Cooled Radiofrequency for Osteoarthritis Knee- A US FDA Approved Alternative of Knee Joint Replacement

What Is Osteoarthritis Knee?

What is it? Knee osteoarthritis (OA) is a chronic painful degenerative joint disease that affects the knee. OA most commonly affects the knee joint than other joints in our body.

According to a study named “Epidemiology of knee osteoarthritis in India and related factors” published in the Indian Journal of Orthopedics in September 2016, the prevalence of OA knee was found to be 28.7% in the general population. This indicates that out of 100 general populations, approximately 29 persons suffer from OA knee. Furthermore, in the same study amongst the Indian people, the chances of development of OA knee increase further in females, with an increase of body weight, and those who live a sedentary life without any exercise.

What exactly happens? In osteoarthritis, the cartilages that cover the end of bones in the joint become thin, and the joint surface becomes rougher and irregular. It means that the knee doesn’t move as smoothly as it should, causing a stiff and painful knee. In severe stages, it leads to knee deformity and impairment of mobility. 

Who Are At Risk Of The Development Of Osteoarthritis?

Age is the most crucial factor for this degeneration and thinning process of cartilage. It is widespread after the 60s. As mentioned earlier, the prevalence of OA Knee is more in females than males. Genetic predisposition and gender are non-modifiable risk factors, whereas obesity, lack of exercise, and occupations involving prolonged standing, kneeling, squatting, and heavy lifting are modifiable risk factors. With increasing sedentary lifestyles and obesity, young people are also at risk of developing OA knee. 

When To Suspect Osteoarthritis Of Knee? 

If the knee hurts during climbing stairs, standing up from a sitting position, one should think of OA of the knee. Knee pain due to osteoarthritis usually worsens in the morning, cold weather, excessive inactivity, and stiffness and swelling in the knees. In addition, there will be cracking or popping sounds during the folding and straightening of the knee. However, the clinical symptoms and disease progression vary from person to person. 

How Is Oa Knee Diagnosed?

OA Knee is suspected by typical history, age, and physical examination. But the diagnosis is confirmed with an X-ray of the knee joint. It passes through cartilages and other tissues when X-ray is done, but not through the bone. So, cartilage thickness can be measured by measuring the gap between two bones. Less is the gap; less is the thickness of articular cartilage, and more severe is osteoarthritis. Apart from X-rays, sometimes, Ultrasonography, MRI, and some other blood tests are done to confirm osteoarthritis and rule out other types of arthritis.

What Are The Grades Of Oa According To The Severity Of Oa Knee?

The degree of severity is commonly assessed by an X-ray of the knee taken in a standing position. Joint space reduction, irregularity of joint surface, a new bone formation called osteophyte, deformity of the joints are the X-ray changes seen in the OA knee. It is divided into 4 grades.

Grade 1- mild changes

Grade 2- moderate changes

Grade 3- severe changes

Grade 4- extreme changes

What Are The Treatment Options Available For Oa Knee? 

Treatment depends on the grade of osteoarthritis and the age of the patient. Initially, the treatment begins with exercises and simple pain killer medicines. 

Grade 1 can be managed by patient education, activity modification, weight reduction by diet control, and low-impact aerobic exercises. Knee exercises like quadriceps strengthening exercises, physical activities like walking are encouraged. Pharmacotherapy helps to relieve pain and inflammation. Medicines like Paracetamol, Duloxetine, and NSAIDs are used intermittently to reduce pain.

Grades 2 and 3 can be managed by the treatments given in grade 1, along with regenerative therapy and/or visco-supplementation. Regeneration therapy helps in regenerating the damaged cartilages and reduces pain. Platelet-rich plasma (PRP) derived from patients’ blood is the most common regeneration therapy, and various research supports this treatment. Viscosupplementation is an injection of lubricating gel inside the knee. This type of lubricant is present naturally inside our joints. But the gel that is injected is manufactured artificially.

Grade 4 requires knee replacement surgery. Surgery is generally avoided in patients > 80 years, patients having severe comorbidities like uncontrolled diabetes/ hypertension/ heart diseases/kidney diseases, patients < 50 years (as the average life of the prosthesis is around 15 years, patient might need a second surgery in old age). In such patients, US FDA approved Cooled Radiofrequency Ablation of genicular nerves of the knee is a safer and effective alternative.

What Is Cooled Radiofrequency, And How Does It Work?

To know about cooled radiofrequency, we need to see a bit of knee anatomy and its functions- The knee joint comprises three bones. Thighbone (femur), shinbone (tibia), and the knee cap (patella). These form the joint surrounded by cartilage that acts as a shock absorber so that the bones can move without rubbing directly against each other. Ligaments are like solid ropes which link one bone to another and provide stability. Tendons are bands of soft tissues which connect bone and muscles. Nerves supplying the knee joint (articular branches) are called genicular nerves. These nerves carry pain signals from the knee joint to the brain. These nerves do not move muscles because they are not motor nerves.

Cooled RF is a minimally invasive, thermal radiofrequency pain management system using a highly advanced machine (fig.1) to deactivate pain-causing articular nerves supplying the knee joint. Here 60-70% of articular branches are ablated. This procedure does not block the motor nerves, so complications like paralysis are avoided. 

How Is The Procedure Done? 

It is a daycare procedure where the patient is admitted and discharged on the same day. The process is done in operation theatre under sterile technique under local anesthesia. The patient will be awake throughout the procedure.

The procedure is done under x-ray guidance, which helps direct visualization structures and correct RF cannula placement position. (Fig 2) 

Where Is This Procedure Done?

Daradia: The Pain Clinic and the hospital is the first exclusive pain management hospital with 12 beds in India. Cooled radiofrequency procedures have been done here since 2018. Masterclasses and workshops are organized at this hospital regularly to learn these radiofrequency techniques. Postgraduate doctors from specialties like orthopedics, anesthesia, and physical medicine worldwide come here to learn the radiofrequency procedures.

Who Are The Candidates For Cooled Radiofrequency?

The cooled radiofrequency for osteoarthritis knee can be an excellent alternative to knee joint replacement, mainly where replacement surgery can’t be done or should be avoided for many reasons. Its safety and efficacy are outstanding, and most importantly, it is a US FDA-approved procedure.

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