Efficacy and safety of genicular nerve ablation techniques for knee osteoarthritis: a systematic review and meta-analysis of sham-controlled randomized trials

OBJECTIVE: To evaluate the efficacy and safety of genicular neurolysis techniques, including radiofrequency ablation (RFA) and cryoneurolysis, versus sham procedures in adults with knee osteoarthritis (OA) ineligible for arthroplasty. METHODS: This systematic review and meta-analysis included randomized controlled trials (RCTs) comparing cooled, monopolar, or bipolar RFA, or cryoneurolysis, to sham treatment in adults with symptomatic knee OA. Studies with pulsed RFA, active comparators, or lacking pain or function outcomes were excluded. PubMed, Embase, and Cochrane CENTRAL were searched from inception to April 15, 2025, without language restriction. Risk of bias was assessed using the Cochrane RoB 2 tool. Random-effects meta-analysis calculated mean differences (MD) with 95% confidence intervals (CI). Heterogeneity was quantified with I2, and certainty of evidence was rated using GRADE. Trial Sequential Analysis (TSA) assessed conclusiveness. RESULTS: Eight RCTs (n = 627) met eligibility criteria. Compared with sham, ablative techniques significantly reduced pain at 12 weeks (MD -1.65; 95% CI, -2.57 to -0.74; I2 = 83%) and improved WOMAC function scores (MD -11.37; 95% CI, -18.83 to -3.91; I2 = 91%). Subgroup analysis favored conventional monopolar RFA over other modalities. TSA confirmed conclusive benefits for pain at 12 weeks and function at 24 weeks. No serious adverse events were reported. Limitations include high heterogeneity, variable protocols, and limited long-term data. CONCLUSIONS: Genicular neurolysis, particularly conventional monopolar RFA, provides clinically meaningful pain and functional improvement in knee OA with a favorable safety profile. Standardization of techniques and further trials are needed to confirm long-term outcomes. REGISTRATION: PROSPERO CRD420251044248.