The knee is the 2nd most prevalent localization for osteonecrosis, after the hip [1]. Knee osteonecrosis is usually classif ied into 2groups based upon underlying pathophysiological mechanisms: spontaneous osteonecrosis of the knee (SONK; also called primary osteonecrosis)and atraumatic osteonecrosis (also calledsecondaryosteonecrosis) [2].

SONK is considered to be the most common form of osteonecrosis of the knee and mostly affects the medial condyle of postmenopausal women [1,3]. Localized vascular insufficiency result in necrosis of the subchondral bone [4,5]. The lesion is clinically characterized by a sudden onset of severe knee-joint pain and is not generally associated with systemic disorders or previous corticosteroid therapy [6]. Atraumaticosteonecrosis is typically observed in younger patients [7], and in most cases, it is related to medical conditions such as corticosteroid treatment, alcoholism, sickle cell anemia, systemic lupus erythematosus, and hyperbarism [1,4].

Regardless of the categories, treatment of osteonecrosis aims to cease further progression or defer the onset of end-stage arthritis of the knee. Patients who have SONK can be managed either non-operatively or operatively based on the stage of the disease and symptoms experienced. The decision to treat epiphyseal lesions is based mostly on the size of the osteonecrotic area [8]. Currently, non-operative treatment options consist of observation, protected weight bearing, non-steroidal anti-inflammatory drugs, and analgesia, as needed [7]. The etiology of SONK is largely unknown, and there is an unmet demand for an optimal non-operative treatment. In this study, we report the results of using Korean traditional medicine to treat a patient for SONK at Jaseng Hospital of Korean Medicine.

Medical history

In December 2018, a 65-year-old female patient developed pain in the front of the left knee joint, which was accompanied by a mild redness and swelling. She started to limp in severe pain when she had walked for more than 10 minutes. She visited her local clinics and received a total of 4 Steroid injections in her left knee but she continued to experience severe pain. On December 29^th, 2018, she visited Jaseng Hospital of Korean Medicine where a bilateral knee X-ray was performed. Due to the radiographical findings she was scheduled for magnetic resonance imaging (MRI) and was hospitalized on January 8^th, 2019.

Radiography and magnetic resonance imaging results

On December 29, 2018, the patient had a bilateral knee X-ray, which revealed degenerative osteoarthritis of both knees, and the severity of the osteoarthritis was graded as a Kellgren-Lawrence Grade 2/3 (Fig. 1). On January 8, 2019, she underwent left knee MRI, which revealed rule out SONK in the lateral aspect of the medial femoral condyle. This was based on observations of an osteophyte in the knee, high-grade chondromalacia of the medial femorotibial condyle, and the lateral facet of the patella (Fig. 2). Additionally, it revealed a medial meniscal posterior horn root tear, Grade 1 medial collateral ligament (MCL) injury, and tendinosis in the distal patellar tendon.

Treatment methods

Acupuncture/pharmacopuncture therapy

Standardized, disposable, sterilized stainless steel needles of 0.25 × 40 mm size (The Eastern Acupuncture Equipment Manufacturer, Boryung, Korea) were used to perform electro-acupuncture (2 Hz) twice a day for 15-minutes at ST35, LI4, LR7, EX-LE4, EXLE5 and the medial collateral ligament of the knee. SHINBARO2 pharmacopuncture (Jaseng Wonoe Tangjunwon, Namyangju, South Korea) was administered twice a day by injecting 0.5-1 mL per acupoint to EX-LE4and EX-LE5, using a disposable 29 gauge × 13 mm (1/2”) needle, 1 mL/cc insulin syringe (Sungsimmedical, Bucheon, South Korea), to a 1.3 cm depth. The pharmacopuncture components, schedule, and daily doses are presented in Table 1.

Herbal medicine

Mabalgwanjeol-tang and Bogangyeongol-hwan was prescribed for severe knee pain (the patient’s chief complaint). The antiinflammatory effects of Mabalgwanjeol-tang and Bogangyeongolhwan may alleviate symptoms of bone loss-associated diseases [9]. The medicine prescribed for the patient was prepared at Jaseng Hospital of Korean Medicine. The herbal components, daily doses, and, schedule are shown in Table 2.

Conventional medicine

While hospitalized, a family physician consulted with the patient regarding frequent urination and it was recommended that conventional medicine should be taken when the symptom reoccurs. Detailed information of the medicine prescribed by the physician is provided in Table 3.

Assessments

All assessments used for patient evaluation were performed on admission day, the 14^th day of hospitalization, and discharge day (the 21st day of hospitalization).

Numeric Rating Scale

The numeric rating scale (NRS) was used to assess the degree of the patient’s overall subjective experience of pain. It ranged from 0 (no pain) to 10 (worst possible pain).

Western Ontario and McMaster Universities Osteoarthritis Index

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a useful questionnaire for patients with knee pain to qualify their pain. It consists of 24 questions regarding subjective symptoms such as pain, stiffness, and physical function. The index is out of a total of 96 possible points, with 0 being the least amount of pain and 96 being the worst.

European Quality of Life–5Dimensions

The European Quality of Life–5Dimensions (EQ-5D) is a survey of quality of life that consists of 5categories: self-care, mobility, usual activities, anxiety/depression, and pain/discomfort. The utility value was calculated using the Tariff scoring system where0 denotes death and 1 denotes complete health status.

Range of Motion and specialty tests

Range of motion (ROM) is a measurement of the movement of a specific joint or body part. In this case, the patient’s movements of flexion, extension, and lateral bending of both knees were assessed, without assistance. To confirm the problem, specialty provocative tests such as the valgus and varus stress tests were performed.

Ethics statement

The patient’s medical records were obtained retrospectively and approved for use by the Institutional Review Board of Jaseng Hospital of Korean Medicine (IRB file no.: 2021-08-008).

Progress note

On the day of admission, the patient had severe left knee pain which impeded her ability to walk more than 10 minutes. If she exceeded this time limit, she experienced mild swelling and redness developed. At the time of admission, the NRS score for the patient’s knee pain was 6,following2weeksof treatment it was 3, and at discharge the NRS score had decreased to 2 (Fig. 3). The WOMAC score was 53 at the time of admission, 45 after 2 weeks, and 41 at discharge. In detail, her pain score decreased from 15 to 8, which was the most significant decrease; her physical function decreased from 37 to 32; and her stiffness remained at a score of 1, which was the same score as assessed upon admission (Fig. 4). The EQ-5D score was 0.692 at admission, 0.704 after 2 weeks, and 0.715 at discharge (Fig. 5). The ROM of her left knee was within normal limits at admission through to discharge, and the valgus and varus stress tests were negative at admission through to discharge.

Various case reports and systematic reviews concerned with treatment of SONK have been published, but further understanding of the potential of Korean traditional medicine as a treatment for SONK is necessary. Combination therapy consisting of acupuncture, pharmacopuncture, and herbal medicine in this case was used to treat SONK and relieved the patient’s pain and improved their physical function during 3weeks of hospitalization.

In addition to SONK, this case presented with degenerative osteoarthritis, a medial meniscal posterior horn root tear, and a MCL injury, making it diff icult to be sure of immediate improvement in symptoms with surgical treatment of SONK alone. The patient was also at risk of surgery due to old age. Despite taking non-steroidal anti-inflammatory drugs for a long time, there was no improvement, and to improve her overall level of pain she received Korean traditional medicine treatment.

The patient’s pain was most remarkably reduced after acupuncture/pharmacopuncture therapy. Pharmacopuncture is an acupuncture technique that entails the direct stimulation of acupoints with herbal extracts, which may work faster than the conventional form of acupuncture [10,11]. SHINBARO is a purified extract obtained from a mixture of 6oriental herbs (Ledebouriellae Radix, Achyranthis Radix, Acanthopanacis Cortex, Cibotii Rhizoma, Glycine Semen, and Eucommiae Cortex). SHINBARO has been used to treat some bone disorders and inflammatory diseases. Kim et al reported that intra-articular administration of SHINBARO inhibited prostaglandin E2and anti-Type 2collagen antibody production, and regulated the balance of inflammatory mediators, enzymes, and cytokines in the monosodium iodoacetate-induced osteoarthritis rat model [12].

Yamamoto et al reported that the primary event leading to SONK were subchondral insufficiency fractures [6]. It has been reported that bisphosphonates delay the need for surgery in patients who have SONK, and promote repair of the fracture [5,13,14]. It has been reported that the mechanisms of action of Bogangyeongol-hwan may induce alkaline phosphataseactivation in osteoblasts, increase calcified bone matrices, and reduce osteoclast formation [9]. Therefore, Bogangyeongol-hwan may alleviate the symptoms of bone loss-associated disease and protect against SONK mechanisms, such as biphosphonate [9].

An analysis of the main components of Mabalgwanjeol-tang, Lasiosphaera Seu Calvatia and Achyranthes Bidentata Radix, revealed anti-inflammatory effects [15]. In animal models of arthritis, extracts consisting of Achyranthes bidentata and Atractylodes japonica have been reported to be effective in the treatment of arthritis [16].

On Day 9, the patient was diagnosed with bladder inflammation due to urinary frequency and was prescribed 2 courses of ciprofloxacin. It is unlikely that this symptom was adversely associated with Korean medicine treatment for SONK. However, taking this antibioticis a limitation of this study because oral medication other than herbal medicine was taken and so the effects of other medicines cannot be excluded from the outcome of this study.

This was a case study of1patient, therefore the level of evidence is not high. In addition, it cannot be said with certainty that the pain in her left knee was caused by SONK alone. She also had a medial meniscus tear and a MCL injury. The patient needs to be assessed further using follow-up MRI. In spite of these limitations, this is the 1st case report of SONK using Korean medicine combination therapy including acupuncture, pharmacopuncture, and herbal medicine. Further studies are needed.

This case study may demonstrate the eff icacy of Korean traditional medicine in alleviating pain and overcoming functional limitations within a short time period in a patient with SONK, a medial meniscal posterior horn root tear, and a MCL injury. Therefore, a combination therapy consisting of traditional Korean medicine may be a potential alternative non-operative treatment for patients with SONK.

Bilateral knee X-ray (December 29, 2018). This image shows degenerative osteoarthritis in both knees, with a Kellgren-Lawrence Grade 2 on the left knee and Grade 3 on the right knee.

Magnetic resonance imaging scans (January 8, 2019). (A) Coronal T1- weighted image and sagittal proton density-weighted image. (B) Spontaneous osteonecrosis of the knee in the lateral aspect of the medial femoral condyle.

Changes in the numeric rating scale scores during the hospitalization period.

Changes in the Western Ontario and McMaster Universities osteoarthritis index scores during the hospitalization period.

Changes in the European Quality of Life–5 Dimensions Index during the hospitalization period.

Table 1.. Pharmacopuncture Administered to the Patient.

Table 2.. Korean Traditional Medicine Herbal Prescriptions Administered to the Patient.

Table 3.. Conventional MedicineAdministered to the Patient.