Myoscience  Clinical  Reports.  2016;  1(2):1-­‐2.  

 

   

CLINICAL  REPORT  

   

 

SUCCESSFUL  TREATMENT  OF  PAINFUL  STIFFNESS  FOLLOWING  TOTAL  KNEE  ARTHROPLASTY  USING  CRYOABLATION  OF  THE  INFRAPATELLAR  BRANCH  OF  THE  SAPHENOUS  NERVE:  A  CASE  REPORT    

Steven  Makovitch  DO,  Samuel  Chu  MD,  David  Stulberg  MD,  Victoria  Brander  MD  Rehabilitation  Institute  of  Chicago/Northwestern  University  Feinberg  School  of  Medicine,  Chicago,  IL  ________________________________________________________________________________________    INTRODUCTION      The  infrapatellar  branch  of  the  saphenous  nerve  (IPBSN)  is  a  purely  sensory  nerve  that  innervates  the  anteromedial  aspect  of  the  knee  as  well  as  the  anterior  inferior  joint  capsule.1  Injury  to  this  nerve  can  result  from  knee  trauma  or  iatrogenic  causes  such  as  during  a  total  knee  arthroplasty  (TKA).  Patients  may  complain  of  poorly  localized,  sharp  and   burning   anteromedial   knee   pain   especially  with  movement.2   Cryoablation   of   the   IPBSN   creates   a   reversible  second-­‐degree  nerve  injury,  which  results  in  a  conduction  block  that  provides  prolonged  pain  relief.3    CASE  DESCRIPTION  A  75-­‐year-­‐old  woman  presented  with  persistent  knee  pain   and   stiffness   at   3   months   post-­‐TKA   despite   33  sessions  of  Physical  Therapy.  She  reported  a  functional  decline   with   disturbed   sleep   as   well   as   a   constant,  sharp,  anterior  knee  pain  (10/10)  with  a  dull  leg  ache,  all   of   which   worsened   with   movement.   Her   x-­‐rays  demonstrated   a   well-­‐fixed   and   aligned   TKA,   without  identifiable  pathology  for  the  knee  pain.  On  exam  she  exhibited  an  antalgic  gait  with  a   flexed  knee  posture.  There  was  no  swelling  or   instability  of  the  knee  but  a  31°   knee   flexion   contracture   was   measured   (Fig.   1  Left)   and  hypersensitivity  was  noted  over   the  area  of  the   IPBSN   (Fig.   1   Right).   Passive   knee  motion   caused  pain  and  tearfulness  in  the  patient.  

 MANAGEMENT  After   a   collaborative   visit   with   PM&R   and   Orthopaedics   the  patient   was   scheduled   for   an   arthroscopic   debridement   and  manipulation  the  following  week.  After  the  PM&R  evaluation  the  consensus   was   to   attempt   cryoablation   of   the   IPBSN   prior   to  manipulation  surgery.  The  nerve  was   localized  using  ultrasound  and   anatomical   landmarks   at   the   medial   knee   border.   Local  anesthesia  was  delivered  with  2%  Lidocaine.  Cryoablation  of  the  nerve   (temp   -­‐22°C   to   -­‐88°C)   was   performed   at   locations   both  proximal   and   distal   to   the   bifurcation   of   the   IPBSN   using   an  iovera°  cryotherapy  system  (Myoscience,  Fremont,  CA).          

Figure  2.  Longitudinal  view  of  the  IPBSN  (arrowheads)  under  ultrasound.  Sartorius  muscle  (S)  and  Fascia  lata  (arrows)  also  shown.  

Figure  1.  Left:  Patient  with  31°  Knee  Flexion  Contracture.  Right:  Palpation  of  the  IPBSN  (noted  in  image  as  IPS).      

Myoscience  Clinical  Reports.  2016;  1(2):1-­‐2.  

 

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 CLINICAL  COURSE  &  FOLLOW  UP  The   patient   reported   a   pain   score   of   0/10   at   15  mins   post-­‐procedure.   She   allowed   aggressive  manipulation   of   the   knee   and   was   able   to  ambulate  in  the  clinic  without  pain.  Her  scheduled  manipulation  under  anesthesia  was   subsequently  cancelled.    At  10  weeks  post-­‐treatment   the  patient   reported  that   she   was   pain-­‐free   and   could   actively  participate   in   aggressive   home   exercises.   Her  active  knee  Range-­‐of-­‐Motion   improved   from   -­‐15°  to   105°.   The   patient   reported   that   she   is   now  satisfied  with  the  results  of  her  TKA  surgery.    

CONCLUSION  Cryoablation  of  the  IBSN  should  be  considered  for  patients  with  refractory  anterolateral  knee  pain  after  TKA.    

 Results  originally  presented  at  the  2014  AAPM&R  Annual  Assembly,  San  Diego,  CA    Physical  Medicine  and  Rehabilitation  2014;  6(9S):S353    Disclosures:  Dr.  Brander  is  a  consultant  for  Myoscience,  Inc.      REFERENCES  1. Le  Corroller  T,  Lagier  A,  Pirro  N,  Champsaur  P.  Anatomical  study  of  the  infrapatellar  branch  of  the  saphenous  nerve  using  ultrasonography.  

Muscle  Nerve  2011;44(1):50-­‐4.  2. Trescot  AM,  Brown  MN,  Karl  HW.  Infrapatellar  saphenous  neuralgia  -­‐  diagnosis  and  treatment.  Pain  Physician  2013;16(3):E315-­‐24.  3. Trescot  AM.  Cryoanalgesia  in  interventional  pain  management.  Pain  Physician  2003;6(3):345-­‐60.  4. Cooper  IS,  Lee  AS.  Cryostatic  congelation:  a  system  for  producing  a  limited,  controlled  region  of  cooling  or  freezing  of  biologic  tissues.  J  Nerv  

Ment  Dis  1961;133:259-­‐63.                          USA  (FDA):  The  myoscience  iovera°  system  is  used  to  destroy  tissue  during  surgical  procedures  by  applying  freezing  cold.  It  can  also  be  used  to  produce  lesions  in  peripheral  nervous  tissue  by  the  application  of  cold  to  the  selected  site  for  the  blocking  of  pain.  The  iovera°  system  is  not  indicated  for  treatment  of  central  nervous  system  tissue.  

Common  side  effects  include  local  pain/tenderness,  swelling,  bruising,  and  tingling/numbness.  

Myoscience,  Inc.  |  Fremont,  CA  94538  |  myoscience.com    ©  2016  Myoscience,  Inc.  All  rights  reserved.  iovera°  is  a  trademark  of  myoscience,  inc.    MKT-­‐0399  REV  A  

Figure  3.    Cryoablation  of  the  IPBSN