Dr. Ashok Jadon presents information on using radiofrequency ablation (RFA) to treat chronic knee pain by targeting the genicular nerves. He discusses two patients with pacemakers who underwent the procedure safely using a bipolar RFA technique. Both patients experienced over 70% pain relief initially that lessened to 40-50% relief after 6 months but were satisfied with the results. The document concludes bipolar RFA is a safe and effective approach for managing chronic knee pain in patients with pacemakers and more research is still needed.

1. Dr Ashok Jadon,
MD, DNB, MNAMS, FIPP
Chief Consultant Anaesthesia
In-charge Pain Relief Service
Tata Motors Hospital
Jamshedpur-831004
India

2. Background
 Chronic pain in the knees accounts for 15% of chronic pains
in the body.
 Degenerative cause e.g. osteoarthritis is one of the
commonest cause of knee pain
 Radiofrequency ablation (RFA) is a new interventional
approach being used to manage chronic knee pain*
 Three genicular nerves are the targets for RFA*
*Choi, Woo-Jong, et. al."Radiofrequency treatment relieves chronic knee osteoarthritis
pain: a double-blind randomized controlled trial." PAIN 2011;52: 481-487.

3. Genicular nerves
 Sensory nerves branches of the tibial, common peroneal and
obturator nerves.
 They supply the capsule of the knee joint as well as the
intraarticular and extraarticular ligaments.
 Tibial nerve: superior medial, inferior medial and middle
genicular
 Common peroneal nerve: superior lateral and the lateral inferior
genicular
 Obturator nerve: branch of the posterior division of the obturator
nerve

4. RFA of genicular nerves; conventional technique
S
H
A
F
T
EPICONDYLE

5. RFA with pace maker; concerns
 With RFA a variety of changes in pacemaker are possible
during and after the treatment.
 EMI (Electromagnetic interference )
 Sensing failures in 32.0%
 pacing failures in 16.0%
 Prolonged pauses ,
 Tachy-arrhythmias &
 complete pacemaker inhibition
Pfeiffer D, et al. Pacemaker function during radiofrequency
ablation. Pacing Clin Electrophysiol 1995; 18: 1037-44.

6. RFA with pace maker; current guidelines-1
 ASA Practice advisory ; after report by the ASA task force on
for the perioperative management of patients with cardiac
implantable pacemakers. Anesthesiology 2011; 114: 247―261.
 Deactivation of implanted generators and an external pacing electrode.
 Keep grounding electrode 15cm away from pacing leads
 Use “00” mode
 Use Magnet over Pace maker
 Cardiac monitoring
 Pacing system should be carefully evaluated after the procedure.

7. RFA with pace maker; ASA guidelines-2
Use a bipolar electro-cautery system
or an ultrasonic (harmonic) scalpel if
possible.

8. Bipolar RFA

9. Two patients with pacemaker
 64 yrs old male
 He has osteoarthritic changes*
in both knees but left knee was
having sever
 He was on Tablet Losartan,
Asprin, Pregablin,
Amitrptiline and Tramadol
with paracetamol.
 Pacemaker for syncope
 RFA due to refusal for knee
implant due to poor cadiac
reserve and associated high
risk for surgery.
 56yrs female
 Right knee osteoarthritis *
 She was on Tan Nifidipine
retard, pregablin, paracetamol
and pentaprazol
 Pacemaker for complete heart
block with pain in
 RFA due to side effects of
analgesic drugs (gastric ulcer)
and unwillingness for surgery.
*(Kellgren-Lawrence scale (K-L scale) 3-4

10. Methods:
 Medical treatment optimized
 Informed consent
 Physician informed and involved
 With due aseptic precaution under local anaesthesia two 10cm needle with
5mm tip inserted at all three target points
 Needles were inserted parallel (10mm apart)under AP view and depth was
checked in lateral view (up to 2/3 distance of bone)
 Bipolar RFA 80◦C for 90 sec. at each of the three target points (two cycles)
 Pain was evaluated on Oxford Knee Score and VRS before procedure, and at
1wk, 1 month (in hospital) and monthly for 6 months (Telephonic)

11. Patient-1

12. Patient-2

13. Pain relief; Oxford score and VRS
Base
line
OKS
(0-48) &
VRS
(0-10)
One
week
One
month
2nd
Month
3rd
Month
4th
month
5th
month
6th
month
Other
remarks
Case-1
VRS
42
9/10
20
3
20
3
20
3-4
23
3-4
26
4-5
28
5-6
29
3-6
Happy on
medicine
Case-2
VRS
40
9/10
22
2
20
3
20
4
20
3
24
5
30
4-6
30
3-6
TKR

14. Results: Oxford score & VRS
Procedure was uneventful
>70 to 80% relief for 2 and 3 months
40-50% relief at 6months
Satisfied

15. Discussion
 RFA with bipolar electrodes is safe in patients with
pacemakers.
 Yuman fong. Hepatobiliary cancer.In billiary tumors.Chapter-
14;2013:pmph-usa
 Two patients with pacemakers who safely underwent radiofrequency
ablation with bipolar electrodes to treat primary hepatocellular
carcinoma. Sho Ijuin, et al., KANZO 2015 56(2):57-64.
 Bipolar is effective RFA for knee pain
 8 cases done (including leading orthopedic surgeon)
 Results similar to conventional may be better
 Less painful, Less time taking

16. Conclusions
 Bipolar RFA of genicular nerves was safe and effective
to manage chronic knee pain in two patients with
pace maker.
 More studies with more number of cases are required
to prove the ultimate safety of this procedure

18. USG guided PRF
 Tibial, Common peronial, femoral nerve , Saphenous,
subsartorial, peripatellar, and popliteal plexuses along with
innervation of the quadriceps muscle.