Knee Presentation Coolief

Knee Cooled RF
Training Presentation
Disclaimer
● The information provided in the following presentations is for educational purposes only. Techniques
can vary depending on the individual expertise, experience and school-of-thought of the licensed
healthcare professional physician using COOLIEF* Cooled RF. Always use your independent medical
judgement and discretion when using COOLIEF* Cooled RF*. The procedures described herein are
not a recommendation by Avanos Medical for certain placement techniques and only aim to present
information based on current medical literature and clinical data.
● Healthcare providers are solely responsible for ensuring that any medical procedures they perform,
including ones involving COOLIEF* Cooled RF, are within their licensed scope of practice and that
they have appropriate facility credentials. Avanos’ training of a range of healthcare professionals does
not imply Avanos’ belief that any individual healthcare professional is properly licensed or credentialed
to perform the procedures that are the subject of the training.
● The following presentations are not intended as a recommendation to purchase or use Avanos
products.
● Avanos Medical, Inc. is sponsoring this presentation. The presentation has been reviewed by Avanos
and is consistent with Avanos product labeling.
● There are inherent risks in all medical devices. For complete product information, including indications,
contraindications, warnings, precautions, and potential adverse effects, see the COOLIEF* Cooled RF
Instructions For Use at www.avanospainmanagement.com.
2
Agenda
Indication for Use
Patient Selection Considerations
Diagnostic Block
Procedure Technique
Precautions
Summary
Appendix
3
Indication for Use
The COOLIEF* Cooled Radiofrequency Probe is to be

used in conjunction with a radiofrequency generator to create
lesions in nervous tissue. This device is also indicated for
creating radiofrequency lesions of the genicular nerves for the
management of moderate to severe knee pain of more than 6
months with conservative therapy, including medication, in
patients with radiologically-confirmed osteoarthritis (grade 2-4)
and a positive response (≥50% reduction in pain) to a
diagnostic genicular nerve block.
Please see Instructions for Use for detailed information regarding proper use
that includes indications and lists of warnings, precautions and
contraindications 4
Diagnosis
● Osteoarthritis of Knee; ICD-10 Code (M17.0)
– COOLlEF* Cooled RF is indicated for creating radiofrequency lesions of the genicular

nerves for the management of moderate to severe kneepain of more than 6 months
with conservative therapy, including medication, in patients with radiologically-
confirmed osteoarthritis (grade 2-4) and a positive response (≥50% reduction in pain)
to a diagnostic genicular nerve block.
● Chronic knee pain > 6 months, and no longer adequately managed by

conservative therapy; ICD-10Diagnostic Block
Code (M25.569)
● Greater than 50% pain relief from a single block of the geniculate nerves
(no more than 0.5–1.0 mL injectate per block)
6
Diagnostic Block
Geniculate Branch Diagnostic Block Technique
● Supine position with ipsilateral knee elevated

using towels. Sterile prep and drape with strict
aseptic technique.
● AP image of knee joint.

Identify 3 target sites:
– Superior lateral geniculate nerve where the lateral
femoral shaft meets the epicondyle
– Superior medial geniculate nerve where the
medial femoral shaft meets the epicondyle
– Inferior medial geniculate nerve where the medial
tibial shaft meets the condyle
● Recommendation is to anesthetize skin and

soft tissues with 1% Lidocaine. At each target,
advance 25 gauge needle using “tunnel
technique” until bony contact is made. DO NOT block the inferior lateral
geniculate nerve. Lesioning this
● Adjust c-arm fluoroscopy for lateral image to nerve has a high probability to
assess for appropriate placement. Maneuver injure the adjacent common
needle tip to be half-way across diaphysis
before injecting high potency 0.5–1.0 ml local
peroneal nerve.
anesthetic at each site
8
Suprapatellar Branch Diagnostic Block Technique
● Physician to determine if lesioning the nerve

from the rectus intermedius supplying the
subpatellar plexus (referred to as “suprapatellar
branch”) would be appropriate
● Target is Midline femur about 3 cm cephalad of

the upper patellar border
– Utilize cm markings on the introducer needle
● Obtain a lateral view to verify appropriate

positioning of introducer on periosteum
9
Diagnostic Block Technique
10
COOLIEF* Cooled RF Technique
● Use same positioning and targets as the prognostic block
● Remove stylet, insert probe and stimulate each geniculate nerve branch at
2 Hz up to 1-2 volts searching for any lower extremity motor activity.
● The inferior lateral geniculate branch is deliberately omitted to avoid potential

lesioning of the common peroneal/fibular nerve.
12
● If no motor response is observed, then remove the probe and inject

local anesthetic into each introducer prior to lesioning.
● Radiofrequency lesioning setting at 60°C (80°-90° adjacent tissue

temperature) for 2:30 min at each site.
13
Optional 4th Lesion
● Optional lesion for the nerve from the rectus intermedius supplying the
subpatellar plexus.
14
Common Mistake
Condyles Misaligned
15
COOLIEF* Cooled RF Treatment for
Post-prosthetic Knee Pain
Menzies, Robert D., and Jeffery K. Hawkins. "Analgesia and improved performance in a patient treated by cooled
radiofrequency for pain and dysfunction post-bilateral total knee replacement." Pain Practice 15.6 (2015).
16
Procedural Video
17
Precautions
Precautions
● DO NOT block the inferior lateral geniculate nerve. Lesioning this nerve may
potentially injure the adjacent common peroneal nerve.
● Motor testing must be performed
● Risk of advancing too far in AP view
● Risk of eschar formation if too superficial. Highest risk at inferomedial branch.
● For patients with cardiac pacemakers, a variety of changes can occur during
and after the treatment. In sensing mode the pacemaker may interpret the RF
signal as a heartbeat and may fail to pace the heart. Contact the pacemaker
company to determine if the pacemaker should be converted to a fixed-rate
pacing during the radiofrequency procedure. Evaluate the patient’s pacing
system after the procedure.
19
Summary
Summary: RFL for Peripheral Joint Pain
● The anatomic basis for therapeutic partial sensory denervation

of the knee joint by Cooled RF lesioning techniques has been
demonstrated.
● Adjacent neurovascular structures and variations in anatomic
innervation must be considered in order to plan safe and
effective RF denervation procedures.
● Strong evidence exists for knee RF denervation
21
Thank You
For more information, please visit
avanospainmanagement.com
1-800-448-3569
1-844-4AVANOS (1-844-428-2667)
*Registered Trademark or Trademark of Avanos Medical, Inc. or its affiliates.

© 2018 AVNS. All rights reserved.
RESHAPING
THERMAL RADIOFREQUENCY
22 PAIN RELIEF
Appendix
Knee Outcomes
Clinical Literature
Author Year Published Journal Type
Chen 2020 BMC Musculoskeletal Disorders Randomized, Prospective Trial
Title Cooled Radiofrequency Ablation Provides Extended Clinical Utility in the Management of Knee Osteoarthritis: 12-Month
Results from a Prospective, Multi-Center, Randomized, Cross-Over Trial Comparing Cooled Radiofrequency Ablation to a
Single Hyaluronic Acid Injection
Publication Overview This was a 12-month follow-up to the 6-month Chen study; it reviews pain relief in patients 12 months after receiving CRFA and the 6 month
pain-relieving effects of CRFA in patients who crossed over after receiving HA in the original study.
Summary Points CRFA can provide pain relief for at least 12 months and it is also effective in patients who had unsatisfactory pain relief results from
receiving HA.
Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/32517739
Chen 2020 Journal of Bone and Joint Surgery Randomized, Prospective Trial
Title Cooled Radiofrequency Ablation Compared with a Single Injection of Hyaluronic Acid for Chronic Knee Pain
Publication Overview The effectiveness of CRFA and a single HA injection were compared with regard to pain relief, function, and patient satisfaction 6
months post-procedure.
Summary Points CRFA is superior to HA in pain reduction, function, and patient satisfaction 6 months post-procedure.
Hagedorn 2020 Pain Medicine Literature Review
Title Beyond Revision Surgery: Work-Up and Interventional Treatments for the Painful Total Knee Arthroplasty
Publication Overview The authors outline the diagnosis and evaluation of painful TKA and review interventional strategies for pain management.
Summary Points Genicular RFA has been well studied, is considered safe, and has been shown to confer long-lasting improvements in pain and function in
post-TKA patients.
25
Clinical Literature
Davis 2019 Regional Anesthesia and Pain Medicine Randomized Prospective Trial
Title Twelve-Month Analgesia and Rescue, By Cooled Radiofrequency Ablation Treatment of Osteoarthritic Knee Pain: Results
from a Prospective, Multi-Center, Randomized, Cross-Over Trial
Publication Overview This was a 12 month follow up to the 2018 Davis study; it reviews pain relief in patients 12 months after receiving CRFA and the 6 month
pain-relieving effects of CRFA in patients who crossed over after receiving IAS in the original study.
Summary Points CRFA can provide pain relief for at least 12 months and it is also effective in patients who had unsatisfactory pain relief results from
receiving IAS injections.
Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/30772821
Hunter 2019 Regional Anesthesia and Pain Medicine Long-Term Follow-Up from
Randomized, Prospective Trial
Title Cooled Radiofrequency Ablation Treatment of the Genicular Nerves in the Treatment of Osteoarthritic Knee Pain: 18 and
24-Month Results
Publication Overview In this long term follow up to the 2018 Davis study, the effects of CRFA are examined at 18 and 24 months post-procedure in subjects who
originally received CRFA and subjects who crossed over to receive CRFA.
Summary Points CRFA can provide improved pain levels, functionality, and perceived effects in knee OA patients through 24 months.
Orhurhu 2019 Current Pain and Headache Reports Systematic Review
Title Systemic Review of Radiofrequency Ablation for Management of Knee Pain

Publication Overview The authors examined 18 publications related to the use of RF in the knee to assess the short- and long-term effects of the procedure.
Summary Points RF treatments provide immediate, short-term, and long-term pain relief in patients with knee OA.
26
Clinical Literature
Davis 2018 Regional Anesthesia and Pain Medicine Randomized Prospective Trial
Title Prospective, Multicenter, Randomized, Crossover Clinical Trial Comparing the Safety and Effectiveness of Cooled
Radiofrequency Ablation with Corticosteroid Injection in the Management of Knee Pain From Osteoarthritis
Publication Overview The effectiveness of CRFA and a single corticosteroid injection were compared with regard to pain relief 6 months post- procedure.
Summary Points CRFA is superior to a single steroid injection in pain reduction 6 months post-procedure.
Jamison 2018 Journal of Pain Research Literature Review
Title Radiofrequency Techniques to Treat Chronic Knee Pain: A Comprehensive Review of Anatomy, Effectiveness, Treatment
Parameters, and Patient Selection
Publication Overview The authors evaluate 9 clinical studies related to RFA, reviewing the anatomy, selection criteria, parameters, clinical studies, and
complications.
Summary Points RFA, including CRFA, is an effective treatment option for knee OA patients, with effects sustaining for at least 3 months.
Ariel De Lima 2018 Revista Brasileira de Ortopedia Literature Review
Title Indications of the Neurotomy of Genicular Nerves by Radiofrequency for the Treatment of Knee Osteoarthritis: A Literature
Review
Publication Overview The present review study evaluated 19 papers searching for the main indications of RF for the treatment of knee OA.
Summary Points The careful reading of the 19 analyzed papers suggests that RF can be considered as another weapon in the therapeutic
armamentarium to alleviate chronic knee pain secondary to OA or persistent pain after TKA.
Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/31363275/
27
Clinical Literature
McCormick 2017 Pain Medicine Retrospective, Cross-Sectional Survey
Title Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Knee Osteoarthritis: Six- Month
Outcomes
Publication Overview The authors surveyed patients who underwent CRFA six or more months after the procedure to assess pain levels, global subjective
improvement, and medication usage. It also aimed to identify factors that contributed to more successful outcomes.
Summary Points CRFA improves pain and functionality and has the potential to provide total pain relief in knee OA patients 6 months post- procedure. Pain
duration and diagnostic blocks can serve as predictors of success for the procedure.
McCormick 2017 Pain Medicine Prospective Randomized Trial
Title A Prospective Randomized Trial of Prognostic Genicular Nerve Blocks to Determine the Predictive Value for the Outcome of
Cooled Radiofrequency Ablation for Chronic Knee Pain Due to Osteoarthritis
Publication Overview The authors evaluated the potential of nerve blocks to predict the outcome of CRFA by comparing pain reduction after 6 months in
patients who received nerve blocks with that of those who did not.
Summary Points CRFA improves pain and functionality at 6 months and effectiveness is not impacted by the implementation of nerve blocks prior to the
procedure.
Camprodon 2017 Clinical Trials in Degenerative Disease Retrospective Case Series
Title Pain Treatment with Cooled Radiofrequency in Osteoarthritis and Total Knee Arthroplasty: Case Series in Hospital
Universitario De Son Espases
Publication Overview The authors reviewed the records of 40 patients who underwent CRFA of the genicular nerve to analyze the results of CRFA one year post-
procedure.
Summary Points CRFA is effective in improving pain, general health, and overall rating one year post-procedure.
Link to Manuscript https://www.researchgate.net/publication/322230274
28
Clinical Literature
Chen 2021 Journal of the American Academy of Systematic Literature Review

Orthopaedic Surgeons
Title Thermal Nerve Radiofrequency Ablation for the Nonsurgical Treatment of Knee Osteoarthritis: A Systematic Literature
Review
Publication Overview This is a broad systematic literature review evaluating the relative effectiveness of geniculate nerve RFA compared with other
nonsurgical treatments for knee OA.
Summary Points The results presented in this review demonstrate geniculate nerve thermal RFA to be a superior nonsurgical treatment of knee OA
compared with NSAIDs and IA corticosteroid injections.
Link to Manuscript https://journals.lww.com/jaaos/Abstract/2021/05010/Thermal_Nerve_Radiofrequency_Ablation_for_the.7.aspx
Zhang 2021 The Journal of International Medical Meta-Analysis

Research
Title Efficacy and Safety of Radiofrequency Ablation for Treatment of Knee Osteoarthritis: A Meta-Analysis of
Randomized Controlled Trials
Publication Overview This study is a meta-analysis of multiple randomized controlled trials to evaluate the efficacy and safety of RFA for treating knee OA. This is
the first article of its type coming from authors in China.
Summary Points This study shows that RFA is effective in managing knee OA. This study combines results from CRFA and standard RFA studies; it
does not draw a difference between the two technologies.
29
Clinical Literature
Chen 2021 Regional Anesthesia and Pain Medicine Multicenter Analysis
Title Clinical and Technical Factors Associated with Knee Radiofrequency Ablation Outcomes: A Multicenter Analysis
Publication Overview The study investigated several demographic, clinical, and technical factors that may affect treatment outcomes for knee RFA.
Summary Points Methods and technologies that increase lesion area (including cooled radiofrequency ablation) were associated with greater pain relief and
were positively associated with treatment outcome.
Eshraghi 2021 Regional Anesthesia and Pain Medicine Retrospective Analysis
Title Cooled Radiofrequency Ablation of the Genicular Nerves for Treatment of Chronic Knee Pain
Publication Overview This retrospective study evaluated the effectiveness of CRFA in the general chronic knee pain population.
Summary Points This study demonstrates the clinical effectiveness of CRFA for the treatment of chronic knee pain by improvements in PDI scores and
NRS scores for the majority of patients.
Link to Manuscript https://rapm.bmj.com/content/early/2021/02/11/rapm-2020-101502
Carlone 2021 Anthroplasty Today Retrospective Review
Title Is Cooled Radiofrequency Genicular Nerve Block and Ablation a Viable Option for the Treatment of Knee
Osteoarthritis?
Publication Overview This retrospective review study determined demographic and psychosocial factors that influence the effectiveness of CRFA and genicular
nerve block treatments in patients with chronic knee pain.
Summary Points CRFA was demonstrated to be effective as part of a multimodal pain regimen.
30
Clinical Literature
Chen 2020 Journal of the American Academy of Literature Review

Orthopedic Surgeons
Title Thermal Nerve Radiofrequency Ablation for the Nonsurgical Treatment of Knee Osteoarthritis: A Systematic Literature
Review
Publication Overview The authors reviewed 7 randomized control trials to evaluate RFA in comparison to other nonsurgical modalities for knee OA.
Summary Points RFA is superior to NSAIDS and IA corticosteroid injections for the treatment of pain from knee OA.
Gonzalez 2020 Techniques in Vascular and Review Article

Interventional Radiology
Title Cooled Radiofrequency Genicular Neurotomy

Publication Overview This article identifies the gap in the treatment options between short-term pain solutions and surgical approaches.
Summary Points This publication was written from the perspective of an interventional radiologist and provides an overview of the technology,
technical considerations, and clinical evidence supporting the use of CRFA.
Rayamajhi 2021 Journal of Nepal Health Research Cross-Sectional Study

Council
Title Clinical Outcome of Cooled Radiofrequency Ablation in Chronic Knee Pain Osteoarthritis: An Initial Experience from Nepal
Publication Overview This cross-sectional study with retrospective review focused on the changes in NRS from baseline to 6 months utilizing CRFA on
patients in Nepal suffering from knee OA. This is the first publication of its type coming out of Nepal.
Summary Points Ultrasound-guided CRFA of genicular targets reduces NRS significantly at all timepoints.
Link to Manuscript http://jnhrc.com.np/index.php/jnhrc/article/view/3450
31
Clinical Literature
Kapural 2019 Pain Physician Retrospective Clinical Trial
Title Long-Term Retrospective Assessment of Clinical Efficacy of Radiofrequency Ablation of the Knee Using a Cooled
Radiofrequency System
Publication Overview The authors reviewed the electronic health records of patients from their clinics and determined patients outcomes based on their charts.
Summary Points CRFA is effective in a large, real world patient population. Repeat CRFA treatments and post-TKR CRFA treatments are as
effective as initial CRFA treatments.
Carrier 2019 Interventional Pain Management Retrospective Chart Review
Title Effectiveness of Genicular Nerve Cooled Radiofrequency Ablation on Chronic Knee Osteoarthritis Pain
Publication Overview The authors analyzed the change in pain scores of 33 subjects who underwent CRFA for knee OA at 2 weeks, 4-6 weeks, and 7-33
weeks post-procedure.
Summary Points CRFA is effective in reducing pain in knee OA patients at 2 weeks and 4-6 weeks post-procedure. BMI does not appear to correlate with
outcomes.
Link to Manuscript https://www.researchgate.net/publication/315886163
Shea 2019 Interventional Pain Management Retrospective Chart Review
Title Conventional Thermal versus Water-Cooled Genicular Nerve Radiofrequency Lesioning: A Retrospective Chart
Review
Publication Overview The authors examined the VAS across the first year of follow-up in patients who received RFA for chronic knee pain to compare
standard to cooled RFA.
Summary Points RFA is effective in improving pain in patients with chronic knee pain through 6 months.
Link to Manuscript https://painmedicine-casereports.com/current/pdf?article=MzI4&journal=18
32
Clinical Literature
House 2019 Pain Medicine Prospective Observational Cohort

Study
Title Severity of Knee Osteoarthritis and Pain Relief After Cooled Radiofrequency Ablation of the Genicular Nerves
Publication Overview Investigators performed 91 knee CRFA procedures in order to identify factors associated with successful results of CRFA.
Summary Points CRFA is most effective when implemented in the earlier stages of knee OA.
Kapural 2020 Pain Management Literature Review
Title A Technological Overview of Cooled Radiofrequency Ablation and its Effectiveness in the Management of Chronic
Knee Pain
Publication Overview The authors examine the clinical benefits, patient selection considerations, and predictors of treatment success for CRFA.
Summary Points CRFA delivers more energy and creates larger lesions than SRFA; it is clinically superior to steroid and HA injections.
Broida 2020 Radiology Case Reports Case Study
Title Alternate Treatment Approach to Subchondral Insufficiency Fracture of the Knee Utilizing Genicular Nerve Cooled
Radiofrequency Ablation and Adjunctive Bisphosphonate Supplementation: A Case Report
Publication Overview A patient with chronic knee pain, who could not undergo surgery due to her lifestyle, received CRFA, and her pain and functionality
were monitored through 6 months.
Summary Points CRFA provides an effective solution for patients with severe knee pain when there is a lack of consensus among doctors, or when surgery is
not desired or not possible.
33
Clinical Literature
Desai 2019 BMC Musculoskeletal Disorders Economic Study
Title Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Osteoarthritis of the Knee: A Cost
Effectiveness Analysis Based on Trial Data
Publication Overview The authors examined the economic outcomes of CRFA, including costs, cost-effectiveness, and health benefits.
Summary Points CRFA is a highly cost-effective treatment for patients with knee OA.
Oladeji 2019 Journal of Knee Surgery Literature Review
Title Cooled Radiofrequency Ablation for the Treatment of Osteoarthritis-Related Knee Pain: Evidence, Indications and Outcomes
Publication Overview The authors reviewed 8 existing publications that investigate the effects of CRFA in patients with knee OA.
Summary Points CRFA is an effective alternative to traditional treatments for patients with knee OA.
Ajrawat 2019 Pain Medicine Systematic Review
Title Radiofrequency Procedures for the Treatment of Symptomatic Knee Osteoarthritis: A Systematic Review
Publication Overview The authors reported on the effect of RFA on pain, functionality, quality of life, patient satisfaction, and adverse events across 33
studies.
Summary Points RFA improves pain, functionality, and QOL in knee OA patients for up to 3-12 months with limited complications.
34
Clinical Literature
Reddy 2016 Anesthesiology and Pain Medicine Case Series
Title Cooled Radiofrequency Ablation of Genicular Nerves for Knee Osteoarthritis Pain: A Protocol for Patient Selection and
Case Series
Publication Overview CRFA was performed on the genicular nerve of 4 patients presenting with knee OA. Pain levels, functionality, and medication
usage were assessed at 6 and twelve months.
Summary Points CRFA was successful in the reduction of pain, improvement of function, and avoidance of surgery at 6 months; however, patients should
be selected under a stringent protocol.
Farrell 2016 PM&R Case Report
Title Demonstration of Lesions Produced by Cooled Radiofrequency Neurotomy for Chronic Osteoarthritic Knee Pain: A Case
Presentation
Publication Overview A patient presented with degenerative joint disease and subsequently received CRFA. In vivo images of the lesions created during ablation
were captured.
Summary Points Images of lesions show CRFA as causing large, spherical lesions, which are thought to be more effective than lesions created in
SRFA.
Gupta 2017 Pain Physician Literature Review
Title Comparative Effectiveness Review of Cooled versus Pulsed Radiofrequency Ablation for the Treatment of Knee Osteoarthritis:
A Systematic Review
Publication Overview The authors reviewed 17 publications related to various kinds of RF for the treatment of knee OA, providing an overview of procedures,
nerve targets, adverse events, and duration of treatment effects.
Summary Points CRFA is an effective treatment for both pre-surgery knee OA patients and post-TKA patients.
35
Clinical Literature
Bellini 2015 Anesthesiology Intensive Therapy Case Series
Title Radiofrequency System Relieves Chronic Knee Osteoarthritis Pain: The First Case-Series
Publication Overview The researchers performed CRFA on the genicular nerve of 9 elderly patients with knee OA; monitored pain and functionality
through 12 months.
Summary Points CRFA of genicular nerves is effective in improving pain and function in patients not recommended for invasive procedures.
Menzies 2015 World Institute of Pain Case Report
Title Analgesia and Improved Performance in a Patient Treated by Cooled Radiofrequency for Pain and Dysfunction Post Bilateral
Total Knee Replacement
Publication Overview A patient who had already had total knee replacements underwent CRFA; the authors monitored his pain and functionality for 9 months
afterward.
Summary Points CRFA is effective in improving pain, function, and medication dependence, even in patients who have already undergone total knee
replacement.
Rojhani 2016 Journal of Physical Medicine & Case Report

Rehabilitation
Title Water-Cooled Radiofrequency Provides Pain Relief, Decreases Disability, and Improves Quality of Life in Chronic Knee
Osteoarthritis
Publication Overview A patient with end-stage knee OA received CRFA, and the authors assessed pain, functionality, and quality of life through 3 months.
Summary Points CRFA has the potential to improve pain, functionality, and quality of life in patients with end stage knee OA, with minimal adverse effects.
36
Anatomy Overview
Peripheral RF for Knee Pain
The knee joint is innervated by the articular branches of various nerves, including
the femoral, common peroneal, saphenous, tibial and obturator nerves.
Hirasawa, Y., et al. "Nerve distribution to the human knee joint: anatomical and immunohistochemical study." International
orthopaedics 24.1 (2000): 1-4.
The cutaneous and articular sensory innervation of the knee region is complex
and displays considerable variation.
Lund, J., et al. "Continuous adductor‐canal‐blockade for adjuvant post‐operative analgesia after major knee surgery:
preliminary results." Acta Anaesthesiologica Scandinavica 55.1 (2011): 14-19.
38
The Sensory Supply to the Knee
● Sensory nerves follow Hilton’s Law1 and derive largely from nerves supplying the
quadriceps muscles. The distal branches were consistent in our 2014 clinical series of 8
knee dissections, agreeing with Gardner2 (1948) and Horner3 (1994) as being related to
the overlying muscle and the capsular attachments to femur and tibia.
● Inferomedial sensation is supplied from a branch of the saphenous nerve.
● Inferolateral sensation is supplied by the peroneal division of the sciatic nerve (fibular
nerve). This is excluded from RF lesioning due to the extensive lower extremity motor
innervation supplied by the peroneal and recurrent peroneal nerve and the inability to
safely perform an exclusively sensory nerve interruption by RF technique given the
proximity of motor nerve fibers.
● The nerves do not follow a fixed vascular supply to the anterior knee joint although a very
small artery and vein is intimately associated with each nerve.
● Nomenclature - Proper names (i.e. nerve from the rectus medialis), geniculate branches
(i.e. superomedial geniculate n.) or retinacular nerves used interchangeably. No
extensive sensory neural rete is present.
1. HÉbert‐Blouin, Marie‐NoËlle, et al. "Hilton's law revisited." Clinical Anatomy 27.4 (2014): 548-555.
2. Gardner, Ernest. "The innervation of the knee joint." The Anatomical Record 101.1 (1948): 109-130.
3. Horner, Gregory, and A. Lee Dellon. "Innervation of the human knee joint and implications for surgery." Clinical orthopaedics and related
research 301 (1994): 221-226.
39
25 ga stainless steel wires outline course of
geniculate nerves
Franco, Carlo D., et al. "Innervation of the anterior capsule of the human knee: implications for
radiofrequency ablation." Regional anesthesia and pain medicine 40.4 (2015): 363-368.
40
Vascularity
41

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Knee Cooled RF

Indication for Use

Patient Selection Considerations

The COOLIEF* Cooled Radiofrequency Probe is to be

● Osteoarthritis of Knee; ICD-10 Code (M17.0)

– COOLlEF* Cooled RF is indicated for creating radiofrequency lesions of the genicular

● Chronic knee pain > 6 months, and no longer adequately managed by

● Supine position with ipsilateral knee elevated

● AP image of knee joint.

● Recommendation is to anesthetize skin and

● Physician to determine if lesioning the nerve

● Target is Midline femur about 3 cm cephalad of

● Obtain a lateral view to verify appropriate

● Use same positioning and targets as the prognostic block

● The inferior lateral geniculate branch is deliberately omitted to avoid potential

● If no motor response is observed, then remove the probe and inject

● Radiofrequency lesioning setting at 60°C (80°-90° adjacent tissue

● Motor testing must be performed

● Risk of advancing too far in AP view

● Risk of eschar formation if too superficial. Highest risk at inferomedial branch.

● The anatomic basis for therapeutic partial sensory denervation

*Registered Trademark or Trademark of Avanos Medical, Inc. or its affiliates.

Chen 2020 BMC Musculoskeletal Disorders Randomized, Prospective Trial

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/32517739

Author Year Published Journal Type

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/32898379

Author Year Published Journal Type

Hagedorn 2020 Pain Medicine Literature Review

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/3251773

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/30772821

Author Year Published Journal Type

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/31605667

Author Year Published Journal Type

Orhurhu 2019 Current Pain and Headache Reports Systematic Review

Title Systemic Review of Radiofrequency Ablation for Management of Knee Pain

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/31286282

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/29095245

Author Year Published Journal Type

Jamison 2018 Journal of Pain Research Literature Review

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/30271194

Author Year Published Journal Type

Ariel De Lima 2018 Revista Brasileira de Ortopedia Literature Review

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/31363275/

McCormick 2017 Pain Medicine Retrospective, Cross-Sectional Survey

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/28431129

Author Year Published Journal Type

McCormick 2017 Pain Medicine Prospective Randomized Trial

Link to Manuscript https://www.ncbi.nlm.nih.gov/pubmed/29300971

Author Year Published Journal Type

Camprodon 2017 Clinical Trials in Degenerative Disease Retrospective Case Series

Link to Manuscript https://www.researchgate.net/publication/322230274

Chen 2021 Journal of the American Academy of Systematic Literature Review

Link to Manuscript https://journals.lww.com/jaaos/Abstract/2021/05010/Thermal_Nerve_Radiofrequency_Ablation_for_the.7.aspx

Author Year Published Journal Type

Zhang 2021 The Journal of International Medical Meta-Analysis

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/33887985

Chen 2021 Regional Anesthesia and Pain Medicine Multicenter Analysis

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/33483425

Author Year Published Journal Type

Eshraghi 2021 Regional Anesthesia and Pain Medicine Retrospective Analysis

Link to Manuscript https://rapm.bmj.com/content/early/2021/02/11/rapm-2020-101502

Author Year Published Journal Type

Carlone 2021 Anthroplasty Today Retrospective Review

Link to Manuscript https://pubmed.ncbi.nlm.nih.gov/33604437