Recently, denervation therapy has been applied clinically for the treatment of intractable osteoarthritis (OA). This therapy provides an alternative for patients who are insensitive to conservative therapies or unwilling to receive surgery and general anesthesia. However, therapeutic effect of this method, especially the long-term efficacy, is still controversial.

1. REZA AMINNEJAD; MD.

2. AFFILIATIONS
1. Department of Pain Management, Nanjing Drum Tower Hospital, The Affiliated Hospital of
Nanjing University Medical School, Nanjing, China;
2. Department of Anesthesiology, Xuzhou Medical University, Xuzhou, China
DR. REZA AMINNEJAD

3. INTRODUCTION
Knee OA usually affects patients over age 45 years and has a relatively high prevalence
rate of 40%.
Conservative treatments are physical therapy, medication, and injection therapy.
Surgical interventions such as arthroplasty and total knee replacement are valid and reliable
options for refractory cases (limited by significant expense, morbidity, mortality, and persistent
pain after surgery).
Recently, denervation therapy has been applied clinically for treatment of knee OA.
DR. REZA AMINNEJAD

4. DENERVATION THERAPY
The basic premise lies in accurate placement of the electrode nearby the targeted nerves
responsible for transmitting pain sensation.
Two distinct modalities are thermal lesion or cryoneurolysis.
DR. REZA AMINNEJAD

5. SENSORY INNERVATION OF THE KNEE JOINT
Tibial nerve
Common peroneal nerve
Femoral nerve
Obturator nerve
As these nerves are mixed nerve fibers, setting them as lesion targets is impractical. Then,
what's the solution?
DR. REZA AMINNEJAD

6. Periarticular or intraarticular branches
DR. REZA AMINNEJAD

7. SENSORY INNERVATION OF THE KNEE JOINT (CAN BE BLOCKED)
Tibial nerve (Sup. Medial, Inf. Medial & Middle Genicular N.)
Common peroneal nerve (Sup. Lateral, Inf. Lateral & Recurrent Genicular N.)
Femoral nerve (twigs to the tree vasti)
Obturator nerve (Genicular branche from it’s posterior devision)
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13. AIM OF THE STUDY
The aim of the systematic review was to examine the efficacy on pain
alleviation and functional recovery in the short and long term after applying
denervation therapy to the genicular nerves of patients with OA with chronic
knee pain.
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15. ELIGIBILITY CRITERIA
Inclusion Criteria
1) Full text study
2) Patients aged > 60 years
3) Previous conservative treatments > 3 months
4) Pain visual analog scale (VAS) > 30 mm in 100 mm or 3 cm in
10 cm
5) Radiologic OA grade > 2 according to the Kellgren-
Lawrence (K-L) grading system (0 = none, 1 = doubtful, 2 =
minimal, 3 = moderate, and 4 = severe)
6) Investigated and reported measures of pain intensity and
joint function of denervation therapy versus control agents
(conservative treatment including analgesic medication,
intraarticular steroid or hyaluronic acids injection, sham
operation).
Exclusion Criteria
1) Patients with mental handicaps or psychiatric conditions
precluding adequate communication
2) Presence of any contraindication for the invasive interventions,
such as coagulation disorders, systemic or local infection,
presence of connective tissue disease
3) Patients had intraarticular steroid or hyaluronic acids during
the previous 3 months
4) Patients had previous knee surgery
DR. REZA AMINNEJAD

16. RESULTS
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18. STUDY CHARACTERISTICS
Among the 6 included studies, 5 were prospective RCTs, and the remainder was a
prospective non-RCT.
Although many tools can be used for nerve ablation, the method used in included studies was
only radiofrequency ablation.
The comparison set for denervation therapy includes sham operation, genicular nerve block,
conventional analgesic therapy, and intraarticular knee injection.
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27. METHODOLOGICAL QUALITY AND RISK OF BIAS
DR. REZA AMINNEJAD

28. ASSESSMENT OF PAIN ALLEVIATION AFTER DENERVATION THERAPY
No data concerning the long-term (one year and longer) pain relief effect of denervation
treatment was found (data of pain intensity up to 24 weeks after operation was collected).
Three pain scores were used in the studies, including VAS (0-10), VAS (0-100), and Numeric
Rating Scale (0-10).
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33. ASSESSMENT OF KNEE FUNCTIONAL IMPROVEMENT AFTER DENERVATION THERAPY
In this study WOMAC total score was applied to assess the functional improvement of the
knee.
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35. WOMAC OSTEOARTHRITIS INDEX
The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is widely used in the
evaluation of Hip and Knee Osteoarthritis. It is a self-administered questionnaire consisting of
24 items divided into 3 subscales:
Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing upright
Stiffness (2 items): after first waking and later in the day
Physical Function (17 items): using stairs, rising from sitting, standing, bending, walking, getting
in / out of a car, shopping, putting on / taking off socks, rising from bed, lying in bed, getting
in / out of bath, sitting, getting on / off toilet, heavy domestic duties, light domestic duties
The test questions are scored on a scale of 0-4, which correspond to: None (0), Mild (1),
Moderate (2), Severe (3), and Extreme (4).
DR. REZA AMINNEJAD

36. DISCUSSION
DR. REZA AMINNEJAD

37. USUAL MODALITIES FOR KNEE OA HEALTH CARE
Physiotherapy
Medication
Intraarticular Injection (PRP, Stem Cells, …)
Denervation therapy (since 2011)
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Conservative
Treatments
Denervation
Treatment
TKA

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More
Traumatic
More
Costs
Surgery
Less
Traumatic
Less
Costs
Denervation

41. SUMMERY OF RESULTS
Pain Scores Joint Function
DR. REZA AMINNEJAD

42. LIMITATIONS
The severity of knee OA in patients included in different studies varies, which may be a
confounding when conducting meta-analysis.
The comparisons in different researches vary and therapeutic effect of these treatments was
different.
The statistic difference between pre- and post interventional pain intensity is not equal to
difference in clinical effect.
The duration of follow-up in all studies was relatively short.
Several different scales for knee joint were used in the studies.
Denervation may aggravate the degeneration of the knee!
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45. THANKS FOR YOUR ATTENTION
DR. REZA AMINNEJAD