Indications of the Neurotomy of Genicular Nerves by Radiofrequency for the Treatment of Knee Osteoarthritis: A Literature Review

Lima, Diego Ariel de; Gonçalves, Marcelo Carvalho Krause; Grando, Souterland Thiago Correia e Sá; Cintra, Thiago Luiz de Lima; Pinto, Dilamar Moreira; Gonçalves, Romeu Krause

doi:10.1055/s-0039-1692121

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Review Article • Rev. bras. ortop. 54 (03) • May-Jun 2019 • https://doi.org/10.1055/s-0039-1692121 copy

Indications of the Neurotomy of Genicular Nerves by Radiofrequency for the Treatment of Knee Osteoarthritis: A Literature Review^* * The present work was performed at the Instituto de Traumatologia e Ortopedia Romeu Krause, Recife, PE, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Osteoarthritis (OA) is one of the most frequent and incapacitating pathologies today, especially of the knee. Among the possible approaches for knee OA, the neurotomy of the genicular nerves by radiofrequency (RF) has been gaining prominence. However, as this is a relatively new procedure, indications for its implementation are still unclear. The objective of the present reviewis to identify the main indications of the use of RF for the treatment of knee OA in themedical literature. A review of the literature was performed in January 2018 through a search in the PubMed, ClinicalKey and Google Scholar databases. After reviewing themain articles on the subject, it was concluded that the main indications of the use of RF for the treatment of kneeOAwere:OA Kellgren-Lawrence grades 3 and 4, withmoderate to severe pain and failure of conservative treatment, mainly in elderly people; persistence of pain even after total knee arthroplasty (TKA); patients with an indication for TKAwho refuse to undergo surgical treatment.

Keywords:
neurosurgical procedures; radio waves; rhizotomy; osteoarthritis, knee; knee joint

Author and year	Indication	Study Conclusion
Kirdemir et al, 2017²⁵25 Kirdemir P, Çatav S, Alkaya Solmaz F. The genicular nerve: radiofrequency lesion application for chronic knee pain. Turk JMed Sci 2017;47(01):268-272	Patients with grade 2 to 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 6 months.	Genicular neurotomy results in a significant pain reduction and functional improvement in elderly patients with chronic pain due to gonarthrosis and, therefore, it may be an effective treatment in such cases.
Santana Pineda et al, 2017²⁶26 Santana Pineda MM, Vanlinthout LE, Moreno Martín A, van Zundert J, Rodriguez Huertas F, Novalbos Ruiz JP. Analgesic Effect and Functional Improvement Caused by Radiofrequency Treatment of Genicular Nerves in Patients With Advanced Osteoarthritis of the Knee Until 1 Year Following Treatment. Reg Anesth Pain Med 2017;42(01):62-68	Patients with grade 3 and 4 OA at the Kellgren-Lawrence classification and VAS score ≥ 5 for > 6 months under conservative treatment.	Ultrasound-guided RF genicular neurotomy relieves intractable pain and disability in most patients with advanced knee OA. This treatment is safe and minimally invasive, and it can be performed in an outpatient setting.
Sarı et al, 2018²⁷27 Sari S, Aydin ON, Turan Y, Özlülerden P, Efe U, Kurt Ömürlü I. Which one is more effective for the clinical treatment of chronic pain in knee osteoarthritis: radiofrequency neurotomy of the genicular nerves or intra-articular injection? Int J Rheum Dis 2018;21(10):1772-1778. Doi: 10.1111/1756- 185X.12925 https://doi.org/10.1111/1756-...	Patients with grade 2 to 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 3 months, moderate to severe pain, and not eligible for TKA.	RF genicular neurotomy is a safe and efficient treatment, providing functional improvements and analgesia in patients with chronic knee OA.
Kesikburun et al, 2016²⁸28 Kesikburun S, Yasar E, Uran A, Adigüzel E, Yilmaz B. Ultrasound- Guided Genicular Nerve Pulsed Radiofrequency Treatment For Painful Knee Osteoarthritis: A Preliminary Report. Pain Physician 2016;19(05):E751-E759	Patients with grade 3 and 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 6 months and who had at least a 50% reduction on the VAS scale after genicular nerves blocking with an anesthetic solution.	Pulsed RF genicular neurotomy was considered safe and beneficial in OA-associated knee pain.
Bellini et al, 2015²⁹29 Bellini M, Barbieri M. Cooled radiofrequency system relieves chronic knee osteoarthritis pain: the first case-series. Anaesthesiol Intensive Ther 2015;47(01):30-33	Patients with OA that was refractory to conservative treatment for 3 months and with moderate and severe pain.	Most patients with chronic knee pain experienced clinically relevant pain relief and functional improvement after refrigerated RF genicular neurotomy at 1-, 3-, 6- and 12-month follow-up.
Davis et al, 2018³⁰30 Davis T, Loudermilk E, DePalma M, Hunter C, Lindley D, Patel N, et al. Prospective, Multicenter, Randomized, Crossover Clinical Trial Comparing the Safety and Effectiveness of Cooled Radiofrequency Ablation with Corticosteroid Injection in the Management of Knee Pain From Osteoarthritis. Reg Anesth Pain Med 2018;43(01):84-91	Patients with grade 2 to 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 6 months with NRS ≥6, OKS ≥35, use of opioids or equivalents and who had at least a 50% reduction on the NRS scale after genicular nerves blocking with an anesthetic and corticoid solution.	Refrigerated RF genicular neurotomy is a long-term therapeutic option to manage pain and improve function and quality of life in patients with gonarthrosis when compared to corticosteroid injections.
McCormick et al, 2017³¹31 McCormick ZL, Korn M, Reddy R, Marcolina A, Dayanim D, Mattie R, et al. Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Knee Osteoarthritis: Six-Month Outcomes. Pain Med 2017;18(09):1631-1641	Patients with OA that was refractory to the conservative treatment and who had an improvement after genicular nerves blocking with an anesthetic solution.	Refrigerated RF genicular neurotomy demonstrated a success rate of 35%, and 19% of the procedures resulted in complete pain relief after 6 months of follow-up.
Iannaccone et al, 2017³²32 Iannaccone F, Dixon S, Kaufman A. A Review of Long-Term Pain Relief after Genicular Nerve Radiofrequency Ablation in Chronic Knee Osteoarthritis. Pain Physician 2017;20(03): E437-E444	Patients with OA that was refractory to the conservative treatment and who had an improvement of at least 80% after genicular nerves blocking with an anesthetic solution.	Refrigerated RF genicular neurotomy can provide an average of > 60% pain relief at a 6-month follow-up.
Qudsi-Sinclair et al, 2017³³33 Qudsi-Sinclair S, Borrás-Rubio E, Abellan-Guillén JF, Padilla Del Rey ML, Ruiz-Merino G. A Comparison of Genicular Nerve Treatment Using Either Radiofrequency or Analgesic Block with Corticosteroid for Pain after a Total Knee Arthroplasty: A Double-Blind, Randomized Clinical Study. Pain Pract 2017;17 (05):578-588	Patients with persistent pain for at least 6 months after TKA and refractory to conservative treatment.	More studies are required to further evaluate the long-term response.
Sarı et al, 2017³⁴34 Sari S, Aydin ON, Turan Y, Sen S, Özlülerden P, Ömürlü IK, et al. Which imaging method should be used for genicular nerve radio frequency thermocoagulation in chronic knee osteoarthritis? J Clin Monit Comput 2017;31(04):797-803	Patients with grade 2 to 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 3 months.	The results of RF neurotomy aided with ultrasound or fluoroscopy are similar.
Shen et al, 2017³⁵35 Shen WS, Xu XQ, Zhai NN, Zhou ZS, Shao J, Yu YH. Radiofrequency Thermocoagulation in Relieving Refractory Pain of Knee Osteoarthritis. Am J Ther 2017;24(06):e693-e700	Patients with persistent pain due to OA for at least 3 months and VAS ≥6.	RF genicular neurotomy is more effective than regular treatment to relieve refractory pain and promote functional recovery in patients with knee OA.
Mogahed et al, 2017³⁶36 Mogahed M, Mohamed R, Mohamed Refaat H. Intraarticular Pulsed Radiofrequency vs. Radiofrequency Neurotomy in Patients with Chronic Knee Pain due to Osteoarthritis (OA). J Anesth Clin Res 2017;8(10):2-6	Patients with OA that was refractory to conservative treatment for 3 months and VAS > 5, and not eligible for TKA.	Both conventional and pulsed RF neurotomy control pain in patients with knee OA, decreasing the amount of analgesic medication required.
Mata et al, 2017³⁷37 Mata J, Valentí P, Hernández B,Mir B, Aguilar JL. Study protocol for a randomised controlled trial of ultrasound-guided pulsed radiofrequency of the genicular nerves in the treatment of patients with osteoarthritis knee pain. BMJ Open 2017;7(11):e016377	Patients with grade 2 to 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 6 months and had VAS ≥4 for more than 3 months.	The study is not yet concluded, but it recommends that further researches are required to assess long-term responses.
Gulec et al, 2017³⁸38 Gulec E, Ozbek H, Pektas S, Isik G. Bipolar Versus Unipolar Intraarticular Pulsed Radiofrequency Thermocoagulation in Chronic Knee Pain Treatment: A Prospective Randomized Trial. Pain Physician 2017;20(03):197-206	Patients with grade 2 and 3 OA at the Kellgren-Lawrence classification with pain for at least 3 months.	Bipolar RF is more advantageous in reducing chronic knee pain and improving functional recovery compared to unipolar RF. Further studies are required.
Masala et al, 2014³⁹39 Masala S, Fiori R, Raguso M, Morini M, Calabria E, Simonetti G. Pulse-dose radiofrequency for knee osteoartrithis. Cardiovasc Intervent Radiol 2014;37(02):482-487	Patients with grade 3 and 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 6 months.	Pulsed RF genicular neurotomy appears to be an effective and reliable technique for palliative management of chronic pain in patients with knee OA.
Hashemi et al, 2016⁴⁰40 Hashemi M, Nabi BN, Saberi A, Sedighinejad A, Haghighi M, Farzi F, et al. The Comparison between twomethods for the relief of knee osteoarthritis pain: radiofrequency and intra-periarticular ozone injection: a clinical trial study. Int J Med Res Health Sci. 2016;5 (7S):539-546	Patients with grade 2 and 3 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 3 months.	RF genicular neurotomy and intraperiarticular ozonation are good clinical indications in knee OA, with RF superiority at patients > 65 yearsold.
Ramírez Ogalla et al, 2014⁴¹41 Ramírez Ogalla I, Martín AM, Santana Pineda MM, Rodríguez Huertas F. Eficacia de la radiofrecuencia convencional de geniculados para el tratamiento del dolor en gonartrosis moderadasevera. Rev Soc Esp Dolor. 2014;21(04):212-218	Patients with grade 3 and 4 OA at the Kellgren-Lawrence classification that was refractory to conservative treatment for 3 months and had VAS ≥5.	RF genicular neurotomy has shown significant benefit in terms of pain reduction and functional improvement at a 6-month follow-up in patients with chronic knee OA and, therefore, it can be an effective treatment in such cases. Further trials with larger sample sizes and longer follow-up periods are required.
Eyigor et al, 2015⁴²42 Eyigor C, Eyigor S, Akdeniz S, Uyar M. Effects of intra-articular application of pulsed radiofrequency on pain, functioning and quality of life in patients with advanced knee osteoarthritis. J Back Musculoskeletal Rehabil 2015;28(01):129-134	Patients with grade 3 OA at the Kellgren-Lawrence classification that was refractory to the conservative treatment.	It is possible to affirm that RF genicular neurotomy is effective and safe for pain management in patients with advanced knee OA. Therefore, we believe that this procedure will be included in the guidelines for the treatment of chronic pain in the future, especially with the increase in the number of studies.
Yuan et al, 2016⁴³43 Yuan Y, Shen W, Han Q, Liang D, Chen L, Yin Q, et al. Clinical observation of pulsed radiofrequency in treatment of knee osteoarthritis. Int J Clin Exp Med 2016;9(10):20050-20055	Patients with OA refractory to conservative treatment.	The effect of pulsed RF genicular neurotomy is obviously superior to the use of intra-articular betamethasone injection in the treatment of refractory knee OA, being an effective method in elderly patients.

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[1] Address for correspondence
Diego Ariel de Lima, MD, PhD, Universidade Federal Rural do Semi-Árido (UFERSA), Av João da Escóssia, 1300, casa 124, Mossoró, RN 59607-330, Brazil (e-mail: arieldelima.diego@gmail.com).

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Indications of the Neurotomy of Genicular Nerves by Radiofrequency for the Treatment of Knee Osteoarthritis: A Literature Review* * The present work was performed at the Instituto de Traumatologia e Ortopedia Romeu Krause, Recife, PE, Brazil.

Abstract

Indications of the Neurotomy of Genicular Nerves by Radiofrequency for the Treatment of Knee Osteoarthritis: A Literature Review^* * The present work was performed at the Instituto de Traumatologia e Ortopedia Romeu Krause, Recife, PE, Brazil.