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Can ultrasound-guided radiofrequency ablation of genicular nerves of the knee, be performed without locating corresponding arterial pulsations—a cadaveric study

BMC Musculoskeletal Disorders volume 24, Article number: 654 (2023) Cite this article

Abstract

Introduction

Given the rising prevalence of knee osteoarthritis, radiofrequency ablation of genicular nerves (RFA) has emerged as a promising treatment option for knee pain. The knee has an extremely complex and variable innervation with nearly 13 genicular nerves described. The frequently ablated genicular nerves are the superomedial (SMGN), the superolateral (SLGN), and the inferomedial (IMGN) genicular nerves. Conventionally, under ultrasound guidance, these nerves are ablated near the corresponding arterial pulsations, but due to the rich vascular anastomosis around the knee joint, identifying the arteries corresponding to these constant genicular nerves can be tedious unless guided by some bony landmarks. In this study, we have evaluated whether it is possible to accurately target these three genicular nerves by just locating bony landmarks under ultrasound in human cadaveric knee specimens.

Methods

Fifteen formalin-fixed cadaveric knee specimens were studied. SMGN was targeted 1 cm anterior to the adductor tubercle in the axial view. For SLGN, in the coronal view, the junction of the lateral femoral condyle and shaft was identified, and at the same level in the axial view, the crest between the lateral and posterior femoral cortex was targeted. For IMGN in the coronal view, the midpoint between the most prominent part of the medial tibial condyle and the insertion of the deep fibers of the medial collateral ligament was marked. The medial end of the medial tibial cortex was then targeted at the same level in the axial view. The needle was inserted from anterior to posterior, with an in-plane approach for all nerves. Eosin, 2% W/V, in 0.1 ml was injected. Microdissection was done while keeping the needle in situ. Staining of the nerve was considered a positive outcome, and the percentage was calculated. The nerve-to-needle distance was measured, and the mean with an interquartile range was calculated.

Result

The accuracies of ultrasound-guided bony landmarks of SMGN, SLGN, and IMGN were 100% in terms of staining, with average nerve-to-needle distances of 1.67, 3.2, and 1.8 mm respectively.

Conclusion

It is with 100% accuracy, that we can perform RFA of SMGN, SLGN, and IMGN under ultrasound guidance, by locating the aforementioned bony landmarks.

Peer Review reports

Introduction

Choi et al. first described the radiofrequency ablation (RFA) of genicular nerves for knee pain in osteoarthritis patients in 2011, under fluoroscopic guidance. They targeted the superomedial genicular nerve (SMGN), the superolateral genicular nerve (SLGN), and the inferomedial genicular nerve (IMGN) [1]. The genicular nerve RFA was effective in alleviating chronic osteoarthritis (OA) knee pain, in these randomized trials [2,3,4], longitudinal cohort studies [5,6,7], and meta-analysis [8,9,10,11]. Long-term effects—up to 6 months [7,8,9, 12] and 1 year [5, 7, 13]- can be obtained if the nerves are accurately targeted.

Genicular nerve RFA is a conditionally recommended method in the ACR 2019 guidelines for the management of OA knee [14]. In OA knee patients with grades 2–4 of the Kellegren-Lawrence (K-L) classification, significant pain Visual analogue scale (VAS) > 5, not responding to simple conservative management [5, 15, 16],—unwilling for total knee arthroplasty (TKA) [17], not fit for TKA [18], along with TKA [19], and even after TKA- genicular nerve RFA is practiced [4, 19,20,21,22]. Apart from OA knee patients, cooled RFA was also used for subchondral insufficiency fracture of the knee [23], rheumatoid arthritis (RA) [24], post-Anterior cruciate ligament (ACL) reconstruction [25], and juvenile idiopathic arthritis (JIA) patients with chronic knee pain [26].

The factors that determine the effect of RFA are disease severity, genicular nerve course, nerve needle proximity, and the Gauge (G) of the RFA needle used. The size of the lesion produced by an RFA needle is proportional to its electrode width [27, 28]. As a practical rule, the nerve has to be within twice the electrode's width. For adequate nerve lesions, using smaller electrodes of 20 G or 22 G, the electrode should be on the nerve, and a change of 1 mm can miss the nerve. But with larger electrodes of 18 and 16 G, there can be more flexibility [29]. Hence, the nerves should be precisely localized for ablation.

Out of 13 genicular nerves described around the knee [30], the most targeted nerves are the SMGN, SLGN, and IMGN. It is well established that there are five constant genicular nerves innervating the anterior knee capsule: SMGN, SLGN, IMGN, the recurrent genicular nerve, and the infrapatellar branch of the saphenous nerve (IPBSN) [30, 31]. But the SMGN, SLGN, and IMGN are frequently ablated, and hence included here.

Superomedial genicular nerve

SMGN was previously described as a branch from the tibial nerve, branching from the upper part of the popliteal fossa and curling around the femur, and making bony contact at the shaft and the condyle junction [1, 15, 32,33,34] where it can be targeted. But with further studies, this nerve was found to be a terminal branch of the nerve to the vastus medialis (NVM), which descends with the adductor magnus tendon and makes bony contact around 1 cm anterior to the most prominent part of the adductor tubercle. There are different approaches prevailing for targeting this nerve. Conventionally, the bony cortex near the corresponding artery at the shaft and medial epicondyle junction is used as the landmark for targeting this nerve [24, 35,36,37,38,39]. The junction of the shaft and medial epicondyle of the femur in the coronal plane and half of the depth of the femur in the axial view is also used [40]. Another approach is to target in relation to the adductor tubercle [30, 31, 41,42,43], which is nearly 1 cm anterior to the adductor tubercle [33].

Superolateral genicular nerve

Previously, SLGN was described as a branch from the vastus lateralis [41, 42, 44]. Further anatomical studies revealed that SLGN originated from the sciatic nerve in 90% of the studied specimens and the common peroneal nerve in the remaining 10%. [30, 45] Even though there is variation in origin, the distal course is constant [41]. Conventionally, the nerve is targeted at the bony cortex, near the corresponding artery, over the junction of the shaft and lateral femoral epicondyle [24, 35,36,37,38,39, 42, 44]. Recently described techniques include, targeting the superolateral popliteal fossa, medial to biceps femoris tendon, around 2.6 cm proximal to the most prominent part of the lateral femoral epicondyle visualized under ultrasound [46], or locating the junction of the shaft and lateral epicondyle of the femur in the coronal plane and to target either half of the depth of femur in axial view [32, 40] or the crest separating lateral and posterior cortex, in axial view [43].

Inferomedial genicular nerve

The IMGN was described as arising from the tibial nerve in the popliteal fossa and curving around the tibia to emerge anteriorly, deep to the medial collateral ligament, at the midpoint between the most prominent part of the medial tibial condyle and the medial collateral ligament's (MCL) initial insertion [1, 30, 32,33,34, 41, 47]. Conventionally, it is targeted at the junction of the medial tibial condyle and shaft in the coronal plane and half the girth of the tibia in the axial plane [32, 43, 48] and near the corresponding artery [24, 35,36,37,38,39,40]. Another technique is to target half the distance between the most prominent part of the medial tibial condyle and the insertion of deep fibers of the medial collateral ligament visualized under ultrasound [33, 34].

Though there have been detailed cadaveric study to describe newer anatomical targets, to ablate these genicular nerves in 2021 [43], still genicular nerve ablation is performed with conventional techniques, as evidenced by the studies that succeeded [35, 38]. This may be due to the lack of evidence from multiple studies. So, studies on a greater number of populations from different ethnicities can augment the level of evidence for the same. Hence this study was done to evaluate the accuracy of genicular nerve block, by ultrasound-guided identification of the bony landmarks, described below.

Methodology and techniques

A total of 15 formalin-fixed human cadaveric knee specimens were studied. The age, gender, and length of the cadavers were documented. Ultrasound scanning was performed using the 5–13 MHz linear probe of the Venue Go R3 ultrasonography (USG) machine.

To locate the SMGN landmark (Fig. 1A) the probe was placed in the coronal plane, visualizing the medial joint line, and it was translated superiorly to identify the adductor tubercle. At this point, the probe orientation was changed to a transverse direction, and one cm anterior to the adductor tubercle was measured and identified (Fig. 2).

Fig. 1
figure 1

Schematic representation of target points A-SMGN, B-SLGN, C-IMGN LAT: lateral, MED: medial, POST: posterior, MCL: medial collateral ligament

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Fig. 2
figure 2

SMGN identification under USG guidance. A Probe position. The needle entry is shown by a grey arrow. B The transverse view at the level of the adductor tubercle. The target point of SMGN is marked with a red Asterix. The needle tract is marked by an orange dotted line. Rt- right. Trans- Transverse view

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For the SLGN landmark (Fig. 1B) the probe was placed in the coronal plane, visualizing the lateral joint line, and superiorly translated to identify the junction of shaft and condyle. Then the probe was rotated by 90 degrees to a transverse view to locate the crest between the lateral and posterior cortex (the lateral most end of the lateral cortex) (Fig. 3).

Fig. 3
figure 3

SLGN identification under USG guidance. A- probe position for coronal view. B- Probe position for transverse view. The needle entry point is shown the by a grey arrow. C- longitudinal view. Plus shows the junction of the shaft and lateral femoral epicondyle. D- Transverse view showing the target with red Asterix. The needle track is marked by an orange dotted line. LOG: longitudinal, LT: left

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The IMGN landmark (Fig. 1C), was located with the probe placed in the coronal plane, visualizing the medial joint line, and it was translated inferiorly to visualize the insertion of deep fibres of the MCL. The midpoint between the most prominent part of the medial tibial condyle and the insertion of the medial collateral ligament was identified, and the orientation of the probe was rotated by 90 degrees to a transverse view to locate the medial end of the medial cortex (Fig. 4).

Fig. 4
figure 4

IMGN identification under USG guidance. A- Probe position for longitudinal view. B- Probe position for transverse view. The needle entry is shown by the grey arrow. C- shows the coronal view, plus sign marks the midpoint between the most prominent part of the medial tibial condyle and insertion of deep MCL. D- Transverse view, which shows the target with a red Asterix. The needle track is marked by an orange dotted line. Rt- right, trans-transverse view

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For all three nerves, a 22-gauge Quincke 38-mm spinal needle was inserted, from anterior to posterior with an in-plane approach. 0.1 ml of eosin, 2% W/V was injected. Dissection was done while keeping the needles in situ, under visualization through the SurgiTel EVK450, a loupe microscope, and using microdissection scissors.

Dissection

A cruciform incision with no: 11 surgical blades centering the needle was made for all three nerves. The subcutaneous tissue and fat were removed with microdissection scissors without altering the needle position. The needles were forcefully pierced into the periosteum and bone for anchorage.

For SMGN, the vastus medialis muscle was cut longitudinally, in the middle of the thigh. The fascial tunnel of the vastus medialis was identified. The SMGN was identified inside this tunnel. The nerve was traced proximally to identify its branching from the nerve to the vastus medialis. Then it was traced distally, carefully dissecting the rest of the tissue under visualization through the Loupes microscope.

To dissect the SLGN, the cadaver was positioned in a side-lying position. After skin and subcutaneous dissection, the biceps femoris muscles, the iliotibial tract, and their fascia were cut through the needle and retracted. In this plane, the fatty tissue was carefully removed under visualization through a loupe microscope, keeping the soft tissue just around the needle for anchorage. The common peroneal nerve was identified. The branches of the nerve were dissected carefully, and SLGN was identified as making bony contact near the epicondyle-shaft junction. Then, the remaining soft tissue around the needle was removed by forcing the needle into the periosteum and holding it.

For IMGN, the cadaver was positioned supine. After removing the skin and subcutaneous tissue in the aforementioned manner, the deep fascia was cut through the needle. The MCL was visible. The MCL was cut transversely through the needle and retracted proximally and distally. The fascia was removed using microdissection forceps under a loupe microscope. The needle was advanced to pierce the periosteum to maintain stability. The IMGN and vessels were identified.

For all the three nerves, nerve-to-needle distance were measured using a vernier callipers of 0.1 mm accuracy and 0.01 mm accuracy.

Result

Out of the 15 cadaveric knee specimens studied, 10 (67%) were from male cadavers. The median length of the cadaver is 162.0 cm, with an interquartile range of 154.5 to 169.0 cm. The median age of the cadavers was 66, with an interquartile range of 61 to 70 (Table 1).

Table 1 Demographic details of the cadavers
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Dissection findings

SMGN

The SMGN was the distal branch of the NVM in 100% of the specimens (Fig. 5A). The nerve at the middle of the thigh entered a fascial tunnel, and it took an exit from the fascial tunnel near the distal third of the femur (Fig. 5B). After which it descended down along with the adductor magnus tendon. The nerve made contact with the femur, at 10.15 mm (average) anterior to the adductor tubercle and the adductor magnus insertion. Figure 5C shows the measurement of nerve to needle distance.

Fig. 5
figure 5

Dissected SMGN. A- SMGN originating from the NVM. B- The SMGN is partially dissected out to show its passage through the fascial tunnel. C The distance from nerve to needle tip measured. VM- vastus medialis (All are right knee specimens)

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SLGN

SLGN was originating from the posterior articular nerve (branch of either the sciatic nerve, or the common peroneal nerve) in 73 percent of specimens (n = 11) (Fig. 6), or as a direct branch from the common peroneal nerve in 27 percent of specimens (n = 4) (Fig. 7A). After making bony contact at the shaft-condyle junction, it divided into two branches. We noticed that, in all specimens, the transverse branch was getting stained as the descending branch already descended towards the lateral femorotibial space. The nerve’s path was extremely tortuous (Fig. 7A). Figure 7B shows the measurement of nerve to needle distance.

Fig. 6
figure 6

Popliteal fossa dissection- IMGN, and SLGN origin- The IMGN (Yellow arrow) arising from the tibial nerve and passing deep to the medial gastrocnemius (*). The SLGN branches from the posterior articular nerve, which in turn branches from the sciatic nerve

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Fig. 7
figure 7

A Course of SLGN – Branching from the common peroneal nerve (orange thick arrow), and dividing into 2 branches. Yellow arrow- transverse branch. Orange arrow- descending branch. CPN- Common peroneal nerve (thick white arrow). B nerve to needle distance measured. (Both are right knee specimens)

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IMGN

IMGN originated from the tibial nerve in the popliteal fossa, in 40 percent (n = 6) of the knee specimens (Fig. 6). In 60 percent (n = 9) of the knee specimens, it was found to be branching from the long articular branch of the sciatic or tibial nerve (Fig. 8). Invariable of its origin, it traversed deep to the medial gastrocnemius, curving around the tibia from posterior to anterior as a neurovascular bundle beneath the medial collateral ligament (Fig. 9A). Figure 9B shows the measurement of nerve-to-needle distance.

Fig. 8
figure 8

Popliteal fossa dissection- IMGN origin from the articular nerve. Shows the long articular nerve (orange arrow) originating from tibial nerve to supply the posterior capsule, and gives off IMGN (white arrow), which traverses deep to the medial gastrocnemius (*). Other muscular branches are shown in the blue arrow. Right knee specimen

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Fig. 9
figure 9

Dissected IMGN. A and B IMGN marked with arrows. The Asterix shows the superficial MCL. The star shows deep MCL. The yellow arrow shows the inferomedial genicular vessels. B: measurement of IMGN to needle tip. (Both are right knee specimens)

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The staining characteristics and nerve-to-needle distance of the three nerves are shown in Table 2.

Table 2 Staining and nerve-to-needle distance of genicular nerves
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Discussion

The bony landmarks that we have used for genicular nerve localization are found to be highly accurate. Hence, accurate genicular nerve RFA can be done, even if corresponding arterial pulsations are unidentifiable. During the dissection, we also found that the nerve courses were in accordance with the described landmarks.

SMGN

The SMGN was the distal branch of the NVM in 100% of the specimens, as was described in these anatomical studies [30, 31]. The nerve was stained in 100 percent of the specimens, just like Yasar et al. found in their cadaveric study [33]. Wong et al., Kesikburun et al., Ahmed and Arora, Cankurtaran et al., Gupta et al., and Ghai et al. targeted the nerve anterior to the adductor tubercle in OA knee patients and found to be effective in alleviating pain [34, 36, 42, 44, 46, 49].

The average nerve-to-needle distance measured was 9.9 mm, which is well within any RFA ablation diameter.

SLGN

SLGN had two different origins, as described by Fonkoue et al. and Kim et al. [30, 45]. Our study landmark was 100 percent accurate in terms of staining, like in the previous study by Fonkoue et al. [43]. Further the average nerve-to-needle distance measured was 3.2 mm, which is within the RFA diameter. Hence, at this point, SLGN can be ablated with high accuracy for RFA.

We also found that the crest between the lateral cortex and posterior cortex described by Founke et al. [43] is anatomically the same as half the girth of the femur described by Vanneste et al. and Mittal et al. [32, 40] which is further same as the lateral most end of the lateral cortex. Hence all these descriptions can be used to locate the nerve in axial view.

IMGN

IMGN originated from the tibial nerve in the popliteal fossa, in 40 percent (n = 6) of the knee specimens, as was described by Tran et al. and Robert et al. [50, 51] (Fig. 6) In 60 percent (n = 9) of the knee specimens, it was found to be branching from the long articular branch of the sciatic or tibial nerve, as was described by Kim et al. [45] (Fig. 8). Invariable of its origin, it traversed deep to the medial gastrocnemius, curving around the tibia from posterior to anterior as a neurovascular bundle beneath the medial collateral ligament (Fig. 9A).

In this study, we have targeted the nerve midway between the most prominent part of the medial tibial condyle and the insertion of the deep fibers of MCL, as was done by Yasar et al., Wong et al., Kesikburun et al., and Ghai et al. [33, 34, 46, 52]. We found this to be 100% accurate in in terms of staining. The nerve-to-needle distance was 1.8 mm, and this can be used for RFA.

Conclusion

Our study results showed that the ultrasound guided RFA of SMGN, SLGN, and IMGN can be done, with 100% accuracy by using the described bony landmarks even if the corresponding arterial pulsations are unidentifiable.

Limitations

Less number of cadaveric knee specimens was a limitation.

Availability of data and materials

All data given in study is provided in Supplementary table 1 along with the legend.

Abbreviations

SLGN:

Superolateral genicular nerve

IMGN:

Inferomedial genicular nerve

W/V:

Weight by volume

RFA:

Radiofrequency ablation

K-L:

Kellegren- Lawrence

VAS:

Visual analogue scale

TKA:

Total knee arthroplasty

RA:

Rheumatoid arthritis

JIA:

Juvenile idiopathic arthritis

IPBSN:

Infrapatellar branch of saphenous nerve

NVM:

Nerve to vastus medialis

MCL:

Medial collateral ligament

USG:

Ultrasonography

References

  1. Choi WJ, Hwang SJ, Song JG, Leem JG, Kang YU, Park PH, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain. 2011;152(3):481–7.

    PubMed  Google Scholar 

  2. Qudsi-Sinclair S, Borrás-Rubio E, Abellan-Guillén JF, Padilla Del Rey ML, Ruiz-Merino G. A comparison of genicular nerve treatment using either radiofrequency or analgesic block with corticosteroid for pain after a total knee arthroplasty: a double-blind, randomized clinical study. Pain Pract Off J World Inst Pain. 2017;17(5):578–88.

    Google Scholar 

  3. Davis T, Loudermilk E, DePalma M, Hunter C, Lindley D, Patel N, et al. 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. Reg Anesth Pain Med. 2018;43(1):84–91.

    PubMed  Google Scholar 

  4. Rambhia M, Chen A, Kumar AH, Bullock WM, Bolognesi M, Gadsden J. Ultrasound-guided genicular nerve blocks following total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2021;46(10):862–6.

    PubMed  Google Scholar 

  5. Santana Pineda MM, Vanlinthout LE, Moreno Martín A, van Zundert J, Rodriguez Huertas F, Novalbos Ruiz JP. Analgesic effect and functional improvement caused by radiofrequency treatment of genicular nerves in patients with advanced osteoarthritis of the knee until 1 year following treatment. Reg Anesth Pain Med. 2017;42(1):62–8.

    CAS  PubMed  Google Scholar 

  6. McCormick ZL, Korn M, Reddy R, Marcolina A, Dayanim D, Mattie R, et al. Cooled radiofrequency ablation of the genicular nerves for chronic pain due to knee osteoarthritis: six-month outcomes. Pain Med Malden Mass. 2017;18(9):1631–41.

    Google Scholar 

  7. Iannaccone F, Dixon S, Kaufman A. A review of long-term pain relief after genicular nerve radiofrequency ablation in chronic knee osteoarthritis. Pain Physician. 2017;20(3):E437–44.

    PubMed  Google Scholar 

  8. Wu L, Li Y, Si H, Zeng Y, Li M, Liu Y, et al. Radiofrequency ablation in cooled monopolar or conventional bipolar modality yields more beneficial short-term clinical outcomes versus other treatments for knee osteoarthritis: a systematic review and network meta-analysis of randomized controlled trials. Arthrosc - J Arthrosc Relat Surg. 2022;38(7):2287–302.

    Google Scholar 

  9. Chou SH, Shen PC, Lu CC, Liu ZM, Tien YC, Huang PJ, et al. Comparison of efficacy among three radiofrequency ablation techniques for treating knee osteoarthritis: a systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(14):7424.

    PubMed  PubMed Central  Google Scholar 

  10. Liu J, Wang T, Zhu ZH. Efficacy and safety of radiofrequency treatment for improving knee pain and function in knee osteoarthritis: a meta-analysis of randomized controlled trials. J Orthop Surg. 2022;17(1):21.

    Google Scholar 

  11. Li G, Zhang Y, Tian L, Pan J. Radiofrequency ablation reduces pain for knee osteoarthritis: a meta-analysis of randomized controlled trials. Int J Surg. 2021;91:105951.

    PubMed  Google Scholar 

  12. Koshi E, Cheney CW, Sperry BP, Conger A, McCormick ZL. Genicular nerve radiofrequency ablation for chronic knee pain using a three-tined electrode: a technical description and case series. Pain Med Malden Mass. 2020;21(12):3344–9.

    Google Scholar 

  13. Kidd VD, Strum SR, Strum DS, Shah J. Genicular nerve radiofrequency ablation for painful knee arthritis: the why and the how. JBJS Essent Surg Tech. 2019;9(1): e10.

    PubMed  PubMed Central  Google Scholar 

  14. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72(2):220–33.

    PubMed  PubMed Central  Google Scholar 

  15. Sarı S, Aydın ON, Turan Y, Özlülerden P, Efe U, Kurt Öİ. Which one is more effective for the clinical treatment of chronic pain in knee osteoarthritis: radiofrequency neurotomy of the genicular nerves or intra-articular injection? Int J Rheum Dis. 2018;21(10):1772–8.

    PubMed  Google Scholar 

  16. Kirdemir P, Çatav S, Alkaya SF. The genicular nerve: radiofrequency lesion application for chronic knee pain. Turk J Med Sci. 2017;47(1):268–72.

    CAS  PubMed  Google Scholar 

  17. Lipnick S. Editorial commentary: radiofrequency ablation for patients with osteoarthritis of the knee could be indicated for patients failing conventional nonoperative treatment and wishing to avoid total knee arthroplasty. Arthrosc J Arthrosc Amp Relat Surg. 2022;38(7):2303–6.

    Google Scholar 

  18. Podmore B, Hutchings A, van der Meulen J, Aggarwal A, Konan S. Impact of comorbid conditions on outcomes of hip and knee replacement surgery: a systematic review and meta-analysis. BMJ Open. 2018;8(7): e021784.

    PubMed  PubMed Central  Google Scholar 

  19. Stake S, Agarwal AR, Coombs S, Cohen JS, Golladay GJ, Campbell JC, et al. Total knee arthroplasty after genicular nerve radiofrequency ablation: reduction in prolonged opioid use without increased postsurgical complications. JAAOS Glob Res Rev. 2022;6(8):e22.00125.

    Google Scholar 

  20. Wylde V, Beswick A, Bruce J, Blom A, Howells N, Gooberman-Hill R. Chronic pain after total knee arthroplasty. EFORT Open Rev. 2018;3(8):461–70.

    PubMed  PubMed Central  Google Scholar 

  21. Kukreja P, Venter A, Mason L, Kofskey AM, Northern T, Naranje S, Ghanem E, Lawson P Jr, Kalagara H, Lawson PA. Comparison of genicular nerve block in combination with adductor canal block in both primary and revision total knee arthroplasty: a retrospective case series. Cureus J Med Sci. 2021;13(7):16712.

    Google Scholar 

  22. Khan FM, Tran A, Wong PKW, Aiyedipe S, Loya MF, Cristescu MM, et al. Management of uncomplicated total knee arthroplasty chronic pain and stiffness utilizing cooled radiofrequency ablation: a single institution pilot study. Skeletal Radiol. 2022;51(6):1215–23.

    PubMed  Google Scholar 

  23. Broida SE, Wong PKW, Umpierrez E, Kakarala A, Reimer NB, Gonzalez FM. Alternate treatment approach to subchondral insufficiency fracture of the knee utilizing genicular nerve cooled radiofrequency ablation and adjunctive bisphosphonate supplementation: a case report. Radiol Case Rep. 2020;15(6):691–6.

    PubMed  PubMed Central  Google Scholar 

  24. Elsaman AM, Maaty A, Hamed A. Genicular nerve block in rheumatoid arthritis: a randomized clinical trial. Clin Rheumatol. 2021;40(11):4501–9.

    CAS  PubMed  Google Scholar 

  25. Deviandri R, Yuliana V, Irawan D, Rahman AN. Genicular nerve radiofrequency ablation for pain control following anterior cruciate ligament reconstruction - a case report. Trauma Case Rep. 2022;40: 100661.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Radwan A, Ohrndorf S, Aly H, Hamed M, Khalifa A, Elsaman AM. Genicular nerve block in juvenile idiopathic arthritis: a randomized clinical trial. Clin Rheumatol. 2023; 42(3):879–88.

  27. Bogduk N, Macintosh J, Marsland A. Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain. Neurosurgery. 1987;20(4):529–35.

    CAS  PubMed  Google Scholar 

  28. Cosman ER, Dolensky JR, Hoffman RA. Factors that affect radiofrequency heat lesion size. Pain Med Malden Mass. 2014;15(12):2020–36.

    Google Scholar 

  29. Schneider BJ, Doan L, Maes MK, et al. Systematic review of the effectiveness of lumbar medial branch thermal radiofrequency neurotomy, stratified for diagnostic methods and procedural technique. Pain Med. 2020;21(6):1122–41. https://doi.org/10.1093/pm/pnz349.

    Article  PubMed  Google Scholar 

  30. Fonkoué L, Behets C, Kouassi JÉK, Coyette M, Detrembleur C, Thienpont E, et al. Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study. Surg Radiol Anat SRA. 2019;41(12):1461–71.

    PubMed  Google Scholar 

  31. Fonkoue L, Behets CW, Steyaert A, Kouassi JE, Detrembleur C, De Waroux BL, Cornu O. Accuracy of fluoroscopic-guided genicular nerve blockade: a need for revisiting anatomical landmarks. Reg Anesth Pain Med. 2019;44(10):950–8.

  32. Vanneste B, Tomlinson J, Desmet M, Krol A. Feasibility of an ultrasound-guided approach to radiofrequency ablation of the superolateral, superomedial and inferomedial genicular nerves: a cadaveric study. Reg Anesth Pain Med. 2019;44(10):966–70.

  33. Yasar E, Kesikburun S, Kılıç C, Güzelküçük Ü, Yazar F, Tan AK. Accuracy of ultrasound-guided genicular nerve block: a cadaveric study. Pain Physician. 2015;18(5):E899-904.

    PubMed  Google Scholar 

  34. Kesikburun S, Yaşar E, Uran A, Adigüzel E, Yilmaz B. Ultrasound-guided genicular nerve pulsed radiofrequency treatment for painful knee osteoarthritis: a preliminary report. Pain Physician. 2016;19(5):E751-759.

    PubMed  Google Scholar 

  35. Güler T, Yurdakul FG, Önder ME, Erdoğan F, Yavuz K, Becenen E, et al. Ultrasound-guided genicular nerve block versus physical therapy for chronic knee osteoarthritis: a prospective randomised study. Rheumatol Int. 2022;42(4):591–600.

    PubMed  PubMed Central  Google Scholar 

  36. Wong J, Bremer N, Weyker PD, Webb CAJ. Ultrasound-guided genicular nerve thermal radiofrequency ablation for chronic knee pain. Case Rep Anesthesiol. 2016;2016:1–3.

    Google Scholar 

  37. Yilmaz V, Umay E, Gundogdu I, Aras B. The comparison of efficacy of single intraarticular steroid injection versus the combination of genicular nerve block and intraarticular steroid injection in patients with knee osteoarthritis: a randomised study. Musculoskelet Surg. 2021;105(1):89–96.

    CAS  PubMed  Google Scholar 

  38. Chang YW, Tzeng IS, Lee KC, Kao MC. Functional outcomes and physical performance of knee osteoarthritis patients after ultrasound-guided genicular nerve radiofrequency ablation. Pain Med Malden Mass. 2022;23(2):352–61.

    Google Scholar 

  39. Kim DH, Choi SS, Yoon SH, Lee SH, Seo DK, Lee IG, et al. Ultrasound-guided genicular nerve block for knee osteoarthritis: a double-blind, randomized controlled trial of local anesthetic alone or in combination with corticosteroid. Pain Physician. 2018;21(1):41–52.

    PubMed  Google Scholar 

  40. Mittal N, Catapano M, Peng PWH. Knee ablation approaches. Phys Med Rehabil Clin N Am. 2021;32(4):779–90.

    PubMed  Google Scholar 

  41. Franco CD, Buvanendran A, Petersohn JD, Menzies RD, Menzies LP. Innervation of the anterior capsule of the human knee: implications for radiofrequency ablation. Reg Anesth Pain Med. 2015;40(4):363–8.

    PubMed  Google Scholar 

  42. Ahmed A, Arora D. Ultrasound-guided neurolysis of six genicular nerves for intractable pain from knee osteoarthritis: a case series. Pain Pract Off J World Inst Pain. 2019;19(1):16–26.

    Google Scholar 

  43. Fonkoue L, Stoenoiu MS, Behets CW, Steyaert A, Kouassi JEK, Detrembleur C, et al. Validation of a new protocol for ultrasound-guided genicular nerve radiofrequency ablation with accurate anatomical targets: cadaveric study. Reg Anesth Pain Med. 2021;46(3):210–6.

    PubMed  Google Scholar 

  44. Ahmed A, Arora D. Ultrasound-guided radiofrequency ablation of genicular nerves of knee for relief of intractable pain from knee osteoarthritis: a case series. Br J Pain. 2018;12(3):145–54.

    PubMed  Google Scholar 

  45. Kim JH, Shustorovich A, Arel AT, Downie SA, Cohen SP, Kim SY. Genicular nerve anatomy and its implication for new procedural approaches for knee joint denervation: a cadaveric study. Pain Med Malden Mass. 2022;23(1):144–51.

    CAS  Google Scholar 

  46. Ghai B, Kumar M, Makkar JK, Goni V. Comparison of ultrasound guided pulsed radiofrequency of genicular nerve with local anesthetic and steroid block for management of osteoarthritis knee pain. Korean J Pain. 2022;35(2):183–90.

    CAS  PubMed  PubMed Central  Google Scholar 

  47. Valls JMO, Vallejo R, Pais PL, Soto E, Rodríguez DT, Cedeño DL, et al. Anatomic and ultrasonographic evaluation of the knee sensory innervation: a cadaveric study to determine anatomic targets in the treatment of chronic knee pain. Reg Anesth Pain Med. 2017;42(1):90–8.

    Google Scholar 

  48. Lash D, Frantz E, Hurdle MF. Ultrasound-guided cooled radiofrequency ablation of the genicular nerves: a technique paper. Pain Manag. 2020;10(3):147–57.

    PubMed  Google Scholar 

  49. Cankurtaran D, Karaahmet OZ, Yildiz SY, Eksioglu E, Dulgeroglu D, Unlu E. Comparing the effectiveness of ultrasound guided versus blind genicular nerve block on pain, muscle strength with isokinetic device, physical function and quality of life in chronic knee osteoarthritis: a prospective randomized controlled study. Korean J Pain. 2020;33(3):258–66.

    CAS  PubMed  PubMed Central  Google Scholar 

  50. Tran J, Peng PWH, Lam K, Baig E, Agur AMR, Gofeld M. Anatomical study of the innervation of anterior knee joint capsule: implication for image-guided intervention. Reg Anesth Pain Med. 2018;43(4):407–14.

    PubMed  Google Scholar 

  51. Roberts SL, Stout A, Dreyfuss P. Review of knee joint innervation: implications for diagnostic blocks and radiofrequency ablation. Pain Med. 2020;21(5):922–38.

    PubMed  Google Scholar 

  52. Wong PKW, Kokabi N, Guo Y, Reiter D, Reimer NB, Oskouei S, et al. Safety and efficacy comparison of three- vs four-needle technique in the management of moderate to severe osteoarthritis of the knee using cooled radiofrequency ablation. Skeletal Radiol. 2021;50(4):739–50.

    PubMed  Google Scholar 

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Acknowledgements

Dr. Sandipan Hazra and Dr. Satyasheel Singh Asthana for their guidance in the protocol's drafting. Dr. Faizal for helping with the dissection of the cadaveric knee specimens. Mr. Arif, Mr. Devender, Mr. Mukesh, and Mr. Sreekanth for their help in the dissection hall.

We are highly obliged to all the deceased who have donated their body to the Department of Anatomy AIIMS Jodhpur, under the Cadaver Donation Programme.

Funding

None of the Authors have received any funding for this work.

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Authors and Affiliations

  1. Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Phase 2 Basni, Jodhpur, Rajasthan, India, 342005

    Chinchu Kolakkanni, Nitesh Manohar Gonnade, Ravi Gaur, Rambeer Ghuleliya & Abins TK

  2. Department of Anatomy, All India Institute of Medical Sciences, Phase 2 Basni, Jodhpur, Rajasthan, India

    Ashish Kumar Nayyar

  3. Department of Physical Medicine and Rehabilitation, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Doiwala, Jolly Grant, Dehradun, Uttarakhand, India, 248140

    Rambeer Ghuleliya

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  1. Chinchu Kolakkanni
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Contributions

Dr. Chinchu Kolakkanni, Dr. Nitesh Manohar Gonnade, and Dr. Ravi Gaur wrote the main manuscript text. Dr. Ashish Kumar Nayyar prepared the figures 1, 5-6. Dr. Rambeer Ghuleliya and Dr. Abins TK prepared Figures 2-4, and 7-9.

Corresponding author

Correspondence to Nitesh Manohar Gonnade.

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Ethics approval and consent to participate

The study approved by Ethical Committee: Institutional Ethics Committee, All India Institute of Medical Sciences, Jodhpur. In this study all the methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from the next of kin.

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Not applicable.

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The authors declare no competing interests.

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Supplementary Information

Additional file 1: Supplementary table 1.

Staining characters and nerve-to-needle distance for USG-guided bony landmark techniques.

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Kolakkanni, C., Gonnade, N.M., Gaur, R. et al. Can ultrasound-guided radiofrequency ablation of genicular nerves of the knee, be performed without locating corresponding arterial pulsations—a cadaveric study. BMC Musculoskelet Disord 24, 654 (2023). https://doi.org/10.1186/s12891-023-06761-8

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Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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