Tag Archive | knee osteoarthritis

July 2020 Article Exchange with JOSPT

For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of July 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT systematic review and meta-analysis titled “Effectiveness of Weight-Loss Interventions for Reducing Pain and Disability in People with Common Musculoskeletal Disorders.”

The authors found low-credibility evidence that behavioral weight-loss interventions produced small to moderate improvements in pain intensity and disability in people with hip or knee osteoarthritis. They also found moderate-credibility evidence that combined diet and exercise weight-loss strategies improved pain intensity and disability compared to diet-only interventions for knee osteoarthritis.

PT More Effective than Steroid Injections for Knee OA

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicinethe following commentary comes from Jaime L. Bellamy, DO.

A majority of patients I see for knee osteoarthritis (OA) want a quick fix. Many would like to skip conservative treatment–activity modification, weight loss, physical therapy (PT), anti-inflammatory medication, and intra-articular steroid injections–and go straight to surgical management. Regarding nonoperative management of knee OA, the most recent AAOS Clinical Practice Guidelines “strongly” recommend that patients participate in PT and “inconclusively” recommend intra-articular steroid injections.1 Yet, in my clinical practice, I confess to typically offering a knee injection first, before PT.

I may change that practice in light of the randomized controlled trial (RCT) by Deyle et al. in the April 9, 2020 issue of The New England Journal of Medicine. The trial compared PT to glucocorticoid knee injections among 156 primary-care knee OA patients within a military health system. The primary outcome measure was the WOMAC score at 1 year. Secondary outcomes included the Alternate Step Test and the Timed Up and Go test.

Seventy-eight patients randomly assigned to each group were included in the analysis. The PT intervention included detailed home-exercise instructions and 8 sessions with a therapist over the initial 4- to 6-week period. Patients could also attend 1 to 3 PT sessions at the 4-month and 9-month reassessments. Knee-injection patients received 1 ml of triamcinolone acetonide (40 mg per milliliter) and 7 ml of 1% lidocaine up to three times in one year.

The mean baseline WOMAC scores were similar between the groups. However, at 1 year, the authors found a mean between-group difference of 18.8 points in WOMAC scores, favoring PT over injections. Secondary outcomes also favored PT over knee injections.

Regardless of this RCTs limitations, such as the lack of reporting on knee-injection techniques, the findings serve as a reminder to orthopaedists to recommend PT as an effective nonoperative treatment option for knee OA. Additionally, our primary care colleagues can use this data to help convince patients with knee OA that they do not need to rush in to see a surgeon.

Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.

Reference

  1. AAOS Clinical Practice Guidelines, Treatment of Osteoarthritis of the Knee, 2nd Edition (2013), http://www.orthoguidelines.org/topic?id=1005, accessed 4/14/2020.

Curb Your Enthusiasm about Stem Cells for Knee OA

Mark Miller, MD is a professor of orthopaedic surgery at the University of Virginia, founder and co-director of the Miller Review Courses, and former deputy editor for sports medicine at JBJS. In a piece he authored recently for The Conversation, Dr. Miller labeled stem-cell treatments for knee osteoarthritis (OA) “unproven, expensive, and potentially dangerous.”

About 2 years ago, Dr. Miller himself underwent bilateral knee replacements for severe knee arthritis. He understands why patients may fall prey to misleading marketing hype that claims stem cell treatments can help people postpone or entirely avoid knee replacement. (See related OrthoBuzz post.) “My mission,” he writes, is to “try to keep the enthusiasm regarding new cutting-edge options in check,” adding that “the excitement about stem cells has outpaced the science,” especially when it comes to knee OA.

Although stem cell injections have been promoted as a way to regenerate cartilage in arthritic joints, Dr. Miller echoes the American Association of Hip and Knee Surgeons when he says that “there are no proven…therapies that can delay or reverse the progressive joint destruction that occurs with osteoarthritis.” Moreover, the do-no-harm part of the Hippocratic oath requires doctors to give their patients “a clear picture of the potential benefits and side effects of their treatment options,” writes Dr. Miller, who cited a December 20, 2018 New York Times article describing 12 patients who were hospitalized for serious infections after receiving stem cell injections into their knees, shoulders, or spines.

For their part, Dr. Miller says patients should employ the “buyer beware” concept because stem cell therapy for osteoarthritis is not only unproven but also expensive—and usually not covered by medical insurance. The best approach to knee OA, says Dr. Miller, is what is nowadays called shared decision making: “Physicians need to work closely with patients to help them understand their options and which choice may be best for them.”

Shedding Low-Level Laser Light on Knee OA

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Low-level laser therapy (LLLT) has been used in multiple countries to treat the pain and function deficits associated with knee osteoarthritis (OA). The wavelength typically used is in the near-infrared region. However, this therapy is not recommended by most clinical guidelines, including those of the Osteoarthritis Research Society International. The hesitancy to recommend LLLT is due largely to conflicting published findings and unresolved dose-related issues such as wavelength, intensity, and frequency of treatment. For treating knee OA, the World Association for Laser Therapy (WALT) recommends applying four times the laser dose with continuous rather than pulsed irradiation.

To try to resolve conflicting evidence, Stausholm et al. conducted a systematic review and meta-analysis of randomized, placebo-controlled trials of LLLT, distilling 22 trials from 2,735 initially identified articles.1 Pain, as measured by a 0 to 100 mm visual analog scale (VAS), was significantly reduced by LLLT compared with placebo at the end of therapy (14.23 mm VAS; 95% CI 7.31 to 21.14) and during follow-ups 1 to 12 weeks later (15.92 mm VAS; 95% CI 6.47 to 25.37). Subgroup analysis revealed that pain was significantly reduced by the recommended LLLT doses compared with placebo at the end of therapy (18.71 mm VAS; 95% CI 9.42 to 27.99) and during follow-ups 2 to 12 weeks after the end of therapy (23.23 mm VAS; 95% CI 10.60 to 35.86).

Pain reduction from the recommended doses peaked during follow-ups 2 to 4 weeks after the end of therapy. Disability was also significantly reduced by LLLT, and no adverse events were reported in any of the studies. Notably, in light of JBJS Editor-in-Chief Marc Swiontkowski’s recent comments about the quality of meta-analyses, this meta-analysis was reported in accordance with PRISMA guidelines and all included trials were evaluated for risk of bias.

What remains unclear is how far past the skin the varied wavelengths and intensities (usually 1 to 8 Joules) of laser energy penetrate. Likewise, tissue heating has not been measured or analyzed. Still, at present, it appears that LLLT used with WALT guidelines is a safe and potentially effective treatment for the pain and dysfunction of knee OA.

Reference

  1. Stausholm MB, Naterstad IF Msc, Joensen J, Lopes-Martins RÁB, Sæbø H Msc, Lund H, Fersum KV, Bjordal JM. Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials. BMJ Open. 2019 Oct 28;9(10):e031142. doi: 10.1136/bmjopen-2019-031142. PMID: 31662383

Sprifermin: Another Shot at Joint Preservation

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

To date, we have found only one documented disease-modifying intervention that slows the progression of knee osteoarthritis (OA)—weight loss.1 There are few positive findings about drugs or other therapeutic interventions that might prolong the life of the human joint. However, sprifermin, a recombinant human fibroblast growth factor that can be genetically engineered from bacteria, has been tested in a randomized proof-of-concept trial as an intra-articular injection in humans,2 with modestly promising results.

In a very recent study on the effect of sprifermin and several other potentially disease-modifying compounds on bovine chondrocytes, researchers used 3D cultures to assess chondrocyte proliferation and/or extracellular matrix production.3 All of the growth factors evaluated, including sprifermin, resulted in elevated markers of anabolic chondrocyte activity. For the most part, cyclic doses were more effective than continuous doses over 4 weeks. Of importance, only sprifermin decreased type I collagen expression and had no hypertrophic effects. The authors conclude in the abstract that “these results confirm that sprifermin is a promising disease-modifying OA drug.”

In a 5-year randomized human dose-finding trial,4 patients with symptomatic knee OA were divided into 5 groups, as follows:

  1. 100 μg of sprifermin administered every 6 months (n = 110)
  2. 100 μg of sprifermin administered every 12 months (n = 110)
  3. 30 μg of sprifermin administered every 6 months (n = 111)
  4. 30 μg of sprifermin administered every 12 months (n = 110)
  5. Placebo injections administered every 6 months (n = 108)

The greatest changes in the primary endpoint—increased total femorotibial joint cartilage thickness from baseline to 2 years—was 0.05 mm (95% CI, 0.03 to 0.07 mm) in the group that received 100 μg of sprifermin every 6 months and 0.04 mm (95% CI, 0.02 to 0.06 mm) in the group that received 100 μg of sprifermin every 12 months. However, compared with the placebo group, those receiving sprifermin had no statistically different change in WOMAC scores. On average, 40% of all the patients in the study experienced arthralgia associated with the injections.

More certainty about the efficacy, safety, and durability of sprifermin may come when data from the remaining 3 years of this study are analyzed (see ClinicalTrials.gov identifier NCT01919164).

References

  1. Gersing AS, Solka M, Joseph GB, Schwaiger BJ, Heilmeier U, Feuerriegel G, Nevitt MC, McCulloch CE, Link TM. Progression of cartilage degeneration and clinical symptoms in obese and overweight individuals is dependent on the amount of weight loss: 48-month data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2016 Jul;24(7):1126-34. doi: 10.1016/j.joca.2016.01.984. PMID: 26828356 PMCID: PMC4907808.
  2. Lohmander LS, Hellot S, Dreher D, et al. 2014. Intraarticular sprifermin (recombinant human fibroblast growth factor 18) in knee osteoarthritis: a randomized, double-blind, placebo-controlled trial. Arthritis Rheumatol. 66(7):1820–31.
  3. Müller S, Lindemann S, Gigout A. Effects of sprifermin, IGF1, IGF2, BMP7 or CNP on bovine chondrocytes in monolayer and 3D culture. J Orthop Res. 2019 Oct 14. doi: 10.1002/jor.24491. [Epub ahead of print] PMID: 31608492.
  4. Hochberg MC, Guermazi A, Guehring H, Aydemir A, Wax S, Fleuranceau-Morel P, Bihlet AR, Byrjalsen I, Andersen JR, Eckstein F. Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With OsteoarthritisThe FORWARD Randomized Clinical Trial. JAMA. 2019;322(14):1360-1370. doi:10.1001/jama.2019.14735

Eschew the “Quick Fix” Approach to Early Knee OA

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in Arthritis Care & Researchthe following commentary comes from Jeffrey B. Stambough, MD.

As orthopaedic surgeons, we share a collective objective to help patients improve function while minimizing pain. When patients come to our office for a new clinical visit for knee osteoarthritis (OA), we spend time getting to know them and gathering information about their activities, limitations, and functional goals. We balance this patient-reported information with discrete data points, such as weight, range-of-motion restrictions, and radiographic disease classification. Based on the symptom duration and other factors, most patients are not candidates for a knee replacement at this first visit. However, despite the publication of clinical practice guidelines for the nonoperative management of knee OA in 2008, with an update in 2013, significant variation exists in how orthopaedists treat these patients.

This guideline–practice disconnect is emphasized in findings from a recent study in Arthritis Care & Research that examined nonoperative knee OA management practices during clinic visits between 2007 and 2015. The authors found that the overall prescription of NSAID and opioid medications increased 2- and 3-fold, respectively, over that time, while recommendations for lifestyle interventions, self-directed activity, and physical therapy decreased by about 50%.

To me, the most troubling finding from this study is the sharp increase in narcotic prescriptions, because recent evidence demonstrates that narcotics do not effectively treat arthritis pain. Moreover, for patients who go on to arthroplasty, recent studies have found that preoperative opioid use portends worse postsurgical outcomes in terms of higher revision rates,  worse function scores, and decreased knee motion.

The findings from this study also speak to a larger societal issue for doctors and patients alike: the desire for a “quick fix.”  Despite the time pressure from increasing EHR documentation burdens, dwindling reimbursements, or lack of local resources, we owe it to our patients to counsel them on lifestyle modifications and self-management strategies to help them stay mobile, lose weight (if necessary), and take charge of their joint health. As orthopaedic surgeons, we must continue to strive to de-emphasize opioid pain medication when treating knee OA patients and support them in a holistic manner to ensure their overall health and the function and longevity of their native knee joint.

Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.

MRI for Detecting Rapidly Progressive Knee OA: No Crystal Ball

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Knee osteoarthritis (KOA) typically develops over a decade or more. However, 1 in 5 people with KOA have more pain and disability at onset, have accelerated radiographic knee osteoarthritis (AKOA), and experience end-stage disease within 4 years. The use of demographics and clinical findings has resulted in only a 40% rate of correctly classifying patients who will develop AKOA instead of longer-term KOA.

Investigators recently conducted a case–control study using data from the OsteoArthritis Initiative (OAI), including demographic, clinical, and biochemical data, along with radiographic and magnetic resonance (MR) imaging data.1 The researchers hypothesized that the addition of an MR imaging-based scoring system would more accurately identify patients at risk for AKOA. They used classification and regression tree (CART) models to assess the ability of baseline MR features to classify participants who will develop AKOA and whether adding baseline MR features to an existing model improved classification of adults who will develop AKOA.

The existing model consisted of clinical data that included pain, function, physical exam findings, and quality-of-life measures. Demographic data included age, sex, and BMI collected at baseline. Biochemical data included high-sensitivity C-reactive protein and serum blood sugar. Data obtained from MR imaging scores included bone marrow lesion volume, effusion-synovitis volume, cartilage damage index, meniscal extrusion and degeneration, cruciate ligament degeneration, and patellar fat pad changes.

Contrary to the hypothesis, the CART models with and without MR features each explained approximately 40% of the variability. Adding MR-based features to the model improved specificity (0.90 vs. 0.82), but lowered sensitivity (0.62 vs. 0.70). Interestingly, the authors found that serum glucose, effusion-synovitis volume, and cruciate ligament degeneration were statistically important variables in classifying individuals who are likely to develop AKOA.

The clinical take home is that early MR data may be useful in sorting out mechanical complaints, but not in determining who will develop AKOA. In contrast, in later stages of KOA, MR images may reveal far greater damage than can be detected on radiographs.

Reference

  1. Price LL, Harkey MS, Ward RJ, MacKay JW, Zhang M, Pang J, Davis JE, McAlindon TE, Lo GH, Amin M, Eaton CB, Lu B, Duryea J, Barbe MF, Driban JB. Role of Magnetic Resonance Imaging in Classifying Individuals Who Will Develop Accelerated Radiographic Knee Osteoarthritis. J Orthop Res. 2019 Nov;37(11):2420-2428. doi: 10.1002/jor.24413. Epub 2019 Jul 29. PMID: 31297900

Delaying Knee Replacement: Driven to Distraction?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Some symptomatic patients with knee osteoarthritis (OA) present relatively early in the radiographic disease process, while others present after serious articular cartilage loss has occurred. In either case, young knee OA patients are often looking for ways to get relief while postponing a total knee arthroplasty (TKA).

One such recently introduced alternative is knee joint distraction (KJD), a joint-preserving surgery used for bicompartmental tibiofemoral knee osteoarthritis or unilateral OA with limited malalignment. Significant long-term clinical benefit as well as durable cartilage tissue repair have been reported in an open prospective study with 5 years of follow-up.1 A more recent study of distraction2 presents 2-year follow-up results of a 2-pronged trial that measured patient-reported outcomes, joint-space width (JSW), and systemic changes in biomarkers for collagen type-II synthesis and breakdown.

In one arm, end-stage knee OA patients who were candidates for TKA were randomized to KJD (n=20) or TKA (n=40). In the second arm, earlier-stage patients with medial compartment OA and a varus angle <10° were randomized to KJD (n=23) or high tibial osteotomy (HTO; n=46). In the distraction patients, the knee was distracted 5 mm for 6 weeks using external fixators with built-in springs, placed laterally and medially, and weight-bearing was encouraged. WOMAC scores and VAS pain scores were assessed at baseline and at 3, 6, 12, 18, and 24 months.

At 24 months, researchers found no significant differences between the KJD and HTO groups in that part of the trial. In the KJD/TKA arm, there was no difference in WOMAC scores between the two groups, but VAS scores were lower in the TKA group. The improvement in mean joint space width seen at one year in the KJD group of the KJD/TKA arm decreased by two years, though the values were still improved compared to baseline. However, the joint space width improvement seen at 1 year for both groups in the KJD/HTO arm persisted for two years. For all KJD patients, the ratio of biomarkers of synthesis over breakdown of collagen type-II was significantly decreased at 3 months but reversed to an increase between 9 and 24 months.

It is hard to believe that 6 weeks of joint distraction could trigger a process that yields such positive and long-lasting results. While much more research with longer follow-up is needed, KJD may prove particularly useful in younger knee OA patients trying to delay joint replacement.

References

  1. van der Woude, JAD, Wiegant, K, van Roermund, PM, Intema, F, Custers, RJH, Eckstein, F. Five-year follow-up of knee joint distraction: clinical benefit and cartilaginous tissue repair in an open uncontrolled prospective study. Cartilage. 2017;8:263-71.
  2. Jansen MP, Besselink NJ, van Heerwaarden RJ, Roel J.H. Custers1, Jan-Ton A.D. Van der Woude J-TAD, Wiegant K, Spruijt S, Emans PJ, van Roermund PM, Mastbergen SC, Lafeber FP. Knee joint distraction compared with high tibial osteotomy and total knee arthroplasty: two-year clinical, structural, and biomarker outcomes. ORS 2019 Annual Meeting Paper No. 0026 (Cartilage. 2019 Feb 13:1947603519828432. doi: 10.1177/1947603519828432. [Epub ahead of print])

Microbiomes, OA, and Diabetic Foot Ulcers

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

We hear the term “microbiome” with increasing frequency nowadays. Merriam-Webster’s online dictionary defines it as “a community of microorganisms (such as bacteria, fungi, and viruses) that inhabit a particular environment and especially the collection of microorganisms living in or on the human body.” Two recent studies suggest how the microbiome can affect musculoskeletal health.

Incorporating the term “the arthritis of obesity,” Rochester, New York researchers1 used obese mice with trauma-induced knee osteoarthritis (OA) to provide evidence that there is a “gut-joint connection” in the OA degenerative process. After supplementing the diets of some of the mice with oligofructose (a prebiotic fiber), the authors found reduced systemic inflammation, reduced obesity-associated macrophage migration to the synovium, and suppressed obesity-induced joint-structure changes.

Another recent study investigated the on-body microbiome as it relates to diabetic foot ulcers (DFUs). Despite clinical signs and nonspecific biomarkers of infection, there is no specific and sensitive measure available to monitor or prognosticate the success of foot salvage therapy (FST) in patients with DFUs. These investigators hypothesized that the initial microbiomes of healed versus nonhealed DFUs are distinct and that the changes in the DFU microbiome during FST are prognostic of clinical outcome.2

Twenty-three DFU patients undergoing FST had wound samples collected at 0, 4, and 8 weeks following wound debridement and antibiotic treatment. Eleven ulcers healed and 12 did not. Healed DFUs had a larger abundance Actinomycetales and Staphylococcaceae (p < 0.05), while nonhealed ulcers had a higher abundance of Bacteroidales and Streptococcaceae (p < 0.05).

In the future, assessment of the initial microbiome and monitoring changes in the prevalence of specific microbiome constituents in patients with diabetic foot ulcers may be a clinical tool for predicting treatment response to foot salvage therapy. It’s also conceivable that microbiome analysis could eventually help patients and surgeons decide between FST and amputation.

References

  1. Schott EM, Farnsworth CW, Grier A, Lillis JA, Soniwala S, Dadourian GH, Bell RD, Doolittle ML, Villani DA, Awad H, Ketz JP, Kamal F, Ackert-Bicknell C, Ashton JM, Gill SR, Mooney RA, Zuscik MJ. Targeting the gut microbiome to treat the osteoarthritis of obesity. JCI Insight. 2018 Apr 19;3(8). pii: 95997. doi: 10.1172/jci.insight.95997. [Epub ahead of print] PMID: 29669931, PMCID: PMC593113
  2. MacDonald A, Brodell JD Jr, Daiss JL, Schwarz EM, Oh I. Evidence of differential microbiomes in healing versus non-healing diabetic foot ulcers prior to and following foot salvage therapy. J Orthop Res. 2019 Mar 25. doi: 10.1002/jor.24279. [Epub ahead of print] PMID: 30908702

RF Ablation for Knee Arthritis

Sometimes, patients with painful knee osteoarthritis do not get sufficient pain relief with conservative treatments and do not want (or are not suitable candidates for) arthroplasty. Now, with the advent of genicular nerve radiofrequency ablation (GNRFA), such patients have another option.

As described in a recent issue of JBJS Essential Surgical Techniques, GNRFA has been shown to provide consistent pain relief for 3 to 6 months. Using heat generated from electricity delivered via fluoroscopically guided needle electrodes, the procedure denatures the proteins in the 3 genicular nerves responsible for transmitting knee pain. Although there is a paucity of high-quality studies on the efficacy of this procedure, one study found that, on average, GNRFA led to improvement of >60% from baseline knee pain for at least 6 months.

In the authors’ practice, GNFRA is generally not repeated if it is ineffective the first time, but the procedure has been shown to be safe when administered repeatedly in patients who respond well. Proper positioning of the electrodes is essential, but the authors caution that without ample experience, “it may be difficult to isolate the exact anatomic location of ≥1 of the genicular nerves.”

General anesthesia is not required for the procedure, which is commonly performed by interventional pain specialists. Despite theoretical concerns, no Charcot-type joints have been reported after GNRFA. The authors emphasize, however, that the procedure provides temporary relief at best; it does not eliminate the potential for nerve regrowth and does not alter the arthritic disease process. Even more importantly, GNRFA needs to be studied with higher-level clinical research designs, ideally an adequately powered sham/placebo-controlled randomized trial.

For more information about JBJS Essential Surgical Techniques, watch this video featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski.