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Ciaffi J, Papalexis N, Vanni E, Miceli M, Faldini C, Scotti L, Zambon A, Salvarani C, Caporali R, Facchini G, Ursini F. Minimally invasive interventional procedures for osteoarthritis and inflammatory arthritis: A systematic review and meta-analysis. Semin Arthritis Rheum 2024; 68:152525. [PMID: 39137511 DOI: 10.1016/j.semarthrit.2024.152525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 07/12/2024] [Accepted: 07/22/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE to summarize the evidence on the efficacy of minimally invasive interventional procedures such as radiofrequency ablation (RFA) and transcatheter arterial embolization (TAE) in patients with osteoarthritis or inflammatory arthritis. METHODS a literature search was conducted in PubMed and Web of Science databases. Both randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) were included. The results were organized according to the treated anatomical site: knee, hip, foot and ankle, shoulder, hand and wrist, sacroiliac joints. Data about treatment efficacy were extracted. The main outcome was change in pain intensity using the 0-10 visual analog scale (VAS) from baseline to 1 month. Additional timepoints at 3, 6 and 12 months were assessed. Change in functional status was evaluated. Pooled estimates were calculated as the mean difference (MD) and 95 % confidence interval relative to baseline. The meta-analyses of RCTs and NRSI were conducted separately. RESULTS of the 4599 retrieved articles, 164 were included in the review and, considering all the established timepoints, 111 (38 RCTs and 73 NRSI) were selected for the meta-analysis. Only one article described patients with inflammatory arthritis. In the meta-analysis of RCTs, one month after the procedure, MD in VAS was -3.98 (-4.41 to -3.55; k = 21) for knee RFA, and -3.18 (-3.96 to -2.39; k = 8) for sacroiliac joints RFA. In the meta-analysis of NRSI, MD in VAS was -4.12 (-4.63 to -3.61; k = 23) for knee RFA, -3.84 (-4.77 to -2.92; k = 7) for knee TAE, -4.34 (-4.96 to -3.71; k = 2) for hip RFA, -3.83 (-4.52 to -3.15; k = 3) for shoulder RFA and -4.93 (-5.58 to -4.28; k = 14) for sacroiliac joints RFA. Significant decrease in pain intensity was found also at 3, 6 and 12 months. Additionally, functional status improved at all the assessed timepoints. CONCLUSION minimally invasive interventional procedures can improve pain and functional status of patients affected by OA or chronic sacroiliac pain of degenerative origin. Further research is warranted in the field of inflammatory rheumatic diseases.
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Affiliation(s)
- Jacopo Ciaffi
- Medicine & Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | - Nicolas Papalexis
- Diagnostic and Interventional Radiology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Elena Vanni
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia and Università di Modena e Reggio Emilia, Modena, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cesare Faldini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy; 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Lorenza Scotti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
| | - Antonella Zambon
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia and Università di Modena e Reggio Emilia, Modena, Italy
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan and ASST G. Pini-CTO, Milan, Italy
| | - Giancarlo Facchini
- Diagnostic and Interventional Radiology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Francesco Ursini
- Medicine & Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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Vanneste T, Belba A, Oei GTML, Emans P, Fonkoue L, Kallewaard JW, Kapural L, Peng P, Sommer M, Vanneste B, Cohen SP, Van Zundert J. 9. Chronic knee pain. Pain Pract 2024. [PMID: 39219017 DOI: 10.1111/papr.13408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Chronic knee pain is defined as pain that persists or recurs over 3 months. The most common is degenerative osteoarthritis (OA). This review represents a comprehensive description of the pathology, diagnosis, and treatment of OA of the knee. METHODS The literature on the diagnosis and treatment of chronic knee pain was retrieved and summarized. A modified Delphi approach was used to formulate recommendations on interventional treatments. RESULTS Patients with knee OA commonly present with insidious, chronic knee pain that gradually worsens. Pain caused by knee OA is predominantly nociceptive pain, with occasional nociplastic and infrequent neuropathic characteristics occurring in a diseased knee. A standard musculoskeletal and neurological examination is required for the diagnosis of knee OA. Although typical clinical OA findings are sufficient for diagnosis, medical imaging may be performed to improve specificity. The differential diagnosis should exclude other causes of knee pain including bone and joint disorders such as rheumatoid arthritis, spondylo- and other arthropathies, and infections. When conservative treatment fails, intra-articular injections of corticosteroids and radiofrequency (conventional and cooled) of the genicular nerves have been shown to be effective. Hyaluronic acid infiltrations are conditionally recommended. Platelet-rich plasma infiltrations, chemical ablation of genicular nerves, and neurostimulation have, at the moment, not enough evidence and can be considered in a study setting. The decision to perform joint-preserving and joint-replacement options should be made multidisciplinary. CONCLUSIONS When conservative measures fail to provide satisfactory pain relief, a multidisciplinary approach is recommended including psychological therapy, integrative treatments, and procedural options such as intra-articular injections, radiofrequency ablation, and surgery.
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Affiliation(s)
- Thibaut Vanneste
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- MHeNs, Mental Health and Neuroscience Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Amy Belba
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Gezina T M L Oei
- Department of Anesthesiology and Pain Medicine, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Pieter Emans
- Department of Orthopaedic Surgery, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Loic Fonkoue
- Department of Morphology, Experimental and Clinical Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Neuro-Musculo-Skeletal Department, Experimental and Clinical Research Institute, Universite Catholique de Louvain, Brussels, Belgium
| | - Jan Willem Kallewaard
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Philip Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael Sommer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- MHeNs, Mental Health and Neuroscience Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Bert Vanneste
- Department of Anesthesia and Pain Medicine, AZ Groeninge, Kortrijk, Belgium
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation, Psychiatry and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- MHeNs, Mental Health and Neuroscience Research Institute, Maastricht University, Maastricht, The Netherlands
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Dalili D, Holzwanger DJ, Fleming JW, Igbinoba Z, Dalili DE, Beall DP, Isaac A, Yoon ES. Advanced Interventional Procedures for Knee Osteoarthritis: What Is the Current Evidence? Semin Musculoskelet Radiol 2024; 28:267-281. [PMID: 38768592 DOI: 10.1055/s-0044-1781432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The prevalence of knee osteoarthritis (OA) is the highest among all joints and likely to increase over the coming decades. Advances in the repertoire of diagnostic capabilities of imaging and an expansion in the availability and range of image-guided interventions has led to development of more advanced interventional procedures targeting pain related to OA pain while improving the function of patients presenting with this debilitating condition. We review the spectrum of established advanced interventional procedures for knee OA, describe the techniques used to perform these procedures safely, and discuss the clinical evidence supporting each of them.
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Affiliation(s)
- Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, London, United Kingdom
- Department of Diagnostic and Interventional Radiology, Epsom and St Helier University Hospitals NHS Trust, Dorking Road, Epsom, London, United Kingdom
| | - Daniel J Holzwanger
- Division of Vascular and Interventional Radiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Jacob W Fleming
- Comprehensive Specialty Care, Edmond, Oklahoma City, Oklahoma
| | - Zenas Igbinoba
- Department of Radiology, Hospital for Special Surgery, New York, New York
| | - Daniel E Dalili
- Department of Radiology, Southend University Hospital, Mid and South Essex NHS Trust, United Kingdom
| | - Douglas P Beall
- Comprehensive Specialty Care, Edmond, Oklahoma City, Oklahoma
| | - Amanda Isaac
- School of Biomedical Engineering & Imaging Sciences, Kings College London, London, United Kingdom
| | - Edward S Yoon
- Department of Radiology, Hospital for Special Surgery, New York, New York
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Kwon HJ, Kim CS, Kim DH, Shin JW, Choi D, Choi SS. Effectiveness of the Cooled Radiofrequency Ablation of Genicular Nerves in Patients with Chronic Knee Pain Due to Osteoarthritis: A Double-Blind, Randomized, Controlled Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:857. [PMID: 38929474 PMCID: PMC11206112 DOI: 10.3390/medicina60060857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Background: Increasing evidence supporting the clinical effectiveness of cooled radiofrequency ablation (RFA) therapy for genicular nerves in patients with chronic knee osteoarthritis (OA) exists. However, no study has been conducted to eliminate the potential influence of a placebo effect associated with this procedure. Therefore, we evaluated the efficacy of cooled RFA compared with a sham procedure in patients with painful knees due to OA. Methods: In this double-blind, randomized, controlled study, participants were randomly assigned to receive cooled RFA of the knee (cooled RFA group, n = 20) or a sham procedure (sham group, n = 20). The primary outcome was the proportion of successful responders at the three-month follow-up. The secondary outcomes were successful responders at one and six months; pain intensity of the knee; functional status; medication; and satisfaction at one, three, and six months after the procedures. Results: For the primary outcome, the successful responder rate was significantly higher in the cooled RFA group (76.5%) than in the sham group (33.3%) (p = 0.018). For the secondary outcome, more successful responders were observed in the cooled RFA group than in the sham group at one and six months after the procedure (p = 0.041 and 0.007, respectively). The decreased knee pain intensity was maintained throughout the six-month follow-up period in the cooled RFA group. No differences were observed in functional status, medication change, or satisfaction in both groups. Conclusions: The cooled RFA of genicular nerves offers significant pain relief and surpasses the effects attributable to a placebo.
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Affiliation(s)
| | | | | | | | | | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; (H.-J.K.); (C.-S.K.); (D.-H.K.); (J.-W.S.); (D.C.)
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Alomari A, Bhatia A. An update on radiofrequency denervation for arthritis-related knee joint pain: a synthesis of the current evidence. BJA Educ 2024; 24:164-172. [PMID: 38646452 PMCID: PMC11026924 DOI: 10.1016/j.bjae.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 04/23/2024] Open
Affiliation(s)
- Abeer Alomari
- Toronto Western Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Anuj Bhatia
- Toronto Western Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, Toronto, ON, Canada
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Shi W, Vu TN, Annaswamy T, Wu H, Moore B, Hatchard N, Mears C, Kunselman AR. Effectiveness comparison of genicular nerve ablation for knee osteoarthritic versus post-total knee arthroplasty pain. INTERVENTIONAL PAIN MEDICINE 2024; 3:100390. [PMID: 39239503 PMCID: PMC11372902 DOI: 10.1016/j.inpm.2024.100390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 09/07/2024]
Abstract
Background Genicular nerve radiofrequency ablation (GNRFA) is a popular and effective procedure to treat arthritic knee pain. For refractory arthritic pain that fails conservative treatment, total knee arthroplasty (TKA) has been an excellent option. Unfortunately, 15-30% of people who undergo a TKA continue to experience pain and stiffness in the knee. The treatment options for post-TKA knee pain are limited. Pain providers have been trialing GNRFA on this pain condition. However, convincing evidence of its efficacy in treating post-TKA pain is still lacking. Methods This is a retrospective study of 73 patients who had undergone genicular nerve RFA, 46 (63.01%) with osteoarthritic pain, and 27 (36.99%) with post-TKA pain. We compared the outcomes (pain relief, function, and complications) between these two groups at 3 months and 6 months after RFA. Results Before RFA, there was no significant difference in initial pain and functional level between these two groups. After RFA, the two groups had comparable pain relief at 3 months (p = 0.68) and 6 months (p = 0.53), and similar functionality at 3 months (p = 0.36) and 6 months (p = 0.65).The overall success rate (≥50% pain relief after RFA) was 80.82%, 95% CI: 70.34%-88.22% (osteoarthritic group 80.43%, 95% CI: 66.83%-89.35%, post-TKA 81.48%, 95% CI: 63.30%-91.82%, P = 0.91) at 3-month follow-up and 56.16%, 95% CI: 44.76%-66.95% (osteoarthritic group 56.52%, 95% CI: 42.25%-69.79%, post-TKA 55.56%, 95% CI: 37.31%-72.41%, P = 0.94) at 6-month follow-up.There were no reported complications in either group. Conclusions Genicular Nerve Radiofrequency Ablation (GNRFA) holds the potential to be equally effective for both post-TKA knee pain and osteoarthritic knee pain.
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Affiliation(s)
- Weibin Shi
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center / Penn State College of Medicine, Hershey, PA, USA
- Penn State Hershey Rehabilitation Hospital, Hummelstown, PA, USA
| | - To-Nhu Vu
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S Hershey Medical Center / Penn State College of Medicine, Hershey, PA, USA
| | - Thiru Annaswamy
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center / Penn State College of Medicine, Hershey, PA, USA
- Penn State Hershey Rehabilitation Hospital, Hummelstown, PA, USA
| | - Hong Wu
- Department of Physical Medicine and Rehabilitation, RUSH University Medical College, Chicago, IL, USA
| | - Bryan Moore
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center / Penn State College of Medicine, Hershey, PA, USA
- Penn State Hershey Rehabilitation Hospital, Hummelstown, PA, USA
| | - Nicole Hatchard
- Department of Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center / Penn State College of Medicine, Hershey, PA, USA
- Penn State Hershey Rehabilitation Hospital, Hummelstown, PA, USA
| | - Chad Mears
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S Hershey Medical Center / Penn State College of Medicine, Hershey, PA, USA
| | - Allen R Kunselman
- Department of Public Health Sciences, Penn State Hershey College of Medicine, Hershey, PA, USA
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Tidwell CM, DeMarco PJ. Temperature-Mediated Neural Interventions in Knee Osteoarthritis: a Review of Cryoneurolysis and Cooled Radiofrequency Ablation with Ultrasound Guidance. Curr Rheumatol Rep 2024; 26:89-95. [PMID: 38127092 DOI: 10.1007/s11926-023-01127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW Knee osteoarthritis is a debilitating chronic disease affecting nearly half of the world's population at some point in their lives. Treatment of pain and loss of function associated with this disease has been limited. In this review, we seek to explore how neural interventions with ultrasound guidance may be an emerging option for non-pharmacologic pain relief in patients with knee osteoarthritis. RECENT FINDINGS Cryoneurolysis techniques have been demonstrated to provide pain relief out to 150 days post-treatment in knee osteoarthritis in select individuals. There have also been studies of cryoneurolysis pre-operatively to total knee replacement providing reduced pain, reduced opioid use post-operatively, and shorter hospital length of stay. Cooled radiofrequency ablation (CRFA) has been demonstrated to significantly reduce pain, improve functionality, and reduce pharmacologic needs in knee osteoarthritis out to 2 years. Both interventions appear to have increased accuracy with ultrasound, and CRFA appears to be associated with improved patient outcomes. The research demonstrates the efficacy of both cryoneurolysis and cooled radiofrequency ablation in the treatment of knee osteoarthritis. Ultrasound guidance in neurolysis provides an additional tool with real-time, high-accuracy nerve localization. These therapies should be considered for certain patients to assist in pain management in the non-operative and post-operative phase of knee osteoarthritis management. Further research is needed to further define the long-term effects and the long-term utility of the techniques in knee pain.
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Affiliation(s)
- Christopher M Tidwell
- National Institutes of Health, National Institute of Arthritis, Musculoskeletal, and Skin Diseases, Building 10, Suite 10N311, 9000 Rockville Pike, Bethesda, Rockville, MD, 20812, USA
| | - Paul J DeMarco
- National Institutes of Health, National Institute of Arthritis, Musculoskeletal, and Skin Diseases, Building 10, Suite 10N311, 9000 Rockville Pike, Bethesda, Rockville, MD, 20812, USA.
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Fuqua A, Premkumar A, Jayaram P, Wagner C. Complications and opioid-prescribing patterns following genicular nerve radiofrequency ablation versus intra-articular injection: a matched cohort study. Reg Anesth Pain Med 2024:rapm-2023-105053. [PMID: 38302251 DOI: 10.1136/rapm-2023-105053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/24/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND AND OBJECTIVES Genicular nerve radiofrequency ablation (GNRFA) is an emerging procedure used to relieve pain from severe knee osteoarthritis. While there have been rare reports of significant complications, their incidence has not been well established. The objective of this study was to examine complication rates at 30 and 90 days post treatment as well as characterize opioid-prescribing patterns before and after treatment. METHODS A large national database was queried to identify patients undergoing GNRFA from 2015 to 2022 and matched to control cohorts composed of patients receiving either intra-articular corticosteroid (CSI) or hyaluronic acid injection (HAI) of the knee. Complication rates at 30 and 90 days were analyzed. Opioid utilization was assessed in the 6 months before and after treatment. RESULTS Rates of infection (0.1%, CI 0.02% to 0.5% vs 0.2%, CI 0.05% to 0.6%), septic arthritis (<0.1%, CI 0.003% to 0.4% vs 0.1%, CI 0.02% to 0.5%), deep vein thrombosis (2.0%, CI 1.3% to 2.7% vs 1.6%, CI 1.0% to 2.2%), pulmonary embolism (1.2%, CI 0.6% to 1.7% vs 1.3%, CI 1.1% to 2.5%), bleeding (<0.1%, CI 0.003% to 0.4% vs 0%, CI 0% to 0.3%), seroma (<0.1%, CI 0.003% to 0.4% vs 0.2%, CI 0.05% to 0.6%), nerve injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%) and thermal injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%) were not different between CSI and GNRFA cohorts at 30 days. Rate of swelling was significantly greater in the GNRFA cohort (9.4%, CI 7.6% to 10.4% vs 6.4%, CI 4.8% to 7.2%, p=0.003) at 30 days. At 90 days, rates of septic arthritis (0.1%, CI 0.02% to 0.5% vs 0.3%, CI 0.08% to 0.7%), deep vein thrombosis (3.1%, CI 2.1% to 3.8% vs 3.1%, CI 2.2% to 3.9%), pulmonary embolism (1.5%, CI 0.9% to 2.1% vs 1.8%, CI 1.2% to 2.5%), and nerve injury (0%, CI 0% to 0.3% vs <0.1%, CI 0.003% to 0.4%) were not significantly different.Between HAI versus GNRFA cohorts, no significant differences were seen in rates of infection (0.3%, CI 0.08% to 0.07% vs 0.7%, CI 0.3% to 1.2%), septic arthritis (0.2%, CI 0.05% to 0.6% vs 0.4%, CI 0.2% to 0.9%), deep vein thrombosis (2.0%, CI 1.3% to 2.7% vs 1.9%, CI 1.2% to 2.7%), pulmonary embolism (1.5%, CI 0.9% to 2.2% vs 1.7%, CI 1.1% to 2.5%), bleeding (0.1%, CI 0.02% to 0.5% vs 0.2%, CI 0.05% to 0.6%), seroma (<0.1%, CI 0.03% to 0.4% vs 0%, CI 0% to 0.3%), nerve injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%), swelling (14.0%, CI 11.6% to 15.1% vs 12.0%, CI 10.3% to 13.6%), and thermal injury (<0.1%, CI 0.03% to 0.4% vs <0.01%, CI 0.3% to 0.4%) at 30 days. Rates of infection (0.7%, CI 0.3% to 1.2% vs 1.4%, CI 0.9% to 2.1%), septic arthritis (0.3%, CI 0.1% to 0.8% vs 0.5%, CI 0.2% to 1.1%), deep vein thrombosis (3.6%, CI 2.6% to 4.4% vs 3.1%, CI 2.2% to 4.0%), pulmonary embolism (2.3%, CI 1.5% to 3.0% vs 2.1%, CI 1.4% to 3.0%) and nerve injury (0%, CI 0% to 0.3% vs 0.1%, CI 0.02% to 0.5%) were not significantly different at 90 days.There were no significant differences in level of pretreatment opioid utilization although overall consumption in mean daily morphine equivalents was greater in the GNRFA cohort. Opioid utilization significantly increased in the first 30 days after ablation in patients with no prior opioid use compared to controls. In patients with some and chronic prior opioid use, opioid requirements were generally decreased in all treatment groups at 6 months with no clearly superior treatment in reducing opioid consumption. CONCLUSION Our study demonstrated that GNRFA possesses a safety profile similar to that of intra-articular injections although significant adverse events such as venous thromboembolism and septic arthritis may occur rarely. Although opioid utilization generally increased in the 30 days after ablation compared with intra-articular injection, similar reduction in opioid consumption at 6 months was seen in patients with prior opioid use in the ablation and control cohorts.
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Affiliation(s)
- Andrew Fuqua
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Prathap Jayaram
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Casey Wagner
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Karm MH, Kwon HJ, Kim CS, Kim DH, Shin JW, Choi SS. Cooled radiofrequency ablation of genicular nerves for knee osteoarthritis. Korean J Pain 2024; 37:13-25. [PMID: 38155108 PMCID: PMC10764214 DOI: 10.3344/kjp.23344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023] Open
Abstract
Knee osteoarthritis (OA) is a prevalent and debilitating musculoskeletal condition that significantly affects the quality of life of millions of individuals worldwide. In recent years, cooled radiofrequency ablation (CRFA) has become a viable treatment option for knee OA. This review thoroughly evaluated the existing literature on CRFA therapy for knee OA. It delved into the mechanisms behind CRFA, evaluated its clinical efficacy, and investigated potential avenues for future research and application. The insights gained from this review are crucial for healthcare professionals, researchers, and policymakers, offering an updated perspective on CRFA's role as a viable therapeutic option for knee OA.
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Affiliation(s)
- Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan-Sik Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Poursalehian M, Bhia I, Ayati Firoozabadi M, Mortazavi SMJ. Genicular Artery Embolization for Knee Osteoarthritis: A Comprehensive Review. JBJS Rev 2023; 11:01874474-202309000-00004. [PMID: 37683080 DOI: 10.2106/jbjs.rvw.23.00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
» Genicular artery embolization (GAE) is a promising treatment option for patients with knee osteoarthritis who are unresponsive to nonsurgical treatments and not yet candidates for surgery.» Current evidence supports the effectiveness of GAE in reducing pain and synovitis, with few reported major adverse events.» The cost-effectiveness and long-term results of GAE compared with other treatment options require further investigation.» Limitations of existing studies include small sample sizes, single-center trials, and lack of comparison between embolic agents and other treatments.» Future research should focus on larger, multicenter trials with longer follow-up periods and head-to-head comparisons with alternative treatment modalities to establish the role of GAE in the management of knee osteoarthritis.
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Affiliation(s)
- Mohammad Poursalehian
- Joint Reconstruction Research Center, Orthopedic Surgery Department, Imam Khomeini Hospital, Tehran, Iran
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Chalidis B, Papadopoulos P, Givissis P, Pitsilos C. Is Radiofrequency Ablation Superior to Intra-Articular Injections for the Treatment of Symptomatic Knee Osteoarthritis?-A Systematic Review. J Pers Med 2023; 13:1227. [PMID: 37623477 PMCID: PMC10455107 DOI: 10.3390/jpm13081227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
The radiofrequency ablation (RFA) is considered a valid, minimally invasive treatment modality for the management of symptomatic knee osteoarthritis (OA). The aim of this study was to compare the outcomes of RFA with that of commonly used intra-articular injections for the persistent knee pain due to OA. Medline/Pubmed and Scopus databases were systematically searched up to April 2023 to identify studies comparing the effect of RFA and intra-articular injections (IAIs) on knee OA. Nine studies including 899 patients fulfilled the eligibility criteria and were included in the systematic review. The RFA procedure was related with improved knee pain relief compared to IAIs at 3-, 6- and 12-month follow-up (p < 0.001). Similarly, functional improvement was greater in RFA treatment than that observed after hyaluronic acid (HA), steroid or platelet-rich plasma (PRP) injections (Visual Analogue Scale p < 0.001, Numeric Rating Scale p = 0.019, Western Ontario and McMaster University Osteoarthritis Index p = 0.012). The overall procedural complication rate of RFA was 10.2% and was higher than steroid (p = 0.023) and PRP (p = 0.017) injections. However, no severe adverse events were reported. For patients with symptomatic knee OA, RFA seems to be more effective than IAIs in alleviating pain and improving joint function, despite the relatively higher incidence of non-serious adverse events. However, due to the limited number of studies and patients, this result should be interpreted with caution and not be generalized to the entire knee OA population.
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Affiliation(s)
- Byron Chalidis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece;
| | - Pericles Papadopoulos
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, 54635 Thessaloniki, Greece; (P.P.); (C.P.)
| | - Panagiotis Givissis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece;
| | - Charalampos Pitsilos
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, 54635 Thessaloniki, Greece; (P.P.); (C.P.)
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Vallejo R, Benyamin R, Orduña-Valls J, Vallejo A, Thomas SM, Cedeño DL. A randomized controlled study of the long-term efficacy of cooled and monopolar radiofrequency ablation for the treatment of chronic pain related to knee osteoarthritis. INTERVENTIONAL PAIN MEDICINE 2023; 2:100249. [PMID: 39238667 PMCID: PMC11372914 DOI: 10.1016/j.inpm.2023.100249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 09/07/2024]
Abstract
Background Chronic knee pain due to osteoarthritis (OA) is expected to become more prevalent. Although conventional therapies may provide relief they are not long-lasting. Persistent pain may lead to total knee replacement, which is not free of adverse outcomes. Monopolar and cooled radiofrequency ablation (RFA) of genicular nerves is an effective option. However, either method may provide distinctive results depending on expected lesion size, a key aspect considering the anatomical variability of knee innervations. This prospective, double-blind, randomized controlled trial evaluated the efficacy and durability of knee RFA using a cooled probe or a monopolar probe of comparable diameter. Methods This investigator-initiated, post-market, double-blinded, prospective, randomized controlled trial was approved by the Western IRB. 79 subjects with chronic knee pain due to knee OA were enrolled in multiple locations of a single center. 75 subjects were randomized (1:1) into RFA treatment with either a 4 mm/17G cooled active tip (CRFA) or a 10 mm/16G monopolar active tip (MRFA) using conventional procedures. Primary endpoint was change in knee pain level (100 mm VAS score) from baseline at 24-week post-treatment. Other endpoints include change in functionality, global perceived effect, and frequency of adverse events. Evaluation spanned to 52-week post-treatment. Significance of results (p < 0.05) was calculated using standard statistical analyses. Results Both CRFA and MRFA provided significant reduction (41 mm and 39 mm, respectively) of chronic knee pain at 24-week. At the 52-week visit, reduction in pain level was sustained for CRFA (42 mm) but seems to decrease for MRFA (31 mm). Improvements in functionality were also significant and sustained with both treatments, although tend to decrease with MRFA at 52-week. Most patients also perceived a very good/good effect of treatments along the duration of the study. Conclusion RFA of knee genicular nerves for the treatment of OA chronic pain is effective for 52 weeks post-ablation when using a CRFA (4 mm/17G active tip) or MRFA (10 mm/16G active tip). The benefits of CRFA seems to be better sustained beyond 24 weeks than the ones of MRFA, although no significant differences were observed at 52 weeks.
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Affiliation(s)
- Ricardo Vallejo
- Millennium Pain Center, 2406 E. Empire St., Bloomington, IL, 61704, USA
- Lumbrera Research, 33 Derby Way, Bloomington, IL, 61704, USA
| | - Ramsin Benyamin
- Millennium Pain Center, 2406 E. Empire St., Bloomington, IL, 61704, USA
| | - Jorge Orduña-Valls
- Hospital Quirón Salud Valencia, Av. de Blasco Ibáñez, 14, 46010, Valencia, Spain
- Hospital Clínico Universitario de Valencia, Av. de Blasco Ibáñez, 17, 46010, Valencia, Spain
| | - Alejandro Vallejo
- Millennium Pain Center, 2406 E. Empire St., Bloomington, IL, 61704, USA
- Midwestern University, 555 31st Street, Downers Grove, IL, 60515, USA
| | - Samuel M Thomas
- Millennium Pain Center, 2406 E. Empire St., Bloomington, IL, 61704, USA
- College of Osteopathic Medicine, Munroe, 3200 Grand Ave, Des Moines, IA, 50312, USA
| | - David L Cedeño
- Millennium Pain Center, 2406 E. Empire St., Bloomington, IL, 61704, USA
- Lumbrera Research, 33 Derby Way, Bloomington, IL, 61704, USA
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Vanneste T, Belba A, Kallewaard JW, van Kuijk SMJ, Gelissen M, Emans P, Bellemans J, Smeets K, Terwiel C, Van Boxem K, Sommer M, Van Zundert J. Comparison of cooled versus conventional radiofrequency treatment of the genicular nerves for chronic knee pain: a multicenter non-inferiority randomized pilot trial (COCOGEN trial). Reg Anesth Pain Med 2023; 48:197-204. [PMID: 36653065 PMCID: PMC10086476 DOI: 10.1136/rapm-2022-104054] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Radiofrequency (RF) treatment of the genicular nerves has the potential to reduce chronic knee pain due to osteoarthritis or persistent postsurgical pain, however, a direct comparison between the two main modalities used, conventional and cooled, is lacking. METHODS This double blind, non-inferiority, pilot, randomized controlled trial compared the effects of cooled and conventional RF in chronic knee pain patients suffering from osteoarthritis or persistent postsurgical pain after total knee arthroplasty. Patients were randomized following a 1:1 rate. The primary outcome was the proportion of patients with ≥50% pain reduction at 3 months postintervention. Other outcomes were knee pain, functionality, quality of life, emotional health, and adverse events up to 6 months postintervention. Conventional RF treatment was tested for non-inferiority to cooled in reducing knee pain at 3 months follow-up. RESULTS Forty-nine of 70 patients were included, of which 47 completed a 3-month follow-up. The primary outcome was achieved in 4 of 23 patients treated with conventional RF (17%) vs in 8 of 24 with cooled (33%) (p=0,21). Results from the non-inferiority comparison were inconclusive in relation to the non-inferiority margin. There was no statistically significant difference between secondary outcomes. There were no serious adverse events. CONCLUSIONS Both conventional and cooled RF treatment reduced pain in the osteoarthritis and persistent postsurgical pain population. This pilot study did not demonstrate statistically significant differences in the proportion of patients experiencing ≥50% pain reduction between techniques. The non-inferiority analysis was inconclusive. These results warrant further research. TRIAL REGISTRATION NUMBER NCT03865849.
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Affiliation(s)
- Thibaut Vanneste
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Amy Belba
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Sander M J van Kuijk
- Department of Clinical Epidemiology & Medical Technology Assessment, Maastricht UMC+, Maastricht, The Netherlands
| | - Marloes Gelissen
- Department of Anesthesiology and Pain Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Peter Emans
- Department of Orthopaedic Surgery, CAPHRI School for Public Health and Primary Care, Maastricht UMC+, Maastricht, The Netherlands
| | - Johan Bellemans
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Orthopedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
- GRIT Belgian sports clinic, Leuven, Belgium
| | - Kristof Smeets
- Department of Rehabilitation Sciences and Physiotherapy, BIOMED REVAL Rehabilitation Research Institute, Hasselt University, Hasselt, Belgium
| | - Chris Terwiel
- Department of Anesthesiology and Pain Medicine, Rijnstate, Arnhem, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Micha Sommer
- Department of Anesthesiology and Pain Medicine, Maastricht UMC+, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht UMC+, Maastricht, The Netherlands
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Panagopoulos A, Tsiplakos P, Katsanos K, Antzoulas P, Lakoumentas J. Cooled radiofrequency ablation versus cryoneurolysis of the genicular nerves for the symptomatic pain management in knee osteoarthritis: a study protocol of a prospective, randomized, single-blinded clinical trial. J Orthop Surg Res 2023; 18:295. [PMID: 37041607 PMCID: PMC10091842 DOI: 10.1186/s13018-023-03737-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/21/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Cooled radiofrequency ablation (CRFA) and cryoneurolysis (CRYO) are two novel methods of genicular neurolysis to relief pain in symptomatic knee osteoarthritis (KOA). In this study, the two methods will be compared, giving us the opportunity to investigate their efficacy, safety and complications. METHODS In this prospective randomized trial 70 patients with KOA will be recruited using a diagnostic block of four genicular nerves. Two groups will be created through software randomization: a CRFA group (35 patients) and a CRYO group (35 patients). The target of the interventions will be four genicular nerves; the superior medial, superior lateral, inferior medial, as well as the medial (retinacular) genicular branch from vastus intermedius. The primary outcome of this clinical trial will be the efficacy of CRFA or CRYO at 2-, 4-, 12-and 24-weeks post-intervention using the Numerical Rating Pain Scale (NRPS). The secondary outcomes are the safety of the two techniques, as well as the clinical evaluation using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS), and the 7-point scale of Patient Global Impression of Change (PGIC). DISCUSSION These two novel techniques can block pain transmission through genicular nerves in different ways. In contrast to cryoneurolysis, the CRFA method has been well documented in the past. This is the first clinical trial to compare CRFA vs CRYO and draw conclusions about their safety and efficacy. TRIAL REGISTRATION ISRCTN87455770 [ https://doi.org/10.1186/ISRCTN87455770 ]. Registered 29/3/2022, first patient recruited 31/8/2022.
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Affiliation(s)
- A Panagopoulos
- Orthopaedic Department, Patras University Hospital, University of Patras, Patras, Greece.
| | - P Tsiplakos
- Orthopaedic Department, Patras University Hospital, University of Patras, Patras, Greece
| | - K Katsanos
- Department of Interventional Radiology, Patras University Hospital, University of Patras, Patras, Greece
| | - P Antzoulas
- Orthopaedic Department, Patras University Hospital, University of Patras, Patras, Greece
| | - J Lakoumentas
- Department of Medical Physics, School of Medicine, Patras University, Patras, Greece
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15
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Malaithong W, Tontisirin N, Seangrung R, Wongsak S, Cohen SP. Bipolar radiofrequency ablation of the superomedial (SM), superolateral (SL) and inferomedial (IM) genicular nerves for chronic osteoarthritis knee pain: a randomized double-blind placebo-controlled trial with 12-month follow-up. Reg Anesth Pain Med 2022; 48:rapm-2022-103976. [PMID: 36543391 PMCID: PMC9985752 DOI: 10.1136/rapm-2022-103976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Variability in anatomy in the knees supports the use of aggressive lesioning techniques such as bipolar-radiofrequency ablation (RFA) to treat knee osteoarthritis (KOA). There are no randomized controlled trials evaluating the efficacy of bipolar-RFA. METHODS Sixty-four patients with KOA who experienced >50% pain relief from prognostic superomedial, superolateral and inferomedial genicular nerve blocks were randomly assigned to receive either genicular nerve local anesthetic and steroid injections with sham-RFA or local anesthetic and steroid plus bipolar-RFA. Participants and outcome adjudicators were blinded to allocation. The primary outcome was Visual Analog Scale pain score 12 months postprocedure. Secondary outcome measures included Western Ontario and McMaster Universities Arthritis (WOMAC) and Patient Global Improvement-Indexes (PGI-I). RESULTS Both groups experienced significant reductions in pain, with no significant differences observed at 12 months (reduction from 5.7±1.9 to 3.2±2.6 in the RFA-group vs from 5.0±1.4 to 2.6±2.4 in the control-group (p=0.40)) or any other time point. No significant changes were observed between groups for WOMAC and PGI-I at the primary endpoint, with only the control group experiencing a significant improvement in function at 12-month follow-up (mean reduction from 91.2±38.2 to 67.1±51.9 in the RFA-group (p=0.06) vs from 95.8±41.1 to 60.6±42.8 in the control group (p=0.001); p=0.85 between groups). CONCLUSION Our failure to find efficacy for genicular nerve RFA, coupled with evidence showing that a plenitude of nerves supply the knee joint and preliminary studies indicating superiority of lesioning strategies targeting more than three nerves, suggest controlled trials using more aggressive lesioning strategies are warranted. TRIAL REGISTRATION NUMBER TCTR20170130003.
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Affiliation(s)
| | - Nuj Tontisirin
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rattaphol Seangrung
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siwadol Wongsak
- Department of Orthopedic Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Steven P Cohen
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Physical Medicine & Rehabilitation, and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Departments of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Abstract
Osteoarthritis (OA) is one of the most common diseases worldwide and is expected to increase in incidence as the age of the general population rises. Both oral medications, such as NSAIDs, and surgical treatments used for OA management have limitations. Demand is rising for minimally invasive techniques such as intraarticular injections and percutaneous interventions for use in place of or in conjunction with oral medications and surgical therapies, and the past 2 decades have seen a rapid expanse in both pharmacologic and nonpharmacologic minimally invasive OA treatments. Image guidance with fluoroscopy, CT, or ultrasound is often used in conjunction with these procedures to achieve precise treatment localization to achieve maximal therapeutic effect. The choice of modality used for image guidance is often influenced by clinician experience, patient characteristics, and equipment availability. This article reviews the mechanisms of action, contraindications, complications, and efficacy of conventional and developing minimally invasive OA treatments. The minimally invasive treatment options described in this Review include therapeutic injections such as antiinflammatory agents, viscosupplements, and biologics, as well as nonpharmacologic treatments of subchondroplasty, nerve ablation, genicular artery embolization, intraarticular pulsed radiofrequency therapy, and MRI-guided focused ultrasound therapy.
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17
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Wu BP, Grits D, Foorsov V, Xu J, Tankha P, Bolash RB. Cooled and traditional thermal radiofrequency ablation of genicular nerves in patients with chronic knee pain: a comparative outcomes analysis. Reg Anesth Pain Med 2022; 47:rapm-2022-103693. [PMID: 35922077 PMCID: PMC9895122 DOI: 10.1136/rapm-2022-103693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Genicular nerve radiofrequency ablation (GNRFA) is a minimally invasive intervention for patients with chronic knee pain (CKP) not responding to conservative treatments. Few investigations have compared treatment outcomes of cooled-RFA (c-RFA) and thermal-RFA (t-RFA), two common approaches of GNRFA. This study aims to investigate and compare outcomes, including probability of treatment success, between c-RFA and t-RFA in patients with CKP. METHODS This retrospective cohort study analyzed a total of 208 propensity score matched patients, including 104 patients who received c-RFA and 104 patients who received t-RFA. The primary outcome was probability of pain relief after the procedure, defined as reduction in Numeric Rating Scale (NRS) pain score of 2 or greater. The secondary outcomes were degree of NRS pain score reductions, duration of relief, and the probability of patients receiving TKA within 1 year of treatment. RESULTS T-RFA was associated with a higher probability of pain relief within 1, 3, and 6 months after procedure when compared with c-RFA. Probabilities of pain relief from t-RFA and c-RFA were 62% (95% CI 51% to 71%) and 43% (95% CI 34% to 53%; p=0.01) within 1 month, 78% (95% CI 68% to 85%) and 55% (95% CI 45% to 64%; p<0.001) within 3 months, and 79% (95% CI 70% to 86%) and 59% (95% CI 49% to 68%; p<0.01) within 6 months, respectively. t-RFA was also associated with greater mean NRS pain score reduction at 1 month after procedure: -4.71 (95% CI -5.3 to -4.1) when compared with -3.59 (95% CI -4.3 to -2.9; p=0.02) from c-RFA. T-RFA and c-RFA were comparable in pain score reduction at 3, 6, 9 and 12 months after procedure. Both groups demonstrated comparable duration of relief and probability of patients receiving TKA within 1 year. DISCUSSION Both t-RFA and c-RFA effectively reduced NRS pain scores in most patients with CKP within the 1 year follow-up period. Genicular nerve t-RFA was associated with a higher probability of treatment success and a greater degree of pain relief at 1 month after the procedure when compared with c-RFA in propensity score matched patients with CKP.
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Affiliation(s)
- Bernie P Wu
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Grits
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Victor Foorsov
- Department of Orthopedic Surgery/Regional Medical Group, Northwestern Medicine, Chicago, Illinois, USA
| | - Jijun Xu
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pavan Tankha
- Center for Comprehensive Pain Recovery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert B Bolash
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Total Knee Arthroplasty After Genicular Nerve Radiofrequency Ablation: Reduction in Prolonged Opioid Use Without Increased Postsurgical Complications. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202208000-00010. [PMID: 35960987 PMCID: PMC9377675 DOI: 10.5435/jaaosglobal-d-22-00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
Abstract
Genicular nerve radiofrequency ablation (GNRFA) is an increasingly used nonsurgical treatment modality for patients with advanced knee osteoarthritis. Previous studies have demonstrated this to be an effective and safe method to decrease pain and increase functionality in this patient population. The purpose of this study was to compare 2-year postoperative complication rates and rates of prolonged postoperative opioid usage between patients undergoing total knee arthroplasty (TKA) after previous GNRFA and those undergoing TKA alone.
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Pilot study for treatment of symptomatic shoulder arthritis utilizing cooled radiofrequency ablation: a novel technique. Skeletal Radiol 2022; 51:1563-1570. [PMID: 35029737 DOI: 10.1007/s00256-022-03993-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/08/2022] [Accepted: 01/09/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To introduce cooled radiofrequency nerve ablation (C-RFA) as an alternative to managing symptomatically moderate to severe glenohumeral osteoarthritis (OA) in patients who have failed other conservative treatments and who are not surgical candidates or refuse surgery. MATERIAL AND METHODS This prospective pilot study includes a total of 12 patients experiencing chronic shoulder pain from moderate to severe glenohumeral OA. Patients underwent anesthetic blocks of the axillary, lateral pectoral, and suprascapular nerves to determine candidacy for C-RFA treatment. Adequate response after anesthetic block was over 50% immediate pain relief. Once patients were deemed candidates, they underwent C-RFA of the three nerves 2-3 weeks later. Treatment response was evaluated using the clinically validated American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) to assess pain, stiffness, and functional activities of daily living. Follow-up outcome scores were collected up to 6 months after C-RFA procedure. RESULTS Twelve patients underwent C-RFA procedure for shoulder OA. VAS scores significantly improved from 8.8 ± 0.6 to 2.2 ± 0.4 6 months after the C-RFA treatment (p < 0.001). Patient's ASES score results significantly improved in total ASES from 17.2 ± 6.6 to 65.7 ± 5.9 (p < 0.0005). No major complications arose. No patients received re-treatment or underwent shoulder arthroplasty. CONCLUSION Image-guided axillary, lateral pectoral, and suprascapular nerve C-RFA has minimal complications and is a promising alternative to treat chronic shoulder pain and stiffness from glenohumeral arthritis.
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Lipnick S. Editorial Commentary: Radiofrequency Ablation for Patients With Osteoarthritis of the Knee Could Be Indicated for Patients Failing Conventional Nonoperative Treatment and Wishing to Avoid Total Knee Arthroplasty. Arthroscopy 2022; 38:2303-2306. [PMID: 35809982 DOI: 10.1016/j.arthro.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 02/02/2023]
Abstract
Patients with knee osteoarthritis are constantly looking for ways to combat their pain and improve their quality of life. As newer treatments present themselves, it is up to the orthopaedic specialists to provide the best treatment possible. Radiofrequency ablation, usually administered by a pain management specialist, has shown to be an acceptable alternative treatment and should be considered in the management of osteoarthritis. It should be considered for patients who have failed nonoperative treatments and are not interested in pursuing total knee arthroplasty, and possibly for patients who have persistent pain after total knee arthroplasty.
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Radiofrequency Ablation in Cooled Monopolar or Conventional Bipolar Modality Yields More Beneficial Short-Term Clinical Outcomes Versus Other Treatments for Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Arthroscopy 2022; 38:2287-2302. [PMID: 35157969 DOI: 10.1016/j.arthro.2022.01.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 01/29/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate various radiofrequency ablation (RFA) treatments for knee osteoarthritis (OA) and determine the best modality, target, number of electrodes, and image guidance for improving knee pain and function. METHODS Electronic databases were searched for randomized controlled trials (RCTs) comparing the efficacy of RFA treatments for knee OA from inception up to September 30, 2021. The primary outcome was the visual analog scale (VAS), and the secondary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Bayesian network meta-analysis was performed to synthesize the mean difference (MD) and rank the comparative effectiveness of treatments. RESULTS A total of 21 eligible RCTs (from 2011 to 2021, involving 1,818 patients) with 8 RFA treatments, 6 intra-articular injections, NSAIDS, exercise, and placebo were assessed. Conventional bipolar genicular nerve RFA (GNRFA) had the greatest net benefit on the VAS at 6 months (MD, -5.5; 95% confidence interval [CI], -4.3 to -6.7; SUCRA, .98). And cooled monopolar GNRFA had the greatest net benefit on the WOMAC at 6 months (MD, -33; 95% CI, -37 to -29; SUCRA, .99). In conventional and pulsed modalities, bipolar RFA was associated with a significant decrease in VAS and WOMAC than monopolar RFA. Combining pulsed intra-articular RFA and platelet-rich plasma injection had no additional positive effects on VAS or WOMAC at 3 months. CONCLUSIONS RFA is effective in improving both knee pain and function in patients with OA, at least in the short term (6 months). Patients respond better to the cooled modality than the conventional and pulsed modalities. Bipolar is more effective than monopolar for improving pain and function in conventional and pulsed modalities. Fluoroscopy and ultrasound guidance showed no differences in improving pain and function. The effectiveness of RFA in cooled modality using bipolar or in combination with various intra-articular injections remains to be compared. LEVEL OF EVIDENCE II, systematic review and meta-analysis of Level I and II studies.
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Hunt C, Provenzano DA, Eshraghi Y, Mittal N, Souza D, Buchheit T. Should intra-articular hyaluronic acid be used routinely for knee osteoarthritis pain? PM R 2022; 14:879-885. [PMID: 34837674 PMCID: PMC9970143 DOI: 10.1002/pmrj.12740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/13/2021] [Accepted: 11/11/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Christine Hunt
- Department of Pain Medicine, Mayo Clinic, Jacksonville, FL, USA 32224
| | | | - Yashar Eshraghi
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA 70112,Department of Anesthesia, Interventional Pain Management, Ochsner Health System, University of Queensland Ochsner Clinical School, New Orleans, Louisiana, USA 70115
| | - Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA 44233
| | - Thomas Buchheit
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA 27710,Anesthesiology Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA 27705
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23
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Lyman J, Khalouf F, Zora K, DePalma M, Loudermilk E, Guiguis M, Beall D, Kohan L, Chen AF. Cooled radiofrequency ablation of genicular nerves provides 24-Month durability in the management of osteoarthritic knee pain: Outcomes from a prospective, multicenter, randomized trial. Pain Pract 2022; 22:571-581. [PMID: 35716058 PMCID: PMC9541208 DOI: 10.1111/papr.13139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/29/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022]
Abstract
Objective To assess long‐term outcomes of cooled radiofrequency ablation (CRFA) of genicular nerves for chronic knee pain due to osteoarthritis (OA). Methods A prospective, observational extension of a randomized, controlled trial was conducted on adults randomized to CRFA. Subjects were part of a 12‐month clinical trial comparing CRFA of genicular nerves to a single hyaluronic injection for treatment of chronic OA knee pain, who then agreed to visits at 18‐ and 24‐months post CRFA and had not undergone another knee procedure since. The subjects were evaluated for pain using the Numeric Rating Scale (NRS) function using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), subjective benefit using the Global Perceived Effect (GPE) scale, quality of life using the EuroQol‐5‐Dimensions‐5 Level (EQ‐5D‐5L) questionnaire, and safety. Results Of 57 subjects eligible, 36 enrolled; 32 completed the 18‐month visit with a mean NRS score of 2.4 and 22 (69%) reporting ≥50% reduction in pain from baseline (primary endpoint); 27 completed the 24‐month visit, with a mean NRS of 3.4 and 17 (63%) reporting ≥50% pain relief. Functional and quality of life improvements persisted similarly, with mean changes from baseline of 53.5% and 34.9% in WOMAC total scores, and 24.8% and 10.7% in EQ‐5D‐5L Index scores, at 18‐ and 24‐months, respectively. There were no identified safety concerns in this patient cohort. Conclusion In this subset of subjects, CRFA of genicular nerves provided durable pain relief, improved function, and improved quality of life extending to 24 months post procedure, with no significant safety concerns.
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Affiliation(s)
- Jeffrey Lyman
- Institute for Orthopedic Research and Innovation, Coeur d'Alene, Idaho, USA
| | - Fred Khalouf
- University Orthopedics Center, Altoona, Pennsylvania, USA
| | - Keith Zora
- University Orthopedics Center, State College, Pennsylvania, USA
| | | | - Eric Loudermilk
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Maged Guiguis
- Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | | | - Lynn Kohan
- PCPMG Clinical Research Unit LLC, Anderson, South Carolina, USA
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts, USA
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24
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Desai MJ, Bentley A, Keck WA. Cooled radiofrequency ablation of the genicular nerves for chronic pain due to osteoarthritis of the knee: a cost-effectiveness analysis compared with intra-articular hyaluronan injections based on trial data. BMC Musculoskelet Disord 2022; 23:491. [PMID: 35610642 PMCID: PMC9128114 DOI: 10.1186/s12891-022-05445-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 05/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Effective symptom control in painful knee osteoarthritis (OA) may improve patient quality of life. In a randomised crossover trial (NCT03381248), COOLIEF* cooled radiofrequency ablation (CRFA) reduced pain and stiffness and improved physical function and quality of life compared with intra-articular hyaluronan (HA) injections. The present study aimed to establish the cost effectiveness of CRFA versus intra-articular HA injections for treating moderate-to-severe OA knee pain from a US Medicare perspective. Methods We conducted a cost-effectiveness analysis using utility data (EQ-5D) from the randomised crossover trial of CRFA versus intra-articular HA injections, which had follow-ups at 1, 3, 6, and 12 months. Patients in the HA group with unsatisfactory outcomes (e.g., continued pain) at 6 months could cross over to CRFA. Economic analysis outcomes included quality-adjusted life-years (QALYs), costs, and cost effectiveness (cost per QALY gained). Base-case analyses were modelled on a 6-month time horizon (to trial crossover). Due to limited trial data in the HA arm beyond 6 months, scenarios explored potential outcomes to 12 months if: 1) Utility with HA persisted for a further 6 months; 2) A second HA injection was received at 6 months and achieved the same utility change for the second 6 months. In both scenarios, the CRFA arm used trial data for patients who received CRFA from baseline to 12 months. Alternative costing scenarios were also explored. Results CRFA resulted in an incremental QALY gain of 0.020 at an incremental cost of US$1707, equating to an incremental cost-effectiveness ratio (ICER) of US$84,392 per QALY over 6 months, versus intra-articular HA injections. Extending the analysis to 12 months and assuming persistence in utility in the HA arm resulted in a larger utility gain for CRFA (0.056 QALYs) and a lower ICER of US$30,275 per QALY. If patients received a second HA injection, the incremental benefit of CRFA out to 12 months was reduced (QALY gain 0.043) but was offset by the costs of the second HA injection (incremental cost US$832). This resulted in an ICER of US$19,316 per QALY. Conclusions CRFA is a cost-effective treatment option for patients with OA-related knee pain considering the typical US threshold of US$100,000/QALY.
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Affiliation(s)
- Mehul J Desai
- International Spine, Pain & Performance Center, Washington DC, USA. .,George Washington University, School of Medicine & Health Sciences, Washington DC, USA.
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25
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Fogarty AE, Burnham T, Kuo K, Tate Q, Sperry BP, Cheney C, Walega DR, Kohan L, Cohen SP, Cushman DM, McCormick ZL, Conger A. The Effectiveness of Fluoroscopically Guided Genicular Nerve Radiofrequency Ablation for the Treatment of Chronic Knee Pain Due to Osteoarthritis: A Systematic Review. Am J Phys Med Rehabil 2022; 101:482-492. [PMID: 35006653 DOI: 10.1097/phm.0000000000001813] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ABSTRACT The objective was to determine the effectiveness of fluoroscopically guided genicular nerve radiofrequency ablation for painful knee osteoarthritis. Primary outcome measure was improvement in pain after 6 mos. Secondary outcomes included the Oxford Knee Score and Western Ontario and McMaster Universities Osteoarthritis Index. Two reviewers independently assessed publications before October 10, 2020. The Cochrane Risk of Bias Tool and Grades of Recommendation, Assessment, Development, and Evaluation system were used. One hundred ninety-nine publications were screened, and nine were included. Six-month success rates for 50% or greater pain relief after radiofrequency ablation ranged from 49% to 74%. When compared with intra-articular steroid injection, the probability of success was 4.5 times higher for radiofrequency ablation (relative risk = 4.58 [95% confidence interval = 2.61-8.04]). When radiofrequency ablation was compared with hyaluronic acid injection, the probability of treatment success was 1.8 times higher (relative risk = 1.88, 95% confidence interval = 1.38-2.57). The group mean Oxford Knee Score and Western Ontario and McMaster Universities Osteoarthritis Index scores improved in participants receiving genicular radiofrequency ablation compared with intra-articular steroid injection and hyaluronic acid injection. According to Grades of Recommendation, Assessment, Development, and Evaluation, there is moderate-quality evidence that fluoroscopically guided genicular radiofrequency ablation is effective for reducing pain associated with knee osteoarthritis at minimum of 6 mos. Further research is likely to have an important impact on the current understanding of the long-term effectiveness of this treatment.
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Affiliation(s)
- Alexandra E Fogarty
- From the Division of Physical Medicine and Rehabilitation, Department of Neurology, Washington University School of Medicine, St Louis, Missouri (AEF); Division of Physical Medicine and Rehabilitation, Department of Orthopedics, University of Utah, Salt Lake City, Utah (TB, KK, QT, CC, DMC, ZLM, AC); University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California (BPS); Department of Anaesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (DRW); Division of Pain Management, Department of Anaesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia (LK); Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland (SPC); and Department of Surgery, Walter Reed Army Medical Center, Washington, DC (SPC)
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Alternative treatment of hip pain from advanced hip osteoarthritis utilizing cooled radiofrequency ablation: single institution pilot study. Skeletal Radiol 2022; 51:1047-1054. [PMID: 34609519 DOI: 10.1007/s00256-021-03927-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To establish the effectiveness of cooled radiofrequency ablation in managing hip pain from osteoarthritis at 6 months after receiving treatment in patients who failed conservative treatments and are not surgical candidates due to comorbidities or unwillingness to undergo arthroplasty surgery by targeting the femoral and obturator branches and assessing the degree of hip pain relief and change of function. MATERIALS AND METHODS This prospective pilot study includes a total of 11 consecutive patients experiencing persistent chronic hip pain in the setting of advanced osteoarthritis. Patients initially underwent anesthetic blocks of the obturator and femoral nerve branches to determine cooled radiofrequency ablation candidacy. After adequate response to the anesthetic blocks (> 50% immediate pain relief), patients were subjected to the procedures 2-3 weeks later. Treatment response was evaluated utilizing clinically validated questionnaires and visual analog score in order to assess impact on pain severity, stiffness, and functional activities of daily living. Follow-up outcome scores were collected up to 6 months after cooled radiofrequency ablation procedure. RESULTS A total of 11 hips were treated consecutively between August 2019 and March 2020 (mean patient age 61.4 years; 8 M:3F). The mean total HOOS score improved significantly from baseline at 17.0 ± 6.0 to 52.9 ± 5.4 at a mean of 6.2 months after treatment (p < 0.0001), with significant improvement in mean pain score from 16.1 ± 6.6 to 53.4 ± 7.4 (p < 0.0001) and mean stiffness score from 15.0 ± 8.1 to 53.6 ± 11.0 (p < 0.0001). No major complications were encountered. No patients went on to re-treatment, surgery, or other intervention. CONCLUSION Image-guided obturator and femoral nerve cooled radiofrequency ablation is effective and safe in treating chronic hip pain/stiffness in the setting of advanced osteoarthritis.
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27
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Koshi E, Meiling JB, Conger AM, McCormick ZL, Burnham TR. Long-term clinical outcomes of genicular nerve radiofrequency ablation for chronic knee pain using a three-tined electrode for expanded nerve capture. INTERVENTIONAL PAIN MEDICINE 2022; 1:100003. [PMID: 39301447 PMCID: PMC11411598 DOI: 10.1016/j.inpm.2021.100003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/16/2021] [Accepted: 11/16/2021] [Indexed: 09/22/2024]
Abstract
Objective Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment option for chronic knee pain in native knee osteoarthritis and total knee arthroplasty (TKA) patients. Recent dissections have revealed significant variability in typical genicular nerve targets and other sensory nerves not included in previous studies. Early, short-term results suggest that more complete sensory denervation with GNRFA may result in more significant pain reduction; however, no long-term clinical outcome exists. We aim to present long-term clinical outcomes after an expanded GNRFA technique with a three-tined radiofrequency cannula. Methods Eleven consecutive patients with ≥6 months of knee pain underwent an expanded GNRFA protocol targeting the superomedial (SMGN), superolateral (SLGN), inferomedial genicular nerves (IMGN), in addition to the nerves to vastus medialis (NVM), lateralis (NVL), and intermedius (NVI). Long-term pain and impression of change outcomes were collected in a cross-sectional fashion. Results At ≥18 months (mean 24 months) post-GNRFA, 91% (95% CI = 59, 100%), 73% (95% CI = 46, 99%), and 9% (95% CI = 0, 26%) of patients reported ≥50%, ≥80%, and 100% pain relief, respectively. Additionally, 27% (95% CI = 1, 54%) and 64% (95% CI = 35, 92%) of individuals reported a PGIC score of 6 ("much improved") and 7 ("very much improved"), respectively. The proportion of individuals who reported the MCID for the PGIC (score of ≥6) was 91% (95% CI = 59, 100%). There were no adverse events reported amongst the patients in this cohort. No patients progressed to surgery. Conclusion This single-arm cohort suggests that an expanded GNRFA protocol targeting SMGN, SLGN, IMGN, NVM, NVL, and NVI nerves with a three-tined electrode, resulted in significant long-term (≥18 months) improvements in pain and patient-perceived global improvement. Large, head-to-head trials are needed to establish whether this GNRFA protocol is superior to those used in previous clinical studies and those currently used more commonly in practice.
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Affiliation(s)
- Edvin Koshi
- Department of Physical Medicine and Rehabilitation, Dalhousie University, 650 Washmill Lake Drive, Suite 250, Halifax, Nova Scotia, B3S 0H8, Canada
| | - James B Meiling
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Aaron M Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA
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Pulsed Radiofrequency Rhizotomy of the Genicular Nerves of the Knee Guided by Radioscopy and Ultrasonography: Step-By-Step Technique. Arthrosc Tech 2022; 11:e391-e396. [PMID: 35256981 PMCID: PMC8897599 DOI: 10.1016/j.eats.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
Osteoarthritis (OA) of the knee is highly prevalent and causes pain, stiffness, and harms the quality of life of millions of patients. Scientific evidence about radiofrequency ablation or rhizotomy of genicular nerves has been presented with increasing frequency in the literature for the treatment of chronic pain related to knee OA as an alternative to total knee arthroplasty. The main indication for this procedure is symptomatic OA unresponsive to conservative treatment, regardless of the disease evolution, although more common indications are in Kellgren-Lawrence grade III or IV, in post-total knee arthroplasty residual pain without an identified cause, in patients with comorbidities and high surgical risk, and those who do not want to undergo surgery. The aim of this study is to describe the step-by-step rhizotomy technique with pulsed radiofrequency of the 3 genicular nerves, guided by radioscopy and ultrasonography.
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29
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Villa JM, Pannu TS, Higuera-Rueda CA. What's New in Adult Reconstructive Knee Surgery. J Bone Joint Surg Am 2022; 104:97-106. [PMID: 34780387 DOI: 10.2106/jbjs.21.01080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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30
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Liu J, Wang T, Zhu ZH. Efficacy and safety of radiofrequency treatment for improving knee pain and function in knee osteoarthritis: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17:21. [PMID: 35033150 PMCID: PMC8760716 DOI: 10.1186/s13018-021-02906-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/30/2021] [Indexed: 12/29/2022] Open
Abstract
Background The clinical utility of radiofrequency (RF) in patients with knee osteoarthritis (OA) remains unclear. We conducted a meta-analysis to systematically evaluate the efficacy and safety of RF treatment in patients with knee OA. Methods Searches of the PubMed, Web of Science, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data databases were performed through August 30, 2021. The major outcomes from published randomized controlled trials (RCTs) involving patients with knee OA were compared between RF and control groups, including Visual Analogue Scale (VAS) or Numerical Rating Scale (NRS) scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Global Perceived Effect (GPE) scale, and adverse effects at available follow-up times. Results Fifteen RCTs involving 1009 patients were included in this meta-analysis, and the results demonstrated that RF treatment correlated with improvements in pain relief (VAS/NRS score, all P < 0.001) and knee function (WOMAC, all P < 0.001) at 1–2, 4, 12, and 24 weeks after treatment as well as patients’ degree of satisfaction with treatment effectiveness (GPE scale, 12 weeks, P < 0.001). OKSs did not differ significantly between the two groups. Moreover, treatment with RF did not significantly increase adverse effects. Subgroup analysis of knee pain indicated that the efficacy of RF treatment targeting the genicular nerve was significantly better than intra-articular RF at 12 weeks after treatment (P = 0.03). Conclusions This meta-analysis showed that RF is an efficacious and safe treatment for relieving knee pain and improving knee function in patients with knee OA. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02906-4.
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Affiliation(s)
- Jian Liu
- Department of Emergency, The First Hospital of Hunan University of Chinese Medicine, No. 95 Shaoshan Middle Road, Changsha, 410007, Hunan Province, China
| | - Ting Wang
- Department of Emergency, The First Hospital of Hunan University of Chinese Medicine, No. 95 Shaoshan Middle Road, Changsha, 410007, Hunan Province, China
| | - Zhen-Hua Zhu
- Department of Emergency, The First Hospital of Hunan University of Chinese Medicine, No. 95 Shaoshan Middle Road, Changsha, 410007, Hunan Province, China.
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Dey S, Das G, Surange P, Agarwal A, Kothari K, Natarajan K, Mehta P, Sharma G, Siddhaye U, Jain N, Mohan VK. Radiofrequency ablation in chronic pain syndromes: An evidence- and consensus-based indian society for the study of pain guidelines, 2022. INDIAN JOURNAL OF PAIN 2022. [DOI: 10.4103/ijpn.ijpn_123_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Cleland TL, Gharib M, Williams R, Jain NB. What's New in Orthopaedic Rehabilitation. J Bone Joint Surg Am 2021; 103:2063-2069. [PMID: 34546999 DOI: 10.2106/jbjs.21.00868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Travis L Cleland
- Department of Physical Medicine and Rehabilitation, Crystal Clinic Orthopaedic Center, Akron, Ohio
| | - Mahmood Gharib
- Department of Physical Medicine and Rehabilitation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Reed Williams
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nitin B Jain
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
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Conger A, Gililland J, Anderson L, Pelt CE, Peters C, McCormick ZL. Genicular Nerve Radiofrequency Ablation for the Treatment of Painful Knee Osteoarthritis: Current Evidence and Future Directions. PAIN MEDICINE 2021; 22:S20-S23. [PMID: 34308957 DOI: 10.1093/pm/pnab129] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Genicular nerve radiofrequency ablation (RFA) is increasingly being performed to treat chronic pain due to knee osteoarthritis (KOA). This narrative review provides a concise summary of the relevant neuroanatomy, randomized controlled trials, appropriate patient selection, and safety relating to genicular RFA. Cadaveric studies demonstrate significant variability in the location of the genicular nerves, which has stimulated debate about the ideal target locations for genicular RFA. Despite this, favorable outcomes have been observed in studies targeting only the superior medial genicular nerve, inferior medial genicular nerve, and superior lateral genicular nerve. Several randomized controlled trials demonstrate superiority of genicular RFA compared with intra-articular steroid, viscosupplementation, and oral analgesics. Genicular RFA of the superior medial genicular nerve, inferior medial genicular nerve, and superior lateral genicular nerve appears to be an effective treatment for painful KOA, but targeting additional sensory nerves may further improve treatment success. Although genicular RFA appears relatively safe on the basis of the available data, additional large-scale studies are needed to provide greater confidence.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, Salt Lake City, Utah, USA
| | - Jeremy Gililland
- Department of Orthopedics, University of Utah, Salt Lake City, Utah, USA
| | - Lucas Anderson
- Department of Orthopedics, University of Utah, Salt Lake City, Utah, USA
| | - Christopher E Pelt
- Department of Orthopedics, University of Utah, Salt Lake City, Utah, USA
| | - Christopher Peters
- Department of Orthopedics, University of Utah, Salt Lake City, Utah, USA
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Mishra P, Edwards D, Huntoon M, Sobey C, Polkowski G, Corey J, Mishra KL, Shinar A, Engstrom S, Palmer C, Bruehl S. Is preoperative genicular radiofrequency ablation effective for reducing pain following total knee arthroplasty? A pilot randomized clinical trial. Reg Anesth Pain Med 2021; 46:752-756. [PMID: 34215667 DOI: 10.1136/rapm-2021-102501] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/02/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVE Although total knee arthroplasty (TKA) is an effective treatment for severe knee osteoarthritis (OA), a subset of patients experience significant postoperative pain and dissatisfaction. Several clinical trials support the analgesic benefits of genicular nerve radiofrequency ablation (GN-RFA) for non-operative knee OA, but only one prior trial has examined the effects of this intervention given preoperatively on postoperative outcomes following TKA, showing no analgesic benefit of cooled GN-RFA. The current study evaluated whether conventional thermal GN-RFA performed preoperatively resulted in significant improvements in pain and function following TKA. METHODS This was a single-center, prospective, randomized, sham-controlled, double-blinded pilot trial in which patients received either conventional GN-RFA (n=30) or sham (n=30) between 2 and 4 weeks prior to their TKA. Baseline measures were obtained preprocedurally on the day of intervention, with follow-up outcomes obtained preoperatively on the day of surgery, and at 2 and 6 weeks postoperatively. RESULTS Patients receiving GN-RFA showed no significant improvements relative to sham controls in the primary outcome, pain intensity at rest at 6-week follow-up. Secondary outcomes, including pain with ambulation and physical function, also showed no significant differences between groups at any follow-up assessment. CONCLUSIONS Conventional GN-RFA of the superior lateral, superior medial, and inferior medial genicular nerves when performed prior to TKA did not provide clinically significant pain relief or improvement in functional status at 2 or 6 weeks postoperatively. TRIAL REGISTRATION NUMBER NCT02947321.
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Affiliation(s)
- Puneet Mishra
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Edwards
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc Huntoon
- Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Christopher Sobey
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gregory Polkowski
- Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Corey
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly Louise Mishra
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew Shinar
- Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Engstrom
- Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cassandra Palmer
- University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Stephen Bruehl
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Burgos LA, Greenwood AJ, Tarima SS, Baynes KE, Durand MJ, Yopp CA, Donohue NK. Pain relief following genicular nerve radiofrequency ablation: does knee compartment matter? Pain Manag 2021; 11:705-714. [PMID: 34102867 DOI: 10.2217/pmt-2021-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To investigate the effect of knee osteoarthritis (OA) compartment location on pain relief following genicular radiofrequency ablation. Materials & methods: A retrospective chart review was performed on 62 patients. Visual analog scale scores at 3 and 6 months post procedure were compared with baseline and between compartment groups. Results: Pain significantly improved for all patients at 3 and 6 months (p < 0.001 and p = 0.005, respectively). Medial compartment OA was a significant predictor of improvement at 3 months (p = 0.042). Patellofemoral compartment OA was a significant predictor for a higher visual analog scale at 3 months (p = 0.018). Conclusion: Compartmental location of knee OA impacts pain relief following genicular radiofrequency ablation. Future protocols could target nerves based on which compartments are more affected on imaging.
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Affiliation(s)
- Luisa A Burgos
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Austin J Greenwood
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Sergey S Tarima
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Keith E Baynes
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Matthew J Durand
- Department of Physical Medicine & Rehabilitation, Cardiovascular, Center, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Christopher A Yopp
- Department of Anesthesiology, Division of Pain Management, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Nicholas K Donohue
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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A commentary on "Radiofrequency ablation reduces pain for knee osteoarthritis: A meta-analysis of randomized controlled trials" (Int J Surg. 2021 Epub ahead of Print). Int J Surg 2021; 91:105985. [PMID: 34098077 DOI: 10.1016/j.ijsu.2021.105985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 02/05/2023]
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Zhang H, Wang B, He J, Du Z. Efficacy and safety of radiofrequency ablation for treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials. J Int Med Res 2021; 49:3000605211006647. [PMID: 33887985 PMCID: PMC8072859 DOI: 10.1177/03000605211006647] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To evaluate the efficacy and safety of radiofrequency ablation for the treatment of knee osteoarthritis. Methods A literature review was conducted using the PubMed, Cochrane Review, Embase, and Google Scholar databases. Two reviewers independently assessed the eligibility of all retrieved studies. The research was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure the reliability and verity of the results. The statistical analysis was performed using STATA version 13.0. Results Nine randomized controlled trials were collected for the data extraction and meta-analysis. Significant differences in the pain score at 4, 12, and 24 weeks were found between patients treated with radiofrequency ablation and those treated with placebo. Furthermore, the use of radiofrequency ablation was associated with an improved outcome of the Western Ontario and McMaster Universities Arthritis Index at 4, 12, and 24 weeks. No serious adverse events were observed in any patients who underwent radiofrequency ablation. Conclusion Radiofrequency ablation is efficacious and safe for reducing pain and improving knee function in patients with knee osteoarthritis, without increasing the risk of adverse effects.
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Affiliation(s)
- Hua Zhang
- Department of Anesthesiology and Pain Management, The Third People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Bo Wang
- Department of Anesthesiology and Pain Management, The Third People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Jie He
- Department of Anesthesiology and Pain Management, The Third People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Zhongju Du
- Department of Anesthesiology and Pain Management, The Third People's Hospital of Hangzhou, Hangzhou, Zhejiang, China
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Potter BK. From Bench to Bedside: Pain Relief is Cool. Clin Orthop Relat Res 2021; 479:239-241. [PMID: 33428346 PMCID: PMC7899589 DOI: 10.1097/corr.0000000000001614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/25/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin K Potter
- B. K. Potter, Directorate for Surgical Services, Walter Reed National Military Medical Center & the Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD, USA
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Chen AF, Khalouf F, Zora K, DePalma M, Kohan L, Guirguis M, Beall D, Loudermilk E, Pingree MJ, Badiola I, Lyman J. Cooled radiofrequency ablation provides extended clinical utility in the management of knee osteoarthritis: 12-month results from a prospective, multi-center, randomized, cross-over trial comparing cooled radiofrequency ablation to a single hyaluronic acid injection. BMC Musculoskelet Disord 2020; 21:363. [PMID: 32517739 PMCID: PMC7285532 DOI: 10.1186/s12891-020-03380-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/29/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Safe and effective non-surgical treatments are an important part of the knee osteoarthritis (OA) treatment algorithm. Cooled radiofrequency ablation (CRFA) and hyaluronic acid (HA) injections are two commonly used modalities to manage symptoms associated with knee OA. METHODS A prospective 1:1 randomized study was conducted in 177 patients comparing CRFA to HA injection with follow-ups at 1, 3, 6 and 12 months. HA subjects with unsatisfactory outcomes at 6-months were allowed to crossover and receive CRFA. Knee pain (numeric rating scale = NRS), WOMAC Index (pain, stiffness and physical function), overall quality of life (global perceived effect = GPE, EQ-5D-5 L), and adverse events were measured. RESULTS At 12-months, 65.2% of subjects in the CRFA cohort reported ≥50% pain relief from baseline. Mean NRS pain score was 2.8 ± 2.4 at 12 months (baseline 6.9 ± 0.8). Subjects in the CRFA cohort saw a 46.2% improvement in total WOMAC score at the 12-month timepoint. 64.5% of subjects in the crossover cohort reported ≥50% pain relief from baseline, with a mean NRS pain score of 3.0 ± 2.4 at 12 months (baseline 7.0 ± 1.0). After receiving CRFA, subjects in the crossover cohort had a 27.5% improvement in total WOMAC score. All subjects receiving CRFA reported significant improvement in quality of life. There were no serious adverse events related to either procedure and overall adverse event profiles were similar. CONCLUSION A majority of subjects treated with CRFA demonstrated sustained knee pain relief for at least 12-months. Additionally, CRFA provided significant pain relief for HA subjects who crossed over 6 months after treatment. TRIAL REGISTRATION This trial was registered on ClinicalTrials.gov, NCT03381248. Registered 27 December 2017.
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Affiliation(s)
- Antonia F. Chen
- Department of Orthopaedics, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 USA
| | - Fred Khalouf
- University Orthopedics Center, 3000 Fairway Dr, Altoona, PA 16602 USA
| | - Keith Zora
- University Orthopedics Center, 476 Rolling Ridge Drive, State College, PA 16801 USA
| | - Michael DePalma
- Virginia iSpine Physicians, 9020 Stony Point Pkwy #140, Richmond, VA 23235 USA
| | - Lynn Kohan
- University of Virginia School of Medicine, 545 Ray C Hunt Drive, Charlottesville, VA 22903 USA
| | - Maged Guirguis
- Ochsner Clinic Foundation, 2820 Napoleon Ave, Ste 210A, New Orleans, LA 70115 USA
| | - Douglas Beall
- Clinical Investigations, 1800 Renaissance Blvd Suite 110, Edmond, OK 73013 USA
| | - Eric Loudermilk
- PCPMG Clinical Research Unit LLC, 100 Healthy Way #1260, Anderson, SC 29621 USA
| | | | - Ignacio Badiola
- University of Pennsylvania, 3737 Market Street Room 6113, Philadelphia, PA 19104 USA
| | - Jeffrey Lyman
- Institute for Orthopedic Research and Innovation, 1110 W Park Place, Suite 212, Coeur d’Alene, ID 83814 USA
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