| 1. ObjectiveKnee Osteoarthritis (KOA) is known as a chronic, progressing degenerative joint disease, involving a number of biomechanical and biological factors. However, researches are nowadays focused more on biological factors, other than biomechanical factors which play an important role in KOA. Along with the further investigation on the etiology and pathology of KOA, we proposed a theory:the equilibrium stationary system of soft-tissue and bone in KOA based on alignment of lower limb. We believed that KOA is a constantly biomechanical repair process of soft-tissue and bone (STB) when the equilibrium stationary system is broken, the normal alignment of lower limb is the fundament of the system. Therefore, based on alignment of lower limb, investigating the pathological mechanism of equilibrium stationary system (ESS)of STB may facilitate to reveal the pathogenesis of biomechanical factors in KOA. The study focused on factors influencing the alignment of lower limb and tried to explore a convenient and effective way to evaluate the alignment by tomography (X ray, MR) also applied traditional methods of syndrome differentiation in Meridian-Sinew to explain the pathogenesis of KOA concerning STB.2. MethodsFirstly, by analyzing the anatomical characteristics and biomechanical model of knee,we founded the basis of the equilibrium stationary state of STB, and by combining the theory of Meridian-Sinew with our study, we explored a way to explain the pathogenesis of KOA concerning STB. Secondly, we evaluated alignment of lower limb by means of measuring the angles concerning KOA.That was a convenient and effective method which could provide an important basis to assess the alignment of lower limb in the process of total knee arthroplasty(TKA).By analysing the disequilibrated state of STB in the procedures of TKA, we conduct research to explore the way to equilibrate the relationshipe of STB in in the process of TKA for late KOA. Thirdly, we screened the factors influencing the alignment of lower limb in in different stages of KOA by means of MR. We also apply traditional methods of syndrome differentiation in Meridian-Sinew to analyze statistically the conditions of KOA so as to explain the pathogenesis of KOA and sum up the interacting patterns of STB.3. Result3.1 By analyzing the anatomical characteristics and biomechanical model of knee, we believe the equilibrium stationary system of STB in KOA is based on the anatomical characteristics and motion characteristics. The normal alignment of lower limb is the fundamental in the system. The theory of Meridian-Sinewcan in traditional Chinese medicine can provide a way to explain the pathogenesis of KOA concerning soft tissue and bone.3.2 The HKA angle was 186.7°±2.1°, and the FTA angle was 183.8°±1.7°,there was a correlation between the FTA angle and HKA (r=0.712,P<0.01)3.3 The patients in knee arthroplsty with meniscus injury was analyzed, including the medial meniscus in 30 cases (5 cases in the anterior horn,12 cases in body,13 cases in posterior corner), lateral meniscus injury in 8 patients (2 cases in the anterior horn,3 cases in body,3 cases in posterior corner), lateral meniscu injury was much lower than the medial meniscu. Anterior cruciate ligament surgery had shown a certain degree of congestion and edema, partial rupture in 8 patients, there were two cases of complete rupture. Posterior cruciate ligament was relatively intact,but show contracture.The lateral collateral ligament and medial collateral ligament Were well preserved, the medial collateral ligament showed contracture.Analysesing the degeneration zone in medial platform according to regional division, we found degeneration mainly in 3,4,6,7,8,2 zone. The 2,3,4 zone under the protection of the meniscus had the same cartilage degeneration as the 6,7,8, zone.3.4 The FTA angle preoperative was 183.8°±1.7°,postoperative was 175.6°±2.1°, statistical study showed the curative effect of two groups had a significant difference (P<0.01).The TS angle preoperative was 8.6°±2.4°,postoperative was 7.4°±3.8°,there was no statistical significance between two groups (P>0.05).The PT angle was preoperative 83.7°±2.1°postoperative was 88.6°±2.0°, statistical study showed the curative effect of two groups had a significant difference (P<0.01). The FC angle preoperative was 80.3°±3.2°, postoperative was 81.7°±2.6°, statistical study showed the curative effect of two groups had a significant difference (P<0.05). After a follow-up of three months, the HSS score improved from 40.7±7.4 (preoperative) to 64.7±6.2 (2 weeks postoperative),84.7±6.8 (3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). The VAS score improved from 7.8±3.3(preoperative) to 20.4±2.6 (2 weeks postoperative),25.4±2.8 (3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). The ROM improved fom 87°±8°(preoperative) to 98°±6°(2 weeks postoperative), 110°±6°(3 months postoperative), statistical study showed the curative effect of preoperative and postoperative had a significant difference (P<0.01). the ROM between 2weeks and 3months had a significant difference (P<0.05).3.5 We measured three angles in KOA, when the KL grading was in gradeⅡ, the mean FTA angle was 177.5°±1.7°, when the KL grading was in gradeⅢ, the mean FTA angle was180.2°±1.2°, when the KL grading was in gradeⅣ, the mean FTA angle was182.7°±2.3°, statistical study showed the curative effect of three groups had a significant difference (P<0.01). When the KL grading was in gradeⅡ, the mean PT angle was 85.5°±2.1°, when the KL grading was in gradeⅢ, the mean PT angle was 84.1°±1.4°, when the KL grading was in gradeⅣ, the mean PT angle was 83.2°±2.6°, statistical study showed the curative effect inⅡandⅣgrade had a significant difference (P<0.01). There was no statistical significance between HandⅢ,ⅢandⅣ(P>0.05), which showed the PT angle in tibia was an important factor in aligmengt. When the KL grading was in gradeⅡ, the mean FC angle was 81.4°±0.9°,when the KL grading was in gradeⅢ, the mean PT angle was 80.9°±1.2°,when the KL grading was in gradeⅣ, the mean PT angle was 80.3°±0.7°, there was no statistical significance between three groups(P>0.05). which showed the FC angle in femur was not an important factor influencing aligmengt.3.6 The research in MR showed when the signal was normal in meniscus, there were no osteophyte in medial tibial plateau in six cases (66.67%).when the signal was intrameniscus, there were osteophyte in medial tibial plateau in 36 cases (81.82%).When the signal was tear, there were osteophyte in medial tibial plateau in 42 cases(95.24%). There was statistical significance between three groups (P<0.05). There were 40 cases appear bone marrow edema(BME) in subchondral bone.34 cases in medial,15 cases in lateral,9 cases in medial and lateral. when the signal was tear,the medial meniscal displacement (MMD)<3mm was 19 cases(38%). the MMD>3mm was 23cases(51.12%). there was statistical significance between three groups (P<0.05).3.7 Study on syndrome differentiation in Meridian-Sinew proves that osteorthritis is a kind of Meridian-Sinew diseases, which provides evidence for theoretical basis of Meridian-Sinew therapy. In clinical study,95 cases of patients with osteoarthritis were investigated on syndrome differentiation and frequency of focus along Meridian-Sinew region. A single Meridian-Sinew diseases type was 16(16.84%, two Meridian-Sinew diseases type were 54(56.84%), three Meridian-Sinew diseases type were 25 (26.32%), in which Foot Sanyin Meridian-Sinew Diseases were 70 (73.68%),Foot Yangming channel sinew were 64 (67.37%),Foot Taiyang channel sinew were 58 (61.06%).The frequency of focus in Foot Sanyin Meridian-Sinew was also measured statistically. We found the location mainly in Liaoxijian,Xiguanci,Liaoliaoci,Yinlingshang and Xuehaici4.Conclusions4.1 The theory of equilibrium stationary system of STB in KOA is established on the bases of anatomical characteristics of knee and biomechanical model of KOA. In view of the concept of Whole-view and Equilibrium-view in tradirional chinese medicine as well as pathological characteristics of KOA, the study apply traditional methods of syndrome differentiation in Meridian-Sinew to explain the pathogenesis of KOA concerning STB, so that the value of syndrome differentiation in Meridian-Sinew is verified.4.2 It is concluded that there is a correlation between the FTA angle and HKA. The FTA angle, which can better reflect the alignment of lower limb is important both for preoperatively planning of total knee arthroplasty(TKA) and evaluating of surgical results. However, performing the measurement of FTA should follow the strict technical standards of radiographing and measuring.4.3 It is concluded from the observation made in the procedures of TKA that the malalignment of lower limb is related closely to chronic wearing of cartilage,compression of subchondral bone, and ligament contracture in TKA.The correction of malalignment depends not only on accurate osteotomy, but also the releasing of soft-tissue surrounding the knee, which leads to optimizing the balance of the knee joint. Also, it demonstrates the importance of equilibrium stationary system of STB.4.4 Analyzing the images of X-rays and MR of KOA reveals that MMD, BMD, synovial effusion and osteophyte contribute to the pain in knees. The incidence of degeneration and rupture of meniscuses is rather high in the cases of KOA. MMD and bone marrow edema, the major factors lead to the malalignment of lower limb, play an important role in the progress of KOA. These demonstrate the disequilibrium of knee joints under the action of the malalignment.4.5 Study on standards of syndrome differentiation in Meridian-Sinew has proved that most cases of KOA involved more than one line of Meridian-Sinew simultaneously.The conditions usually initiate from Foot Yangming Meridian-Sinew or/and Foot Taiyang Meridian-Sinew and then transfer to Foot Sanyin Meridian-Sinew. We have noticed that Liaoxijian,Xiguanci,Liaoliaoci,Yinlingshang and Xuehaici are the mainly-affected points. The equilibrium stationary system of STB taken shape from the three groups of main Meridian-Sinews and the alignment of lower limb is the premise of a stable knee joint. The study we have done may be useful when we treat KOA with syndrome differentiation in Meridian-Sinew. |
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