Alternate treatment approach to subchondral insufficiency fracture of the knee utilizing genicular nerve cooled radiofrequency ablation and adjunctive bisphosphonate supplementation: A case report

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.