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 physician
using COOLIEF* Cooled RF. Always use your independent medical
judgment and discretion when using COOLIEF* Cooled RF. The
procedures described herein are not a recommendation by AVANOS for
certain placement techniques and only aim to present information
based on current medical literature and clinical data.

● The following presentations are not intended as a recommendation

to purchase or use AVANOS* products.

● AVANOS is sponsoring this presentation. The presentation

has been reviewed by AVANOS and is consistent with
their product labeling.

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 Dr Robin Correa

Consultant Pain Management and Anaesthetics

University Hospitals Coventry and Warwickshire NHS Trust
robin.correa@uhcw.nhs.uk
Profile

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Location

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 Juliet

November 2020

Left knee pain began 2011

Constant pain with weight

bearing

Minimal benefit with Pregabalin

475 mg

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 Juliet

April 2022

Another unsuccessful operation

Diagnostic blocks in June followed by a Cooled RF neurotomy

Procedure has been nothing short of a miracle for me. I am able to

comfortably climb stairs, drive and for the first time in years I went for a
short run last week

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COVID

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COVID

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Treatment

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Agenda

Anatomy Overview

Patient Selection Considerations

Diagnostic Block

Procedure Technique

Precautions

Summary

Clinical Literature

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Anatomy Overview
 Anatomy Overview

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.

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Anatomy Overview

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Anatomy Overview

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Patient Selection Considerations
Patient Selection Considerations

Diagnosis

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

● Post arthroplasty knee pain

● Osteorthritis knee pain

● Greater than 50% pain relief from a single block of the geniculate nerves

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Diagnostic Block
Geniculate Branch Diagnostic Block Technique

● Supine position with ipsilateral knee

elevated. Sterile prep and drape with strict
aseptic technique.
● True AP image of distal femur.
Identify 2 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

● Anesthetize skin and soft tissues with

1% Lidocaine. At each target, advance
25 gauge needle using “tunnel technique”
until bony contact is made.
– Repeat using true AP image for proximal tibia.
Identify target for inferior medial geniculate
nerve where the medial tibial shaft meets the
epicondyle using technique above.

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Geniculate Branch Diagnostic Block Technique

● Physician to determine if lesioning the nerve

from the rectus intermedius supplying the
subpatellar plexus.

● DO NOT block the inferior lateral geniculate

nerve. Lesioning this nerve has a high
probability to injure the adjacent common
peroneal nerve.

● Adjust c-arm fluoroscopy for lateral image

– Obtain lateral image to assess for appropriate
placement

● Adjust needle tip to be half-way across diaphysis

before injecting high potency 0.5–1.0 ml local
anesthetic at each site. Target is Midline femur
about 2 cm cephalad of the upper patellar border

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COOLIEF* Cooled RF Technique
COOLIEF* Cooled RF Technique

● Use same positioning and targets as the diagnostic block

● Remove stylet, insert probe and stimulate each geniculate nerve branch at
2 Hz up to 1-2 volt searching for any lower extremity motor activity.

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

of the common peroneal/fibular nerve.

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Modified Needle Placement

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Anatomy Overview

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COOLIEF* Cooled RF Technique

● If no 2 Hz motor response is observed, then remove the probe and

inject 2 ml local anesthetic into each introducer.

● Radiofrequency lesioning setting at 60°C for 2:30 min at each site.

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4th Lesion

● Lesion for the nerve from the vastus intermedius supplying the
subpatellar plexus.

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Common Mistake

Epicondyles Not Lined-up

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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 postbilateral total knee replacement." Pain Practice 15.6 (2015).
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Precautions
Precaution

● DO NOT block the inferior lateral geniculate nerve. Lesioning

this nerve will injure the adjacent common peroneal nerve.

● Need to perform motor testing

● Risk of advancing too far in AP view

● Risk of eschar formation if too superficial

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 Complications

Adverse vascular events are documented in the literature as case reports.

27 cases were reported, 25.9% (7/27) involved the lateral superior genicular artery,
40.7% (11/27) involved the medial superior genicular artery, and 33.3% (9/27)
involved the medial inferior genicular artery.

Most often, these vascular injuries result in the formation of pseudoaneurysm,

arteriovenous fistula (AVF), hemarthrosis, and/or osteonecrosis of the patella.

Is Genicular Nerve Radiofrequency Ablation Safe? A Literature Review and Anatomical Study. Pain
Physician. 2016 Jul;19(5):E697-705

Soo Yeon Kim 1, Phuong Uyen Le 2, Boleslav Kosharskyy, Alan D Kaye 3, Naum Shaparin, Sherry A
Downie 4

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Summary
Summary: RFL for Peripheral Joint Pain

● The anatomic basis for therapeutic partial sensory denervation

of the knee joints 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

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Knee Outcomes
EFORT Congress June 2021
Diagnostic Block Results

52 patients were referred. Of these 39 were TKRs, 2 were UKRs and 11 had
Revision TKR (RTKR). Pain improvement assessed using the 0 to 10 Numerical
Rating Scale for pain (NRS), (0, no pain – 10, maximum imaginable pain)

82% (43/52) reported significant improvement in their knee pain as measured by

the NRS. Median improvement 7, range 5-10 points, (p < 0.01)

36/43 patients were referred for CRFA

7 patients remained pain free & delayed referral

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EFORT Congress June 2021
CRFA Results
Responder defined NRS improvement ≥2

26/36 patients underwent CRFA

76% (16/21) improved following a single course of treatment defined as NRS

≥2 (range -2 to 8, p < 0.05)

3 were lost to follow-up

Median follow-up: 6.5 months (range 70-491 days),

There was no correlation between beneficial effect & time to follow-up or time
since index arthroplasty.

Success of GNI not translating as well to CRFA, median NRS improvement 2 for
CRFA vs. 7 for GNI

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 Clinical Literature
Ikeuchi, Masahiko, et al. "Percutaneous radiofrequency treatment for refractory
anteromedial pain of osteoarthritic knees." Pain Medicine 12.4 (2011): 546-551.
N=35, RF(N=18), Local anesthetic only (N=17). Age 69-85
4, 8, 12 week follow up. Outcome measures: VAS, WOMAC
Statistically significant pain relief (VAS) for the radiofrequency group at 4, 8, and 12 weeks
No adverse events

Choi, Woo-Jong, et al. "Radiofrequency treatment relieves chronic knee osteoarthritis

pain: a double-blind randomized controlled trial." PAIN® 152.3 (2011): 481-487.
Genicular neurotomy vs. sham. N= 38, RF(N=19), sham(N=19);Age 61-75
1, 4, and 12 week follow up. Outcome measures: VAS, Oxford knee scoreIn the RF group 10/17(59%),
11/17(65%), and 10/17(59%) achieved at least 50% knee pain relief at 1, 4, and 12 weeks respectively
No adverse events

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.
Literature review followed by dissection of 8 human knees
Confirmed Choi nerve targets
Innervation of the anterior capsule of the knee follow consistent paths
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 Clinical Literature

Menzies, Robert D., et al. "Analgesia and improved performance in a patient treated
by cooled radiofrequency for pain and dysfunction postbilateral total knee
replacement." Pain Practice 15.6 (2015).
Following CRF neurotomy, the patient reported marked OKS improvements for both knees (left knee,
pain score: 0 to 4 in 3-months; total score: 24 to 42 in 3-months and right knee, pain: 1 to 4 in 1-month;
total: 30 to 42 in 1-month). Pain relief and better knee function occurred up to 9- and 6-months, for the
left and right knees, respectively. Moreover, the patient reported a significant improvement in quality of
life, as illustrated by minimal knee pain, less reliance on analgesics, and ability to walk more freely,
including on stairs.

Bellini, Martina, et al. "Cooled radiofrequency system relieves chronic knee

osteoarthritis pain: the first case-series." Anaesthesiology intensive therapy 47.1
(2015): 30-33.
N=9
There was improvement in VAS pain scores: 2 ± 0.5 at 1-month, 2.3 ± 0.7 at 3-months, 2.1 ± 0.5 at 6-
months, and 2.2 ± 0.2 at 12-months after the procedure. WOMAC score: 20 ± 2 at 1-month, 22 ± 0.5 at
3-months, 21 ± 1.7 at 6-months, and 20 ± 1.0 at 12-months.

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 Clinical Literature

Farrell, Michael E., et al. "Demonstration of Lesions Produced by Cooled

Radiofrequency Neurotomy for Chronic Osteoarthritic Knee Pain: A Case
Presentation." PM&R 9.3 (2017): 314-317.
67 year old male patient
In vivo images of lesions created by cooled RF
MRI offers a visual correlation for the success of cooled RF treating knee osteoarthritis

Rojhani, Solomon, et al. "Water-cooled radiofrequency provides pain relief,

decreases disability, and improves quality of life in chronic knee osteoarthritis."
American journal of physical medicine & rehabilitation 96.1 (2017): e5-e8.
81 year old female patient
Follow up at 6 weeks and 3 months after bilateral cooled RF ablation:
- NRS: 0 (prior to procedure score of 8)
- WOMAC: 22 and 26 (prior to procedure score of 72)

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Thank You