Based On The Theory Of "muscle Injury" To Explore The Mechanism Of Acupotomy In The Treatment Of Knee Osteoarthritis

Objective:According to TCM theory,"Jin Shang"(tendon injury)is the main pathological manifestation of KOA,and plays an important pathological role in its pathogenesis and progress.Acupotomy,as one of the external therapies of traditional Chinese medicine,can improve the symptoms of KOA and delay the progress of KOA through its relaxation effect in the treatment of "Jin Shang" lesions of KOA.In previous study,we summarized the characteristics of soft tissue inflammation around knee joint in KOA patients by using musculoskele ultrasonography in previous clinical studies,and found that it was correlated with the "Jin Shang"manifestations.We also found that the expression of TLRs/NF-κB inflammatory pathway is activated and expressed in synovial hyperplasia and cartilage destruction and plays an important regulatory role in the process of KOA degeneration.However,the specific manifestation of "Jin Shang" in KOA and the mechanism of acupotomy in treating KOA by releasing"Jin Shang"have not yet been clarified.In this study,based on the previous research,based on the theory of "Jin Shang",clinical and basic experiments were carried out to explain the mechanism of acupotomy treatment of KOA froom clinical and basic aspects.Methods:Clinical studies:(1)Study one:Cross-sectional study design.Patients with KOA were included according to case selection criteria.VAS score and Lysholm score were collected to evaluate KOA symptoms.Musculoskele ultrasound was used to evaluate soft tissue inflammation around the knee joint,and magnetic resonance imaging(MRI)was used to evaluate cartilage destruction of the knee joint.Analyze the correlation between inflammation of soft tissue around knee joint and KOA symptoms and cartilage injury,and further summarize the specific manifestations of "Jin Shang" in KOA from the perspective of imaging.(2)Study two:Randomized controlled trial design,according to case selection criteria,KOA patients were included and randomly divided into experimental group and control group.The experimental group was treated with ultrasound-guided acupotomy,while the control group was treated with traditional blind-probe acupotomy.The symptoms,"Jin Shang" manifestations and safety differences between the two groups were compared before and after treatment.Analyze the specific role of acupotomy in releasing "Jin Shang" during puncture treatment,and to explore the specific mechanism of acupotomy in treating KOA by releasing "Jin Shang"from a clinical point of view.(3)Experiment one:Fifty-four 8-week-old Wistar rats were randomly divided into normal group,sham-operated group,model group,acupotomy group,blocked group and acupotomy+blocked group with 9 rats in each group.No operation was applied in the normal group.KOA model rats were made by Hulth method in the model group,acupotomy group,blocked group and acupotomy+blocked group.The sham operation group only cuts the switch capsule and sutures to eliminate the interference of surgical factors.After successful modeling,the acupotomy group was given acupotomy treatment,the blocked group was given block therapy,and the acupotomy+blocked group was given two kinds of treatment at the same time.After all treatment,synovial membrane,surface cartilage and patellar ligament of knee joint of rats were taken、and synovial inflammation were evaluated during operation.The cartilage tissue was sectioned and stained with safranine O-fast green.The degree of cartilage destruction was evaluated by Mankin criterion after magnification under optical microscope.The maximum stress,displacement and elastic modulus of the patellar ligament were measured and the biomechanical properties of the patellar ligament were analyzed.Verify the mechanism of acupotomy therapy for KOA in inhibiting joint degeneration and improving biomechanics from the perspective of histomorphology and biomechanics.(4)Experiment two:KOA rat model and intervention were the same as Experiment one.The expression levels of TLR-4,MyD88,TRAF-6,NF-κB,IL-1β and TNF-α in synovial and cartilage tissues were detected by real-time PCR and Western blot respectively.The levels of IL-1β,TNF-α and MMP-13 in serum of rats in each group were detected by ELISA kit.The specific mechanism of acupotomy in the treatment of KOA was analyzed from the perspective of molecular biology.Results:(1)Study one:A total of 78 KOA patients were enrolled according to case screening criteria.In the aspect of musculoskeletal ultrasonography,the average synovial hyperplasia(3.10 + 5.68 mm),joint effusion(6.10 + 3.67 mm)and medial meniscus bulging distance(2.56+2.61 mm)in KOA patients exceeded the normal range,and there was a significant difference with the normal value(P<0.05).The correlation analysis showed that synovial hyperplasia(R=0.49,P=0.00),joint effusion(R=0.23,P=0.04)were significantly positively correlated with VAS score,and VAS score was also significantly correlated with the presence of sub-patellar fat pad inflammation(t=5.90,P= 0.00);medial meniscus bulging(R=-0.23,P = 0.04)and lateral meniscus bulging distance(R=-0.23,P=0.01)were significantly negatively correlated with Lysholm score.The existence of infrapatellar fat pad inflammation(t=-3.11,P=0.00)and patellar ligament contracture(t=3.09,P=0.00)was also significantly correlated with Lysholm score.The WORMS score of articular cartilage was positively correlated with synovial hyperplasia(R= 0.26,P= 0.02),patellar ligament termination(t= 1.96,P = 0.05),and meniscus damage rating was positively correlated with medial meniscus bulging distance(R=0.25,P=0.03).According to X-ray K-L grading and stratification study,the WORMS score of cartilage was positively correlated with synovial thickness(R=0.38,P=0.05),joint effusion depth(R=0.44,P=0.02),patellar ligament contracture(t=4.97,P=0.00)and patellar ligament endpoint inflammation(t=2.37.,P=0.03).The meniscus damage rating was positively correlated with the medial meniscus bulging distance(R=0.48,P=0.01).Under K-L grade Ⅳ,the meniscus damage rating was positively correlated with synovial thickness(R=0.69,P=0.01)and the medial meniscus bulging distance(R=0.58,P=0.04).(2)Study two:One hundred and twenty-three KOA patients completed the research process,including 59 in the experimental group and 63 in the control group.In terms of KOA symptoms,the VAS score and Lysholm score were significantly improved in both groups after treatment,and the improvement of VAS and Lysholm in the experimental group was significantly better than that in the control group at the second follow-up(P<0.05).The thickness of synovium,the depth of joint effusion,the distance of medial meniscus bulging and the infrapatellar fat pad inflammation in both groups were significantly improved after treatment(P<0.05).In addition,the contracture of patellar ligament and inflammation of patellar ligament insertion in the experimental group were significantly improved after treatment(P<0.05).(3)Experiment one:After Hulth’s modeling,there was no significant difference in ethology between the normal group and the sham-operated group.The Lequesne score of the model group,the acupotomy group,the blocked group and the acupotomy+blocked group were significantly higher than that of the norm al group,indicating that the operation model successfully simulated the limited joint function of KOA,and the scores of the needle-knife group,the closed group and the acupotomy + blocked group were significantly lower than those of the model group(P<0.05),and the three treatments were all significantly lower than those of the model.There was no significant difference between the two groups.In terms of histomorphology,there was no significant difference between the nonnal group and the sham-operated group.The synovial membrane and cartilage of model group,acupotomy group,blocked group,acupotomy+blocked group were significantly degenerated compared with the normal group.The Mankin scores of three treatment groups,acupotomy group,blocked group and acupotomy＋blocked group were significantly lower than those of model group(P<0.05).The Mankin score of acupotomy group was significantly lower than that of closed group in the three treatment groups(P<0.05).In terms of biomechanics,there was no significant difference between the normal group and the sham-operated group.The maximum stress and displacement of each group were significantly higher than those of the model group(P<0.05),but there was no significant difference between the two groups.In terms of elastic modulus,there was no significant difference between the normal group and the sham-operated group,while the model group and the three treatment groups were significantly lower than the nomial group,and the acupotomy group was significantly higher than the model group.(4)Experiment two:There was no significant difference in the expression of TLRs/NF-κB pathway in synovium and cartilage between normal group and sham-operated group.In synovial tissue,the expression of TLRs/NF-κB signaling pathway key components TLR-4,MyD88,TRAF-6,NF-κB and downstream inflammatory factors IL-1β,TNF-a in the three treatment groups was significantly lower than that in the model group.The expression of TLR-4 and NF-κB in the acupotomy group was significantly lower than that in the blocked group(P<0.05),and the expression of NF-κB was significantly higher than that in the blocked group(P<0.05).The expression of TLRs/NF-κB signaling pathway components in the acupotomy+blocked group was lower than that in the other two groups(P<0.05).In cartilage tissue,the expression of TLRs/NF-κB signaling pathway key components TLR-4,MyD88,TRAF-6,NF-κB and downstream inflammatory factors IL-1β,TNF-a in the three treatment groups were also significantly lower than that in the model group(P<0.05),and the expression of MyD88,IL-1β protein in the acupotomy group was significantly lower than that in the blocked group(P<0.05),while the expression of TLR-4 in the acupotomy group was significantly lower than that in the blocked group(P<0.05).The serum levels of IL-1β and MMP-13 in acupotomy group were significantly lower than those in model group,while TNF-a had no significant difference compared with model group(P>0.05),and the level of IL-l beta in acupotomy group was significantly lower than that in closed group(P<0.05).Conclusion:(1)The manifestations of soft tissue inflammation are closely related to KOA symptoms and cartilage damage,which accords with the characteristics of "Jin Shang".(2)Musculoskele ultrasound technique can accurately evaluate the manifestation and treatment process of "Jin Shang" around knee joint,which improves the efficacy and safety of acupotomy in the treatment of KOA,and investigated the specific mechanism of acupotomy in the treatment of KOA by releasing "Jin Shang".(3)Acupotomy therapy can improve the biomechanical properties of patellar ligament,inhibit the morphological damage of synovium and cartilage,and alleviate KOA symptoms.(4)Acupotomy therapy can inhibit the activation and expression of TLRs/NF-κB signaling pathway in the synovium and cartilage of KOA model rats,and reduce the levels of IL-1βand MMP-13 in serum,thus inhibiting joint degeneration and alleviating symptoms.