post-operative knee pain (>1 year out)

[SpineandWine]

Hi,
What is a good treatment for post-operative knee pain 1 year out (TKA), negative work-up of infection (3 phase scan, infecitous labs, no mechanical instability)
Assuming, no genicular nerve block/ablation is option, no pes-anserine bursa.
Does someone have streamlined approach to this? Would love review articles/approaches

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[Doctodd]

Post op what? TKR? Scope?

 

[SpineandWine]

Post op what? TKR? Scope?

Changed original post - TKA
Actually, have another patient with pain after scope.

 

[Dr. Ice]

Hi,
What is a good treatment for post-operative knee pain 1 year out (TKA), negative work-up of infection (3 phase scan, infecitous labs, no mechanical instability)
Assuming, no genicular nerve block/ablation is option, no pes-anserine bursa.
Does someone have streamlined approach to this? Would love review articles/approaches

PNS

 

[lobelsteve]

genic block/RF only.

No PNS
No DRG

 

[Doctodd]

if it's TKR, it can be scar tissue pain which you can do PT and injection/break up scar tissue. If s/p scope, PRP all day long. Or genic RF for either.

 

[SpineandWine]

genic block/RF only.

No PNS
No DRG

I just told you, no genic blocks/RFA
It’s my colleagues mom
Hesitant to do PNS unless it works - haven’t done it for knee pain before

 

[SpineandWine]

if it's TKR, it can be scar tissue pain which you can do PT and injection/break up scar tissue. If s/p scope, PRP all day long. Or genic RF for either.

PRP? Like ligamentous?
No joint left since TKA

 

[drrosenrosen]

why no genic?

 

[SpineandWine]

why no genic?

Not approved by insurance, hesitant in charging her.

Any other good way you guys would do on your own parents?
Would anyone do PNS on their parents

 

[Doctodd]

PRP? Like ligamentous?
No joint left since TKA

If s/p TKR, it’s probably scar pain outside the joint. If you can reach it with a needle, I’d do a scar injection with a drop of steroid.

 

[MitchLevi]

If it’s your colleague’s mom, do a genicular RFA for free. No nerve block, just the RFA.

 

[Ferrismonk]

If it's just chronic knee pain despite TKA and no other problem noted (failed hardware, scar tissue, etc.), AND you want to treat this with interventions, you have only a few options.

1. Genicular NB/RF
2. PNS/DRG
3. Brace

If your patient is a VIP, I'd just do the block/RF for free or at my supply cost assuming insurance didn't cover it. PNS/DRG depending on severity of pain and if she's a good candidate for such a device. Bracing only if no other options, will make her weaker.

 

[SpineandWine]

If it's just chronic knee pain despite TKA and no other problem noted (failed hardware, scar tissue, etc.), AND you want to treat this with interventions, you have only a few options.

1. Genicular NB/RF
2. PNS/DRG
3. Brace

If your patient is a VIP, I'd just do the block/RF for free or at my supply cost assuming insurance didn't cover it. PNS/DRG depending on severity of pain and if she's a good candidate for such a device. Bracing only if no other options, will make her weaker.

What else can be issue if not scar tissue that’s able to be rectified?
I have ortho colleagues that do this but does anyone test for mechanical instability

 

[MitchLevi]

What else can be issue if not scar tissue that’s able to be rectified?
I have ortho colleagues that do this but does anyone test for mechanical instability

You’ve received the only answer available sir. You can GRFA her, PNS it or give meds. This is incredibly common and happens with 15-20% of TKA.

Around 1/3 of pts are dissatisfied with their TKA.

Do a genicular RFA for free.

 

[Orin]

My general process is to tease out whether it's spontaneous or inducible pain.

If it's inducible, then consider the implant problems and then focus on bone health -> biologics -> genic blocks with the usual nociceptive meds thrown in.
If it's spontaneous, then consider LSB vs stimulation pathway with the usual neuropathic meds thrown in.

I assume she is Medicare Advantage and they are refusing the genicular.
I've been pushing back and asking to do the diagnostic genicular block to verify the pain is of peripheral nerve origin and not related to hip or spinal disease. There is a CMS guidance saying you use any nerve block to diagnose the pain, which makes it easier as you can quote your local LCD.

If that block helps, then you can argue for other things, but you want to do the block to know what you're dealing with.

 

[Agast]

If it’s your colleague’s mom, do a genicular RFA for free. No nerve block, just the RFA.

Or their rich doctor kid can pay for it

Assuming they love their mom

 

[BobBarker]

I think his issue is he is ASC only. So can’t just run back and do it after clinic.

 

[Tramadeezy]

Genicular embolization? Underlying infection ruled out with ESR, CRP, WBC?

 

[lobelsteve]

Genic rfa for free. If you did pns on my mom id punch you in the face. What nerve? What literature?

 

[MitchLevi]

Genic rfa for free. If you did pns on my mom id punch you in the face. What nerve? What literature?

HAHAHAHAHA!

I won’t PNS your mom dude (I don’t even do PNS).

Do the RFA in the ASC under charity care.

 

[Agast]

HAHAHAHAHA!

I won’t PNS your mom dude (I don’t even do PNS).

Do the RFA in the ASC under charity care.

So a doctor’s mom is going to get charity care RFA at the surgery center every 6 months for her knee pain?

 

[SpineandWine]

Sad that best care we can provide is not approved by insurance/government.
You never see Shoulder surgery or knee surgery falling to wayside.

Options for post TKA knee pain for the regular patient who is on govnerment insurance now stand at either PNS or NOTHING

 

[Agast]

I just did a peer to peer for a 97 yo woman, the peer acknowledged that genicular nerve would be good if her insurance covered it but he did not have the authority to overturn it. Sad thing is she is a very vigorous 97 and moves way more than some of my 66 yos.

 

[MitchLevi]

So a doctor’s mom is going to get charity care RFA at the surgery center every 6 months for her knee pain?

It ain’t gonna last 6 months, but no, you do it once or twice and it underperforms so they stop asking and just disappear from your schedule. They saw you and got your best effort, and that’s all they wanted to begin with…

 

[afob100]

Diclofenac 3% gel.

For prior auth, put ICD code L57.0 actinic keratosis to get it approved. 100 gram /month max.

Anecdotally, it works great for patients who get partial relief with the OTC stuff.

 

[GoBeers]

Diclofenac 3% gel.

For prior auth, put ICD code L57.0 actinic keratosis to get it approved. 100 gram /month max.

Anecdotally, it works great for patients who get partial relief with the OTC stuff.

weird how actinic keratosis is the only thing that get diclofenac 3% gel approved

 

[knoxdoc]

I had a lady who had knee pain s/p TKA. We talked about GNB/RF but she was hesitant. I started her on gabapentin for her "nerve pain" and she came back a month later with 75% improvement. Complete placebo effect. Try it.

 

[soccrwz]

Sad that best care we can provide is not approved by insurance/government.
You never see Shoulder surgery or knee surgery falling to wayside.

Options for post TKA knee pain for the regular patient who is on govnerment insurance now stand at either PNS or NOTHING

Just do a GNB in office, this usually get paid in office but not asc. All you need is a 5 mL syringe and a hypodermic needle and some local anesthetic, cost on that is almost nothing. You could do it landmark based although not sure if this gets paid, or just do the infrapatellar saphenous (inferiormedial geniculate) as that is the one the PNS usually target anyway and do it gratis.

 

[gaspasser127]

i would do PNS

I would PNS my parents - Sprint for
The right indication

What’s the downside with Sprint? Cost?

Lack of evidence?

Show me convincing data that genicular RFA works long term.

 

[MitchLevi]

What’s the downside with Sprint?

N = 2, and I had a lead fracture in one of these 2. So, my lady who we tried multifidus stim at L4 has a small piece of wire in her body for the rest of her life.

Show me convincing data that genicular RFA works long term.

I believe you have this backwards, and I’m not at all impressed with genicular RFA. Why would Sprint for 60 days result in any longer lasting relief than a genicular RFA? Mechanistically, explain that one please.

 

[Ferrismonk]

Could also consider Curonix which is a permanent lead with less hassle than Sprint with dressing changes.

Yes, you should check if the joint is unstable first. If so, needs revision.

I can see how PNS works for knee pain. We do saphenous/adductor canal blocks all the time in anesthesia for TKA with good post-op relief.

 

[SpineandWine]

Genic rfa for free. If you did pns on my mom id punch you in the face. What nerve? What literature?

most evidence in pain is bull sh**

 

[MitchLevi]

Did this last week for cash - $715. At best I will give this 3M. It's 18g at 80C for 2 min, then did 60 additional seconds at the two superior needles given she hurts worse up there. I am not offering her anything else for this knee. I could Sprint this, but a 300 micron wire (I believe that is still the size of the lead unless it changed) near an extremely mobile joint screams fracture to me. I could get trained on Nalu, but I'm not going to do it until I see more data from journals...NOT from conferences. I am completely done for when it comes to my trusting the "experts" in my field after my neuromonitoring fiasco during SCS implants. I believe nothing.

 

[drrosenrosen]

Did this last week for cash - $715. At best I will give this 3M. It's 18g at 80C for 2 min, then did 60 additional seconds at the two superior needles given she hurts worse up there. I am not offering her anything else for this knee. I could Sprint this, but a 300 micron wire (I believe that is still the size of the lead unless it changed) near an extremely mobile joint screams fracture to me. I could get trained on Nalu, but I'm not going to do it until I see more data from journals...NOT from conferences. I am completely done for when it comes to my trusting the "experts" in my field after my neuromonitoring fiasco during SCS implants. I believe nothing.

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We believe in nozing, Lebowski!

 

[BobBarker]

@MitchLevi tell me more about the neuromonitoring fiasco

 

[MitchLevi]

@MitchLevi tell me more about the neuromonitoring fiasco

Haha. I went to several conferences where I listened to ppl talk about the need for neuromonitoring during implants. Basically, the community should get away from MAC implants and do general, bc cases are taking too long and pts don’t like MAC. Faster implants with better technique if you do it under general…BUT, you have to use neuromonitoring for pt safety.

So I started using NM during implants. Fine. They significantly delayed start time and would occasionally stim motors without telling me during the case. Pt’s leg would jerk randomly, which really isn’t that big of a deal TBH. Just annoying.

One day I had an incompetent NM rep in the middle of a case tell me she was getting evidence of nerve damage that wasn’t there previously. It made no sense. I stopped the case, took a ton of images to ensure I’m safe and ultimately carried on and finished the case. All weekend I was anxious about it. It was literally nothing.

I asked multiple SCS rep how many doctors they worked with who used NM, and they all said just one or two surgeons who do paddles.

I realized the speakers at all these conferences probably have equity in these companies, and that’s why they made all these absurd recs.

They even got those recs inserted into the NACC guidelines.

 

[clubdeac]

Have them try quell 😉

https://support.quellrelief.com/hc/en-us

 

[lobelsteve]

Haha. I went to several conferences where I listened to ppl talk about the need for neuromonitoring during implants. Basically, the community should get away from MAC implants and do general, bc cases are taking too long and pts don’t like MAC. Faster implants with better technique if you do it under general…BUT, you have to use neuromonitoring for pt safety.

So I started using NM during implants. Fine. They significantly delayed start time and would occasionally stim motors without telling me during the case. Pt’s leg would jerk randomly, which really isn’t that big of a deal TBH. Just annoying.

One day I had an incompetent NM rep in the middle of a case tell me she was getting evidence of nerve damage that wasn’t there previously. It made no sense. I stopped the case, took a ton of images to ensure I’m safe and ultimately carried on and finished the case. All weekend I was anxious about it. It was literally nothing.

I asked multiple SCS rep how many doctors they worked with who used NM, and they all said just one or two surgeons who do paddles.

I realized the speakers at all these conferences probably have equity in these companies, and that’s why they made all these absurd recs.

They even got those recs inserted into the NACC guidelines.

If Windsor weren't dead he could tell you all about IOM.

 

[gaspasser127]

Haha. I went to several conferences where I listened to ppl talk about the need for neuromonitoring during implants. Basically, the community should get away from MAC implants and do general, bc cases are taking too long and pts don’t like MAC. Faster implants with better technique if you do it under general…BUT, you have to use neuromonitoring for pt safety.

So I started using NM during implants. Fine. They significantly delayed start time and would occasionally stim motors without telling me during the case. Pt’s leg would jerk randomly, which really isn’t that big of a deal TBH. Just annoying.

One day I had an incompetent NM rep in the middle of a case tell me she was getting evidence of nerve damage that wasn’t there previously. It made no sense. I stopped the case, took a ton of images to ensure I’m safe and ultimately carried on and finished the case. All weekend I was anxious about it. It was literally nothing.

I asked multiple SCS rep how many doctors they worked with who used NM, and they all said just one or two surgeons who do paddles.

I realized the speakers at all these conferences probably have equity in these companies, and that’s why they made all these absurd recs.

They even got those recs inserted into the NACC guidelines.

Lol

Insanity

 

[MitchLevi]

If Windsor weren't dead he could tell you all about IOM.

While flying to Paris

 

[dozitgetchahi]

You’ve received the only answer available sir. You can GRFA her, PNS it or give meds. This is incredibly common and happens with 15-20% of TKA.

Around 1/3 of pts are dissatisfied with their TKA.

Do a genicular RFA for free.

Rheumatology here.

My first question: why was the knee replaced and what was the pathology going on at that point? And is the knee swollen/warm/erythematous? And are you absolutely sure there is no infection (IMHO ortho tends to half ass the post TKA infection evaluations most of the time).

If you are certain there is no infection, and the knee is swollen/warm, and originally the pt had some sort of inflammatory arthritis (especially RA), then there is some thinking that occasionally tiny shreds of remaining synovium that lingered after the synovectomy may have reformed into a small sphere-like “joint capsule” that can again become inflamed like the original joint did (this is somewhat controversial). If this is happening, than the solution is better control of the pt’s underlying inflammatory arthritis.

If the replacement was done for OA or any other similar reason, then yeah, I agree with above. And believe me, there are a LOT of patients that are unhappy with their TKAs, and sooner or later they all seem to get sent to me 🤦

 

[BobBarker]

Yes, I did many, many with general and IOM in fellowship. Took forever for the case to start, longer to start the case than to do it. Intubate, secure tube, insert a bajillion needles, flip, position and secure patient, reposition the needles, get baselines, prep, drape is well over 30 minutes.

The real kick in the pants, is when we got an unusual reading we just looked at the films, saw everything was fine, ignored the finding and completed the case.

 

[Espn123]

genic block/RF only.

No PNS
No DRG

Suit yourself, but some patients may be missing out…

 

[Espn123]

Haha. I went to several conferences where I listened to ppl talk about the need for neuromonitoring during implants. Basically, the community should get away from MAC implants and do general, bc cases are taking too long and pts don’t like MAC. Faster implants with better technique if you do it under general…BUT, you have to use neuromonitoring for pt safety.

So I started using NM during implants. Fine. They significantly delayed start time and would occasionally stim motors without telling me during the case. Pt’s leg would jerk randomly, which really isn’t that big of a deal TBH. Just annoying.

One day I had an incompetent NM rep in the middle of a case tell me she was getting evidence of nerve damage that wasn’t there previously. It made no sense. I stopped the case, took a ton of images to ensure I’m safe and ultimately carried on and finished the case. All weekend I was anxious about it. It was literally nothing.

I asked multiple SCS rep how many doctors they worked with who used NM, and they all said just one or two surgeons who do paddles.

I realized the speakers at all these conferences probably have equity in these companies, and that’s why they made all these absurd recs.

They even got those recs inserted into the NACC guidelines.

 

[MitchLevi]

Yes, I did many, many with general and IOM in fellowship. Took forever for the case to start, longer to start the case than to do it. Intubate, secure tube, insert a bajillion needles, flip, position and secure patient, reposition the needles, get baselines, prep, drape is well over 30 minutes.

The real kick in the pants, is when we got an unusual reading we just looked at the films, saw everything was fine, ignored the finding and completed the case.

Exactly my experience too

 

[painfree23]

I just did a peer to peer for a 97 yo woman, the peer acknowledged that genicular nerve would be good if her insurance covered it but he did not have the authority to overturn it. Sad thing is she is a very vigorous 97 and moves way more than some of my 66 yos.

So annoying when they do this. I always get their name and tell them I’m going to give their name to the patient. Just out of spite.

 

[Ducttape]

if no GRFA, then aggressive home exercise, yoga and duloxetine.

could advocate to her PCP to consider prn tramadol.

 

[kstarm]

I had a lady who had knee pain s/p TKA. We talked about GNB/RF but she was hesitant. I started her on gabapentin for her "nerve pain" and she came back a month later with 75% improvement. Complete placebo effect. Try it.

Why do you believe this is a placebo effect?