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Radiofrequency denervation of the hip joint for pain management: case report and literature review.

BACKGROUND

Osteoarthritis results in activity and functional limitations, high health care and economic costs, and increased mortality. (1,2) Osteoarthritis (OA) of the hip and knee is the primary etiology of walking-related disability in the United States. (3) Depending on age, hip joint OA alone has an estimated prevalence of 28% to 43% radiologically, and 10% to 17% based on symptoms. (4) The prevalence of this is rising, attributed in some studies to the advancing age of the population and increased incidence of obesity. (5,6)

While no reversible treatment for hip joint OA is available, total hip arthroplasty has been shown to provide excellent pain relief, return of function, and medication reduction. (7) With relatively low associated complication rates, (7) it is the standard of care for patients failing conservative treatment. However, barriers to arthroplasty treatment include patient factors such as comorbidities and active health issues, system factors (surgical wait times, lifespan of surgical implants, etc), and societal factors such as gender and race. (1,7-9)

Proposed conservative treatments for OA have varying levels of evidence and efficacy and include lifestyle modifications (weight loss, exercise, nutriceuticals), (10-14) physical therapy (modalities, bracing, gait aids, shoe modifications, acupuncture, aquatic therapy, strengthening), (15-18) pharmaceuticals (topical medications, acetaminophen, nonsteroidal anti-inflammatories, opioids, nitric oxide), (19) and joint injections (steroids, hyaluronic acid, prolotherapy, autologous blood injections). (20,21)

Thermal radiofrequency (TRF) denervation of the sensory articular nerves to the hip joint is emerging as a possible adjunctive treatment for coxalgia. This has been validated for the management of zygapophyseal joint pain, having been shown to improve pain and function, and has good long term reproducibility. (22,23) Exact mechanisms of action are not known, but coagulation likely denatures peripheral nerves, preventing conduction in small myelinated and unmyelinated nerve fibers until the nerve regenerates. (24) This treatment is predicated on the need for limited anatomical variation, validated bony landmarks under fluoroscopy, and careful patient selection. (25)

CASE REPORT BACKGROUND

Written permission for publication of this case report was obtained in concordance with current ethical guidelines.

A 55-year-old male presented with severe pain and functional limitations as a result of left groin pain attributed to osteoarthritis. Past medical history included hypertension, dyslipidemia, sleep apnea, type 2 diabetes mellitus, depression, and opioid addiction. Medications included atenolol, hydrochlorothiazide, amlodipine, trazodone, duloxetine, amitriptyline, quetiapine, and pregabalin. Physical examination revealed an antalgic gait, painful range of motion for the left hip, mild pain to palpation in the left groin, and a glove and stocking decrease for pinprick in the lower limbs. X-ray imaging revealed mild superior-lateral hip osteoarthritic changes. Magnetic resonance arthrogram revealed a small, undisplaced, anterior labral tear.

He failed multiple treatments including physical therapy, medications, and various injections. Arthroscopic debridement of the labral tear did not result in clinical improvement, but significant osteoarthritic changes were noted superior-laterally. Because the waitlist for a hip arthroplasty was in excess of one year, thermal radiofrequency lesioning of the articular branches was offered in the interim. Given the patient had a concordant but time-limited response to intrarticular hip injection on 2 separate occasions, diagnostic blocks of the femoral and obturator branches were not performed.

For the obturator articular component, a 10 cm radiofrequency cannula with a 10 mm active tip (Diros Technology Inc., Markham, Ontario, Canada) was advanced into position from an inferior-lateral position, directed towards the inferior-lateral margin of the "teardrop" using a combination of ultrasound (L14-5w linear array probe, Zonare Z.one Ultra sp, Zonare Medical Systems, Mountain View, CA) and fluoroscopy (C-arm, Siemens, Burlington, Ontario, Canada) in an anterior-posterior (AP) projection. Two treatments were made with the cannula translated 1 cm from inferior to superior.

For the femoral branches, the cannula was positioned using the same imaging modalities from the lateral projection. The initial target was immediately inferior to the anterior inferior iliac spine in the upper third of the acetabulum. For the first treatment, 2 lesions were made moving superiorly to inferiorly separated by 1 cm, while the second treatment used 2 lesions along the same trajectory separated by 1 cm medially to laterally (Figure 1). Each radiofrequency lesion occurred at 80[degrees]C for 2 minutes.

The first treatment provided almost 90% relief, a return to almost all baseline function except playing hockey, and discontinuation of pain medication for a period of 6 months. The second treatment provided between 20% to 50% relief, with moderate ongoing functional limitations and the necessity for adjunctive pain medication until joint replacement 4 months later.

To our knowledge, this is the first report to describe an inferior-lateral approach for lesioning the obturator branch, clinical application of successive lesions to increase denervation area, and outcomes in a patient receiving a second treatment with previously excellent results. Discussion includes relevant anatomic research, previous clinical studies, possible reasons for differences in outcomes for the second treatment, and future directions.

METHODS

Technical details of the procedure performed on our patient are described in the preceding section.

Literature searches were performed in PubMed, Embase, and Google Scholar. Search terms included hip joint, osteoarthritis, radiofrequency, femoral nerve, sciatic nerve, obturator nerve, hip joint anatomy, neurectomy, articular branch, joint denervation, coxalgia, pain, and hip joint anatomy. Citations were reviewed by authors Gupta and Finlayson, yielding 7 articles relevant to hip joint radiofrequency in a clinical setting, and 18 articles relevant to hip joint innervation or surgical neurectomy. Review of the bibliographies of these studies yielded 2 more radiofrequency articles (for a total of 9), and 12 more anatomy/surgery articles (for a total of 29). Only English language articles were reviewed by authors Gupta and Finlayson, except where a foreign language study was considered to provide unique information.

COMMENT

Clinical Studies-Treatment of Hip Pain Without RF Denervation

There is considerable clinical precedent for denervation treatment for the hip joint for pain. Obturator neurectomy for osteoarthritis of the hip was introduced by Camitz (26) in 1933 and Mol (27) in 1935. Tavernier and Godinot reported successful outcomes in 38% of 57 patients undergoing surgical obturator neurectomy for hip OA. (28) By combining neurectomy of the obturator and quadratus femoris component, 22 of 24 cases initially had satisfactory results, (29) however, the long term outcomes between 3 and 18 month follow-ups showed excellent results in only 2 patients, and no improvement in 22. (30)

Results from another study showed 28 of 42 patients with hip pain of varying etiologies responded to surgical neurectomy of the obturator and quadratus femoris components, where failures were attributed to an extrapelvic surgical approach and variability in joint innervation. Hip flexion weakness and sensory loss were commonly reported, but not as having any important functional significance. (31) Padovani performed surgical neurectomy including the femoral contribution to achieve complete sensory denervation. (32) Subsequent studies have been reported over the years, but this technique eventually fell from favor owing to mixed results and residual symptoms attributed to iatrogenic nerve injury. (33-35) Akatov and Dreval employed obturator main branch TRF in 15 patients with coxarthrosis, but the reported technical details and clinical outcomes were not clear. All but one patient had sensory disturbances postprocedure, and 3 other patients required additional treatment for myofascial pain. (36)

[FIGURE 1 OMITTED]

Heywang-Kobrunner and colleagues used CT guidance for diagnostic and therapeutic large volume, obturator nerve, local anesthetic blocks in 15 patients. Four patients reported excellent relief for between 3 to 11 months, and another 3 patients had good to excellent pain relief varying between one to 8 weeks. For the remaining 8 patients there was either mild effect (4 patients), pain resolved for only one day (2 patients) or no effect. (37)

In contrast, Edmonds-Seal and colleagues compared outcomes for 18 patients with unilateral hip OA in a double blind trial comparing landmark guided, large volume, local anesthetic blocks to saline for the obturator and quadratus femoris branches. Five patients improved in pain and function and 8 patients in mobility, but there was no difference between local anesthetic and saline in treatment outcome, and effect was lost in all but one patient after 4 weeks. There were also a similar number of patients whose pain, function, and mobility worsened postinjection, and one patient seized postblock. (38) Other studies have reported repeat block can be helpful in some patients. (35)

Clinical Studies-Treatment of Hip Pain Using RF Denervation

Rivera and colleagues (39) prospectively studied 17 patients with chronic hip pain who were nonoperative candidates (OA, prolonged postoperative pain). Eight patients reported a decrease in pain of at least 50% at the 6-month follow-up, associated with a statistically significant improvement in WOMAC* and Harris Hip Scores. After noting transient hematoma in 3 cases from vessel puncture, they changed to the lateral needle approach described by Locher and colleagues (40) partway through their study. However, they did not employ multiple lesions per nerve as suggested by Locher et al (ie, lesion stacking). (40)

Kawaguchi and colleagues showed 79% (11 patients) had effective treatment, while 3 patients had an ineffective response. They showed 12 patients had 50% reduction in hip region pain lasting one to 11 months. One patient whose treatment was considered ineffective had close to a 50% reduction in groin pain, but not lateral hip pain. Patients were selected on this basis of response to either obturator blocks and/ or response to intra-articular injections. Nine patients had radiofrequency denervation of the obturator component only, and in addition, 5 had denervation of the femoral component. (41)

Malik and colleagues showed denervation of the femoral and obturator components in 4 patients resulted in reduction in pain between 30% and 70%, improvement in function in 3 of 4, and reduced medication usage in 2 patients. (42)

Wu and Groner looked at pulsed radiofrequency (PRF) as a potential treatment for hip pain in 2 patients, citing a small risk of neuroma and neuritis with TRF. When compared to thermal radiofrequency, PRF applies heat at a lower temperature and therefore does not cause tissue coagulation, and ideal probe placement is perpendicular to the neural structure. Both patients had improved pain and relative function at short-term follow-up. (43) The evidence for comparing PRF to TRF is limited, but there is suggestion they could be equivalent for cervical radicular pain, while TRF shows better efficacy in idiopathic trigeminal neuralgia. (44) We would not recommend PRF for this use, given that the required perpendicular needle placement is in close proximity to the neurovascular structures. (40)

Chaiban and colleagues used ultrasound guidance for treatment of bilateral hip pain in a single patient with hip osteoarthritis, resulting in 80% reduction in pain at 3-month follow-up. (45) Fukui and Nosaka showed significant decrease in pain, improved walking ability, and reduction in pain medication use for 6 months after femoral and obturator articular branch TRF in one patient. The needle was inserted from anterior-posterior for the obturator branch and directed from the superior pubic ramus to the obturator canal. They argued that motor weakness did not occur because only the obturator branch was only partially destroyed when using lesion of 90[degrees]C for 180 seconds. (46) In a Korean language case report, Shin and colleagues reported on a single case of thermal radiofrequency denervation of the femoral and obturator branches resulting in a 50% reduction in pain. (47)

Overall, studies for hip joint radiofrequency were of low quality secondary to small sample sizes, patient selection methodology, inclusion of patients with heterogeneous etiologies for pain (eg, OA, congenital, and metastasis), variable needle placement techniques, and lacking functional outcomes. However, no significant adverse events were reported, with only one study reporting numbness developing in the thigh region in one patient, and another with transient hematoma formation in 3 cases. (39,42)

The relevant articles for hip joint radiofrequency are summarized in the Table.

Anatomical and Safety Considerations for Hip Joint Thermal Radiofrequency

For hip joint thermal radiofrequency denervation, the main anatomic and safety issues are:

* multiple contributions from various nerves,

* variable anatomy and course for each specific nerve,

* vascular injury,

* incomplete denervation secondary to closely associated vessels, and

* further joint injury through nerve or vascular destruction.

The following discussion of anatomy is meant to reflect the perspective of the interventionalist, although most articles do not discuss nerve trajectory with respect to bony structures, which is imperative to designing a reliable and reproducible procedure. Also, for this discussion it is assumed branches that innervate a region of the capsule will supply the neighboring portion of the joint, (48) however, this is not explicitly stated in all articles.

Some guiding principles can be applied to regional innervation of the hip joint, but significant variation has been described. (49) Generally, the anteriormedial portion of the capsule is innervated by the branches of the obturator nerve, anterolateral capsule branches of the femoral nerve, posteromedial joint from branches of the sciatic nerve, and/or nerve to quadratus femoris, superolateral (posterior and anterior) from branches of the superior gluteal nerve. Inferior capsule innervation is possibly from the obturator nerve or inferior gluteal nerve (Figure 2). (40,48,50-65)

The obturator nerve has a variable number of articular branches likely radiating from a common stem located lateral to the obturator foramen inferior to the acetabulum (Figure 3). The radiologic landmark is immediately below the teardrop silhouette seen on AP x-ray, corresponding to the junction of the pubis and ischium, where the lateral line is from the acetabular wall, the medial line formed by the lesser pelvis and the inferior wall from the acetabular notch. (40,41) The branches usually course superior and laterally towards the anteromedial portion of the capsule, but can exit the obturator foramen as inferiorly as the junction between the proximal and middle third. (40)

The excellent anatomic description by Locher and colleagues for a superolateral approach for denervation of obturator components provides a good basis for discussion. The superior approach allows for parallel placement, and therefore the longest lesion along the branches. (40) Our inferior approach may increase the likelihood of denervating multiple branches, but the lesion size will not be in parallel, resulting in a smaller lesion, equivalent to one or 2 electrode widths, (25) and may require longer cannula length depending on the patient.

In our opinion, the initial placement of a 21 gauge spinal needle using the AP approach for guidance and local anesthetic purposes still poses a measurable risk to the neurovascular bundle. (38) In our case, and where the cannula size was previously reported, no radiofrequency cannula larger than 22 gauge was employed. (40,42,44) Rivera and colleagues started with an AP approach presumably using the 22 gauge cannula, but switched to the Locher approach after hematomas were noted. (39,40) For this reason, we do not support use of this component of the approach.

Without the benefit of the 21 gauge guiding needle, (40) and given our limited experience, we found inserting the cannula from the superolateral projection too complex. This concern was not cited by Rivera and colleagues, who also did not report use of the guide needle. (39) In our case, the simultaneous use of ultrasound allowed us to navigate around the neurovascular bundle and advance the needle from the lateral position (allowing us to account for depth), while using intermittent AP fluoroscopy to confirm trajectory. However, the need for both ultrasound and fluoroscopy skills may be a barrier to adoption of this technique.

[FIGURE 2 OMITTED]

Another main advancement of the approach used by Locher and colleagues was the introduction of lesion stacking for this specific application to optimize denervation. (40) This concept has previously been described in detail for thermal radiofrequency of other joints. (25) Locher and colleagues advocated withdrawing and directing the cannula more caudally for those individuals where branches exit the obturator foramen more inferiorly. (40) This trajectory was not specifically analyzed by MRI to confirm safety, but the authors suggest staying lateral to the teardrop to avoid the obturator nerve. (40) Presumably, the cannula would remain against the anterior portion of ischium and pubis, so perhaps the risk to the main obturator nerve, which passes anteriorly, may be overstated, but cadaveric validation would be essential to look at this further.

Our technique would not provide adequate coverage for these more inferior articular branches when compared with the Locher method. While not employed in this case, multipolar thermal radiofrequency could be considered in the future to improve coverage and potentially decrease procedure time. Cosman and Gonzalez showed in ex vivo studies that bipolar thermal radiofrequency could provide a longer and wider lesion than previously reported for monopolar or cooled radiofrequency technology. The depth of the lesion produced is similar in all 3 cases, while in the case of bipolar RF, varying the length of the probe's tip could increase the length of the lesion and increasing spacing between probes could increase width. They concluded that an interprobe spacing of 10 mm, a 10 mm or 15 mm cannula active tip, and an 18 gauge or 20 gauge cannula with radiofrequency for 3 minutes at 90[degrees]C would provide a rectangular lesion relatively insensitive to small variations/inaccuracies in angles, offsets, and tip spacing. (66) Burnham reported excellent clinical response in one patient with unilateral lumbosacral pseudoarticulation who partially responded to conventional z-joint radiofrequency denervation. Using bipolar radiofrequency, a strip lesion was created along the pseudoarticulation, which allowed the patient 16 months of significant functional improvements. (67)

There are numerous reported variations in the number of branches and branch points for the obturator nerve (for example, anterior vs posterior vs main trunk). (40,47,48,56,57) In these situations, the currently described technical approaches would likely be adequate to denervate these varied articular branches, if these branches exit through the obturator foramen and course over the teardrop silhouette described above (the junction of the pubis and ischium on an anteroposterior x-ray). However, there are certain described anatomical variations where the current technical approaches would be inadequate for obturator articular branch denervation. These include cases where there are no obturator branches (61); the articular branches arise before the obturator foramen; there is a dominant anterior obturator nerve (occurs in 10% to 30% of patients); or if the branches do not supply the portion of the joint that is affected clinically. (48-50,52,54,55,58,59,64)

[FIGURE 3 OMITTED]

There is considerably less ability to translate previous anatomic studies to develop a denervation protocol for other articular branches to the joints. According to Locher and colleagues, (40) the variability of the femoral nerve course and branches would necessitate coagulation of several square centimeters (ie, greater than or equal to 50 lesions), but no data was provided as to how this calculation was achieved.

Anatomic concerns also include branches from the femoral innervated muscles for whom trajectories are not clear, relative variability in innervation patterns to the anterior capsule in the presence of an accessory obturator nerve, accessory femoral nerve or superior gluteal nerve branches, the possibility of articular branches that start more inferiorly along the course of the femoral nerve and run with vessels, and a scenario where one common trunk supplies the joint, vessels, and muscles. (47,48,53,55,57,61,62) Therefore, while significant cadaveric work remains, with the preliminary results shown thus far in the literature, we remain hopeful that an acceptable percentage of patients will respond to treatment. Multipolar radiofrequency or a series of successive lesions approaching from the lateral margins (to avoid the femoral nerve) and moving caudally from the anterior inferior iliac spine would require further validation.

Translating current knowledge into a posterior innervation approach will also be challenging without the aid of further cadaveric study. It would appear the inferior to middle-medial to lateral portion of the hip joint are supplied by branches of the sciatic nerve directly, or through the trunk that is given off to the quadratus femoris muscle. Variations include multiple branches from the nerve to the quadratus femoris, different trajectories through the greater and/or lesser sciatic notch, branches from nerves to the obturator internus or superior gemellus, and direct innervation from the sacral branches or obturator nerve. Similarly, the posterior superior portion of the joint may be variably innervated by branches of sciatic nerve, or superior gluteal nerve. (47,48,52-55,57,61-64)

The vascular supply of the femoral neck and hip joint has been closely detailed and must be considered in a posterior approach. An extracapsular arterial ring is formed by branches of the medial and lateral circumflex arteries, contributing to the metaphyseal blood supply. The epiphyseal blood supply is mediated through the ligamentum teres and posterosuperior branches of the lateral epiphyseal vessels. Vascular supply to the joint is therefore predominantly from the posterior circulation of the epiphysis, away from the region of treatment. (67)

Given that the posterior blood supply runs lateral to medial for the hip joint, we propose a radiofrequency approach starting lateral and posterior to the greater trochanter and advancing towards the inferior portion of the acetabulum. Multipolar radiofrequency or successive lesions moving superiorly towards the middle third of the acetabulum may generate sufficient coagulation for the sciatic and/or quadratus femoris nerve branches in this region without affecting any significant neurovascular structures.

Other general reasons for failure of treatment of radiofrequency could arise from joints that have an important innervation from the sympathetic trunk, (48) or posterior femoral cutaneous nerve. (51) In addition, there could be a long-term risk of developing a Charcot arthropathy, given that denervated nerves and coagulated vessels supply the anteromedial capsule of the hip joint and underlying bone. (47) In some surgical neurectomy studies, femoral head deformity was a noted complication, but this may be attributable to complete denervation of all the sensory branches. (32,47) Animal studies have shown erosion of articular cartilage and bone sclerosis resulting from lumbar sympathetic, 4th lumbar, and 3rd sacral root resection. (34,68,69) The risk of Charcot joint has not been a factor in other similar joint denervation studies. (70)

We therefore propose close clinical follow-up to monitor signs, symptoms, and fall risk where proprioception is a concern. Where indicated, serial imaging could identify changes in patients consistent with a neuroarthropathy. The treatment in these cases would be nonweight-bearing on the affected side until the sensory innervation (ie, pain) returns. (71) In the case of presurgical patients, further joint destruction may be less important if an arthroplasty will eventually be performed.

The final consideration is the value of diagnostic blocks in this setting. Ideally, a low volume comparative diagnostic block could be performed that would have a high positive predictive value for response to radiofrequency treatment. The wider innervation area of the articular branches could lead to false negatives if the injection volume was too small, or false positives if a larger volume was used, or multiple branches were injected simultaneously. The other possibility is the use of intrarticular injections for diagnoses, but this would not direct treatment to a specific articular branch. Again, cadaveric and clinical studies are required to develop this further.

CASE REVIEW

The relative failure of the second treatment in this case was likely because stacked lesions in an inferior to superior manner were not performed for the femoral component. As in the first treatment, this would have likely increased the lesion to up to 4 times the cannula's width and increase the chance for denervation. (25) Instead, we opted to attempt to increase lesion length for this component, which we had hoped would translate into longer clinical efficacy.

Other potential reasons for failure include a placebo response to the first treatment, which has been shown to be high in other controlled trials for some interventional procedures. (72) Progression of the patient's underlying osteoarthritis to other parts of the joints not innervated by the femoral or obturator components (73) is another possibly complicating factor for this case. In cases of neurotmesis, the endoneural tubes are disrupted which can result in misdirected axonal regrowth (ie, synkinesis), which could potentially impact subsequent treatment where needle position is based on bony anatomic landmarks. (74)

Our results also dispute the notion that the articular regions subserved by the obturator component primarly cause groin region pain. (41) In this case, it is more likely the failure of treatment is from the femoral component, not the obturator, where the same protocol was followed. Pain referral may be a helpful indicator of which nerve could be mediating pain, but, as shown in this case, is certainly not diagnostic. (31,41) More study is required to delineate the positive predictive value of pain referral patterns in outcomes of patients undergoing articular branch radiofrequency denervation.

CONCLUSIONS

The current clinical literature concerning radiofrequency for treatment of hip joint pain is of low quality. Based on these studies, we propose the following general guidelines for the procedures:

1. Small volumes for diagnostic blocks, (especially if only a single lesion is to be used).

2. Use of omnipaque to rule out vascular spread, at least for the diagnostic blocks.

3. A lateral approach for the obturator branch to avoid the neurovascular structures, and/or supplementation with ultrasound.

4. At the least, motor stimulation to rule out somatic involvement.

5. At a minimum, 10 mm active tips to increase the length of lesion created and therefore the length of clinical response.

6. Consideration of stacked lesions or multipolar TRF to increase lesion size and thereby account for any anatomic variability.

7. Measurement of both pain and functional outcomes using standardized scales.

8. Close clinical monitoring after TRF in order to identify patients' neurological deficits or those at risk for progression to neuroathropathy.

The future research of this application should validate safe and effective parameters for diagnostic blocks and treatment in cadavers for all articular branches as well as any clinical information relevant to injection selection and/or outcomes, estimate the role of multipolar thermal radiofrequency in denervation of the hip joint, (65,66,75-77) and delineate any associated economic benefits of hip joint thermal radiofrequency.

REFERENCES

(1.) Murphy L, Helmick CG. The impact of osteoarthritis in the United States: a population-health perspective. Am J Nurs. 2012;112(3 suppl 1):S13-S19.

(2.) Gupta S, Hawker GA, Laporte A, Croxford R, Coyte PC. The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition. Rheumatology (Oxford). 2005;44(12):1531-1537.

(3.) Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new insights. part 1: the disease and its risk factors. Ann Intern Med. 2000;133:635-646.

(4.) Jordan JM, Helmick CG, Renner JB, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: The Johnston County Osteoarthritis Project. J Rheumatol. 2009;36:809-815.

(5.) Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58:26-35.

(6.) Suri P, Morgenroth DC, Hunter DJ. Epidemiology of osteoarthritis and associated comorbidities. PM R. 2012;4(5 suppl):S10-S19.

(7.) Grayson CW, Decker RC. Total joint arthroplasty for persons with osteoarthritis. PM R. 2012;4(5 suppl):S97-S103.

(8.) Desmeules F, Dionne CE, Belzile EL, Bourbonnais R, Fremont P. The impacts of pre-surgery wait for total knee replacement on pain, function and health-related quality of life six months after surgery. J Eval Clin Pract. 2012;18(1):111-120.

(9.) Canadian Institute for Health Information. Hip and Knee Replacement in Canada-2011 Annual Statistics (Clinical Data) [internet]. Available at: http:// www.cihi.ca/CIHI-ext-portal/internet/EN/Tabbed Content/types+of+care/specialized+services/ joint+replacements/cihi021359. Accessed July 6, 2012.

(10.) Vincent HK, Heywood K, Connelly J, Hurley RW. Obesity and weight loss in the treatment and prevention of osteoarthritis. PM R. 2012;4(5 suppl):S59-S67.

(11.) Sherman AL, Ojeda-Correal G, Mena J. Use of glucosamine and chondroitin in persons with osteoarthritis. PMR. 2012;4(5 suppl):S110-S116.

(12.) De Luigi AJ. Complementary and alternative medicine in osteoarthritis. PM R. 2012;4(5 suppl):S122-S133.

(13.) Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part I: focus on fatty acids and macronutrients. PMR. 2012;4(5 suppl):S145-S154.

(14.) Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part II: focus on micronutrients and supportive nutraceuticals. PMR. 2012;4(5 suppl):S155-S168.

(15.) Brakke R, Singh J, Sullivan W. Physical therapy in persons with osteoarthritis. PM R. 2012;4(5 suppl):S53-S58.

(16.) Semanik PA, Chang RW, Dunlop DD. Aerobic activity in prevention and symptom control of osteoarthritis. PMR. 2012;4(5 suppl):S37-S44.

(17.) Vincent KR, Vincent HK. Resistance exercise for knee osteoarthritis. PMR. 2012;4(5 suppl):S45-S52.

(18.) Segal NA. Bracing and orthoses: a review of efficacy and mechanical effects for tibiofemoral osteoarthritis. PMR. 2012;4(5 suppl):S89-S96.

(19.) Cheng DS, Visco CJ. Pharmaceutical therapy for osteoarthritis. PMR. 2012;4(5 suppl):S82-S88.

(20.) Hameed F, Ihm J. Injectable medications for osteoarthritis. PMR. 2012;4(5 Suppl):S75-S81.

(21.) Vora A, Borg-Stein J, Nguyen RT. Regenerative injection therapy for osteoarthritis: fundamental concepts and evidence-based review. PM R. 2012;4(5 suppl):S104-S109.

(22.) Cohen SP, Williams KA, Kurihara C, et al. Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology. 2010;113(2):395-405.

(23.) Rambaransingh B, Stanford G, Burnham R. The effect of repeated zygapophysial joint radiofrequency neurotomy on pain, disability, and improvement duration. Pain Med. 2010;11(9):1343-1347.

(24.) Letcher FS, Goldring S. The effect of radiofrequency current and heat on peripheral nerve action potential in the cat. J Neurosurg. 1968;29(1):42-47.

(25.) Bogduk N, ed. ISIS Practice Guidelines for Spinal Diagnostics and Treatment Procedures. San Rafael, CA: International Spine Intervention Society; 2004:23.

(26.) Camitz H. Die deformierende huftgelenksarthritis und speziell IHRE behandlung. Acta Orthop Scand. 1933;4(3):193. Cited by: Mulder JD. Denervation of the hip joint in osteoarthritis. J Bone Joint Surg Br. 1948;30B(3):446-448.

(27.) Mol W. De resectie van den nervus obturatorius bij arthritis deformans van hel heupgewricht. Ned Tijdschr Geneeskd. 1935;79:850-855. Cited by: Mulder JD. Denervation of the hip joint in osteoarthritis. J Bone Joint Surg Br. 1948;30B(3):446-448.

(28.) Tavernier L, Godinot CH. Traitement chirurgical de l 'arthrite seche de la hanche: Suivi de travaux de la Clinique de L Faculte de Lyon. Paris: Masson & Cie; 1945. Cited by: Mulder JD. Denervation of the hip joint in osteoarthritis. J Bone Joint Surg Br. 1948;30B(3):446-448.

(29.) Tavernier L, Truchet P. La Section des branches articulaires du nerf obturateur dans le traitement de l'arthrite chronique de la hanche, par L. Rev d'Orthop. 1942;28:62-68.

(30.) Mulder JD. Denervation of the hip joint in osteoarthritis. J Bone Joint Surg Br. 1948;30B(3):446-448.

(31.) Obletz BE, Lockie LM, Milch E, Hyman I. Early effects of partial sensory denervation of the hip for relief of pain in chronic arthritis. J Bone Joint Surg Am. 1949;31A(4):805-814.

(32.) Padovani P. L'enervation total de la hanche. Presse Med. 1947;55:225. Cited by: Mulder JD. Denervation of the hip joint in osteoarthritis. J Bone Joint Surg Br. 1948;30B(3):446-448.

(33.) Boloczko S, Bieniecki M. Resection of the obturator nerve for analgesic treatment of degenerative-deforming changes of the hip joint. Chir Narzadow Ruchu Ortop Pol. 1990;55(4-6):387-390.

(34.) Liebolt FL, Beal JM, Speer DS. Obturator neurectomy for painful hip. Am J Surg. 1950;79(3):427-431.

(35.) James CD, Little TF. Regional hip blockade. A simplified technique for the relief of intractable osteoarthritic pain. Anaesthesia. 1976;31(8):1060-1067.

(36.) Akatov OV, Dreval ON. Percutaneous radiofrequency destruction of the obturator nerve for treatment of pain caused by coxarthrosis. Stereotact Funct Neurosurg. 1997;69(1-4 Pt 2):278-280.

(37.) Heywang-Kobrunner SH, Amaya B, Okoniewski M, Pickuth D, Spielmann RP. CT-guided obturator nerve block for diagnosis and treatment of painful conditions of the hip. Eur Radiol. 2001;11(6):1047-1053.

(38.) Edmonds-Seal J, Turner A. Khodadadeh S, Bader DL, Fuller DJ. Regional hip blockade in osteoarthrosis. Anaesthesia. 1982;37(2):147-151.

(39.) Rivera F, Mariconda C, Annaratone G. Percutaneous radiofrequency denervation in patients with contraindications for total hip arthroplasty. Orthopedics. 2012;35(3):e302-e305.

(40.) Locher S, Burmeister H, Bohlen T, et al. Radiological anatomy of the obturator nerve and its articular branches: basis to develop a method of radiofrequency denervation for hip joint pain. Pain Med. 2008;9(3):291-298.

(41.) Kawaguchi M, Hashizume K, Iwata T, Furuya H. Percutaneous radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of hip joint pain. Reg Anesth Pain Med. 2001;26(6):576-581.

(42.) Malik A, Simopolous T, Elkersh M, Aner M, Bajwa ZH. Percutaneous radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of non-operable hip pain. Pain Physician. 2003;6(4):499-502.

(43.) Wu H, Groner J. Pulsed radiofrequency treatment of articular branches of the obturator and femoral nerves for management of hip joint pain. Pain Pract. 2007;7(4):341-344.

(44.) Van Boxem K, van Eerd M, Brinkhuizen T, et al. Radiofrequency and pulsed radiofrequency treatment of chronic pain syndromes: the available evidence. Pain Pract. 2008;8(5):385-393.

(45.) Chaiban G, Paradis T, Atallah J. Use of ultrasound and fluoroscopy guidance in percutaneous radiofrequency lesioning of the sensory branches of the femoral and obturator nerves. Pain Pract. 2013 [Epub ahead of print].

(46.) Fukui S, Nosaka S. Successful relief of hip joint pain by percutaneous radiofrequency nerve thermocoagulation in a patient with contraindications for hip arthroplasty. J Anesth. 2001;15(3):173-175.

(47.) Shin KM, Nam SK, Yang MJ, Hong SJ, Lim SY, Choi YR. Radiofrequency lesion generation of the articular branches of the obturator and femoral nerve for hip joint pain: a case report. Korean J Pain. 2006;19(2):282-284.

(48.) Birnbaum K, Prescher A, HeMer S, Heller KD. The sensory innervation of the hip joint--an anatomical study. Surg Radiol Anat. 1997;19(6):371-375.

(49.) Gardner E. The innervation of the hip joint. Anat Rec. 1948;101(3), 353-371.

(50.) Katritsis E. Anatomical observations on the accessory obturator nerve. Anat Anz. 1980;148:440-445.

(51.) Woodburne RT. The accessory obturator nerve and the innervation of the pectineus muscle. Anat Rec. 1960;136:367.

(52.) Kaplan EB. Resection of the obturator nerve for relief of pain in arthritis of the hip joint. J Bone Joint Surg Am. 1948;30A(1):213-216.

(53.) Lewis WH, ed. Gray's Anatomy of the Human Body 24th Edition. Philadelphia PA: Lea and Febiger; 1942.

(54.) Schaeffer JP, ed. Morris' Human Anatomy: A Complete Systematic Treatise--Tenth edition. Philadelphia, PA: The Blakiston Company; 1942.

(55.) Piersol GA. Piersol's Human Anatomy: Ninth Edition. Huber GC, ed. Philadelphia, PA: J. B. Lippincott Company; 1930.

(56.) Geselevich AM. Die Innervation der Gelenkkapseln an den Gliedmallen des Pferdes (fur Kliniker). Arch. fur wiss. U. prakt. Zierh. 1935;75:134-143.

(57.) Kaiser RA. Obturator neurectomy for coxalgia; an anatomical study of the obturator and the accessory obturator nerves. J Bone Joint Surg Am. 1949;31A(4):815-819.

(58.) Sadovsky DM. Innervation of the capsule of the hip joint. Verstn Khir. 1933;31:100-103.

(59.) Fick R, von Bardel-eben K. Handbuch de Anatomie des Menschen, vol 2. Gustav Fischer Verlag Jena; 1904.

(60.) Bardeen CR. The accessory obturator nerve. Anat Anz. 1901;19:209.

(61.) Duzea R. Note sur les nerfs de l'articulation coxofemorale. Lyon med. 1886;52:35-38.

(62.) Chandelux A. Note sure les nerfs de l'articulation coxo-femorale. Lyon med. 1886;51:551-554.

(63.) Bouchard A, Beaunis H. Nouveaux elements d'anantomie descriptive et d'embryologie. Paris: Librairie J.-B. Bailliere et fils; 1880.

(64.) Rudinger N. Die Glenknerven des Menschlichen Korpers. Erlangen: Verlag von Ferdinand Enke; 1857.

(65.) Cruveilhier J. The Anatomy of the Human Body. Pattison GS, ed. New York, NY: Harper and Bros; 1844.

(66.) Cosman ER, Gonzalez CD. Bipolar radiofrequency lesion geometry: implications for palisade treatment of sacroiliac joint pain. Pain Pract. 2011;11(1):3-22.

(67.) Burnham R. Radiofrequency sensory ablation as a lumbosacral junction pseudarticulation (Bertolotti's syndrome): a case report. Pain Med. 2010;11(6):853-855.

(68.) Corbin KB. Alterations in the hip joint after deaf ferentation. Arch Surg. 1937;35:1145-1158.

(69.) Corbin KB, Hinsey JC. Influence of the nervous system on bone and joints. Anat Rec. 1903;75:307-317.

(70.) Choi WJ, Hwang SJ, Song JG, et al. Radiofrequen cy treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain. 2011;152(3):481-487.

(71.) Molines L, Darmon P, Raccah D. Charcot's foot: newest findings on its pathophysiology, diagnosis and treatment. Diabetes Metab. 2010;36(4):251-255.

(72.) Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. New Engl J Med. 2009;361(6):569-579.

(73.) Amin S, LaValley MP, Guermazi A, et al. The relationship between cartilage loss on magnetic resonance imaging and radiographic progression in men and women with knee osteoarthritis. Arthritis Rheum. 2005;52(10):3152-3159.

(74.) Morishima N, Yagi R, Shimizu K, Ota S. Prognostic factors of synkinesis after Bell's palsy and Ramsay Hunt syndrome. Auris Nasus Larynx. 2013;40(5):431-434.

(75.) Pino CA, Hoeft MA, Hofsess C, Rathmell JP. Morphologic analysis of bipolar radiofrequency lesions: implications for treatment of the sacroiliac joint. Reg Anesth Pain Med. 2005;30(4):335-338.

(76.) Kapural L. Intervertebral disk cooled bipolar radiofrequency (intradiskal biacuplasty) for the treatment of lumbar diskogenic pain: a 12-month followup of the pilot study. Pain Med. 2008;9(4):407-408.

(77.) Kapural L, Ng A, Dalton J, et al. Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med. 2008;9(1):60-67.

Gaurav Gupta, MD, FRCPC

Mohan Radhakrishna, MD, FRCPC

Paul Etheridge, MD

L Col Markus Besemann, MD, FRCPC

Roderick J Finlayson, MD, FRCPC

Dr Gupta, a physiatrist, works with the Canadian Forces Health Centre-Ottawa and the Alan Edwards Pain Management Unit of the Department of Anesthesia, Montreal General Hospital. He is also an adjunct professor at McGill University in Montreal, Quebec.

Dr Radhakrishna is a physiatrist in the McGill University Health Centre and the Alan Edwards Pain Management Unit of the Department of Anesthesia, Montreal General Hospital. He is also an assistant professor at McGill University in Montreal, Quebec.

Dr Etheridge is the medical director at the Okanagan Interventional Pain Clinic, Kwlowna, British Columbia. He is also a clinical instructor at the University of British Columbia.

L Col Besemann, a physiatrist, is head of the Canadian Forces physical rehabilitation program at the Canadian Forces Health Services Group Headquarters in Ottawa. He also works at the Canadian Forces Health Centre and is a lecturer at the University of Ottawa.

Dr Finlayson is an anesthesiologist with the Alan Edwards Pain Management Unit of the Department of Anesthesia, Montreal General Hospital. He is also an associate professor at McGill University in Montreal, Quebec.

* Western Ontario and McMaster Universities Arthritis Index
Studies Detailing Clinical Outcomes for Patients Undergoing
Articular Radiofrequency for Treatment of Hip Joint Pain.

Study                     No. of Patients:        Pathology
                         Treatment Details          Types

Chaibin et al (45)     1: TRF femoral and       OA
                         obturator bilateral,
                         80[degrees]C for 6
                         seconds. 22 gauge 5
                         mm active tip.

Rivera et al (39)      17: TRF femoral and      OA, post
                         obtura-tor branches,     THA, post
                         90[degrees]C for 90      girdlestone
                         seconds. 22 gauge 5
                         mm active tip.

Wu and Groner (43)     2: PRF femoral and       FHN, post
                         obturator branches,      THA
                         45[degrees]C for 120
                         seconds. 22 gauge 10
                         mm active tip.

Shin et al (47)        1: Femoral and           Metastasis
                         obturator branch TRF
Malik et al (42)       4: Femoral and           OA, FHN,
                         obturator, TRF           metastasis
                         75[degrees]C to
                         80[degrees]C for 90
                         seconds. Cannula
                         size not reported.
Kawaguchi et al (41)   14: Obturator and/       OA,
                         or femoral branch,       metastasis,
                         TRF 75[degrees]C to      DL
                         80[degrees]C for 90
                         seconds. Cannula
                         size not reported.
Fukui et al (46)       1: Femoral and           OA, infection
                         obturator branch,
                         TRF 90[degrees]C for
                         180 seconds. 22
                         gauge 4 mm active
                         tip.

Akatov and             13 (15 hips):            OA
  Dreval (36)            Obturator nerve
                         proper, TRF
                         80[degrees]C for 120
                         seconds.

Study                       Results           Adverse
                                               Events

Chaibin et al (45)     P: 80% reduction    None
                         at 3 months
                       F, M: N/A

Rivera et al (39)      P: 30% avg          3 Transient
                         reduction at      hematomas
                         6 months, 8
                         patients >50%
                         relief
                       F: improved
                         Harris Hip and
                         WOMAC scores
                       M: N/A
Wu and Groner (43)     P: 50% to 60%       None
                         reduction at
                         3-4 months
                       F: improved
                         ambulation
                       M: N/A
Shin et al (47)        P: 50% reduction    None

Malik et al (42)       P: 30% to 70%       Thigh
                         NRS at 3 months   numbness,
                       F: improved % pt    1 patient
                       M: reduced % pt

Kawaguchi et al (41)   P: 50% relief,      None
                         86% patients
                         avg 4. 2 months
                         (1-11 months)
                       F,M: N/A

Fukui et al (46)       P: 70% relief       None
                         until 4 months;
                         pain increased
                         at 6 months
                       F: improved
                         walking with
                         cane
                       M: stopped use
                         until 6 months

Akatov and             Increased range     Sensory loss
  Dreval (36)            of motion in 9      in all but
                         patients,           one patient.
                         remainder of
                         results not
                         clear. Followed
                         for up to 3
                         years.

Study                             Notes

Chaibin et al (45)     Ultrasound and fluoro
                         guidance. Used sensory
                         and motor stimulation.
                         Selected based on time
                         limited response to bursa
                         and joint injections.
                         Patient continued
                         anticoagulation.
Rivera et al (39)      Diagnostic blocks (3 cc).
                         Inserted needle medial or
                         lateral to femoral artery
                         for obturator. 5 mm
                         active tip. Sensory and
                         motor stimulation used.
                         Switched to Locher40
                         method during course of
                         study.
Wu and Groner (43)     Diagnostic blocks (0.5 cc
                         to 1 cc). Sensory
                         stimulation.

Shin et al (47)        Korean Language.

Malik et al (42)       AP approach. Diagnostic
                         blocks (1 cc LA).

Kawaguchi et al (41)   Suggested pain location
                         predicted articular nerve
                         involved, no block for
                         femoral component. Volume
                         for IA or obturator
                         diagnostic block.
Fukui et al (46)       Diagnostic blocks with
                         contrast (3 cc LA).
                         Sensory stimulation.
                         Obturator cannula walked
                         to obturator cannal from
                         superior pubic ramus.
                         Introduced idea of
                         cryoanalgesia for
                         denervation of articular
                         branches. Procedure not
                         repeated because overall
                         pain reduced.
Akatov and             Needle technique not well
  Dreval (36)            described. Unclear if
                         live fluoro used.
                         Additional treatment for
                         myofascial pain in 3
                         patients. Unclear if
                         diagnostic blocks used,
                         but 2 cc to 3 cc of LA
                         injected prior to lesion
                         to ensure pain resolved.

Glossary:

AS--Ankylosing spondylitis

DL--Dislocation (congenital or trauma)

F--Functional improvement

FHN--Head necrosis (AVN, trauma, Legg- Calve-Perthes)

IA--Intra-articular

LA--Local anesthetic

M--Medication reduction

NRS--Numerical rating score

OA--Osteoarthritis

P--Pain reduction

post THA--Post total hip arthroplasty

PRF--Pulsed radiofrequency

RA--Rheumatoid arthritis

TRF--Thermal radiofrequency
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Author:Gupta, Gaurav; Radhakrishna, Mohan; Etheridge, Paul; Besemann, Markus; Finlayson, Roderick J.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2014
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