Authors:

Solomon Rojhani, MD
Zan Qureshi Pain
Akhil Chhatre, MD

Affiliations:
From Department of Physical Medicine
& Rehabilitation, The Johns Hopkins CASE REPORT
School of Medicine, Baltimore,
Maryland (SR, AC).

Correspondence:
All correspondence and requests for
reprints should be addressed to:
Solomon Rojhani, MD, Department of
Physical Medicine & Rehabilitation,
The Johns Hopkins School of Medicine,
600 N Wolfe St, Phipps 160, Baltimore,
MD 21287.
Disclosures:
The article has been read and approved
by all named authors, and there are no
other persons who satisfied the criteria
for authorship.
Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article.
Editor’s Note:
Supplemental digital content is
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0894-9115/16/0000-0000
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2016 Wolters Kluwer
Health, Inc. All rights reserved.
DOI: 10.1097/PHM.0000000000000549
Water-Cooled Radiofrequency
Provides Pain Relief, Decreases
Disability, and Improves Quality of Life
in Chronic Knee Osteoarthritis
ABSTRACT
Rojhani S, Qureshi Z, Chhatre A: Water-cooled radiofrequency provides pain
relief, decreases disability, and improves quality of life in chronic knee
osteoarthritis. Am J Phys Med Rehabil 2016;00:00Y00.
Chronic osteoarthritis (OA) is a widespread source of pain and disability and
represents a growing economic burden across aging populations. Representing a
major focus of arthritis care, OA of the knee is especially concerning as it has the
potential to restrict mobility and significantly impair quality of life. Chronic OA is
often poorly managed both pharmacologically and nonpharmacologically, with
surgical management representing the definitive treatment. Those who are not
surgical candidates or simply opt for minimally invasive treatments are usually
faced with a lack of alternatives. An additional treatment presents itself in the form
of water-cooled radiofrequency ablation, which involves the use of thermal lesions
to interrupt the active pain pathways. An 81-year-old woman with bilateral severe
knee OA was initially seen and evaluated in an outpatient physiatry clinic after
multiple previous workups of her ongoing knee pain. With a known diagnosis of
end-stage knee OA, the patient chose to proceed with bilateral water-cooled
radiofrequency ablation. At 6 weeks and 3 months after the procedure, the patient
maintained adequate levels of pain relief, markedly improved function, and enhanced
quality of life. Water-cooled radiofrequency ablation has the potential to create lasting
pain relief and with minimal adverse effects in patients with chronic knee OA.
Keywords: Cooled Radiofrequency, Osteoarthritis, Pain, Knee

www.ajpmr.com Cooled Radiofrequency in Knee Osteoarthritis 1

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 C hronic osteoarthritis (OA) is a prevalent and
disabling condition currently affecting an estimated
40 to 50 million Americans, with approximately 10%
to 30% of those afflicted having significant pain,
impaired function, and decreased quality of life.1Y3
The socioeconomic burden of knee and hip OA
alone averages more than $12,000 annually in both
direct and indirect costs of disease.4 Recent studies
have also demonstrated the association between OA
and frailty, which ultimately contributes to mor-
tality in severe disease states.5 Many treatment
options have been reported in depth, ranging from
conservative management to total knee arthroplasty
(TKA) in the case of severe disease.6,7 In mild cases,
patients are often able to diminish symptoms by
simply modifying their activity. Additional well-
validated conservative treatment modalities in-
clude physical therapy programs, oral and topical
pharmacotherapy, intra-articular steroid injection,
and viscosupplementation.8Y10 However, refractory
pain and progressive loss of function often neces-
sitate surgical management.11
Having been successfully implemented in
the treatment of spine pain, the application of
radiofrequency neurotomy (RFA) in disrupting
nociceptive pathways is becoming increasingly preva-
lent in the treatment of peripheral joint pain.12Y14 As in
traditional RFA, the water-cooled radiofrequency
(CRF) system utilizes a similar thermal ablative
mechanism, although with the ability to create a
greater area of neural lesioning in order to im-
prove the probability of effective denervation.15
Targeting of the articular branches of the knee
joint, also known as the genicular nerves (GNs),
follows an anatomical, landmark-based approach
in order to interrupt pain pathways and potentially
sustain improved functioning.16
Case Presentation
The following events, including visits, evalua-
tions, and procedures, in this presentation were
designated as the standard of care for that patient
and as such did not incorporate specialized pro-
tocols, which would otherwise require review by an
institutional review board.
An 81-year-old, nonsmoking African American
woman with a body mass index of 34 kg/m2 (class 1
obesity) presented to an outpatient physiatric clinic
with chronic intermittent bilateral knee pain and
previously diagnosed chronic OA. Initial onset of
pain was noted to be approximately 4 years prior to
presentation and located primarily deep within the
2 Rojhani et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
right knee joint, described as achy in nature, and
with a similar pain afflicting the left knee shortly
thereafter. The pain was noted to be on average a
numeric pain scale rating of 3 of 10 to 4 of 10 daily
and frequently reached 8 of 10. Associated symptoms
included feelings of Bcrunching and cracking[ within
the knee joint, occasional right knee buckling with-
out falling, subjective muscle weakness, knee swell-
ing, and a decreased tolerance to weight bearing.
Symptoms were aggravated by movement and weight
bearing. No loss of range of motion was noted, and
sensation was intact. There was no known mecha-
nism injury, although the patient noted repetitive
standing stress during her career as a chef.
Conservative management of OA consisted of
trials of acetaminophen, heat, elevation, ice, im-
mobilization, rest (nonYweight bearing), and several
courses of physical therapy with mild temporary
improvement in pain. She had continued the use of
acetaminophen (500 mg) up to 5 times weekly and
naproxen (375 mg) twice daily and required the use of
a straight cane to assist with community ambulation.
In addition, treatment included bilateral intra-
articular corticosteroid knee injections and subse-
quent hyaluronate injections over the course of
2 years prior to her presentation. Her experience
with injection therapy initially provided her with
up to 75% relief for up to 6 months, although she
ceased injection therapy with the previous provider
because of waning therapeutic effect. The partici-
pant completed an outpatient physical therapy pro-
gram in the year prior to CRF system and received
home exercise strategies and disease education from
therapy, physiatry, and primary care. She recalls re-
ceiving specialized insoles several years prior, in ad-
dition to using an over-the-counter brace, neither of
which she continued to use because of ineffective-
ness. Her improvements initially manifested as in-
creased walking distance and greater speed with
stair ascension, although this had diminished to
mere feet with increasing pain severity. At that
time, the same provider who performed hyaluronate
injections offered the patient bilateral TKA, which she
refused because of personal fear of surgery.
Medical history includes hypertension, hyper-
lipidemia, hypothyroidism, glaucoma, asthma,
seasonal allergies, and breast cancer treated with
radiation and lumpectomy approximately 11 years
prior. The most up-to-date medication list includes
levothyroxine, metoprolol-hydrochlorothiazide, sim-
vastatin, bimatoprost, acetaminophen, and naproxen.
Family history was found to be noncontributory,
and the patient denied any history of tobacco use,
alcohol use, or the use of illicit substances. She
lived alone in a multilevel home with 2 steps to
enter and a full flight to the second level. Physical
examination was positive for bilateral effusions and
palpable crepitus with passive range of motion.
Bilateral hallux valgus was additionally present.
Review of recently obtained bilateral knee ra-
diographs revealed severe asymmetric joint space
narrowing, multiple osteophytes, bony sclerosis,
the presence of subchondral cysts, and mild effu-
sion, corresponding to a Kellgren-Lawrence grade
4 on the right and grade 3 on the left. In her case, it
was unnecessary to perform diagnostic anesthetic
nerve blocks because of the well-established diag-
nosis of OA, and she was subsequently scheduled for
bilateral CRF ablation. Two weeks prior to scheduling
bilateral CRF ablation, pain level, quality of life, and
level of disability were assessed using the well-
validated Numerical Rating Scale score, Medical
Outcomes Study 36-Item Short-Form Health Survey
(SF-36), and the Western Ontario and McMasters
University Osteoarthritis Index (WOMAC).17Y22 With
norm-based scoring, differences in scale scores
more clearly reflect the impact of the disease pro-
cess, in this case the application of CRF ablation.19

FIGURE 1 SF-36 scores 2 weeks before intervention (A), 6 weeks after intervention (B), and 3 months after intervention
(C) are shown. Improvements in pain and functioning were sustained 6 weeks and 3 months after receiving
bilateral CRF treatments. PF, physical functioning; RP, role-physical; BP, bodily pain; GH, general health;
VT, vitality; SF, social functioning; RE, role-emotional; MH, mental health.

www.ajpmr.com Cooled Radiofrequency in Knee Osteoarthritis 3

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 FIGURE 2 Radiographs of the patient_s left (A) and right (B) knees displaying arthritic changes are displayed. The
patient opted for GN ablation with CRF ablation as shown by the probe positions in the figure. Filled
arrows represent probe targeting the superior medial, superior lateral, and inferior medial GNs.

Numerical Rating Scale score was noted to be
8 of 10, and an initial WOMAC score of 72 revealed
the patient functioning in the range of severe
disability and undoubtedly with constant pain.
Figure 1 highlights the SF-36 scores 2 weeks prior
to the procedure.
The procedure was performed in a fluoroscopy
suite, which had been equipped with a C-arm. The
patient was prepared and received local anesthetic
to each ablation site prior to CRF application. A
single clinician controlled the application of the
CRF electrode throughout the entirety of the pro-
cedure. Once targeting was achieved, radiographic
assessment provided confirmation of electrode
placement (Fig. 2). Then, approximately 0.5 mL of
2% lidocaine was introduced to reduce the dis-
comfort associated with the large-gauge electrode
being used. Radiofrequency ablation was then ap-
plied for a total of 150 seconds to each site utilizing
a Pain Management Radiofrequency Generator
(Kimberly-Clark Corporation, Roswell, Georgia) at
a set temperature setting of 60-C. The patient
underwent CRF (COOLIEF; Kimberly-Clark Corpo-
ration) neurotomy of the bilateral superior lateral,
superior medial, and inferior medial GNs. The pa-
tient tolerated the procedure well, and the proce-
dure was without complications other than local
postprocedure pain. She had completed physical
therapy within the previous year and continued
her home exercise program after the procedure. Six
weeks and 3 months after bilateral CRF ablation,
repeat Numerical Rating Scale evaluation revealed
pain score of 0 of 10 bilaterally at the time of eval-
uation, and WOMAC scores of 22 and 26, reflecting
a minimal level of disability and overall mild pain.
Figure 1 depicts the postintervention SF-36 scores.
DISCUSSION
The application of CRF ablation as it pertains
to ablating articular branches to the knee relies on
the relatively predictable pattern of joint inner-
vation.23,24 Previous studies have demonstrated
a general acceptance of the obturator, femoral,
and sciatic nerves as the origins of the articular
branches, and although their proximal course
through the lower extremity had been a point of
contention, pericapsular location of the GNs displayed
consistent anatomic predictability.23 In terms of
radiographic targeting under fluoroscopic guid-
ance, the relationship between the GN and its
periosteal course displayed reliability at the junc-
tion of the epiphysis and diaphysis of both the
femur and tibia.24Y26 On anteroposterior images,
the epiphyseal/metaphyseal line was the anatomic
target, demonstrating congruence with the vali-
dated 3-point injection protocol.23,24,27
Although neurolysis has been shown to occur
at temperatures close to 45-C, temperatures in
conventional RFA may reach as high as 80-C to 90-C,
heightening the risk of developing complications
related to thermal injury.15 An actively water-cooled
electrode advantageously ablates a greater volume
of tissue at lower temperatures than traditional
RFA, increasing the likelihood of generating re-
producible success and longer-lasting pain re-
lief.15,23,28 Franco et al.23 were able to demonstrate
that a theoretical 10-mm conventional lesion placed

4 Rojhani et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
in the proper position to successfully lesion the GNs
only did so 71% (superior lateral branch), 50%
(superior medial branch), and 67% (inferior medial
branch) of the time. Using the same anatomic po-
sitioning with a 17-gauge CRF ablation electrode
produced 100% interruption in superior medial
and inferior medial branches and 86% of superior
lateral branches, respectively. Fewer probe place-
ments could potentially reduce both fluoroscopy
and lesioning times when compared with tradi-
tional RFA. The spherical lesion bestows additional
advantages, as the CRF ablation probe may be placed
perpendicularly adjacent to the nerve of interest,
whereas conventional RFA produces a narrow ellip-
tical burn requiring a parallel placement.
Conventional RFA in GN ablation has shown
to improve pain and function in chronic knee OA,
maintained for up to 12 weeks, as displayed in the
controlled trials of Ikeuchi et al.25 and Choi et al.24
Similar applications have maintained positive re-
sults.26 Promising outcomes have been reported in
the long-term applications of CRF ablation in the
treatment of sacroiliac and lumbar axial pain
syndromes.29,30 While conventional RFA has been
researched more thoroughly in the treatment of
knee OA, the use and feasibility of CRF ablation
has typically been examined in the setting of on-
going pain after TKA, until its application in a
recent case series involving individuals with knee
OA.27,31,32 International bodies such as the European
Society for Clinical and Economic Aspects of Osteo-
porosis and Osteoarthritis have typically refrained
from including minimally invasive procedures in
standard guidelines, although have noted that the
20% who do not benefit from TKA are left with poor
treatment strategies.11 A greater body of work is
necessary in order to further validate CRF ablation
in the treatment of knee OA, as well as determining
its role as part of treatment algorithms. The poten-
tial for more effective lesioning seems to bear cost-
effectiveness and may find usefulness where RFA
has previously been applied in the treatment of
various musculoskeletal disorders.20,30,33 Poten-
tial complications of RFA include pain at the pro-
cedure site, nerve injury, and dysesthesias, although
no fatalities as a direct result of the procedure have
been reported.
In this case, a patient with years of gradually
worsening pain and progressive functional decline
underwent successful bilateral GN ablation using
the CRF ablation technique. With her most severe
pain, approximately 1 month prior to the proce-
dure, the participant was able to walk 10 ft using a
single point cane before a rest break. At 3 months
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after the procedure, she was able to walk up to
5 blocks without using an assistive device with only
minimal discomfort. This is consistent with the
patient_s desired functional outcomes as outlined
by her prior to ablation, in addition to allowing her
to cut back on oral nonsteroidal therapy and po-
tentially avoiding harmful adverse effects. Once
further validated, CRF ablation may find a niche as
an alternative to chronic opioid therapy, which has
been described in multiple treatment guidelines as
a common final pathway.6,7,11 However, the use of
this treatment continues to be limited by a lack of
high-quality evidence. Larger trials are warranted
in order for this technique to gain further appeal in
the discussion of its role within the bounds of the
treatment guidelines.
CONCLUSIONS
This case represents a growing body of litera-
ture in support of using minimally invasive water-
cooled radiofrequency ablation in the treatment
of chronic knee OA. For many individuals with
chronic OA, pain and impaired function often con-
tribute to the disturbances seen in quality of life and
general well-being. The persistent pain, gradually
worsening disease pattern, and ultimate ineffective-
ness or intolerance of maximal medical therapy are a
common pattern of experience that often eventuates
surgical intervention. Although typically reserved for
surgical failures, there is support for the consider-
ation of CRF ablation in the broader treatment of end-
stage knee OA.
Supplementary Checklist
CARE Checklist: http://links.lww.com/PHM/A269
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