Whats your algorithm to treat knee OA pain?

[Blitz2006]

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- Steroid Injection
- HA injection
- Genicular Nerve Block

Whats your formula, after conservative management has failed?

Steroid x 1, if fails, then HA injection x 1, if fails, then genicular nerve block....correct or wrong?

 

[cowboydoc]

Weight loss, nsaid/tylenol. I've gone almost full scale Iovera to substitute the genicular block/RF, otherwise the above for interventional management.

 

[callmeanesthesia]

- NSAIDs, topical NSAIDs if side effects/contraindications to oral
- Visco if covered
- surgical referral if the patient is interested and a good candidate
- genicular block/RF if not a good surgical candidate/doesn’t want surgery

Would love to be able to do Iovera but couldn’t make it pencil out with how much they charge for supplies. Having a lot of trouble getting genicular ablation covered too - considering going to cash pay for it.

 

[painfree23]

- NSAIDs, topical NSAIDs if side effects/contraindications to oral
- Visco if covered
- surgical referral if the patient is interested and a good candidate
- genicular block/RF if not a good surgical candidate/doesn’t want surgery

Would love to be able to do Iovera but couldn’t make it pencil out with how much they charge for supplies. Having a lot of trouble getting genicular ablation covered too - considering going to cash pay for it.

How much would u charge cash for it ?

 

[callmeanesthesia]

How much would u charge cash for it ?

Open to suggestions. Current charge master has it about $1000 so some discount off that.

 

[painfree23]

Open to suggestions. Current charge master has it about $1000 so some discount off that.

straight to rf or two blocks first?

 

[callmeanesthesia]

straight to rf or two blocks first?

I’ve been doing one block in the same appointment as the initial consultation - palpation and ultrasound guided, lateral approach with a 27g needle (unless they are too big). Follow up in a few days to discuss results and ablation.

 

[painfree23]

I’ve been doing one block in the same appointment as the initial consultation - palpation and ultrasound guided, lateral approach with a 27g needle (unless they are too big). Follow up in a few days to discuss results and ablation.

Palpation and ultrasound? Nice. Do u have ultrasound images u would be willing to share? Do u bill for the block at the initial visit?

 

[thecentral09]

Weight loss, nsaid/tylenol. I've gone almost full scale Iovera to substitute the genicular block/RF, otherwise the above for interventional management.

How are your results with Iovera. I keep being approached to doing it. I have cool RF that admittedly I am not in love with, and wanted to hear what your experience has been with it.

 

[callmeanesthesia]

Palpation and ultrasound? Nice. Do u have ultrasound images u would be willing to share? Do u bill for the block at the initial visit?

I bill for the block with the initial visit. Unfortunately Medicare won’t reimburse for ultrasound or fluoro with 64450 according to my coders, but at least I’m not wasting a fluoro procedure spot.
It’s surprisingly easy to feel the landmarks even on bigger knees. I feel the edge of the condyle, mark it, and confirm my marking position with ultrasound by looking longitudinal and transverse at the bone. Then I stick the needle in at each of those spots perpendicular to skin, down to bone, and put 1 mL local anesthetic. I usually inject 0.5 mL, redirect the needle a little proximal or distal, and inject another 0.5 mL. It’s quick and minimally painful. I just started doing it this way a few weeks ago but it’s worked well so far.

 

[deleted185747]

My algorithm @VA hospital:

Steroid injection. If 4+ months of relief then can repeat if knee OA is severe. If less than 4 months and severe oa then genicular block x 1 and if 50% reduction then cooled RFA. If less than 4 months and mild to moderate OA then visco or PRP depending on age (PRP for those less than age 50 yrs) and other findings. Reserve genicular for refractory severe OA who can’t or won’t receive surgery within 12 months only as there are other options for milder cases.

 

[swamprat]

how about post TKA. Anyone try DRG for these patients?

 

[painfree23]

how about post TKA. Anyone try DRG for these patients?

Seems aggressive , what about the coverage?

 

[PMR2008]

weight loss - consultation with personal trainer/nutritionist if overweight. (A quarter of my patients improve with just this)
Physical therapy - knee brace
Topical NSAIDs- short course of oral NSAIDs
Steroid - if more than 3 months of relief than repeat 3-4 times a year
If not interested in Steroid than HA
If not interested in Steroid or HA - PRP/Stem cell
If less than 3-6 months of relief from HA than genicular block/RF
Than Surgical referral otherwise continue genicular RF

I am going to reach out to the local iovera rep. Seems interesting.

 

[paindoc007]

Seems aggressive , what about the coverage?

Difficulty to get approved unless you lie and say it’s CRPS, which a lot of other pain docs around me do.

 

[cowboydoc]

How are your results with Iovera. I keep being approached to doing it. I have cool RF that admittedly I am not in love with, and wanted to hear what your experience has been with it.

Surprisingly good (compared with genicular RF). Easier for me and on the patients. They have a new tip that makes it more like a u/s guided RFA. I'm concerned about duration, but so far it doesn't seem inferior to genicular RF in that respect either.

The cost would be a deal breaker in PP, I think. I do fine with it on rvus, as it is faster in clinic with u/s than RF with fluoro.

 

[callmeanesthesia]

Surprisingly good (compared with genicular RF). Easier for me and on the patients. They have a new tip that makes it more like a u/s guided RFA. I'm concerned about duration, but so far it doesn't seem inferior to genicular RF in that respect either.

The cost would be a deal breaker in PP, I think. I do fine with it on rvus, as it is faster in clinic with u/s than RF with fluoro.

Yeah, they told me “as long as you have a good payor mix, you won’t lose money.” I didn’t pursue it further.

 

[DocMorpheus]

Weight loss, nsaid/tylenol. I've gone almost full scale Iovera to substitute the genicular block/RF, otherwise the above for interventional management.

How well is the iovera reimbursed? It was my impression that you’d pretty much break even after the cost of the iovera equipemnt and cartridges.

 

[TIVAndy]

I bill for the block with the initial visit. Unfortunately Medicare won’t reimburse for ultrasound or fluoro with 64450 according to my coders, but at least I’m not wasting a fluoro procedure spot.
It’s surprisingly easy to feel the landmarks even on bigger knees. I feel the edge of the condyle, mark it, and confirm my marking position with ultrasound by looking longitudinal and transverse at the bone. Then I stick the needle in at each of those spots perpendicular to skin, down to bone, and put 1 mL local anesthetic. I usually inject 0.5 mL, redirect the needle a little proximal or distal, and inject another 0.5 mL. It’s quick and minimally painful. I just started doing it this way a few weeks ago but it’s worked well so far.
View attachment 249828View attachment 249829

btw are you guys able to use modifier 25 to get paid for E&M and the procedure? i've been getting denials on same day in office procedures..

 

[painfree23]

btw are you guys able to use modifier 25 to get paid for E&M and the procedure? i've been getting denials on same day in office procedures..

Oh really? For which procedures? Nothing yet...

 

[TIVAndy]

Oh really? For which procedures? Nothing yet...

pretty much everything.. except trigger points..

 

[callmeanesthesia]

pretty much everything.. except trigger points..

Haven’t gotten hit with that yet that I know of. I just recently started doing geniculars in clinic though.

 

[painfree23]

Haven’t gotten hit with that yet that I know of. I just recently started doing geniculars in clinic though.

I still need help /advice for doing this in clinic. Thense patients hate the procedure. I honestly rather do a scs stim without sedation than a genicluar without sedation . Any tips ?

 

[lobelsteve]

I still need help /advice for doing this in clinic. Thense patients hate the procedure. I honestly rather do a scs stim without sedation than a genicluar without sedation . Any tips ?

Lidocaine. 25g needles for block, 20g for rfa.

 

[pastafan]

I still need help /advice for doing this in clinic. Thense patients hate the procedure. I honestly rather do a scs stim without sedation than a genicluar without sedation . Any tips ?

More lidocaine. I use about 15 ml for RFA. Stay immediately adjacent to os.

 

[callmeanesthesia]

I still need help /advice for doing this in clinic. Thense patients hate the procedure. I honestly rather do a scs stim without sedation than a genicluar without sedation . Any tips ?

For nerve block I took the advice of someone else on here and started approaching from lateral. I forget who that was but maybe they can chime in too. It’s much less painful. For small/medium knees I feel the condyles and mark, then verify with ultrasound, then go in blind with a 27g 1.5”, perpendicular to skin down to bone, inject 0.5 mL local, redirect proximal or distal and inject another 0.5 mL. For big patients where I can’t feel landmarks, I do it under fluoro with a 25g 3.5”. Mark in AP then trace straight down to the side of the knee (like you’d do for a GT bursa), stick the needles in parallel to the table to the target points.

For the RF I did yesterday, I came in from lateral with a 27g under fluoro, and injected about 2 mL 2% lidocaine all along the sides of the femur and tibia along the target area. Then I localized the skin from AP and put the RF needles in from AP, injecting additional local as I get close to the targets to fully anesthetize the needle tract. That worked really well - she had a lot less pain than previous patients.

 

[pastafan]

For nerve block I took the advice of someone else on here and started approaching from lateral. I forget who that was but maybe they can chime in too. It’s much less painful. For small/medium knees I feel the condyles and mark, then verify with ultrasound, then go in blind with a 27g 1.5”, perpendicular to skin down to bone, inject 0.5 mL local, redirect proximal or distal and inject another 0.5 mL. For big patients where I can’t feel landmarks, I do it under fluoro with a 25g 3.5”. Mark in AP then trace straight down to the side of the knee (like you’d do for a GT bursa), stick the needles in parallel to the table to the target points.

For the RF I did yesterday, I came in from lateral with a 27g under fluoro, and injected about 2 mL 2% lidocaine all along the sides of the femur and tibia along the target area. Then I localized the skin from AP and put the RF needles in from AP, injecting additional local as I get close to the targets to fully anesthetize the needle tract. That worked really well - she had a lot less pain than previous patients.

I posted it in private forum thread with fluoro images. For RFA I use 27 g 1.5 needle and inject from anterior to posterior entire needle length. I then attach extension tubing to RFA needle and inject lido as I advance.

Diagnostic blocks with 27 gauge only coming in laterally after target marked using fluoroscopy.

 

[Ferrismonk]

For nerve block I took the advice of someone else on here and started approaching from lateral. I forget who that was but maybe they can chime in too. It’s much less painful. For small/medium knees I feel the condyles and mark, then verify with ultrasound, then go in blind with a 27g 1.5”, perpendicular to skin down to bone, inject 0.5 mL local, redirect proximal or distal and inject another 0.5 mL. For big patients where I can’t feel landmarks, I do it under fluoro with a 25g 3.5”. Mark in AP then trace straight down to the side of the knee (like you’d do for a GT bursa), stick the needles in parallel to the table to the target points.

For the RF I did yesterday, I came in from lateral with a 27g under fluoro, and injected about 2 mL 2% lidocaine all along the sides of the femur and tibia along the target area. Then I localized the skin from AP and put the RF needles in from AP, injecting additional local as I get close to the targets to fully anesthetize the needle tract. That worked really well - she had a lot less pain than previous patients.

So no sensory/motor testing?

 

[painfree23]

U put the fluorobeam directly AP to the knee right? U don’t put any caudal or cranial tilt? I feel like sometimes it comes in too low on the knee (almost hitting the patella ) using landmarks but on the image it’s in the right place

 

[pastafan]

AP to knee. Cranial tilt sometimes required due to pillows under leg to maintain true AP view.

 

[painfree23]

AP to knee. Cranial tilt sometimes required due to pillows under leg to maintain true AP view.

How do U tell “true AP” for the knee? What r u lining up?

 

[pastafan]

How do U tell “true AP” for the knee? What r u lining up?

Patella centered on femur. C-arm parallel with lower extremity.

 

[callmeanesthesia]

So no sensory/motor testing?

I still motor test but I realize it doesn’t do much. I think mainly the safety comes from the position on lateral view and making sure the tips aren’t too far posterior. As far as sensory, patients seem to feel it radiating into the knee during ablation even with lots of local.

 

[cowboydoc]

How well is the iovera reimbursed? It was my impression that you’d pretty much break even after the cost of the iovera equipemnt and cartridges.

My post from another thread:

I am in a multispecialty group associated with a hospital system. I do with US in clinic. I think our system is looking at this as a way to prepare for the move to outpatient total joint arthroplasty. The analysis showed nearly 2 years to recoup actual costs, not looking at the hospital length of stay and other potential downstream benefits. (perhaps I'm giving administrators too much credit)

The hand-held unit is $6 grand. The tips are about $275 and you probably use about $10-20 of nitrous per case. The reimbursement for 1 nerve is $248 for the first, and a 50% reduction for each additional. It looks like we are getting about $100 for ultrasound guidance.

Of course, Medicare reimbursement is $124 for the 1st nerves and no reimbursement for ultrasound, so that does not pencil out at all.

Summary: I have no idea why a private practice would do this.

(RVU is 1.23 for the 64640, 76942 for U/S guidance is 0.67, so for the typical Iovera treatment, I'm getting 2.82 RVU and it takes 20-30 min)

 

[TIVAndy]

how about post TKA. Anyone try DRG for these patients?

if all else fails. DRG at L3

 

[MiddleOfNowherrr]

PT/short course prescription NSAIDS
If skinny topicals
Weight loss
IA knee injection/viscosupplementation
Genicular
(Would offer PRP but patients in my area complain of $4 ibuprofen so thats a no go since prp is all cash pay)
DRG—you can use the diagnosis “peripheral causalgia” (doesnt make sense to me but this is what abbot promotes) to get it covered but only in the setting of post TKA pain. If no TKA dont bother submitting for DRG for knee pain.
Surgery
Of course the order of these isnt rigid but i tend to more or less follow this algorithm. Iovera looks interesting—for those that do it, how much are you charging? Im assuming this is cash based, as I was under the impression cryoanalgesia isnt covered by most insurance carriers?

 

[Ducttape]

its not covered by Medicare LCD in my particular area. you should look in to yours.

 

[Bsb2015]

Anyone see pain and swelling after Orthovisc 4 weeks out? I don’t think this is pseudo septic arthritis. How long before the patient should expect for the symptoms to go away? Thought with Orthovisc don’t get a big inflammatory response

 

[Ligament]

ideal; PRP, BMC, or A2M depending on pathology. If fails, genicular blocks and radiofrequency ablation or cyroablation. If fails, (and not TKA candidate), DRG stim.

Other options: Steroid. But typically my patients have already tried this many times.

I can no longer afford viscosupplements, not reimbursed sufficiently to do it. I think I loose $50 for every case.

 

[Gauss]

Anyone see pain and swelling after Orthovisc 4 weeks out? I don’t think this is pseudo septic arthritis. How long before the patient should expect for the symptoms to go away? Thought with Orthovisc don’t get a big inflammatory response

nope, you are correct. unrelated to orthovisc. didn't work, new injury, OA flare from too much exercise/fun, ...

 

[Sadder]

colleagues, arthroscopy with shaving, removing of the damaged meniscus as a stage of treatment you consider? Before PRP, Orthotics or after?

 

[lobelsteve]

colleagues, arthroscopy with shaving, removing of the damaged meniscus as a stage of treatment you consider? Before PRP, Orthotics or after?

Never.

 

[pmrmd]

colleagues, arthroscopy with shaving, removing of the damaged meniscus as a stage of treatment you consider? Before PRP, Orthotics or after?

It doesn’t seem orthopods want to do this nearly as much anymore either.

 

[emd123]

- Steroid Injection
- HA injection
insert >TKR<
- Genicular Nerve Block

Whats your formula, after conservative management has failed?

Steroid x 1, if fails, then HA injection x 1, if fails, then genicular nerve block....correct or wrong?

Yes, except insert knee replacement after HA injections, before genicular, for patients that are good surgical candidates. TKR corrects mechanical problems in addition to pain relief, in a way that only killing the pain nerves can't. For patients that still have some quality years left, I personally would rather have a well done TKR, than an ablation that allow me to walk on a knee that's destroyed, functioning poorly and breaking down mechanically more by the day.

 

[SSdoc33]

It doesn’t seem orthopods want to do this nearly as much anymore either.

maybe not in CO, but i still see it all the time. is it down from 20 years ago? probably.