primary changes with osteoarthritis occur in the articular cartilage, followed by associated changes in the subchondral bone [17, 18]. Recently, more focus has been placed on the subchondral bone as the primary cause of symptomatic disease [19 –21]. As knee osteoarthritis develops further, cartilage releases debris into the joint. The menisci degenerates and even sometimes tears. Synovium can proliferate [22]. The International Cartilage Repair Society (ICRS) classification is widely used, and is presented as follows [23]: Grade 0 represents absence of a lesion; Grade 1 represents superficial lesions, including chondromalacia, superficial fissures and cracks or soft indentations; Grade 2 includes lesions extending to less than 50% of the cartilage depth; Grade 3 indicates cartilage defects extending to more than 50% of the cartilage depth, as well as to the calcified layer but not through the subchondral bone; and Grade 4 represents lesions that extend through the subchondral bone.

Although the first known report of knee arthroscopy [24] was presented in 1912, it was not popular. It was only after key advances in fiber-optic and video technologies occurring in the 1970s and 1980s that enables arthroscopy to became widely used for direct visualization, examination, and treatment of intra-articular soft tissues [25]. Radiographically invisible pathologies such as meniscal tears, articular cartilage lesions, and cruciate ligament tears can be readily seen and palpated by arthroscopy. Arthroscopy has been considered as important way for diagnosis and monitoring of KOA [26].

1.2 Traditional Chinese medical perspective of knee osteoarthritis

China is a country with 5,000 years of civilization, and traditional Chinese medicine (TCM) is one of the prestigious medical heritages in the world, with over two thousand years of clinical practices [27, 28]. According to Ge [29] the traditional Chinese medical text by Huang Di Nei Jing does not refer to knee osteoarthritis, but to bi syndrome. External climatic factors such as wind, cold and dampness are perceived as pathogens that can cause disease by invading the body. These three pathogenic factors in particular are judged to lodge within joints and disrupt the normal circulation and nourishment of joint tissues and structures. This disruption inevitably causes tissue and bone damage which could be diagnosed as equivalent to OA. Traditional Chinese medicine can achieve good clinical treatment for curing people [30].

In the study of modern Chinese Medicine, which is based on the “Standard of diagnosis of disease and curative effect of traditional Chinese medicine” that is issued by The State Administration of Traditional Chinese Medicine in 1999 [31], osteoarthritis can be divided into three different syndromes: stagnation of blood stasis; yang deficiency cold stagnation; and kidney-marrow deficiency.

2 Materials and methods

2.1 Study subjects

This study was approved by the Ethics Committee of The Third Affiliated Hospital of Beijing University of Chinese Medicine (Beijing, China). We recruited 90 patients having knee osteoarthritis in June 2013 to June 2015, from The Department of Minimal Invasive Joint, which were divided into three groups that have 30 cases in each group according to the syndrome differentiation. For these patients, there are 41 men and 49 women, and the ages are between 45–75 years old. The average age is 60 years old. At recruitment, there were 49 patients with 12 months since diagnosis, 25 patients who were diagnosed between 12 months and 24 months ago. The follow-up time is more than six months. There was no difference among the three groups of patients demographically (Table 1).

2.2 Diagnostic criteria

The basis for diagnosing knee osteoarthritis using traditional Chinese medicine methods or using modern medical diagnosis is different. Especially, in order to select cases with more specification, this research adopts the diagnostic criteria that we present as follows.

2.2.1 Clinical diagnostic criteria

Using the diagnostic criteria put forward by the American College of Rheumatism in 1995 [32], the diagnostic criteria describe knee osteoarthritis from the symptoms, signs and radiology. The summative criteria can be divided into clinical criterion and clinical and radio-logical diagnosis criterion.

For clinical criterion: (1) Cases have knee pain in the most days of 1 month; (2) Knee joint activities are not smooth (and noise caused by minor obstruction is detected during movement of limbs); (3) Knee joint morning stiffness is less than 30 minutes; (4) Ages are over 38; and (5) Knee joint inspection has bony hypertrophy with or without fricative. Diagnosis of knee osteoarthritis can have the combinations: [(1), (2), (3), (4)], [(1), (2), (5)], or [(1), (4), (5)].

For clinical and radio-logical diagnosis criterion: (1) Cases have knee pain in the most days of 1 month; (2) X-ray shows joint marginal osteophyte formation; (3) Joint fluid laboratory tests are in accordance with osteoarthritis (clarity, viscosity the WBC < 2×10⁹); (4) Ages are of 40 or higher; (5) Knee joint morning stiffness is less than 30 minutes; and (6) Knee joint activities will be playing sound. Diagnosis of knee osteoarthritis can have the combinations: [(1), (2)], [(1), (3), (5), (6)], or [(1), (4), (5), (6)].

2.2.2 Diagnostic criteria of traditional Chinese medicine

We adopt the “Standard of diagnosis of disease and curative effect of traditional Chinese medicine” issued by The State Administration of Traditional Chinese Medicine in 1999. The syndrome differentiation is stagnation of blood stasis (A); yang deficiency cold stagnation (B); and kidney-marrow deficiency (C).

2.3 Subjects used in our study

For the implementation of practical clinical research work, its energy, time, and budget is limited, and not all patients can be included in the study of a disease. As such, we can only choose some patients as our research sample. Selecting the patients of study based on the inclusion and exclusion criteria directly affects the quality of research. Included in the standard are: (1) Cases are in accordance with the above modern medicine diagnostic criteria of osteoarthritis; (2) On the basis of osteoarthritis patients X-ray performance, according to the K-L grade rating method, the case select one to three damage degrees of patients [33]; (3) Patients can be informed consent arthroscopic surgery and subsequent treatment; (4) The condition is in line with the ages of 40–65 one full year of life of primary knee osteoarthritis patients; (5) Patients are able to complete treatment and accept post-operation follow-up; and (6) Patients’ VAS scores are at least 3 points. Exclusion criteria are as follows: (1) Cases do not meet the above mentioned modern medicine diagnostic criteria relating to osteoarthritis; (2) Patients have severe liver and kidney and blood system diseases and mental illness; (3) Patients interrupt treatment or unable to complete the follow-up; and (4) Patients have secondary osteoarthritis.

2.4 Implementation method

First of all, based on the group of all cases of samples of traditional Chinese medicine by the team of experts, we made clear the syndrome of each case and perform arthroscopic surgery (Fig. 1). Initially, patients are treated with local anesthesia. Under the arthroscope examination, the patellar fabrics, and the patellofemoral joint experienced lateral clearance as well as condyle, and medial lateral clearance. After the clearance, inspection and treatment are executed at the same time. Continuous saline flushing, followed by procedures of suturing wounds using gauze, and bandages from knee to lower leg and foot by means of a compression bandage is performed. Then, we instructed the patient to push up their limbs to experience a lower limb feeling so as to facilitate normal blood supply.

2.5 Observation index

At the knee joint, we observed the cartilage has damaged or not and the damage degree, synovium proliferate or not in each group. Cartilage damage uses a standard based on The International Cartilage Repair Society of cartilage damage grading pertaining to the knee’s internal structure.

2.6 Statistical analysis

In accordance to the Chinese medicine syndrome differentiation for osteoarthritis in the model, and by engaging in arthroscopic surgery and other clinicians involved in the project, we are able to observe the different tissues pathological changes under arthroscope, and using the SPSS11.0 statistical software for X² test (Mcnemar test), we have processed measurement data such that it is represented using “Mean±standard deviation” or abbreviated as (Mean±SD). According to the comparison between the two groups using the independent sample t test analysis (Independent t test), we suggested that the difference is significant when P < 0.05.

3 Results

For the syndrome of stagnation of blood stasis, the knee X-ray scan before arthroscope surgery showed that it is doubtful narrowing of the interspace of knee joint and the tibial plateau and femoral condyle did not have obvious damage (Fig. 2). Under arthroscopy, 29 cases presented synovial proliferation, about 97%. In the cartilage damage, 25 cases presented grade 0, 4 cases of grade 1, and one case of grade 3. Two cases had meniscus degeneration and no case had loose bodies (Fig. 5).

For the syndrome of yang deficiency and cold stagnation, the knee X-ray photo before arthroscopic surgery showed a defined narrowing of the interspace of knee joint and local osteosclerosis (Fig. 3). Under arthroscopy, 28 cases presented the cartilage damage from grade 2 to grade 3, about 93%, one case was grade 1, and another was grade 4. In addition, there were 10 cases of synovial proliferation, 8 cases of meniscus degeneration, and 2 cases of loose bodies (Fig. 6).

For the syndrome of kidney-marrow deficiency, the knee X-ray photo before arthroscopic surgery showed a severe narrowing of the interspace of knee joint and large osteophyte, definite deformity of bone (Fig. 4). Under arthroscopy, 29 cases presented the cartilage damage of grade 4 under arthroscopy, about 97%, one case was grade 2. And there were 8 cases of synovial proliferation, 15 cases of meniscus degeneration, and 8 cases of loose bodies (Fig. 7).

4 Discussion

Based on our research, we show that 97% cases have synovial proliferation in the syndrome of stagnation of blood stasis; 93% cases have the cartilage damage from grade 2 to grade 3 in the syndrome of yang deficiency cold stagnation; 97% cases have the cartilage damage of grade 4 in the syndrome of kidney-marrow deficiency (Table 2). This indicates that the knee joint internal structures in different syndromes are not the same under arthroscopy, and we can also explain why the syndrome differentiation of traditional Chinese medicine tends to be like this.

Traditional Chinese medicine in clinical practice has obtained a good effect [34]. However, every coin has two sides, and traditional Chinese medicine has its limitations as well. As the TCM theory originated from ancient medical texts and the classification is based on symptoms and signs, the key limitations are the highly subjective diagnostic process and the lack of scientific support for the TCM classification [35]. Arthroscopic surgery is an excellent version of a minimally invasive surgery, and can accurately show the joint tissues inside of the lesion degree. It involves less postoperative complications by having small incision, reduced inflammatory reaction, and can provide a comprehensive diagnosis [36, 37].

This experiment is an exploratory study and as such the number of samples is limited. We choose the preoperative X-ray to select cases; the primary purpose of this research is to use images under arthroscopy to confirm the correctness of the syndrome differentiation of traditional Chinese medicine. However, postoperative X-rays are also important; the meaning for this research is not further. Modern medicine diagnosis of knee osteoarthritis uses a different classification method in comparison to those by traditional Chinese medicine, but we are still required to perform a more comprehensive research. However, we can be sure that the knee osteoarthritis classification based on traditional Chinese medicine syndromes based on results by arthroscopic surgery has wide advantages and a good future. From this research of the knee osteoarthritis of TCM syndrome type that is coupled with such microscopic imaging, it proves that knee osteoarthritis under arthroscopy and traditional Chinese medicine syndromes couple well to provide a scientific analysis of the syndrome differentiation of knee. Although we are limited by the number of cases in this study, and the extraction of images under arthroscopy still have its shortcomings, classification of syndromes may not be most effectively achieved. But this study still provides medical researchers with a good framework for a similar type of analysis in future.

5 Conclusion

By observing and analyzing the surgical images under arthroscopy, our research discover that the majority of cases pertain to a common damage characteristics in the same group in accordance to the syndrome differentiation of traditional Chinese medicine. As demonstrated by our study, there are obvious differences in the three groups that we have defined. The results also show that there is a well coupled relationship between traditional Chinese medicine syndromes of knee and arthroscopy. At the same time, it proves that the syndrome differentiation of knee can be scientifically achieved under an objective diagnosis based on arthroscopy. This research can guide traditional Chinese medicine practitioners in effective clinical diagnosis and treatment for osteoarthritis patients.

Author Contributions

Conceived and designed the experiments: XDT QFW GYZ. Performed the experiments: XDT JW JZ. Analyzed the data: ZPX LG YTT GYZ. Contributed materials/analysis tools: XDT GYZ LNQ. Wrote the paper: ZPX GYZ.

Footnotes

Acknowledgments

The authors express their appreciation for the clinical support of orthopedics, and valuable discussions with surgeons at the Orthopedic Center of The Third Affiliated Hospital of Beijing University of Chinese Medicine. Special thanks are extended to the medical students’ hard work in recruiting patients for this project. This work was supported in part by the Orthopedic Center. The project was funded by the Natural Science Foundation of Beijing Municipality (NO.SF-2007-3-05).

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