The most exciting development in knee pain treatment: 5 insights from Dr. Antonia Chen

Angie Stewart -   Print  |

Antonia F. Chen, MD, MBA, is the director of research in arthroplasty services at Brigham and Women's Hospital in Boston. Dr. Chen also serves as an associate professor at Boston-based Harvard Medical School.

Dr. Chen told Becker's Spine Review about her thoughts on orthopedic pain management and the role that cooled radiofrequency ablation plays.

Note: Responses were lightly edited for style and clarity.

Question: What do you think the orthopedic pain management landscape will look like in 2021?

Dr. Antonia Chen: We are beginning to see new clinical evidence that suggests some of our more frequently used treatment options for managing knee pain may have untoward side effects. The effect of steroid injections on cartilage damage has been documented in clinical literature. Additionally, the mechanism of action for hyaluronic acid injections was called into question by the FDA and is not endorsed by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines. We are facing the possibility of losing some of our current nonoperative modalities for treating orthopedic pain that we have relied on for years and will need additional treatment options in 2021. Recently, several minimally invasive procedures have been coming onto the scene, and some have demonstrated solid clinical data, which provides hope for modifying the current treatment paradigm. By 2021, I anticipate that some of these nonoperative modalities will no longer be supported by insurance companies, and newer modalities with longer-lasting effects will comprise most of the orthopedic pain management landscape.

Q: What do you think is the most exciting new development for the treatment of knee pain, and why?

AC: The knee pain treatment landscape hasn't changed much in the last 20 years, as we have traditionally implemented diet, exercise, weight loss, oral anti-inflammatory medications and corticosteroid injections. However, newer treatment approaches that specifically target the nerves surrounding the knee that relay pain signals have been very exciting. Cooled radiofrequency ablation provides targeted thermal damage of the sensory nerves innervating the knee, and pain is diminished while the nerve structures heal. Cooled radiofrequency ablation has emerged with a great deal of quality, robust clinical evidence.

Q: What is your experience using cooled radiofrequency ablation?

AC: When I see a patient with knee osteoarthritis, they often think I'm going to immediately recommend surgery since I'm an orthopedic surgeon. These patients are often relieved when I tell them that other options exist. I typically start with more conservative modalities, such as exercise, weight loss and non-steroidal anti-inflammatory drugs. Once patients are not responding to these, I recommend proceeding to injections or cooled radiofrequency ablation. In my practice, patients typically respond well to cooled radiofrequency ablation.

I have also used cooled radiofrequency ablation for patients who have previously undergone surgery but still have residual pain. For patients who have received a partial or total knee replacement, I prefer not to give them corticosteroid injections, so cooled radiofrequency ablation provides an alternative that does not go intra-articularly.

Q: Which patients are the best candidates for this approach?

AC: As this procedure is slightly more invasive than an injection, I initially recommend cooled radiofrequency ablation only after patients have stopped seeing benefits from injections. However, some clinical literature suggests that patients would be better served skipping certain injections, such as viscosupplementation and platelet-rich plasma, and going straight to cooled radiofrequency ablation.

Q: What may be keeping providers from using CRFA more often? Are there any misconceptions to address?

AC: While this is not a new technology, the use of cooled radiofrequency ablation in the treatment of knee osteoarthritis pain is relatively new. Because of its name, cooled radiofrequency ablation is often confused with cryoablation. However, the mechanisms of action of the two technologies are very different. With cooled radiofrequency ablation, an internally cooled probe delivers radiofrequency energy into neural tissue, which heats the tissues to 80 degrees Celsius, causing thermal degradation. With cryoablation, a device uses extremely cold temperature to destroy tissues.

Patients may be concerned that cooled radiofrequency ablation can permanently destroy nerves and that this could block important pain receptors that signal problems, such as a fracture. These sensory nerves do regenerate, but cooled radiofrequency ablation provides pain relief for up to 12 to 24 months before the nerve regenerates. Providers have been concerned that cooled radiofrequency ablation treatment can lead to Charcot joint, but this has not been a reported complication in any cooled radiofrequency ablation study.

Finally, like any technology utilized in a new space, reimbursement can be a hurdle. However, this will likely be overcome, given the considerable amount of clinical evidence supporting the use of cooled radiofrequency ablation.

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