Comparative Effectiveness Review of Cooled Versus Pulsed Radiofrequency Ablation for the Treatment of Knee Osteoarthritis: A Systematic Review

Abstract

Background: Patients suffering from osteoarthritis of the knee and patients post total knee arthroplasty often develop refractory, disabling chronic knee pain. Radiofrequency ablation, including conventional, pulsed, and cooled, has recently become more accepted as an interventional technique to manage chronic knee pain in patients who have failed conservative treatment or who are not suitable candidates for surgical treatment. Objective: This systematic review aimed to analyze published studies on radiofrequency ablation to provide an overview of the current knowledge regarding variations in procedures, nerve targets, adverse events, and temporal extent of clinical benefit. Study Design: A systematic review of published studies investigating conventional, pulsed, or cooled radiofrequency ablation in the setting of chronic knee pain. Methods: Medline, Google Scholar, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were reviewed for studies on radiofrequency ablation for patients with chronic knee pain through July 29, 2016. From the studies, the procedural details, outcomes after treatment, follow-up points, and complications were compiled and analyzed in this literature review. Included studies were analyzed for clinical relevance and strength of evidence was graded using either the NHLBI Quality assessment of controlled intervention studies or the NHLBI quality assessment for before-after (pre-post) studies with no control group. Results: Seventeen total publications were identified in the search, including articles investigating conventional, pulsed, or cooled radiofrequency ablation. These studies primarily targeted either the genicular nerves or used an intraarticular approach. Of the studies, 5 were small-sized randomized controlled trials, although one involved diathermy radiofrequency ablation. There were 8 retrospective or prospective case series and 4 case reports. Utilizing the strength of evidence grading, there is a low level of certainty to suggest a superior benefit between targeting the genicular nerve, an intraarticular approach, or targeting the larger nerves such as femoral and tibial nerves. Utilizing the strength of evidence grading, there is a low level of certainty in supporting the superiority of any specific RFA procedure modality. The majority of the studies report positive patient outcomes, but the inconsistent procedural methodology, inconsistent patient assessment measures, and small study sizes limit the applicability of any specific study to clinical practice. Limitations: While the wide search strategy included a variety of articles, broad conclusions and pooled data could not be obtained based on the studies analyzed. Conclusions: Overall, the studies showed promising results for the treatment of severe chronic knee pain by radiofrequency ablation at up to one year with minimal complications. Numerous studies, however, yielded concerns about procedural protocols, study quality, and patient follow-up. Radiofrequency ablation can offer substantial clinical and functional benefit to patients with chronic knee pain due to osteoarthritis or post total knee arthroplasty. Key words: Radiofrequency ablation, knee osteoarthritis, knee pain, genicular nerve, total knee arthroplasty (TKA), cooled radiofrequency ablation, pulsed radiofrequency ablation

Radiofrequency Ablation, Where It Stands in Interventional Radiology Today

“…Additional uses of pain control ablation include genicular nerve ablation for arthritic knee pain, sacroiliac joint pain neurolysis, ablation of Morton's neuroma, ingrown toe nails, and intervertebral discs. [66][67][68] Endoscopic application of RFA is possible with the Habib Endo HBP catheter for benign and malignant biliary interventions and with the BARRX Anorectal RFA Wand for the treatment of high-grade anal squamous intraepithelial neoplasia. Additional endoscopic treatments using RFA include refractory gastroesophageal reflux disease and ablation of low-and high-grade Barrett's esophagus.…”

Cooled Radio Frequency Ablation for the Treatment of Osteoarthritis-Related Knee Pain: Evidence, Indications, and Outcomes

“…Radio Frequency ablation (RFA) was introduced as a treatment for chronic pain associated with trigeminal neuralgia. 20 This procedure relies on the premise that blocking sensory innervation from a painful structure will ultimately result in pain relief. A high-frequency electric current is used to induce an electromagnetic magnetic field at the tip of the RF electrode.…”

“…The high heat that emanates from the RF probe has the potential to damage adjacent tissues as temperatures reach 70 to 90°C. 20 Further, the heat lesion that is produced is limited in size and shape and therefore it may be challenging to accurately reach some target areas. 25,26 As a result, there has been a great deal of interest in exploring new avenues to address some of the short comings associated with traditional RFA.…”

Radiofrequency ablation for the treatment of knee osteoarthritis: present status and future perspectives

“…In the particular setting of knee OA, all these three RFA techniques have been safely and successfully applied to treat chronic pain; and a large literature core supports RFA with very encouraging results reported both at short-and midterm follow-up (ranging between 1 week and 12 months) [11]. However, a substantial heterogeneity exists across studies, especially in terms of ablative protocols, imaging guidance and anatomic targets of the ablation.…”

“…However, a substantial heterogeneity exists across studies, especially in terms of ablative protocols, imaging guidance and anatomic targets of the ablation. Despite such heterogeneity, most of the available papers reported about US/fluoroscopy guidance applied to target the genicular nerves [11]. Nevertheless, at the moment, it is not possible to state whether one approach/technique is superior to another.…”