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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

Published:February 11, 2022DOI:https://doi.org/10.1016/j.arthro.2022.01.048

      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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      References

        • Roos E.M.
        • Arden N.K.
        Strategies for the prevention of knee osteoarthritis.
        Nat Rev Rheumatol. 2016; 12: 92-101
        • Antony B.
        • Jones G.
        • Jin X.
        • Ding C.
        Do early life factors affect the development of knee osteoarthritis in later life: A narrative review.
        Arthritis Res Ther. 2016; 18: 202
        • Hunter D.J.
        • Schofield D.
        • Callander E.
        The individual and socioeconomic impact of osteoarthritis.
        Nat Rev Rheumatol. 2014; 10: 437-441
        • Gossec L.
        • Paternotte S.
        • Maillefert J.F.
        • et al.
        The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: An international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement.
        Osteoarthritis Cartilage. 2011; 19: 147-154
        • Deshpande B.R.
        • Katz J.N.
        • Solomon D.H.
        • et al.
        Number of pesons with symptomatic knee osteoarthritis in the US: Impact of race and ethnicity, age, sex, and obesity.
        Arthritis Care Res (Hoboken). 2016; 68: 1743-1750
        • Chen A.F.
        • Khalouf F.
        • Zora K.
        • et al.
        Cooled radiofrequency ablation compared with a single injection of hyaluronic acid for chronic knee pain: A multicenter, randomized clinical trial demonstrating greater efficacy and equivalent safety for cooled radiofrequency ablation.
        J Bone Joint Surg Am. 2020; 102: 1501-1510
        • Fine M.
        Quantifying the impact of NSAID-associated adverse events.
        Am J Manag Care. 2013; 19: s267-s272
        • Pisters M.F.
        • Veenhof C.
        • van Meeteren N.L.
        • et al.
        Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review.
        Arthritis Rheum. 2007; 57: 1245-1253
        • Zeng C.
        • Lane N.E.
        • Hunter D.J.
        • et al.
        Intra-articular corticosteroids and the risk of knee osteoarthritis progression: Results from the osteoarthritis initiative.
        Osteoarthritis Cartilage. 2019; 27: 855-862
        • Jevsevar D.S.
        • Brown G.A.
        • Jones D.L.
        • et al.
        The American Academy of Orthopaedic Surgeons evidence-based guideline on the treatment of osteoarthritis of the knee, 2nd edition.
        J Bone Joint Surg Am. 2013; 95: 1885-1886
        • Chen A.F.
        • Mullen K.
        • Casambre F.
        • Visvabharathy V.
        • Brown G.A.
        Thermal nerve radiofrequency ablation for the nonsurgical treatment of knee osteoarthritis: A systematic literature review..
        J Am Acad Orthop Surg. 2021; 29: 387-396
        • Kapural L.
        • Lee N.
        • Neal K.
        • Burchell M.
        Long-term retrospective assessment of clinical efficacy of radiofrequency ablation of the knee using a cooled radiofrequency system..
        Pain Physician. 2019; 22: 489-494
        • Yuan Y.
        • Shen W.
        • Han Q.
        • et al.
        Clinical observation of pulsed radiofrequency in treatment of knee osteoarthritis.
        Int J Clin Exp Med. 2016; 9: 20050-20055
        • El-Hakeim E.H.
        • Elawamy A.
        • Kamel E.Z.
        • et al.
        Fluoroscopic guided radiofrequency of genicular nerves for pain alleviation in chronic knee osteoarthritis.
        A single-blind randomized controlled trial. Pain Physician. 2018; 21: 169-177
        • McCormick Z.L.
        • Cohen S.P.
        • Walega D.R.
        • Kohan L.
        Technical considerations for genicular nerve radiofrequency ablation: Optimizing outcomes.
        Reg Anesth Pain Med. 2021; 46: 518-523
        • 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: 197-206
        • Sarı S.
        • Aydın O.N.
        • Turan Y.
        • et al.
        Which imaging method should be used for genicular nerve radio frequency thermocoagulation in chronic knee osteoarthritis?.
        J Clin Monit Comput. 2017; 31: 797-803
        • Hong T.
        • Wang H.
        • Li G.
        • Yao P.
        • Ding Y.
        Systematic review and meta-analysis of 12 randomized controlled trials evaluating the efficacy of invasive radiofrequency treatment for knee pain and function.
        Biomed Res Int. 2019; 2019: 9037510
        • Wang R.
        • Ma C.
        • Han Y.
        • Tan M.
        • Lu L.
        Effectiveness of denervation therapy on pain and joint function for patients with refractory knee osteoarthritis: A Systematic Review and Meta-Analysis.
        Pain Physician. 2019; 22: 341-352
        • Gazendam A.
        • Ekhtiari S.
        • Bozzo A.
        • Phillips M.
        • Bhandari M.
        Intra-articular saline injection is as effective as corticosteroids, platelet-rich plasma and hyaluronic acid for hip osteoarthritis pain: A systematic review and network meta-analysis of randomised controlled trials.
        Br J Sports Med. 2021; 55: 256-261
        • Gregori D.
        • Giacovelli G.
        • Minto C.
        • et al.
        Association of pharmacological treatments with long-term pain control in patients with knee osteoarthritis: A systematic review and meta-analysis.
        JAMA. 2018; 320: 2564-2579
        • Han S.B.
        • Seo I.W.
        • Shin Y.S.
        Intra-articular injections of hyaluronic acid or steroids associated with better outcomes than platelet-rich plasma, adipose mesenchymal stromal cells, or placebo in knee osteoarthritis: A network meta-analysis.
        Arthroscopy. 2021; 37: 292-306
        • Kesikburun S.
        • Yaşar 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: E751-E759
        • Merrin E.
        • Grimshaw L.A.
        Technique for ultrasound-guided radiofrequency denervation of genicular nerves for chronic knee pain.
        Australas J Ultrasound Med. 2021; 24: 238-245
        • 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 Musculoskelet Rehabil. 2015; 28: 129-134
        • Rojhani S.
        • Qureshi Z.
        • Chhatre A.
        Water-cooled radiofrequency provides pain relief, decreases disability, and improves quality of life in chronic knee osteoarthritis.
        Am J Phys Med Rehabil. 2017; 96: e5-e8
        • Schianchi P.M.
        • Sluijter M.E.
        • Balogh S.E.
        The treatment of joint pain with intra-articular pulsed radiofrequency.
        Anesth Pain Med. 2013; 3: 250-255
        • Davis T.
        • Loudermilk E.
        • DePalma M.
        • 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: 84-91
        • Hunter C.
        • Davis T.
        • Loudermilk E.
        • Kapural L.
        • DePalma M.
        Cooled radiofrequency ablation treatment of the genicular nerves in the treatment of osteoarthritic knee pain: 18-and 24-month Results.
        Pain Pract. 2020; 20: 238-246
        • Chen A.F.
        • Khalouf F.
        • Zora K.
        • et al.
        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: 1-11
        • Filippiadis D.
        • Velonakis G.
        • Mazioti A.
        • et al.
        Intra-articular application of pulsed radiofrequency combined with viscosupplementation for improvement of knee osteoarthritis symptoms: A single centre prospective study.
        Int J Hypertherm. 2018; 34: 1265-1269
        • Arıcan Ş.
        • Hacıbeyoğlu G.
        • Akkoyun Sert Ö.
        • Tuncer Uzun S.
        • Reisli R.
        Fluoroscopy-guided genicular nerves pulsed radiofrequency for chronic knee pain treatment.
        Agri. 2020; 32: 38-43
        • Shen W.-S.
        • Xu X.-Q.
        • Zhai N.-N.
        • Zhou Z.-S.
        • Shao J.
        • Yu Y.-H.
        Radiofrequency thermocoagulation in relieving refractory pain of knee osteoarthritis.
        Am J Ther. 2017; 24: e693-e700
        • Zhao J.
        • Wang Z.
        • Xue H.
        • Yang Z.
        Clinical efficacy of repeated intra-articular pulsed radiofrequency for the treatment of knee joint pain and its effects on inflammatory cytokines in synovial fluid of patients.
        Exp Ther Med. 2021; 22: 1073
        • Cook J.L.
        • Kuroki K.
        • Kenter K.
        • et al.
        Bipolar and monopolar radiofrequency treatment of osteoarthritic knee articular cartilage: acute and temporal effects on cartilage compressive stiffness, permeability, cell synthesis, and extracellular matrix composition.
        J Knee Surg. 2004; 17: 99-108
        • Mishra P.
        • Edwards D.
        • Huntoon M.
        • et al.
        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
        • Desai M.
        • Bentley A.
        • Keck W.A.
        • Haag T.
        • Taylor R.S.
        • Dakin H.
        Cooled radiofrequency ablation of the genicular nerves for chronic pain due to osteoarthritis of the knee: A cost-effectiveness analysis based on trial data.
        BMC Musculoskelet Disord. 2019; 20: 1-9
        • Uematsu H.
        • Osako S.
        • Hakata S.
        • et al.
        A Double-blind, placebo-controlled study of ultrasound-guided pulsed radiofrequency treatment of the saphenous nerve for refractory osteoarthritis-associated knee pain.
        Pain Physician. 2021; 24: E761-E769
        • Mohamed A.T.
        Comparison of intraarticular injection versus radiofrequency neurotomy in knee osteoarthritis.
        Sohag Med J. 2021; 25: 33-40
        • Elawamy A.
        • Kamel E.Z.
        • Mahran S.A.
        • Abdellatif H.
        • Hassanien M.
        Efficacy of genicular nerve radiofrequency ablation versus intra-articular platelet rich plasma in chronic knee osteoarthritis: A single-blind randomized clinical trial.
        Pain Physician. 2021; 24: 127-134
        • El-Tamboly S.
        • Medhat M.
        • Khattab R.
        • Darwish H.
        • deghady A.
        Pulsed radiofrequency ablation of genicular nerve versus intra-articular radiofrequency ablation combined with platelets rich plasma for chronic kneeosteoarthritis.
        Egypt J Anaesth. 2021; 37: 317-325
        • Carpenedo R.
        • Al-Wardat M.
        • Vizzolo L.
        • et al.
        Ultrasound-guided pulsed radiofrequency of the saphenous nerve for knee osteoarthritis pain: A pilot randomized trial.
        Pain Manag. 2022; 12: 181-193
        • Santana-Pineda M.M.
        • Vanlinthout L.E.
        • Santana-Ramírez S.
        • Vanneste T.
        • Van Zundert J.
        • Novalbos-Ruiz J.P.
        A randomized controlled trial to compare analgesia and functional improvement after continuous neuroablative and pulsed neuromodulative radiofrequency treatment of the genicular nerves in patients with knee osteoarthritis up to one year after the intervention.
        Pain Med. 2021; 18: 637-652
        • Han Q.
        • Ma Y.
        • Jia P.
        • Wang X.
        • Wang B.
        • Zheng Y.
        A randomized controlled pilot study comparing the efficacy of pulsed radiofrequency combined with exercise versus exercise alone in pain relief and functional improvement for chronic knee osteoarthritis.
        Pain Pract. 2021; 21: 160-170
        • Chen A.F.
        • Khalouf F.
        • Zora K.
        • et al.
        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
        • Monerris Tabasco M.M.
        • Roca Amatria G.
        • Ríos Márquez N.
        • Jiménez Capel Y.
        • Samper Bernal D.
        Assessment of the effectiveness and safety of two radiofrequency techniques for the treatment of knee pain secondary to gonarthrosis. Prospective randomized double blind study.
        Rev Esp Anestesiol Reanim. 2019; 66: 362-369
        • Davis T.
        • Loudermilk E.
        • DePalma M.
        • et al.
        Twelve-month analgesia and rescue, by cooled radiofrequency ablation treatment of osteoarthritic knee pain: Results from a prospective, multicenter, randomized, cross-over trial.
        Reg Anesth Pain Med. 2019; 44: 499-506
        • Xiao L.
        • Shu F.
        • Xu C.
        • et al.
        Highly selective peripheral nerve radio frequency ablation for the treatment of severe knee osteoarthritis.
        Exp Ther Med. 2018; 16: 3973-3977
        • Sarı S.
        • Aydın O.N.
        • Turan Y.
        • Özlülerden P.
        • Efe U.
        • Kurt Ömürlü İ.
        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: 1772-1778
        • Ray D.
        • Goswami S.
        • Dasgupta S.R.
        • Ray S.
        • Basu S.
        Intra-articular hyaluronic acid injection versus RF ablation of genicular nerve for knee osteoarthritis pain: A randomized, open-label, clinical study.
        Indian J Pain. 2018; 32: 36
        • Jadon A.
        • Jain P.
        • Motaka M.
        • Swarupa C.P.
        • Amir M.
        Comparative evaluation of monopolar and bipolar radiofrequency ablation of genicular nerves in chronic knee pain due to osteoarthritis.
        Indian J Anaesth. 2018; 62: 876-880
        • Hashemi M.
        • Nabi B.N.
        • Saberi A.
        • Sedighinejad A.
        • Haghighi M.
        • Farzi F.
        The comparison between two methods 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: 539-546
        • Rahimzadeh P.
        • Imani F.
        • Faiz S.H.
        • Entezary S.R.
        • Nasiri A.A.
        • Ziaeefard M.
        Investigation the efficacy of intra-articular prolotherapy with erythropoietin and dextrose and intra-articular pulsed radiofrequency on pain level reduction and range of motion improvement in primary osteoarthritis of knee.
        J Res Med Sci. 2014; 19: 696-702
        • Choi W.-J.
        • Hwang S.-J.
        • Song J.-G.
        • et al.
        Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial.
        Pain. 2011; 152: 481-487
        • Sands M.L.
        • Murphy J.R.
        Use of kappa statistic in determining validity of quality filtering for meta-analysis: A case study of the health effects of electromagnetic radiation.
        J Clin Epidemiol. 1996; 49: 1045-1051
        • Ikeuchi M.
        • Ushida T.
        • Izumi M.
        • Tani T.
        Percutaneous radiofrequency treatment for refractory anteromedial pain of osteoarthritic knees.
        Pain Med. 2011; 12: 546-551
        • Kapural L.
        • Deering J.P.
        A technological overview of cooled radiofrequency ablation and its effectiveness in the management of chronic knee pain..
        Pain Manag. 2020; 10: 133-140
        • Das B.
        • Conroy M.
        • Moore D.
        • Lysaght J.
        • McCrory C.
        Human dorsal root ganglion pulsed radiofrequency treatment modulates cerebrospinal fluid lymphocytes and neuroinflammatory markers in chronic radicular pain.
        Brain Behav Immun. 2018; 70: 157-165
        • Orduña Valls J.M.
        • Vallejo R.
        • López Pais P.
        • et al.
        Anatomic and Ultrasonographic evaluation of the knee sensory innervation: A cadaveric study to determine anatomic targets in the treatment of chronic knee pain.
        Reg Anesth Pain Med. 2017; 42: 90-98
        • Cosman Jr., E.R.
        • Gonzalez C.D.
        Bipolar radiofrequency lesion geometry: Implications for palisade treatment of sacroiliac joint pain.
        Pain Pract. 2011; 11: 3-22
        • Kim S.Y.
        • Le P.U.
        • Kosharskyy B.
        • Kaye A.D.
        • Shaparin N.
        • Downie S.A.
        Is genicular nerve radiofrequency ablation safe? A literature review and anatomical study.
        Pain Physician. 2016; 19: E697-E705