Knee OA: Percutaneous Treatments · USG guided PRF of the femoral nerve was also done to address the innervationof the quadriceps muscle. Vas L, et al (2014) Pain Physician. 17(6):493

KneeOA:PercutaneousTreatments

A.D.Kelekis,MD,PhD,EBIR,FSIRAss.ProfessorofInterventionalMusculoskeletalRadiology

UniversityofAthens,2ndRadiologyDepartment,Attikon Hospital

akelekis@med.uoa.gr

OSTEOARTHRITISOFTHEKNEEJOINT

• Knee osteoarthritis is a degenerative type of arthritis• Prevalence increases with age• Ranks as the 11th leading cause of years lived with

disability - 3rd greatest contributor to loss of health-related quality of life • Risk factors: aging, obesity and mechanical stress

•Kiadaliri et al (2016) Association of knee pain and different definitions of knee osteoarthritis with health-related quality of life: a population-based cohortstudy in southern Sweden. Health Qual Life Outcomes 14(1):121•Cross M et al (2014) The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis 73:1323–30•Wu M, et al (2014) Examining the impact of 11 long-standing health conditions on health-related quality of life using the EQ-5D in a general populationsample. Eur J Health Econ 16(2):141–51•HunterDJ et al(2012) Imaging techniques in osteoarthritis. PMR4(Suppl 5):S68–S74

• Kellgrene-Lawrencescale:onthebasisofradiographicfindings

• AmericanCollegeofRheumatology(ACR)proposal:clinicaldefinition

OSTEOARTHRITISOFTHEKNEEJOINT

ArticularCartilagedisease● Lossofcartilage

– Heterogeneous– Progressive

Bone tissue productionSubcortical sclerosis

Osteophytes

PropertyofKenLSchreibmanPhD/MDUniversityofWisconsin,Madison

OSTEOARTHRITISOFTHEKNEEJOINT

• Pain• Stiffness• Swelling• Jointinstability• Reducedmobility• Muscleweakness

Bijlsma JW,Berenbaum F,Lafeber FP(2011)Osteoarthritis:Anupdatewithrelevanceforclinicalpractice.Lancet377(9783):2115–2126

OSTEOARTHRITISOFTHEKNEEJOINT

• Conservativetherapies• physicalandoccupationaltherapy,weightloss,stretchingexercises,acetaminophen,analgesics,oralandtopicNSAIDs,tramadol

• SurgicalOptions• TotalKneeReplacementSurgery(TotalKneeArthroplasty)

• PartialKneeReplacementSurgery(Unicompartmental KneeArthroplasty)

• Localtherapies• Intra-articular injections• Neurolysis – neuromodulation• Trans-arterialtherapies

OSTEOARTHRITISOFTHEKNEEJOINT

INTRA-ARTICULARINJECTIONS

• Corticosteroids

• Hyaluronicsolution

• Concentratedplateletinjections

• Stemcells

• Ozone

CORTICOSTEROIDSANDKNEEOA

daCostaBR, HariR,JüniP.Intra-articular Corticosteroids for Osteoarthritis ofthe KneeJAMA.2016Dec27;316(24):2671-2672.

CORTICOSTEROIDSANDKNEEOA

McAlindonTE etalEffectofIntra-articular Triamcinolone vs Salineon Knee CartilageVolumeandPaininPatientsWithKnee Osteoarthritis: ARandomizedClinical Trial.JAMA.2017May16;317(19):1967-1975.

HYALURONICANDKNEEOA

• Secondlinetreatment• Superiorovertheplacebo(intraarticular injectionofsalineororalplacebo)• VsNSAID:Symptomreliefwasnotsignificantlydifferentbetweenthetwogroupsafter4or12weeks• delaytheneedforkneereplacementsurgery

Richette P.Hyaluronic Acid:StillUsefulin KneeOsteoarthritis? Joint BoneSpine.2017May8.pii:S1297-319X(17)30087-8.

HYALURONICANDKNEEOA

PRPANDKNEEOAIntra-articular PRP injections probably are more efficacious in the treatment of kneeOA in terms of pain relief and self-reported function improvement at 3, 6, and12 months follow-up, compared with other injections, including saline placebo, HA,ozone, and corticosteroids.

ShenLetalThetemporal effectofplatelet-rich plasmaonpainandphysicalfunction inthetreatment of kneeosteoarthritis: systematicreviewandmeta-analysisofrandomized controlled trials.JOrthop Surg Res.2017Jan23;12(1):16.

PRPANDKNEEOA

STEMCELLSANDKNEEOA

PropertyofDimitrios Tsoukas MDwww.miosmedcenter.gr

STEMCELLSANDKNEEOA

NEUROLYSIS-NEUROMODULATION

NEUROLYSISTheabilitytocreateagreaterlocalneuronallesiontoincreasethechangesofeffectivedenervation

• Time:60-90sec.

• Θ:70-90°C

• ContinuousRF

NEUROMODULATIONSimilareffectsonneuronalconduction,thedisruptionof

whichisoftenreversible

• Time:10-12min.

• Θ: <42 °C

• PulsedRF

NEUROLYSIS-NEUROMODULATION

• Genicular nerves(RFA,CWA)

• Intra-articular application(pulsedRF)

• Compositenervesupply(pulsedRF)

PATIENTSELECTION–idealpatient

• adultpatientscapableofprovidingconsent

• symptomatic,advancedkneeosteoarthritis

• X-rays- gradeIItoIVKellgren–Lawrenceclassification

• painscore≥4NVS- locatedatthekneejoint

• withoutneurologicimpairment

PATIENTSELECTION–contraindications

• untreatablecoagulopathy

• active,systemicorlocalinfection

• neurologicsigns

• patientunwillingtoconsenttotheprocedure

GENICULARNERVES

Choi WJ,etal(2011)Radiofrequency treatment relieveschronic knee osteoarthritis pain:adouble-blind randomized controlled trial.Pain152(3):481-7

MaininnervatingarticularbranchesforthekneejointAdjacenttoperiosteumCanbetargetedusingbony landmarksunder fluoroscopy

GENICULARN.cRF technique

GENICULARN.cRF technique

Sensorystimulus:highfrequencyrepetitionrate(50Hzcycles/sec)ina

durationof1millisecondwithathresholdvoltageof0.2to0.5volt

Motorstimulus:lowfrequencyrepetitionrate(2Hzcycles/sec)inadurationof1millisecondwitha

thresholdmyotomal voltageofatleast2volts

GENICULARNERVES

Choi WJ,etal(2011)Radiofrequency treatment relieveschronic knee osteoarthritis pain:adouble-blind randomized controlled trial.Pain152(3):481-7

GENICULARNERVES

Yasar E,etal(2015)AccuracyofUltrasound-Guided Genicular NerveBlock:ACadavericStudy.PainPhysician 18(5):E899-904

GENICULARNERVES

Kesikburun S,etal(2016)Ultrasound-Guided Genicular NervePulsedRadiofrequency Treatment ForPainfulKneeOsteoarthritis: APreliminary

Report. PainPhysician 19(5):E751-9

GENICULARNERVES

Iannaccone F,etal(2017)AReviewofLong-TermPainReliefafterGenicularNerve Radiofrequency AblationinChronic Knee Osteoarthritis.

.PainPhysician 20(3):E437-E444

GENICULARNERVES

KimSY,etal(2016)Isgenicular nerveradiofrequency ablationsafe?Aliterature reviewandanatomicalstudy.PainPhysician 19:E697-705

PULSEDRADIOFREQUENCY• Whencomparedtocontinuousradiofrequency,pulsedmodehasmuchless(ifany)neurodestructive characteristics• Thelongsilentphases(480milliseconds)betweentheshortburstsofenergyapplication(10-20milliseconds)maintaintissuetemperatureunder42°Cwhichisbelowthenervetissuedamagethreshold

INTRA-ARTICULARpRF technique

PULSEDRADIOFREQUENCY

• Karaman etalappliedwithablindtechniquepulsedRFintra-articularly reportingsignificantpaindecrease(>50%)overa6monthsfollow-up• Masala etalreportsignificantpaindecreaseandimprovedautonomyindailylifepostintra-articular applicationofpulsedRFover12monthsfollow-upperiod

Karaman Hetal(2011)Intra-articularly appliedpulsedradiofrequency canreduce chronic knee paininpatients withosteoarthritis. JChinMedAssoc 74(8):336-40Masala S,Fiori R,RagusoM,Morini M,CalabriaE,Simonetti G(2014)Pulse-doseradiofrequency for knee osteoartrithis. Cardiovasc Intervent Radiol 37(2):482-7.

PULSEDRADIOFREQUENCY

• NO reportedevidenceoflong-lastingstructuraleffectsbypulsedRFapplication• NO architecturalimpairmentoftheaxonalmyelinsheathbundles• interstitialedema (whichistemporary andpersistsforafewweekspostthesession)• ultra-structuralchangesoftheCandAdeltanociceptivefibers √

Tun Ket al(2009)Ultrastructural evaluationofpulsedradiofrequency andconventional radiofrequency lesionsinratsciatic nerve.Surg Neurol 72(5):496–500Protasoni Metal(2009)Pulsedradiofrequency effectsonthelumbarganglionoftheratdorsalroot: amorphological lightandtransmission electron microscopystudyatacutestage.Eur SpineJ18(4):473–478

PULSEDRADIOFREQUENCY

Intra-articular applicationofpulsedRF:• suppressestheexcitatoryCfiber responseandthesynaptictransmissionresultinginimmediatepainrelief• causesanimmuneresponseinterruptingproductionofpro-inflammatorycytokines(interleukin-1bandinterleukin-6)

Masala S,Fiori R,RagusoM,Morini M,CalabriaE,Simonetti G(2014)Pulse-doseradiofrequency for knee osteoartrithis. Cardiovasc Intervent Radiol 37(2):482-7.

PULSEDRADIOFREQUENCY

PULSEDRADIOFREQUENCY

bothsensoryandmotornervessupplyingallthestructuresaroundtheknee:joint,muscles,andskinultrasonography(USG)guidedPRFofsaphenous,tibial,andcommonperoneal nerves alongwithsubsartorial,peripatellar,andpopliteal plexusesUSGguidedPRFofthefemoralnervewasalsodonetoaddresstheinnervationofthequadricepsmuscle.

VasL,etal(2014)PainPhysician.17(6):493-506.Pulsedradiofrequency ofthe composite nervesupplytothe kneejoint asanewtechnique forrelievingosteoarthritic pain:apreliminary report.

CONTROVERSIES–continuousorpulsedRF?

CONTROVERSIES–continuousorpulsedRF?

CONTROVERSIES–RFandviscosupplementation?• protectiveeffectonthesuperficiallayerofcartilage(mechanicaleffect)

• reaggregation ofproteglycanmolecules

• inhibitionofarticular nociceptive receptors(analgesiceffect)

• prostaglandin-E2synthesisblockadeandinhibitionofarachidonic acidrelease(anti-inflammatoryaction)

OUROWNEXPERIENCEN

M i n i m um

M a x i m um M e a n

S t d . D e v i a t i o n

h e i g h t 4 5 1 5 4 1 8 5 1 6 8 . 6 4 7 . 4 7 8w e i g h t 4 5 4 9 1 0 3 7 3 . 0 0 1 2 . 8 6 1

b m i 4 5 2 0 . 2 8 3 6 . 0 0 2 5 . 5 5 17 3 . 4 8 5 5 2a g e 4 5 5 8 8 1 6 9 . 4 9 6 . 7 4 1

Va l i d N ( l i s t w i se )

4 5

C H A R AC TE RISTI C M A L E F E M A L EA g e ( y r ) : 7 1 . 3 2 ± 5 .6 97 6 8 . 1 5 ± 7 .2 26

H e i g h t ( c m ) : 1 7 4 . 5 8 ± 5. 74 8 1 6 4 . 3 1 ± 5. 32 0We i g h t ( k g ) : 8 1 . 6 3 ± 11 .4 80 6 6 . 6 9 ± 9 .9 11

B M I : 2 6 . 7 4 8 5 ±3 .3 26 83 2 4 . 6 7 7 0 ±3 .3 95 43

WHYEMBOLIZATIONOFABNORMALVESSELSRELIEVE

PAIN?• Improvementofinflammatoryconditions(abnormalvesselsmaintaininflammation)

• Reductionofstimulationfromaccompanyingnervefiber closetosmallvessels(nervefibers growaroundneovessels)

Mapp etalNatRevRheumatol 2012

Midterm Clinical Outcomes and MR ImagingChanges after Transcatheter Arterial Embolization asa Treatment for Mild to Moderate RadiographicKnee Osteoarthritis Resistant to ConservativeTreatmentOkuno, Yuji et al JVIR, Volume 28 ,Issue 7 , 995 - 1002

EVIDENCE-BASEDMEDICINE

• Exponentialincreaseinthenumberofpublishedmeta-analyses,includingmanythataddressthesamequestionyetyielddifferentconclusions• Marginallydifferentstudydesigns,thecaptureandinclusionofdifferentstudiesanddifferentanalyticapproaches• Whichmeta-analysisbestapproximatesatruesummaryofrelevantliterature• Thenumberofpublishedtrials,whichprovidethebasisforthegrowingnumberofmeta-analyses,hasnotincreased

FelsonDT. Intra-articular Corticosteroids and Knee Osteoarthritis:Interpreting DifferentMeta-analyses.JAMA.2016Dec7;316(24):2607-2608.

• Intra-articularinjections:fromcorticosteroidsandhyaluronictoPRPandStemcells• Neurotomy – neuromodulation:longerlastingeffectwhencomparedtocorticosteroidandhyaluronic(anecdotalexperience– randomizedcomparativetrialongoing)• Intra-arterialtherapies:Treatmentgoalisnottotalvesselocclusionbuttodecreaseabnormalbloodflowandreturnofphysiologicbloodflow

• Advantages:lowcost,shorthospitalstay,safetyandefficaciousprofile

TAKEHOMEMESSAGES

TAKEHOMEMESSAGES• NEUROLYSIS: continuousRFtocreatelocalneuronallesionNEUROMODULATION:createsatheoreticnetwhichstopssignalsover/belowaspecificthresholdwithNO nervedamage

• Lackofevidencesupportingsuperiorityofonetechniqueovertheother

• Longerlastingeffectthancorticosteroidorviscosupplementation?

• Advantages:• lowcost,shorthospitalstay,safetyandefficaciousprofile

Thank you

akelekis@med.uoa.gr

CORTICOSTEROIDSANDKNEEOA

McAlindonTE etalEffectofIntra-articular Triamcinolone vs Salineon Knee CartilageVolumeandPaininPatientsWithKnee Osteoarthritis: ARandomizedClinical Trial.JAMA.2017May16;317(19):1967-1975.