الفهرس 
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Abstract
Osteoarthritis is the most widespread chronic jointdisease worldwide.One ofthe most incurred joints in OA is the knee joint, which isthe largest joint and carriesthe heavy burden of the body.The knee joint joins the thigh with the leg and consists of two articulations: tibiofemoral joint and patellofemoral joint. Pain is the most presented complain; which unless well managed causes sensitization and patients endure more. There are many nerves which carry sensation from the knee jointstructures; the most important are the superior medial, inferior medial and superior lateral genicular nerves. Treatments of OA [pharmacologic, physical, injections or surgery] are noteffective in a percentage of patients, and some of themhave adverse effects.PRF reduces pain and stiffness and improves the knee function.Ultrasound guidance improved the success rate and safety of the procedures and helped to avoid complications.
The current study was carried out on 50 patients with primary knee OA [grades 2 or 3] according to Kellgren–Lawrence classification whose pain relief was not achieved with conservative therapies, intra-articular injection of steroids or hyaluronic acid during the last 3 months, admitted to the outpatient clinic of pain medicine, Medical Research Institute, Alexandria University.
The patients were randomly divided into two equal groups using closed envelope method.
group 1: US guided PRF genicular nerves neuromodulation.
group 2: US guided intra-articular knee joint PRF.
Preoperative evaluation:
All the patients were evaluated by history taking and clinical assessment using NRS for pain and WOMAC osteoarthritis index for daily activities and were given a thorough explanation of the scientific basis, the probable risks and benefits of the treatment, as well as the importance of maintaining a pain diary. All patients received a dose of 2 mg midazolam and 20 mcg fentanyl intravenously, as a premedication to alleviate anxiety.
group 1:
Ultrasound-guided genicular nerves PRF:
After patient preparation and skin sterilization; a linear high frequency ultrasound transducer was used to identify the location of superior medial, superior lateral and inferior medial genicular nerves. Color Doppler is then utilized to try and visualize the adjacentgenicular artery which served as a landmark for the genicularnerve.After proper needle tip placement, gentle aspiration was carried out and 2 milliliters of short acting 2%lidocainewas slowly injected.Those whose NRS decreased by at least 50% were scheduled after 1 week for the PRF.The same procedures repeated then advance with the 100-mm radiofrequency [RF] insulated needle, with a 10-mm active tipusing an in plane approach.Confirming the response to sensory [0.6V at 50Hz] and motor stimulation [2.0V at 2Hz] and satisfactory placement of the needle with no motor response, PRF was applied at 42°Canda pulse width of 20 millisecondsfor 8 minutes at each nerve.
group 2:
Ultrasound-guided intra-articular PRF:
Ultrasound was used to evaluate thejunction of the upper and lateral margins of the patella.The ultrasound probe was placed obliquely toward the center of the joint with a counterforce of the patella.After proper needle tip placement, gentle aspiration was carried out and 2 milliliters of short acting 2%lidocainewas slowly injected. Those whose NRS decreased by at least 50% were scheduled after 1 week for the PRF.The same procedures repeated then a 100-mm radiofrequency (RF) insulated needle, with a 10-mm active tip was advanced toward the center of the joint. Then, PRF was applied with 42°C temperature and a pulse width of 20 milliseconds for 15 minutes.
Measurements:
All patients were assessed initially [before intervention] and reassessed after intervention at time intervals of 1, 4 and 12 weeks for a total follow up period of 3 months.
4. Pain assessment, using Numerical Rating Scale [0-10 points] score for pain.
5. Functional assessment, using Western Ontario and Mcmaster Universities [WOMAC] osteoarthritis index for daily activities.
6. Complications were recorded.
Results:
Regarding group I [genicular nerves PRF]; there was a significant reduction in the average NRS for pain at 1 (p<0.001), 4 (p<0.001) and 12 (p<0.001) weeks by about 57% compared with the initial baseline assessment.19 (76%), 21 (84%) and 20 (80%) out of 25patients achieved at least 50% knee painrelief at 1, 4, and 12 weeks, respectively. While 5 (20%), 3 (12%) and 4 (16%) out of 25patients achieved less than 50% knee painrelief at 1, 4, and 12 weeks, respectively, even though they were satisfied by this degree of relief. There was also a significant improvement in the average WOMAC osteoarthritis index for daily activities at 1 (p<0.001), 4 (p<0.001) and 12 (p<0.001) weeks by about 58.5% compared with the initialbaseline assessment. Complications were minimal, including some degree of pain at injection sites during the procedure when the needle tip came in contact with the periosteum, bruises and hematoma formation at the injection sites following the procedures.
group II [intra-articular PRF]; there was a significant reduction in the average NRS for pain at 1 (p<0.001), 4 (p<0.001) and 12 (p<0.001) weeks by about 38.5% compared with the initial baseline assessment.14 (56%), 15 (60%) and 14 (56%) out of 25patients achieved at least 50% knee painrelief at 1, 4, and 12 weeks, respectively. While 10 (40%), 9 (36%) and 10 (40%) out of 25patients achieved less than 50% knee painrelief at 1, 4, and 12 weeks, respectively, even though they were satisfied by this degree of relief. There was also a significant improvement in the average WOMAC osteoarthritis index for daily activities at 1 (p<0.001), 4 (p<0.001) and 12 (p<0.001) weeks by about 48.3% compared with the initialbaseline assessment. Complications were minimal, including bruises and hematoma formation at the injection sites following the procedures. No major adverse events; like haemarthrosis or septic arthritis were noted during the follow up period
Comparing the results of both groups; group I [genicular nerves PRF] provided more reduction of pain than group II [intra-articular PRF]at each follow up visits. WOMAC osteoarthritis index score in both groups over time after intervention stated that the functionality of the patients in both studied groups was improved.No patient reported apost-procedure adverse event during the follow-up period.