Medical Acupuncture
A Journal For Physicians By Physicians

Spring / Summer 2000- Volume 12 / Number 2
"Aurum Nostrum Non Est Aurum Vulgi"

POSTER PRESENTATIONS

The Role Of Acupuncture In Postoperative Rehabilitation After Total Knee Arthroplasty
Pamela Avery, MD

OBJECTIVE
    To determine if acupuncture, through its analgesic, anti-inflammatory, and immune system support mechanisms, can enhance the postoperative recovery in patients having total knee arthroplasty.
Problem
    A 29-year-old woman undergoing total knee replacement for severe pain, swelling, and limited mobility.
History of Present Illness
    A 29-year-old nurse presented with right knee pain, swelling, and limitation of movement 9 months after right total knee replacement. She had a torn anterior cruciate ligament as an 18-year-old athlete, and subsequently underwent reconstruction with an allograft ligament as well as bone graft to the femoral condyle and tibial plateau. A staphylococcal infection developed and she required a hemi-knee replacement. She experienced loosening and breakdown of the polyethylene components of the knee requiring 2 revisions. Ultimately, 9 years after the original injury, the patient underwent total knee replacement due to severe pain, swelling, and limitation of movement. Immediately following the procedure, the knee developed dramatic swelling, bruising, and bleeding. She was treated conservatively with gradual ambulation, narcotics, and physical therapy. Four months postoperatively, she required manipulation of the joint while under anesthesia, yet the joint remained swollen, painful, and poorly mobile. By 8 postoperative months, active and passive manipulation of the joint in physical therapy was replaced with a water-walking and swimming routine. In addition, the continuous passive movement device was used in the evenings without significant improvement. Consideration was given to knee arthroscopy for lysis of adhesions and evaluation of stability of the prosthesis to determine if a repeat knee reconstruction was indicated. The patient desired a nonsurgical approach if possible and therefore sought consultation concerning acupuncture.
Past History
    All other past medical history was unremarkable except for a 5-year history of infertility with subsequent lysis of adhesions via laparoscopy.
Physical Examination
    The physical examination revealed a significantly altered gait due to a relatively immobile right knee. Well-healed surgical scars were present on the medial aspect of the knee as well as laterally. The right knee was stiff and limited in movement. Knee circumference was significantly larger on the right vs the left (14 and 10 in, respectively). Flexion was limited to 52º and extension stopped at 11º. Tenderness to palpation existed at ST 36, 34; SP 9, 10; BL 40; KI 10; and LR 8 with tenderness throughout the SP meridian. Tongue inspection revealed some mild scalloping of the edges.

Diagnosis
    From a Western perspective, the patient appeared to have limitation of knee movement secondary to protracted swelling and subsequent pain, and possible adhesions without clear evidence of prosthesis instability. From a TCM perspective, she appeared to have obstruction at the knee from the surgical procedure, and scar formation with an underlying SP deficiency resulting in edema, pain, and relative immobility. Her prior history of intra-abdominal adhesions supports the concept of adhesion formation contributing to her limitation of flexion as an underlying predisposition.
TREATMENT
    The patient was instructed to continue her traditional therapy of swimming and water walking while using the same traditional medication regimen, celecoxib and tramadol hydrochloride, as a trial of acupuncture was instituted. She reported regularly to physical therapy for measurements of knee circumference, flexion, and extension of the joint over a 12-week period.

    An acupuncture treatment plan was developed to address both the anterior and posterior aspects of the joint using the following set of points and techniques. Four treatments were performed anteriorly and 4 posteriorly for a total of 8 treatments over a 12-week period. De Qi was elicited at all points using 0.30 Carbo needles. Low-frequency stimulation and moxa or heat tonification were used. Each session lasted approximately 30 minutes, with 20 minutes of electrical stimulation and heat plus 5 minutes of moxibustion. The axes of treatment chosen were Tai Yin/Yang Ming for the anterior surface with local points ST 34, 36; SP 9, 10 during the first 4 treatments (Table 1). Subsequently, energy axis Shao Yin/Tai Yang was used posteriorly with percutaneous electrical nerve stimulation (4 Hz) at lumbar segments T12-L5 (4 levels) and local modules at BL 40, KI 10, LR 8, and GB 33. Microsystems of the ear, hand, and scalp were variously used to enhance local points, principal meridian energy circuits, and percutaneous electrical nerve stimulation (posterior treatments).

Outcome
    The patient noted immediate reduction in pain and swelling within the first 2 treatments (2 weeks). Knee circumference decreased by 2 in and flexion improved by 16º as measured by physical therapy. Over the next 4 weeks (5 treatments total), swelling diminished another 2 in and flexion increased by another 20º. By the end of 12 weeks and 8 total treatments, knee circumference diminished a total of 4 in, flexion increased by 48º, and extension improved by 11º to full extension (0º) [Table 2].
DISCUSSION
    Total knee arthroplasty is a common surgical treatment for severe knee pain and limitation of movement secondary to various medical conditions, most commonly rheumatoid arthritis and osteoarthritis. While the obvious goal of joint replacement is to achieve improved function and decrease pain, it is still a challenge to consistently accomplish this for each patient. One review of 724 replaced knees revealed that only one-third flexed to 105º, while nearly one-half did not flex beyond 90º.1 Patients with the lowest levels of function tended to have the least flexion and vice versa. Commonly, patients with decreased flexion often require knee manipulation under anesthesia. One theory is that adhesions may contribute to the restriction of movement and manipulation can rupture these adhesions. In an effort to identify prognostic indicators for knee manipulation, 1 review compared the records of 60 osteoarthritic patients (94 knees) who required knee manipulation after total knee arthroplasty vs 28 patients (48 knees) who did not.2 The authors concluded that an increase in knee dimension by 12% or greater was a critically independent variable that significantly predisposed patients to manipulation. They also showed that quadriceps adhesions were another major factor leading to manipulation. Another study looked at factors that influenced the postoperative range of motion after total knee arthroscopy.3 That study showed factors influencing the postoperative range of motion in total knee arthroplasty to include preoperative range of motion, the primary indication for arthroplasty, heights of postoperative joint line, patellar thickness, postoperative pain, and successive postoperative rehabilitation.
    Acupuncture has been used to decrease pain and swelling, particularly in acute musculoskeletal disorders. Although acupuncture has been praised for thousands of years, studies of efficacy in patients with osteoarthritis have given conflicting results.4-6 To date, no previous studies have examined the role of acupuncture in the rehabilitative process after total knee arthroplasty. Studies have validated the classic acupuncture conduits and shown them to be distinguishable from lymphatic, vascular, and nervous system pathways. Acupuncture also appears to be more than just a simple method of pain relief; it may reduce inflammation and support the immune system, among many other properties.7

CONCLUSION
    Based on this patient's severely limited mobility at start of treatment and the length of time from surgery, it is reasonable to assume that the acupuncture treatments significantly contributed to the increased range of motion ultimately observed. No other variables were changed in her treatment, and no progress had been seen clinically for several months. She was able to increase function significantly and continued improvement is expected. This case demonstrates that acupuncture may be used to decrease pain and swelling after total knee arthroplasty, even in the extended postoperative phase, thereby increasing mobility and restoring function. If AP knee dimension and adhesion formation are critical variables in predicting which patients may require subsequent manipulation due to immobility, and if postoperative pain influences final range of motion after total arthroplasty, one can theorize that acupuncture applied early in recovery may have significant benefit. Controlling pain and swelling early in the postoperative period could result in early increased function and decreased formation of adhesions, improving the functional outcome after total knee arthroplasty.

REFERENCES

1. Tew M, Forster IW, Wallace WA. Effect of total knee arthroplasty on maximal flexion. Clin Orthop. 1989;247:168-174.
   
2. Daluga D, Lombardi AV Jr, Mallory TH, Vaughn BK. Knee manipulation following total knee arthroplasty: analysis of prognostic variables. J Arthroplasty. 1991;6:119-128.
   
3. Ryu J, Saito S, Yamamoto K, Sano S. Factors influencing the postoperative range of motion in total knee arthroplasty. Bull Hosp Jt Dis. 1993;53:35-40.
   
4. Gaw AC, Chang LW, Shaw L-C. Efficacy of acupuncture on osteoarthritic pain: a controlled, double-blind study. N Engl J Med. 1975;293:375-378.
   
5. Christensen BV, Iuhl IV, Vilbek H, Bulow HH, Dreijer NC, Rasmussen HF. Acupuncture treatment of severe knee osteoarthritis: a long-term study. Acta Anaesthesiol Scand. 1992;36:519-525.
   
6. Berman BM, Lao L, Greene M, et al. Efficacy of traditional Chinese acupuncture in the treatment of symptomatic knee osteoarthritis: a pilot study. Osteoarthritis Cartilage. 1995;3:139-142.
   
7. Dale RA. Demythologizing acupuncture part 1: the scientific mechanisms and the clinical uses. Altern Complement Ther. 1997;1:125-131.

AUTHOR INFORMATION
Dr Pamela Avery is a Board-certified Anesthesiologist with credentials in Pain Management, and practices Medical Acupuncture for Meriter Health System's Complementary Medicine Program in Madison, Wisconsin. Dr Avery integrates complementary medicine with traditional Western techniques, and works closely with patients' primary care physicians.

Pamela Avery, MD
Meriter Hospital Complementary Medicine Program
202 So Park St
Madison, WI 53715
Phone: 608-267-5939
E-mail: pavery.PCP003.PCPDOMAIN@meriter.com

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