Knee OA: Percutaneous Treatments A.D.Kelekis , MD, PhD, EBIR, FSIR Ass. Professor of Interventional Musculoskeletal Radiology University of Athens, 2nd Radiology Department, Attikon Hospital [email protected]
KneeOA:PercutaneousTreatments
A.D.Kelekis,MD,PhD,EBIR,FSIRAss.ProfessorofInterventionalMusculoskeletalRadiology
UniversityofAthens,2ndRadiologyDepartment,Attikon Hospital
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
CORTICOSTEROIDSANDKNEEOA
McAlindonTE etalEffectofIntra-articular Triamcinolone vs Salineon Knee CartilageVolumeandPaininPatientsWithKnee Osteoarthritis: ARandomizedClinical Trial.JAMA.2017May16;317(19):1967-1975.