Broida Samuel Earl, Wong Philip Kin-Wai, Umpierrez Erica, Kakarala Aparna, Reimer Nickolas Bernard, Gonzalez Felix M
Emory University School of Medicine, Atlanta, GA, USA.
Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA.
Radiol Case Rep. 2020 Apr 5;15(6):691-696. doi: 10.1016/j.radcr.2020.02.034. eCollection 2020 Jun.
Subchondral insufficiency fractures of the knee are commonly misdiagnosed fractures that are both very painful and difficult to treat. A conservative treatment modality to control symptoms during rehabilitation has not previously been described. This case report presents the alternate use of cooled radiofrequency ablation technique of the genicular nerves for pain relief and bisphosphonate infusion to address the underlying poor bone mineralization/density with imaging follow-up before and after instituted treatments. A middle-aged female patient presenting with atraumatic pain in the medial aspect of the left knee diagnosed on an original magnetic resonance imaging as an insufficiency fracture and debilitating pain. Multiple-surgeon opinions of total knee arthroplasty were not a consideration the patient wanted or could consider given her lifestyle. Cooled radiofrequency ablation of the genicular nerve branches was performed with significant-complete pain relief achieved that lasted at least 6 months. Bisphosphonate infusions were instituted to address the underlying osteoporosis detected by a dual energy X-ray absorptiometry (DEXA) scan. Clinical performance after the radiofrequency ablations was followed with clinically validated surveys (The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)/Knee Injury and Osteoarthritis Outcome Score (KOOS)) at 2 weeks, 1, 3, and 6 months. Patient was also asked to follow a restricted-modified weight-bearing plan for 3 months followed by physical therapy. Eight weeks apart of bisphosphonate infusions were delivered after proper administration of vitamin D. There was resolution of the insufficiency fracture at the medial femoral condyle between the magnetic resonance imaging exams within 4.5 months apart treated with restricted weight-bearing regimen. Pain resolution, significant improved function, and range of motion were the end results of our instituted treatment plan. This case reports presents an alternate pathway for the treatment of this condition especially when there is lack of consensus among physicians in how to best address this condition.
膝关节软骨下不全骨折是常见的误诊骨折，疼痛剧烈且治疗困难。此前尚未描述过在康复期间控制症状的保守治疗方式。本病例报告介绍了交替使用膝神经冷却射频消融技术缓解疼痛以及输注双膦酸盐以解决潜在的骨矿化/密度不佳问题，并在治疗前后进行影像学随访。一名中年女性患者，左膝内侧出现非创伤性疼痛，最初的磁共振成像诊断为不全骨折且疼痛难忍。鉴于患者的生活方式，全膝关节置换术的多位外科医生意见并非患者想要或能够考虑的。对膝神经分支进行了冷却射频消融，疼痛得到显著完全缓解，持续至少6个月。输注双膦酸盐以解决双能X线吸收法（DEXA）扫描检测到的潜在骨质疏松症。在射频消融术后2周、1个月、3个月和6个月，通过临床验证的调查（西安大略和麦克马斯特大学骨关节炎指数（WOMAC）/膝关节损伤和骨关节炎结局评分（KOOS））对临床疗效进行随访。患者还被要求遵循限制改良负重计划3个月，随后进行物理治疗。在适当补充维生素D后，每隔8周输注一次双膦酸盐。在接受限制负重方案治疗的4.5个月内，两次磁共振成像检查之间，股骨内侧髁的不全骨折得到了愈合。疼痛缓解、功能显著改善和活动范围扩大是我们制定的治疗计划的最终结果。本病例报告展示了治疗这种疾病的另一种途径，特别是当医生在如何最佳治疗这种疾病方面缺乏共识时。
