الفهرس 
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Abstract
Knee osteoarthritis (KOA) is a common disease in middle-aged and elderly people. Pain is the chief complaint and a leading cause of chronic disability.
Previous research has shown knee pain in OA to be multifactorial. Mechanical, structural, inflammatory, bone-related, neurological and psychological factors play a role in the process that results in painful knee OA.
Several pro-inflammatory mediators including nerve growth factor (NGF), nitric oxide (NO) and prostanoids may be recruited into the knee and cause localized damage to tissues, such as synovium, as well as activating peripheral nociceptors. During chronic disease, the nociceptive system can become sensitized, leading to a heightened sensitivity to noxious stimuli (hyperalgesia), and to pain in response to non-noxious stimuli (allodynia). The activation of these nociceptors is subsequently transmitted via the DRG, up through the spinothalamic tract to higher cortical centers where signals are processed and perceived as pain
Many treatment modalities are available depending on the grade of knee OA. Earlier grades of OA are traditionally managed conservatively, whereas surgical knee replacement is the option for advanced grades who might present with multiple comorbidities, making them ineligible for surgery.
Non-steroidal anti-inflammatory and intra-articular corticosteroid are common treatments of arthritis. Despite the low cost of NSAIDs they have many systemic side effects and repeated steroid injections may cause joint cartilage destruction and flare up of the osteoarthritic pro-cess.
Ther¬apeutic options effective on tissue healing have been taken into consideration in recent years in order to prevent the progression of OA. Among these are growth factors that have been studied both in vitro and in vivo as effective factors for the healing of cartilage in OA with promising results.
Platelet-rich plasma (PRP) is an autologous blood derivative containing growth factors released from platelets and endogenous fibrin scaf¬fold. The rational for use of PRP is to stimulate the natural healing cascade and tissue regeneration by a “supra¬-physiologic” release of platelet-derived factors directly at the site of treatment.
Since inflammation and joint damage cause the initiate trigger for pain and although sustained exposure to noxious stimuli can cause neuronal plasticity and a subsequent abnormal sensation of pain, unrelated to the inflammation, the approach of controlling pain by modalities such as nerve blocks and radiofrequency are being introduced in many centers
The targeted branches for nerve block consist of the saphenous nerve, the superior lateral, superior medial, and inferior medial genicular nerves because of their relatively reliable anatomic positions at periosteal areas connecting the femur or tibia shafts to their respective epicondyle. The inferior lateral was not targeted due to its close proximity to the common peroneal nerve.
Nerve blocks may break the pain cycle through interruption of nociceptive signals and allow increased function. This helps to facilitate physical therapy and rehabilitation, thereby preventing disuse muscle atrophy and joint dysfunction.
However, the question of the direct effect of nerve blocks on the healing of cartilage is still not answered, this study was conducted and aimed to evaluate the effect of adding interventional pain management using saphenous and genicular nerve block to PRP on cartilage regeneration and functional recovery in moderate knee OA.
This prospective study was conducted on 45 patients who attended the Physical medicine, Rheumatology and Rehabilitation outpatient clinic at Ain Shams University Hospital with primary knee osteoarthritis diagnosed according to ACR classification of OA of the knee between March 2019 and January 2022.
Patients included were selected with grade 2-3 OA according to Kellgren Lawrence scale and classified randomly into 3 groups (each includes 15 patients) according to the treatment program received: group 1 (ultrasound guided Saphenous and GNB), group 2 (ultrasound guided PRP injection) and group 3 (combined NB + PRP).
To the best of our knowledge, there are no studies in literature assessing our study outcomes. This is the first study to compare between each technique and the combined effect of both of them to treat patients with moderate knee OA.
Most of our patients (66.7%) were middle aged females with mean age of (54.4 ± 5.26). Baseline assessment was fundamental to ensure the similarity of the three groups.
Ultrasound guided injection were done in all three groups to increase the accuracy of knee joint injections whether intra-articular, or saphenous and genicular nerve blocks under aseptic technique.
All studied groups showed significant improvement in pain, function and quality of life that was assessed by using variable knee scoring systems including VAS, WOMAC and SF-12 respectively compared to base line at 1 and 3 months follow up with (P<0.001) in all groups. however, group one (Pain management only) showed at 3 months improvement in all parameters also but with significant rebound in VAS, WOMAC and SF-12 Q still not reaching baseline. Although the combined treatment group 3 showed better improvement in pain on VAS and WOMAC scores at 1 and 3 months in comparison to PRP alone group 2, only the improvement in pain scores was significant between the two groups at 1 month (P=0.046). At 3 months, although the scores were comparable but the improvement was much better in group 3 as they had the worst baseline scores on VAS and WOMAC.
In our study ultrasonography was done before and after 3month of treatment to all studied groups and showed no significant change in sonographic grading after treatment in all study groups regarding effusion, cartilage and osteophyte grading.
Magnetic resonance imaging MRI is one of the most sensitive tools for evaluation of changes in OA and its response to treatment. In our study, we tried to observe the detectable effects if any of PRP alone and PRP+NB on following parameters (subarticular bone marrow abnormality, synovitis, meniscal integrity and maximal thickening of cartilage) and T2 mapping of patellar cartilage. It was done in 50% of patients in PRP and Combined PRP+NB at baseline and 3month after treatment and showed no significant difference between both groups before and after 3month of treatment regarding synovitis, articular cartilage thickness or T2 relaxation time. However, a significant improvement in bone marrow edema at the patellofemoral and medial femorotibial joint (p=0.016, p=0.039 respectively) in group which received combined therapy with no similar changes in PRP only group.