Synovial Hemangioma: An Overlooked Cause of Chronic Knee Pain in Children.

Introduction: Synovial hemangioma of the knee is a benign vascular malformation that is often misdiagnosed due to its non-specific symptoms. Case Report: We present a case involving a 7-year-old male child with chronic knee pain and swelling in the left knee, which remained undiagnosed for over 3 years. Magnetic resonance imaging revealed a synovial vascular malformation. Surgical excision of the lesion and partial synovectomy were performed, and histopathological analysis confirmed the diagnosis of synovial hemangioma. After 18 months of follow-up, there were no signs of recurrence or recurrent joint effusion. Conclusion: Synovial hemangioma of the knee, although uncommon, should be considered as a differential diagnosis in cases of chronic knee pain and swelling. En-bloc excision is the treatment of choice to prevent recurrence, yielding good clinical outcomes.

9. Chronic knee pain.

INTRODUCTION: Chronic knee pain is defined as pain that persists or recurs over 3 months. The most common is degenerative osteoarthritis (OA). This review represents a comprehensive description of the pathology, diagnosis, and treatment of OA of the knee. METHODS: The literature on the diagnosis and treatment of chronic knee pain was retrieved and summarized. A modified Delphi approach was used to formulate recommendations on interventional treatments. RESULTS: Patients with knee OA commonly present with insidious, chronic knee pain that gradually worsens. Pain caused by knee OA is predominantly nociceptive pain, with occasional nociplastic and infrequent neuropathic characteristics occurring in a diseased knee. A standard musculoskeletal and neurological examination is required for the diagnosis of knee OA. Although typical clinical OA findings are sufficient for diagnosis, medical imaging may be performed to improve specificity. The differential diagnosis should exclude other causes of knee pain including bone and joint disorders such as rheumatoid arthritis, spondylo- and other arthropathies, and infections. When conservative treatment fails, intra-articular injections of corticosteroids and radiofrequency (conventional and cooled) of the genicular nerves have been shown to be effective. Hyaluronic acid infiltrations are conditionally recommended. Platelet-rich plasma infiltrations, chemical ablation of genicular nerves, and neurostimulation have, at the moment, not enough evidence and can be considered in a study setting. The decision to perform joint-preserving and joint-replacement options should be made multidisciplinary. CONCLUSIONS: When conservative measures fail to provide satisfactory pain relief, a multidisciplinary approach is recommended including psychological therapy, integrative treatments, and procedural options such as intra-articular injections, radiofrequency ablation, and surgery.

Fluoroscopic-Guided Barbotage and Corticosteroid Injection for the Treatment of Symptomatic Calcification of the Lateral Collateral Ligament: A Case Report.

Periarticular calcification of the knee joint is a rare pathology that may be challenging to diagnose and manage when symptomatic. Here, we describe the first use of fluoroscopic-guided percutaneous needle aspiration and lavage (barbotage) with corticosteroid injection in a case of symptomatic calcification of the lateral collateral ligament (LCL). A 75-year-old female presented with acute lateral knee pain and stiffness, which subsequent radiographic imaging and diagnostic injection confirmed to be attributed to calcification within the LCL. Initial treatment with analgesic medications and a genicular nerve block failed to alleviate symptoms. However, complete resolution of symptoms was achieved following fluoroscopic-guided barbotage and steroid injection. This case underscores the importance of considering LCL calcification in the differential diagnosis of lateral knee pain. This case also illustrates the potential effectiveness of barbotage and adjunctive steroid injection as a minimally invasive treatment option for symptomatic LCL calcification, emphasizing the need for more rigorous studies evaluating treatment strategies for managing periarticular calcifications involving the knee joint.

Peripheral Nerve Stimulation After Total Knee Arthroplasty and Non-Operable Patella Fracture.

Chronic knee pain, affecting over 25% of adults in the United States, has surged by 65% over the past two decades leading to rising functional deficits, mobility problems, and a diminished quality of life. While conservative management with pharmacologic and minimally invasive injections are pursued early in the disease process, total knee arthroplasty for refractory osteoarthritis of the knee is often considered. This procedure usually improves pain and functionality within the first three months. However, a significant portion of patients often suffer from postoperative pain that can become chronic and debilitating. We detail the case of a patient with a previous TKA as well as a non-operable patella fracture who obtained significant relief with PNS despite prior conservative and minimally invasive management.

High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life.

BACKGROUND AND AIMS: Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively. METHODS: A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain. RESULTS: There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01). CONCLUSIONS: Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Awareness and Management of Knee Pain and Osteoarthritis in Saudi Arabia: A Cross-Sectional Analysis.

OBJECTIVE:  The study sought to assess the level of awareness regarding osteoarthritis and its management. METHODS:  This study was cross-sectional, using data from a sample of 389 individuals from the central region of Saudi Arabia. The participants completed an online questionnaire and ensured anonymity.  Results: A total of 389 participants made up the sample for this study, which had a predominance of females (56.6%, n=220), a majority aged <50 years (66.6%, n=259), and most of them (51.7%, n=201) weighing 60-80 kg, substantial proportion lived in the Riyadh region (27.5%, n=107), with more than half (59.4%, n=231) having a university education and working in offices (28.3%, n=110). The majority (73.3%, n=285) of participants were married, and a vast majority (87.9%, n=342) were not smokers. The findings revealed that only 32.9% (n=128) of the participants had good knowledge about osteoarthritis. The study found that stiffness (80.2%, n=312) and swelling (97.9%, n = 381) are the most common signs and symptoms of osteoarthritis; the risk factors for osteoarthritis were genetic factors (79.7%, n=310) and age (91.3%, n=355). The treatment of osteoarthritis identified in the study included exercises such as swimming (85.1%, n=331), physical therapy (86.6%, n=337), and joint replacement surgery (92.0%, n=358). The study established a statistically significant association between age, education level, previous diagnosis of osteoarthritis, family history of osteoarthritis (p = 0.004, 0.001, 0.002, and 0.001, respectively), and level of knowledge about osteoarthritis. However, there was no statistically significant association between gender, marital status, smoking status, previous knee injuries, physical activity level, and the level of knowledge about osteoarthritis (p > 0.05).  Conclusion: Overall, the study revealed that 32.9% (n=128) of the participants had good knowledge about osteoarthritis. Participants aged 50-60 years, those with a university and post-graduate level of education, as well as those who had a previous diagnosis of osteoarthritis and those with a family history of osteoarthritis, had greater and better knowledge and awareness about osteoarthritis. Joint stiffness and swelling were identified, as the most common signs and symptoms of osteoarthritis. The risk factors identified in the study were genetic factors and age, while the treatment options noted by the study were exercise, such as swimming, physical therapy, and joint replacement surgery. The study notes the need for enhanced public awareness of the problems associated with osteoarthritis among the Saudi Arabian population.

Bipolar radiofrequency ablation of genicular nerves in chronic knee pain: A novel technique for more complete sensory denervation.

BACKGROUND: Monopolar radiofrequency ablation (MRFA) of the genicular nerves has been considered the main interventional treatment for chronic knee pain. However, the variable locations of these nerves could suggest that traditional MRFA of genicular nerves may be insufficient to cover the area needed to provide complete sensory denervation. For these reasons, some alternatives have been proposed to achieve an increase in the lesion area that offers better outcomes such a bipolar radiofrequency ablation (BRFA). OBJECTIVE: To describe the efficacy and safety of the bipolar radiofrequency ablation (BRFA) of the genicular nerves in the patients with chronic knee pain. METHODS: A retrospective study was conducted in the Pain Medicine Department. Institutional review board approval from the Hospital Ethical Committee and informed consent were obtained. We reviewed our database for BRFA of genicular nerves from January 2018 to December 2021 for patients with chronic knee pain. The cannulas were placed using ultrasound guidance (10 cm, 22-gauge and 10 mm active curved tip), and each pair of cannulas were subjected to BRFA for 90 seconds at 80∘C. Data analysis was conducted using T-test for paired variables (Visual analogue scale and EuroQol, an instrument intended to complement other forms of quality-of-life measures). RESULTS: Twenty-five patients met inclusion criteria after excluding 7 based on the study design. The mean improvement of our patients according to the VAS was -3.98 (95%CI: -4.37 to -3.59) p< 0.0001 and EuroQol +0.416 (95%CI: 0.364 to 0.468) p< 0.0001. The mean duration of improvement was 8 (6-11) months after BRFA. There were no reported serious adverse events related to the procedure, only local pain for 24 to 48 hours in 3 patients. CONCLUSIONS: We can conclude that BRFA reduces procedural pain and increases the treatment area, providing more complete sensory denervation and improved clinical outcomes.

Neurophysiological pain education for patients with symptomatic knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of neurophysiological pain education in patients with symptomatic knee osteoarthritis considering pain-related variables. METHODS: A systematic review and meta-analysis was carried out according to the PRISMA guidelines. A search was conducted in PubMed, PEDro Database, Cochrane Library, Scopus, and Web of Science. Only randomized controlled trials enrolling patients ≥ 18 years of age with symptomatic knee osteoarthritis were included. The Downs and Black quality assessment tool was used to assess the quality of the articles, and the risk of bias was evaluated with the Cochrane Risk of Bias Assessment Tool. RESULTS: A total of 7 studies were included in the study. Most of the studies were rated as "fair" on the Downs and Black quality assessment tool, and in the category of "some concerns" according to the Cochrane Risk of Bias Assessment Tool. Neurophysiological pain education was conducted alone or combined with exercise, joint mobilizations, or self-management programs. The number of sessions ranged from 1 to 10. The meta-analysis results showed significant differences in favor of the intervention group in pain (MD = -0.49; 95% CI = -0.66; -0.32; p < 0.001) and catastrophization (MD = -1.81; 95% CI = -3.31, -0.3; p = 0.02). CONCLUSION, PRACTICE IMPLICATIONS: Neurophysiological pain education interventions in isolation or combined with exercise, joint mobilizations, or self-management programs have proven to significantly improve pain and catastrophization in patients with symptomatic knee osteoarthritis. These findings could provide clinicians with more information regarding the management of patients with symptomatic knee osteoarthritis.

Evaluating Public Perceptions and Attitudes Toward Total Knee Arthroplasty: A Cross-Sectional Study in Saudi Arabia.

BACKGROUND: Total knee arthroplasty is a surgical procedure used to address knee conditions, including osteoarthritis, that cause persistent pain and impaired joint function. While total knee arthroplasty is effective, misconceptions and knowledge gaps exist among the general public, particularly in Saudi Arabia. METHODS: This cross-sectional study, conducted in Al-Ahsa, Saudi Arabia, utilized an online survey to assess public perception of total knee arthroplasty. A questionnaire was developed, validated, and administered to participants aged 18 and above with a history of chronic knee pain. Data were analyzed for associations between knowledge and perception scores and sociodemographic factors. RESULTS: Out of 704 participants, the majority exhibited poor knowledge (74.1%) of total knee arthroplasty. Factors influencing knowledge included age, education, income, knowing someone who had total knee arthroplasty, hearing about total knee arthroplasty, receiving total knee arthroplasty information, and awareness of total knee arthroplasty indications. Sociodemographic characteristics such as gender, marital status, and perceptions about total knee arthroplasty prevalence did not significantly impact knowledge scores. CONCLUSION: This study reveals a significant knowledge and perception gap among the public in Al-Ahsa, Saudi Arabia, regarding total knee arthroplasty. Tailored education initiatives for patients with chronic knee pain are urgently needed to dispel misconceptions and provide accurate information about total knee arthroplasty. Collaborative efforts between policymakers, healthcare providers, and public health authorities are essential for improving public understanding, enhancing healthcare decision-making, and reducing the burden on healthcare systems.

The effects of upper- vs. lower-body aerobic exercise on perceived pain in individuals with chronic knee pain: a randomised crossover trial.

Background and objectives: Some patients with chronic knee pain experience an increase in knee pain following a single bout of exercise involving their knee joint, which can negatively affect exercise adherence and thus result in reduced overall health and lack of disease management. We want to determine whether a single bout of upper-body (UB) aerobic arm-ergometry exercise is effective in reducing the experience of pain in those with chronic knee pain compared with lower-body (LB) aerobic leg ergometry exercise. Methods: A total of 19 individuals (women = 11, men = 8; age = 63 ± 8 years; body mass index = 24 ± 3 kg/m2) who suffered from chronic knee pain for ≥3 months took part in this study. Arm-ergometry and cycle-ergometry exercises were performed for 30 min at a moderate intensity, separated by 7 days. Pain intensity was assessed by means of a visual analogue scale (VAS) pre- and post-exercise and for 7 days post-exercise. Pressure pain threshold (PPT) and mechanical detection threshold (MDT) were measured pre- and post-exercise at both local and distal anatomical sites. Data are presented as mean ± SD. Results: VAS pain was significantly reduced (p = 0.035) at 1 day post-exercise following the UB exercise trial (-1.4 ± 0.8) when compared with the LB exercise trial (+0.1 ± 2.1). Both UB and LB exercises were effective in reducing local and distal PPT. MDT responses were heterogeneous, and no differences between the UB and LB exercise conditions were noted. Conclusion: An acute bout of upper-body aerobic arm-ergometry exercise evoked a significant decrease in the affected knee joint pain in individuals with chronic knee pain of up to 24 h/1 day post-exercise compared with lower-body aerobic exercise. While the exact mechanisms remain unclear, upper-body exercise may offer a viable, novel therapeutic treatment for patients with chronic knee pain.

Genicular nerve block for emergency department patient: a successful management of subacute osteoarthritic knee pain.

The genicular nerve block (GNB) performed under ultrasound is a common procedure in the perioperative and outpatient setting for the treatment of surgical knee pain and osteoarthritis. It provides motor-sparing analgesia to the knee, making it a potential alternative to other modes of pain management in the emergency department (ED). We present an elderly woman with acute-on-chronic osteoarthritic knee pain which was relieved for a week after a GNB during her ED visit. In patients with knee pain, the ultrasound guided GNB has the potential to provide short-term analgesia for patients with pain refractory to other modes of analgesia. The GNB shows promise as a reliable contribution to a multimodal approach to pain management in the ED setting.

Brief self-exercise education for adults with chronic knee pain: A randomized controlled trial.

OBJECTIVES: Effective brief instructions for self-management of chronic knee pain are needed. METHODS: Forty-six participants with chronic knee pain were randomly allocated into two programmes: material-based education alone or brief self-exercise education (brief-See), which comprised a 100-minute instruction for self-exercise combined with compact pain education. Total function (KOOS4, 4-subscale average of knee injury and osteoarthritis outcome score), pain intensity (NRS, numeric rating scale), self-efficacy (PSEQ, pain self-efficacy questionnaire), and health-related quality of life (EQ-5D, European quality of life-5 dimensions) were evaluated at baseline and 4 and 12 weeks after the initial intervention. A generalized mixed linear model estimated average group differences in changes from baseline and 95% confidence intervals (95% CIs) using intention-to-treat principle. RESULTS: Compared to material-based education alone, the brief-See provided significant additional improvements of 9.4% (95% CI: 2.3 to 16.4) on the KOOS4 and 5.4 points (0.3 to 10.4) on the PSEQ at 12 weeks but did not on the NRS and EQ-5D. Adherence and satisfaction were favourable in the brief-See without any notable adverse event. CONCLUSIONS: Adding the brief-See to material-based education could be more acceptable and restore total function and self-efficacy, which could contribute to the self-management of chronic knee pain in primary care.

Translation, cross-cultural adaptation and reliability of the International Knee Documentation Committee (IKDC) subjective knee form and the tampa scale for kinesiophobia (TSK) into Hebrew.

INTRODUCTION: The International Knee Documentation Committee-Subjective Form (IKDC-SF) is one of the most used measures for evaluating the quality of life among people experiencing knee pain but is not yet available in Hebrew. Similarly, the Tampa Scale for Kinesiophobia (TSK), used to evaluate fear of movement, is not available in Hebrew. This study aimed to determine the reliability and construct validity of the Hebrew IKDC-SF and TSK among people experiencing chronic knee pain. MATERIALS AND METHODS: Translation and cultural adaptation of the IKDC-SF and TSK questionnaires, followed by test-retest reliability within a two-week interval. We report on internal consistency, construct validity, and the psychometric properties of both questionnaires. RESULTS: Both questionnaires showed high internal consistency (Cronbach's α = 0.85 and 0.89, respectively) and test-retest reliability, expressed by the Intra-Class Correlation Coefficient (ICC = 0.89 and 0.80 respectively). The standard error of measurement, group smallest real difference and minimal detectable change for the IKDC-SF were 4.66, 9.13, and 12.91 points, and 3.64, 7.13, and 10.08 points for the TSK, respectively. CONCLUSION: We demonstrated that the Hebrew version of the IKDC-SF and TSK is reliable and valid for assessing QoL, function, and kinesiophobia among people experiencing chronic knee pain.

Effects of Non-Face-to-Face and Noncontact Interventions on Knee Pain and Physical Activity in Older Adults With Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

Increased physical activity is an effective treatment for knee osteoarthritis that causes knee pain. However, due to the coronavirus disease 2019, noncontact and non-face-to-face interventions have increased, but the quality of evidence supporting their effectiveness remains unclear. The purpose of the study was to assess the quality of evidence of the effects of non-face-to-face and noncontact interventions on knee pain and physical activity in older adults with knee osteoarthritis. A meta-analysis was conducted to determine the effects of different intervention methods (education and exercise). The Cochrane Central Register of Controlled Trials, PubMed, Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database were systematically searched. Four randomized controlled trials were included in the analysis. The meta-analysis demonstrated that the educational intervention group was significantly effective, although supportive evidence was low quality. Educational intervention may be effective, but the effects need to be confirmed by higher quality clinical trials.

Peripheral Nerve Stimulation in Chronic Knee Pain: A Case Series.

Introduction Chronic knee pain is increasing in prevalence and is associated with substantial limitations in functional mobility. Peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. However, there is a paucity of research exploring the potential therapeutic benefit of PNS for chronic knee pain. Methods This research is a retrospective case series of all patients who received PNS for the treatment of chronic knee pain performed at a single-center academic medical institution between March 2021 and June 2022. The primary outcome was percent pain reduction six months after implantation. Outcome data was obtained via chart review and phone calls to patients. Secondary outcomes included percent pain reduction two weeks and two months after implantation and adverse medical events related to the procedure and nerve stimulation. Results Fourteen individual patients received PNS for chronic knee pain during the study period. Three of these patients received bilateral PNS for a total of 17 cases. The mean percent pain reduction six months after implantation was 52% (SD=28.2) (N=12). A total of 75.0% of participants (9/12) reported ≥50% reductions in pain six months after implantation. No adverse events were reported relating to the implantation procedure and/or nerve stimulation. Conclusion PNS is a safe and efficacious treatment modality for chronic knee pain with demonstrated long-term benefit. Further research should clarify patient factors associated with improved treatment response.

A randomized controlled study of the long-term efficacy of cooled and monopolar radiofrequency ablation for the treatment of chronic pain related to knee osteoarthritis.

Background: Chronic knee pain due to osteoarthritis (OA) is expected to become more prevalent. Although conventional therapies may provide relief they are not long-lasting. Persistent pain may lead to total knee replacement, which is not free of adverse outcomes. Monopolar and cooled radiofrequency ablation (RFA) of genicular nerves is an effective option. However, either method may provide distinctive results depending on expected lesion size, a key aspect considering the anatomical variability of knee innervations. This prospective, double-blind, randomized controlled trial evaluated the efficacy and durability of knee RFA using a cooled probe or a monopolar probe of comparable diameter. Methods: This investigator-initiated, post-market, double-blinded, prospective, randomized controlled trial was approved by the Western IRB. 79 subjects with chronic knee pain due to knee OA were enrolled in multiple locations of a single center. 75 subjects were randomized (1:1) into RFA treatment with either a 4 â€‹mm/17G cooled active tip (CRFA) or a 10 â€‹mm/16G monopolar active tip (MRFA) using conventional procedures. Primary endpoint was change in knee pain level (100 â€‹mm VAS score) from baseline at 24-week post-treatment. Other endpoints include change in functionality, global perceived effect, and frequency of adverse events. Evaluation spanned to 52-week post-treatment. Significance of results (p â€‹< â€‹0.05) was calculated using standard statistical analyses. Results: Both CRFA and MRFA provided significant reduction (41 â€‹mm and 39 â€‹mm, respectively) of chronic knee pain at 24-week. At the 52-week visit, reduction in pain level was sustained for CRFA (42 â€‹mm) but seems to decrease for MRFA (31 â€‹mm). Improvements in functionality were also significant and sustained with both treatments, although tend to decrease with MRFA at 52-week. Most patients also perceived a very good/good effect of treatments along the duration of the study. Conclusion: RFA of knee genicular nerves for the treatment of OA chronic pain is effective for 52 weeks post-ablation when using a CRFA (4 â€‹mm/17G active tip) or MRFA (10 â€‹mm/16G active tip). The benefits of CRFA seems to be better sustained beyond 24 weeks than the ones of MRFA, although no significant differences were observed at 52 weeks.

Cooled Radiofrequency Ablation Provides Prolonged Pain Relief Compared to Traditional Radiofrequency Ablation: A Real-World, Large Retrospective Clinical Comparison from a Single Practice.

Background: Genicular radiofrequency ablation is an established therapy for chronic knee pain. An analysis comparing different probe sizes and technologies has not yet been undertaken for this indication. This large retrospective, comparison study from a single-center comprehensive pain management practice aims to do that. Methods: Outcomes of 170 patients who underwent traditional radiofrequency ablation (tRFA) for chronic knee pain were compared to 170 consecutive patients who received cooled radiofrequency ablation (CRFA) with similar (p=0.5) pre-procedural pain scores. Results: The VAS pain score at the first post-procedure visit at 4-6 weeks decreased to 5.07±2.8 cm for tRFA and to 4.26 ± 3.2 cm for CRFA (p<0.001 for both from baseline). The difference was profound and significantly better in the favor of CRFA (p<0.001) as the duration of reduction of pain scores by greater than 50% was 2.6 months for tRFA and 11.1 months for CRFA. There were only 15 patients (8.8%) who continued to receive >50% of pain relief in tRFA at 12 months, as opposed to 78 (46%) at 12 months for CRFA. We compared the initial outcomes and long-term pain relief. Long-term outcomes were better for the bigger lesion size treatment group patients. Conclusion: We conclude that the duration and intensity of pain relief were of a greater magnitude after the larger diameter probe cooled RFA.

Is inpatient rehabilitation a predictor of a lower incidence of persistent knee pain 3-months following total knee replacement? A retrospective, observational study.

BACKGROUND: Moderate to severe levels of persistent knee pain have been estimated to affect up to 25% of people 3-months or more after a total knee replacement. It is unknown whether the type of rehabilitation pathway is associated with persistent high pain after surgery. Using a prospectively followed Australian cohort who underwent total knee replacement for knee osteoarthritis, this study aimed to i) report the incidence of high-intensity knee pain (defined as a score ≤ 15 on the Oxford Knee Score pain subscale) across time and ii) identify whether referral to inpatient rehabilitation was one of the predictors of persistent pain at 3-months post-surgery. METHODS: A retrospective analysis of a large prospective study was conducted using the Oxford Knee Score pain subscale to determine if participants had high pain at 3-months, 12-months and 36-months post-surgery. Relative risks for high pain at 3-, 12- and 36-months between the type of rehabilitation pathway were determined using Poisson multivariable regression with robust standard errors. The same technique was also employed to determine potential predictors, including rehabilitation pathway, of high pain at 3 months. RESULTS: The incidence of high pain in all participants was 73% pre-surgery and 10, 5 and 6% at 3-, 12- and 36-months respectively following knee replacement. There was a significant interaction between time and rehabilitation pathway, suggesting that the effect of the rehabilitation pathway varied across time. The incidence of high pain at 3-months did not significantly differ between those who attended inpatient rehabilitation (11.6%) and those discharged directly home (9.5%). Multivariable Poisson regression analysis identified the pre-surgical presence of high pain, co-morbid low back pain or other lower limb problem, younger age and having a major complication within 3-months following surgery as significant predictors of persistent pain whilst discharge to inpatient rehabilitation was not. CONCLUSION: A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis. Participation in an inpatient rehabilitation program does not appear to be an important predictor of ongoing knee pain. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Spinal Cord Stimulation for Post Total Knee Replacement Pain: A Case Series.

It is not uncommon for orthopedic patients to experience pain following a total knee replacement (TKR). Use of oral pain medications, nerve blocks, and periarticular injections are implemented to provide multimodal analgesia and to reduce postoperative chronic pain. Spinal cord stimulation (SCS) can also be used to control pain in patients who are refractory to conservative measures. Few studies have explored this possibility for patients with chronic pain status post TKR. We present three cases that demonstrate the effectiveness of SCS in this challenging patient population.

Cooled radiofrequency ablation of genicular nerves provides 24-Month durability in the management of osteoarthritic knee pain: Outcomes from a prospective, multicenter, randomized trial.

OBJECTIVE: To assess long-term outcomes of cooled radiofrequency ablation (CRFA) of genicular nerves for chronic knee pain due to osteoarthritis (OA). METHODS: A prospective, observational extension of a randomized, controlled trial was conducted on adults randomized to CRFA. Subjects were part of a 12-month clinical trial comparing CRFA of genicular nerves to a single hyaluronic injection for treatment of chronic OA knee pain, who then agreed to visits at 18- and 24-months post CRFA and had not undergone another knee procedure since. The subjects were evaluated for pain using the Numeric Rating Scale (NRS) function using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), subjective benefit using the Global Perceived Effect (GPE) scale, quality of life using the EuroQol-5-Dimensions-5 Level (EQ-5D-5L) questionnaire, and safety. RESULTS: Of 57 subjects eligible, 36 enrolled; 32 completed the 18-month visit with a mean NRS score of 2.4 and 22 (69%) reporting ≥50% reduction in pain from baseline (primary endpoint); 27 completed the 24-month visit, with a mean NRS of 3.4 and 17 (63%) reporting ≥50% pain relief. Functional and quality of life improvements persisted similarly, with mean changes from baseline of 53.5% and 34.9% in WOMAC total scores, and 24.8% and 10.7% in EQ-5D-5L Index scores, at 18- and 24-months, respectively. There were no identified safety concerns in this patient cohort. CONCLUSION: In this subset of subjects, CRFA of genicular nerves provided durable pain relief, improved function, and improved quality of life extending to 24 months post procedure, with no significant safety concerns.