The new age of knee replacement pain management

knee rehabilitation

Physicians implementing new pain management technologies to improve their total knee replacement programs with the use of the iovera® system, a form of focused cryotherapy that uses the body’s natural response to cold to treat peripheral nerves and immediately reduce pain— without the use of drugs.

In many cases, pain management in the pre-operative, intraoperative, and post-operative phases for total joint patients can be difficult, with patients requiring multimodal care. Current options include pre-procedure nerve blocks and months of opioid and non-opioid medications, alongside other modalities, therapies, creams, braces, and physical activity alterations. This inadequate pain management inhibits a patient’s ability to perform prehabilitation, as well as post-operative rehabilitation, resulting in delayed pain improvement and functional gains. 

After a total knee replacement, patients typically experience two types of pain - bony pain from the manipulation and cutting of bone and joint, and incisional pain. Due to this, some patients do not progress as desired, prolonging or jeopardizing improvements in recovery.

One new method that can fill this gap in pain management is cryoanalgesia with the iovera Smart Tips. This simple in-office procedure predominately addresses the small superficial nerves that are attributed to the majority of incisional pain. These include distal branches of the lateral femoral cutaneous nerve, anterior femoral cutaneous nerve, and the infrapatellar branch of the saphenous nerve.

Under ultrasound guidance, each of the three nerves is identified and, after adequate anesthesia, the specialized needle tip is then advanced to the nerve where an ice ball is created at the end of the needle tip. This effectively freezes the nerve and causes neuropraxia, or type 2 nerve damage. Neuropraxic nerve injury does not cause long-lasting defects or losses to the axon function or integrity. It does, however, inhibit function and myelin transmission of the nerve, creating a situation where incisional pain can be significantly decreased or even erased for a period of up to three months. Additionally, this same process can be performed to the deep genicular nerves, resulting in the same pain blocking benefits to any associated bony or residual joint pain.

Prior studies, including one by Dasa et al, showed a 45% reduction in opioid usage and improved knee pain scores at 12 weeks in comparison to control group. Also, Mihalka et al showed 34% of patients (n=124) were opioid free at six weeks post-operatively and, in comparison to control group, iovera patients had lower pain scores at three checkpoints in the global period for the procedure.

This technology has the potential to shift the paradigm of how we think about and manage pain in our total joint programs. It decreases use of addictive, major-side-effect-causing opioid medications, while simultaneously improving our patients’ pain control during rehabilitation and, thus, overall recovery after surgery. We are excited to begin the implementation of this technology and help our patients in an effort to recover faster and get back to the life they want to lead with decreased pain.


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Featured Provider

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Dr. Clay Guynn

Specialties: Physical Medicine, Sports Medicine

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Dr. Clay Guynn is a physical medicine and rehabilitation physician, who is fellowship-trained in sports medicine. He is an expert in the non-surgical management of various painful syndromes, both new and long-lasting, including musculoskeletal disorders, peripheral nerve disorders, sports injuries and neck/back pain.

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