Based on the Declaration of Helsinki, we will design a parallel, block randomization, single-blinding, sham controlled trials. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 1). This study will be performed in the First Affiliated Hospital of Guangzhou University of Chinese Medicine from June 2020 to June 2023 (Figure 1). We will recruit volunteers via advertising, posters and contacting community doctors, and enroll those who meet inclusion criteria.
Fig. 1 Flowchart of the study design.
(1) Patients meeting the I, II, and III levels of Kellgren-Lawrecne's radiological diagnostic criteria ;
(2) The score of pain visual analog scale is above 4 points in the past month;
(3) Age is between 40-70 years old;
(4) Those who have not taken other related treatment drugs or adopted related treatment methods within 2 weeks;
(5) Participate should provide informed consent.
(1) Pregnant or lactating women, or women with a pregnancy plan during the trial;
(2) Patients with infectious diseases or serious diseases, such as cardiovascular, cerebrovascular, liver, kidney, hematopoietic system;
(3) Patients with local infection, ulceration, vascular nerve damage or deep abscess in the knee joint;
(4) Patients with a history of severe knee trauma, or who have undergone surgery or arthroscopy;
(5) Patients with other diseases that cause knee pain, such as tumors, knee joint tuberculosis, rheumatoid arthritis, gouty arthritis, etc.;
(6) Patients who have taken oral corticosteroids or received intra-articular knee injection treatment within 1 month; or have participated in other clinical trials within 3 months;
(7) People who are allergic to the medical devices involved in this trial; contraindications to the use of indomethacin plaster, such as those with a history of allergy to indomethacin, those with liver and kidney dysfunction (alanine aminotransferase (ALT), aspart The amino acid transaminase (AST) is more than 2 times the normal value, and the blood creatinine (cr) is more than the normal value). Patients who have induced asthma, urticaria or allergic reactions after taking aspirin or other non-steroidal anti-inflammatory drugs may have nonsteroidal Patients with a history of gastrointestinal bleeding or perforation after anti-inflammatory drugs, patients with active gastrointestinal ulcer bleeding, or patients with previous recurrent ulcers / bleeds, patients with severe heart failure, perioperative coronary artery bypass surgery, etc. ;
(8) Patients with bleeding tendency, such as long-term use of warfarin, aspirin and other anticoagulants;
(9) People with an abuse history of sedative hypnotics, opioid analgesics, and alcohol;
(10) Patients who cannot cooperate with relevant experiments and measurements.
The patients are in a supine position with the knee flexed 30 ~ 45 °. A cushion is placed below the knee. The physicians will select 6 points from a point set as follow. The point set contains 8 points, including the upper point and lower point medial collateral ligament of the affected knee joint, the upper point and lower point lateral collateral ligament, the subpatellar ligament points, the upper point of the patella, the muscle insertion of the popliteal muscle, and the medial popliteal fossa stimulation points. We will stimulate 6 points for unilateral knee pain and 12 points for bilateral knee pain (Table 1).
After standard disinfection, the physicians will operate Hanzhang Ⅰ type No.4 straight needle knife (Beijing Huaxia Needle Knife Medical Equipment Factory) to run acupotomy therapy (Figure 2). All these physicians have more than 5 years of acupotomy experience and will be retrained 16 hours before the study begins.
The incision line is consistent with the longitudinal axis of the lower limb. The body of needle-knife is perpendicular to the skin. The doctor operates according to the procedures of fixed point, orientation, pressure and penetration. When the needle knife reaches the target depth, the doctors perform a manual operation. After the operation, the needle-knife is pulled out, and local hemostasis is applied for 3 minutes. The wound was disinfected with iodine and the needle eye was covered with a band-aid. Patients receive acupotomy therapy 2 sessions for 2 weeks（once a week）.
Table 1. the location of point set
Fig 2. the needle-knife
Sham acupotomy group
Patients assigned to sham acupotomy group will receive the mock acupotomy, which will be performed just like real acupotomy, but without manual stimulation to achieve any real effect. The needle-knife will pierce through the skin only and stay under the skin for 10 seconds to simulate manipulation time. Patients will receive 2 sessions of sham acupotomy for 2 weeks（once a week）.
All the patients of two groups are allowed to use drugs. Clinicians will give patients indomethacin cream (manufacturer: Nipro Pharma Corporation Saitama Site Plant 2, import drug registration number H20181060) for external use, once daily after 24 hours of acupotomy. They will receive indomethacin cream 12 times in total.
We had selected both clinical outcomes and surrogate outcomes to assess the efficacy of acupotomy. All the outcomes will be measured at baseline and one week after the end of treatment. Besides, we will follow up for WOMAC index and VAS in the 3rd month and 6th month after the end of treatment (Table 2). Before the study begins, we will train the related investigators.
Table 2. Study schedules. T1-T3: from the first treatment period to the third treatment period. W7:
one week after the whole treatment period; M3: the 3th month; M6: the 6th month
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
The WOMAC index is always used to assess knee osteoarthritis symptoms . The scale includes 24 items in three parts, including 5 pain items, 2 stiff items, and 17 joint function items. The scoring record uses a 10cm long visual analog scale scoring rule. The two ends are 0-point and 10-point. 0 points indicate that the item is asymptomatic, and 10 points indicates the most serious degree of the item.
Visual Analog Scale (VAS)
VAS scale is a commonly used scale to reflect the degree of body pain . A 10 cm length VAS scale will be used. The two ends are 0-point and 10-point respectively. The 0 presents painless and 10 shows the most severe pain which is intolerable.
Plantar Pressure Distribution Tests
Plantar pressure distribution tests can observe the function of patients' knee joints . This test uses the Plantar Pressure Distribution Test System (Belgium RSscan Footsacn1.0m). A rehabilitation technician will in charge of measurement. We will collect balanceparameters (foot angle and subtalar joint mobility) to assess the stability of knee joint medial and lateral. The bigger balance parameters indicate the worse stability. Besides, impulse parameters, known as the ratio of the heel and forefoot, will be used to analyze knee buffering stability. The larger the ratio, the stronger the stability.
Interrogation of the results of the patient's front and lateral knee X-rays was performed by an imaging physician. This measurement aims to monitor whether there are existences of osteophyte formation, joint space narrowing, subchondral sclerosis, cartilage degeneration, osteoporosis, valgus deformity, and varus deformity.
Ultrasonography has also been proven as a useful tool in monitoring knee osteoarthritis treatment effectiveness . Specialized ultrasound doctors will collect data via Philip HP SONOS 5500 ultrasound imaging machine. We will pay attention to the knee joint fluid volume and synovial film thickness. These data will show us the degree of damage and repair of knee.
Maximum Knee Circumference
This indicator is used to assess the soft tissue lesions around the knee joint . When conducting the assessment, the patients will be asked to lie supine with the knee joint straight. The doctor will use a soft ruler to measure the circumference of the knee joint along the upper and lower pole of the patella, of the metatarsal bone, and measure around the knee joint.
Joint mobility is also used to check knee function . The arthrometer will be used to measure knee mobility. The patient being tested is positioned on his/her side with the affected leg being measured facing upwards. First, the lateral femoral condyle is positioned over the center of rotation of the arthrometer. Then position the fixed arm along the middle of the femoral joint, and fix the movable arm along the fibula. Lastly, let the patient extend the knee joint as much as possible, and then bend the knee as much as possible, and measure the flexion and extension motion range by moving the movable arm.
Referring to a previous study , we determined that the change in the WOMAC index before and after treatment in the acupotomy group was 16.34 ± 4.19. Then the change in the WOMAC index before and after treatment in the sham acupotomy group was 14.2 ± 4.19, and the effect size was 2.14 . The sample sizes should provide 80% of statistical power and significance level of 0.05.
We calculated the sample sizes of 124 with repeated measurement design via the SAS software package (version 9.4, Tokyo, Japan). Considering the 10% loss of patients during the research, we had decided to enroll 136 participants finally.
A biostatistician will generate a block random number list at a ratio of 1: 1via Stata 14.0 software package. The block size is not discovered until study finishing because of allocation concealment. An independent staff, who does not take part in the performance period of this study, will seal the random number by the opaque envelopes. Then the primary investigator will save these envelopes and open one of them when a participant is enrolled.
This study takes a single-blind approach. The operators will mock the procedure of standard acupotomy therapy in the sham acupotomy group. The operators pierce through the skin only and do not stimulate the relevant ligaments and muscles. The needle-knife will stay under the skin for 10 seconds without any manipulation. At the same time, this experiment will blind other folks (data administrators, biostatisticians, programmers, measurement evaluators, etc.) to minimize performance bias.
For the sake of protecting the rights of the subjects, we will approve free acupotomy treatment for the sham acupotomy group at the end of the trial.
Date Management and Monitor
We will train all the staff to ensure data quality. The researchers will fill the data in the Case Report Forms (CRF) and sign it. CRF does not allow alteration directly. The researchers must report to the primary investigator if they need to alter the CRF. Any changes in CRF need to be signed and dated. Data administrators will enter data into the computer. The CRF and the computer will be locked in the research center, while the primary investigator keeps the key only. The original data will be kept in the research center rather than publish. The data can be access through research center if someone applies with reasons.
The data monitoring and management committee is composed of the Scientific Research Department of the First Affiliated Hospital of Guangzhou University of Chinese Medicine. They independently review and monitor research data. The South China Acupuncture Research Center Clinical Sub-center will form a quality monitoring committee. These committees will visit our clinical research center every 6 months to review and monitor the trial. The study group will run a conference to review this trial every month.
Acupotomy therapy may trigger adverse events including dizziness and local hematoma. When dizziness occurs during treatment, the doctor should stop the treatment immediately. Then the doctor will lay down on the pillow, and take warm water to take the service. If hematoma remains after treatment, the patient will apply a local cold compress, and switch to a hot compress at 24 hours to promote the dissipation and absorption of blood stasis. If an adverse drug reaction occurs, the drug should be discontinued. Active clinical observation and symptomatic treatment should be carried out.
Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine will monitor the safety of this trial and furnish us with advices (e.g., endpoint adjustment) if it is necessary. When an adverse event occurs in a patient, the researchers should record the detail, such as time, severity, duration, treatment measures, and event outcomes. The responsible doctor will determine the causal relationship between the treatment method and the adverse event, and decide to continue or terminate the study. Relevant information must be reported to the ethics committee on the same day.
The following are the criteria for terminating the study: (1) the subject has a serious adverse event or the subject has requested to suspend participation in the trial, or the trial operator believes that it is necessary for the subject to suspend the trial;(2) during the study, the subject is found to have a systemic disease that could not be detected before the start of the clinical trial;(3) for other reasons, researchers believe that patients are not suitable for continued treatment;(4) patients receive privately other interventions that may affect outcomes.
Per-protocol subjects’ analysis and intention-to-treat analysis were used to analyze the efficacy. The safety analysis set is used to analyze the safety evaluation.
We will develop a statistical analysis plan with a statistician. The statistician R 3.4.3 software package is used to performs descriptive statistics, exploratory analysis and dropout analysis. The result is statistically significant when the P-value is less than 0.05. In the intention-to-treat analysis, when the data is missing, the last observation is used for interpolation. Then we will select sensitive analysis for the result.
For continuous variables that obey normal distribution and meet homogeneity of variance, we will use Student’s t-test. if continuous variables cannot meet the condition mentioned above, the Mann-Whitney test or Wilcoxon test will be used. A chi-square test will be performed for discrete or categorical variables. When analyzing data from repeated measurements, we will use analysis of variance or analysis of covariance.
For safety analysis, we will use descriptive analysis at first. Subsequently, the incidence of adverse reactions between the two groups will be compared. The causality for the severity of adverse reactions and the needle-knife operation should be considered in the comparison. If there are a large number of adverse reactions, the relationship with the intervention time and baseline characteristics should be analyzed.