iovera° to treat pain associated with acl reconstruction and rehabilitation

Conditions: Anterior Cruciate Ligament Reconstruction

Summary: to evaluate the outcomes of patients undergoing iovera° treatment of the isn and afcn on postoperative knee pain and function following anterior cruciate ligament reconstruction

the most commonly reconstructed ligament in the knee is the anterior cruciate ligament (acl)1. in 2006 a total of 134,421 acl reconstructions were performed in the united states, representing a 37% increase in procedures since 19941. today, most acl reconstructions are performed on an outpatient basis2. while this has led to improvements in patient satisfaction3 and cost4, it has simultaneously resulted in more complicated postoperative pain management. managing this pain via multi-modal strategies, including peripheral nerve blocks, in the postoperative phase has been shown to decrease opioid related side effects, decrease hospital stay, and increase time to ambulation5. nursing, hospital, and pharmacy utilization in managing pca, continuous regional nerve blocks, and administration of oral opioid dosing are associated with higher costs of care and introduce sources for staff error6,7. furthermore, the idea of multi-modal pain management extends beyond the surgical procedure. decreasing prescription opioid use during outpatient rehabilitation decreases nsaid and opioid related side effects8. myoscience, inc. (fremont, ca) has developed a device - iovera° - as a novel, minimally-invasive procedure using cold to target sensory nerve tissue and provide temporary pain relief through cryoneurolysis. the iovera° device uses well-established principles of cryobiology to temporarily deactivate sensory nerves that contribute to pain. prior studies of the iovera° device have provided evidence of effectiveness and safety for treatment of the infrapatellar branch of the saphenous nerve and another study has demonstrated that a short-term block of this nerve resulted in reduced pain following an acl repair.9 in a multicenter, double-blind, sham-controlled, randomized trial sponsored by myoscience, inc, the iovera° device was shown to temporarily relieve pain in patients with osteoarthritis of the knee. compared to the sham group, patients who received active treatment had a statistically significant greater change from baseline in the womac pain subscale score at day 30 (p=0.0004), day 60 (p=0.0176), and day 90 (p=0.0061). patients deemed womac pain responders at day 120 continued to experience a statistically significant treatment effect at day 150. most expected side effects were mild in severity and resolved within 30 days. the incidence of device- or procedure-related adverse events was similar in the two treatment groups with no occurrence of serious or unanticipated adverse events.10 the goal of the study described herein is to determine the safety and efficacy of the iovera° treatment for reducing the pain associated with anterior cruciate ligament (acl) reconstruction and rehabilitation.

Eligibility criteria:
inclusion criteria: 1. 18 to 49 years of age 2. scheduled to undergo unilateral anterior cruciate ligament reconstruction with patellar tendon autograft 3. in the opinion of the investigator, the subject is an active participant in recreational or competitive sports, physical activity, or other fitness regimen at the time of acl injury and is seeking repair to help return to sport or activity 4. subject is willing and able to give written informed consent. 5. subject is fluent in verbal and written english. 6. subject is willing and able to comply with study instructions and commit to all follow-up visits for the duration of the study. 7. subject is in good general health and free of any systemic disease state or physical condition that might impair evaluation or which in the investigator's opinion, exposes the subject to an unacceptable risk by study participation. exclusion criteria: 1. prior ligamentous injury and/or surgery of either knee (arthroscopic surgeries allowed), contralateral acl reconstruction, previous acl surgery of the target knee, previous graft failure, or relevant musculoskeletal impairment 2. prior surgery or injury in the knee or treatment areas that may have altered the anatomy of the target nerves or resulted in scar tissue in the iovera° treatment areas. 3. any pain disorder, neuro-muscular disorder, or neuropathy that in the opinion of the investigator may confound post-operative assessments for pain or rehabilitation. examples include but are not limited to: fibromyalgia, diabetic neuropathy, multiple sclerosis, etc. 4. history of opioid or alcohol abuse within past 3 years. 5. open and/or infected wound in the treatment areas or any local skin condition at the treatment sites that in the investigator's opinion would adversely affect treatment or outcomes. 6. history of cryoglobulinemia 7. history of paroxysmal cold hemoglobinuria. 8. history of cold urticaria. 9. history of raynaud's disease. 10. any chronic medical condition that in the investigator's opinion would prevent adequate participation. 11. any chronic medication use (prescription, over-the-counter, etc.) that in the investigator's opinion would affect study participation or subject safety. 12. for any reason, in the opinion of the investigator, the subject may not be a suitable candidate for study participation (i.e., worker's compensation, history of noncompliance, drug dependency, etc.).