Ankle RFA

[runfastnow]

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Does anyone have any pearls or guidance on ankle RFA? PubMed seems sparse.

Have a few patients with significant OA from prior fractures who are refusing ankle replacement or cannot have due to various reasons.

Thanks.

 

[Agast]

Have you done ankle blocks first? Identified the peripheral nerve target and then saw post injection relief etc etc

 

[10KHertz]

Agree with above , and are you performing pulsed rfa on these non C fibers ?

 

[bedrock]

Does anyone have any pearls or guidance on ankle RFA? PubMed seems sparse.

Have a few patients with significant OA from prior fractures who are refusing ankle replacement or cannot have due to various reasons.

Thanks.

Are 100% of these patients of yours so sick that they would die under anesthesia?

It only makes medical sense to do peripheral joint RFA these days on patients who failed joint replacements or the truly elderly/sick who can't have surgery.

Not just patients who don’t want to have surgery.

To answer your original question, there are few pure sensory nerve targets in the foot/ankle or hand/wrist, which is why these aren't done as the results are unsatisfactory.

 

[runfastnow]

Thank you - I understand how nerve blocks, response, RFA, etc. works. Otherwise I wouldn't be doing RFA.

Have not done/offered them in the past but saw it mentioned in some literature and had never seen one done anywhere I've been/trained.

Like I mentioned - have a few patients that would be candidates as they are very poor surgical candidates or prior significant traumatic OA/auto-fusion with diminishing returns on intra-articular CSI, bracing, meds, etc.

Skeptical on offering.

Just wanted any pearls from the community if they existed as I found the McCormick knee guidelines significantly positive practice changing. If there isn't then there isn't.

 

[bedrock]

Glad you know everything about how RFA works. Then the answer was here all along.

 

[lobelsteve]

Thank you - I understand how nerve blocks, response, RFA, etc. works. Otherwise I wouldn't be doing RFA.

Have not done/offered them in the past but saw it mentioned in some literature and had never seen one done anywhere I've been/trained.

Like I mentioned - have a few patients that would be candidates as they are very poor surgical candidates or prior significant traumatic OA/auto-fusion with diminishing returns on intra-articular CSI, bracing, meds, etc.

Skeptical on offering.

Just wanted any pearls from the community if they existed as I found the McCormick knee guidelines significantly positive practice changing. If there isn't then there isn't.

If you are following Zach's 9 nerve knee protocol then you are earning 0.25rvu per hour.

 

[runfastnow]

You people are insufferable sometimes. Just asking if anyone had advice. If not go be an **** to your patients or staff - not to a fellow physician asking for help/advice.

 

[Agast]

You people are insufferable sometimes. Just asking if anyone had advice. If not go be an **** to your patients or staff - not to a fellow physician asking for help/advice.

Um…it was just a question wondering what ankle block you did... Not sure why it triggered you…

 

[lobelsteve]

You people are insufferable sometimes. Just asking if anyone had advice. If not go be an **** to your patients or staff - not to a fellow physician asking for help/advice.

I have not seen any evidence we have a pure sensory nerve that is isolated and defined that has been successfully RFA'd for OA ankle.

 

[bedrock]

I have not seen any evidence we have a pure sensory nerve that is isolated and defined that has been successfully RFA'd for OA ankle.

basically the same thing I told mr touchy.

Runfastnow comes here to ask for advice, yet states he knows everything when we answer his question, and then he gets upset.

I think that is the best definition of insufferable.

 

[runfastnow]

I have not seen any evidence we have a pure sensory nerve that is isolated and defined that has been successfully RFA'd for OA ankle.

Thank you - all was needed, all I was looking for. Was initially hoping for a constructive discussion like there has been for other RFA topics. There was a perfectly reasonable (although ultimately unhelpful) discussion about it on here in 2018 and was unsure if any updates since then.

It is insulting when this community comes at you with "have you done a block first?" - well I was/am unaware of a somewhat reliable block for the ankle like we have for knees, etc. so I'm not going to just go blocking random things (or everything) for global ankle pain due to severe OA; or you get questioned on the assessment of surgical candidacy, etc.. Similar tone occurs almost every thread on here if it lasts long enough. Don't be mad when someone pushes back.

 

[Agast]

Thank you - all was needed, all I was looking for. Was initially hoping for a constructive discussion like there has been for other RFA topics. There was a perfectly reasonable (although ultimately unhelpful) discussion about it on here in 2018 and was unsure if any updates since then.

It is insulting when this community comes at you with "have you done a block first?" - well I was/am unaware of a somewhat reliable block for the ankle like we have for knees, etc. so I'm not going to just go blocking random things (or everything) for global ankle pain due to severe OA; or you get questioned on the assessment of surgical candidacy, etc.. Don't be mad when someone pushes back.

Ok, maybe this is a gap in knowledge base for me. I thought prior to doing a radiofrequency ablation of any nerve, you are required to block it first.

I’ve done ankle blocks for chronic foot and ankle pain such as the sausage weal approach to superficial peroneal nerve. That actually helped a little. Never got anything out of saphenous nerve blocks. I think some people have tried peripheral nerve stimulation but insurance does not seem to like that.

 

[lobelsteve]

I turf all foot and ankle to Podiatry. Couple really good folks by me. No shots from me.

 

[cowboydoc]

I did a cryo for focal saphenous issue in a young person and a saphenous, superficial peroneal, sural cryo with u/s guidance in a guy with Charcot and not much to lose. There is a ton of sensory innervation to the ankle, most of which is mixed motor/sensory nerves, so the likelihood of successful targeting for ablation without collateral damage is low.

 

[deleted131481]

I did pulsed RF of sural and saphenous nerve under US once... good relief then never came back so who knows.

 

[Orin]

Overview of the Innervation of Ankle Joint - PubMed

In this article, the literature describing the origin, course, and termination of the nerves innervating the ankle joint is reviewed and discussed. The anterior aspect of the joint capsule receives innervation from articular branches from the saphenous, superficial, and deep fibular nerves...

pubmed.ncbi.nlm.nih.gov

Nerve Ablation in the Foot and Ankle - PubMed

Ablation therapies in the foot and ankle are accessible adjuncts to surgery and comprehensive pain management in recalcitrant pain syndromes. Techniques are best applied to individual patient anatomy with strong advantages in a working knowledge of neuromuscular real-time imaging with...

pubmed.ncbi.nlm.nih.gov

I'm not sure this is a good idea but there is literature discussing it. I suppose you can try the targets for diagnostic blocks and see. The intrinsic foot musculature would be my primary concern, but the gross motor function of the limb would likely be fine.

Also a good case and treatment plan to run past a friendly podiatrist or ankle surgeon, but let us know how it works out.

 

[Ferrismonk]

I don't think it's unreasonable to ask if you've done blocks when you didn't mention that, especially for an unusual RF situation. It's not insulting at all.

That being said, I've never done ankle RF due to mixed sensory/motor nerves. If you don't care about motor in this particular patient, I don't see why it would be worth trying. You may also wish to consider a DRG SCS trial.

 

[stsa84]

I inherited a patient who had received pulsed RF of sural nerve a few times in the past. I've repeated for her twice at this point. First one lasted well for ~10 months, second one was just done a few few weeks ago.

If I had an ankle pain patient with pain that fit dermatomal pattern of a single nerve, I'd block it under U/S and consider pulsed RF. If it was global ankle pain, I'd probably just refer to podiatry.

 

[Ducttape]

Sural nerve is pure sensory so I have no concerns with rfa... and have done so pulsed. Also the saphenous.

Not so the posterior tibial or peroneal