Subacromial temperature profile during bipolar radiofrequency use in shoulder arthroscopy. Comparison of Coblation® vs. VAPR®

Radiofrequency in arthroscopic shoulder surgery: a systematic review

BACKGROUND

Radiofrequency has seen an increase in use in orthopedics including cartilage lesion debridement in the hip and knee as well as many applications in arthroscopic shoulder surgery. The purpose of this systematic review is to evaluate the safety and usage of radiofrequency in the shoulder.

METHODS

This systematic review was registered with PROSPERO (international registry) and followed the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines. Embase and PubMed were searched using: "shoulder," "rotator cuff," "biceps," "acromion" AND "monopolar," "bipolar," "ablation," "coblation," and "radiofrequency ablation." The title and abstract review were performed independently. Any discrepancies were addressed through open discussion.

RESULTS

A total of 63 studies were included. Radiofrequency is currently utilized in impingement syndrome, fracture fixation, instability, nerve injury, adhesive capsulitis, postoperative stiffness, and rotator cuff disease. Adverse events, namely superficial burns, are limited to case reports and case series, with higher-level evidence demonstrating safe use when used below the temperature threshold. Bipolar radiofrequency may decrease operative time and decrease the cost per case.

CONCLUSIONS

Shoulder radiofrequency has a wide scope of application in various shoulder pathologies. Shoulder radiofrequency is safe; however, requires practitioners to be cognizant of the potential for thermal burn injuries. Bipolar radiofrequency may represent a more efficacious and economic treatment modality. Safety precautions have been executed by institutions to cut down patient complications from shoulder radiofrequency. Future research is required to determine what measures can be taken to further minimize the risk of thermal burns.

Intra-articular temperature monitoring during radiofrequency ablation in ex-vivo bovine hip joints via Fiber Bragg grating sensors

PURPOSE

Radiofrequency ablation is an increasingly used surgical option for ablation, resection and coagulation of soft tissues in joint arthroscopy. One of the major issues of thermal ablation is the temperature monitoring across the target areas, as cellular mortality is a direct consequence of thermal dosimetry. Temperatures from 45 °C to 50 °C are at risk of damage to chondrocytes. One of the most reliable tools for temperature monitoring is represented by fiber optic sensors, as they allow accurate and real-time temperature measurement via a minimally invasive approach. The aim of this study was to determine, by fiber Bragg grating sensors (FBGs), the safety of radiofrequency ablation in tissue heating applied to ex-vivo bovine hip joints.

METHODS

Ex vivo bovine hips were subjected to radiofrequency ablation, specifically in the acetabular labrum, for a total of two experiments. The WEREWOLF System (Smith + Nephew, Watford, UK) was employed in high operating mode and in a controlled ablation way. One optical fiber embedding seven FBGs was used to record multipoint temperature variations. Each sensor was 1 mm in length with a distance from edge to edge with each other of 2 mm.

RESULTS

The maximum variation was recorded in both the tests by the FBG1 (i.e., the closest one to the electrode tip) and was lower than to 2.8 °C. The other sensors (from FBG2 to FBG7) did not record a significant temperature change throughout the duration of the experiment (maximum up to 0.7 °C for FBG7).

CONCLUSIONS

No significant increase in temperature was observed at any of the seven sites. The sensor nearest to the radiofrequency source exhibited the highest temperature rise, but the variation was only 3 °C. The minimal temperature increase registered at the measurement sites, according to existing literature, is not expected to be cytotoxic. FBGs demonstrate the potential to fulfil the strict requirements for temperature measurements during arthroscopic surgery.

Heat-Related Complications from Radiofrequency and Electrocautery Devices Used in Arthroscopic Surgery: A Systematic Review

Purpose

To investigate the occurrence of heat-related complications from radiofrequency and electrocautery devices in patients undergoing arthroscopic surgery.

Methods

A systematic review was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting complications after arthroscopy using electrosurgery devices were included. Only English- and Dutch-language articles were included. Basic science/nonclinical studies/human cadaveric studies and animal studies were excluded. Article selection was performed by 2 separate reviewers. Interobserver agreement of the selection procedure was determined by Cohen’s kappa. All included articles were critically appraised using an adapted version of the ROBINS-I tool.

Results

Twenty-five studies were included in this systematic review. A total of 309 cases of heat-related complications were identified. Chondrolysis was present in 45 cases and dermal burns in 15 cases. Axillary nerve injuries were reported in 197 cases of arthroscopic adhesive capsulitis release. However, it was unclear whether these injuries were directly related to the overheating of the arthroscopic fluid. No one specific risk factor for thermal complications was identified, but related factors included the leakage of the arthroscopy fluid, use of a thermal device continuously for a long period of time, proximity of the thermal device to the tissue, intra-articular local anesthetic injection or the use of intra-articular pain pumps, and certain surgical procedures, such as thermal capsulorrhaphy, capsular release, and synovectomy.

Conclusions

The most common heat-related complications in arthroscopy are dermal burns and chondrolysis. Risk factors include leakage of arthroscopy fluid, use of a thermal device, intra-articular anesthetics/pain pumps, and performing specific surgical procedures.

Level of Evidence

Systematic review of level III-IV studies.

Clinical outcome of biportal endoscopic revisional lumbar discectomy for recurrent lumbar disc herniation

BACKGROUND

Although literature provides evidence regarding the superiority of surgery over conservative treatment in patients with lumbar disc herniation, recurrent lumbar disc herniation (RLDH) was the indication for reoperation in 62% of the cases. The major problem with revisional lumbar discectomy (RLD) is that the epidural scar tissue is not clearly isolated from the boundaries of the dura matter and nerve roots; therefore, unintended durotomy and nerve root injury may occur. The biportal endoscopic (BE) technique is a newly emerging minimally invasive spine surgical modality. However, clinical evidence regarding BE-RLD remains limited. We aimed to compare the clinical outcomes after performing open microscopic (OM)-RLD and BE-RLD to evaluate the feasibility of BE-RLD.

METHODS

This retrospective study included 36 patients who were diagnosed with RLDH and underwent OM-RLD and BE-RLD. RLDH is defined as the presence of herniated disc material at the level previously operated upon in patients who have experienced a pain-free phase for more than 6 months. BE-RLD was performed as follows: two independent surgical ports were made inside the medial pedicular line of the target segment and on the intact upper and lower laminas. Peeling off the soft tissue from the vertebral lamina helps to easily identify the traversing nerve root and the recurrent disc material without dealing with the fibrotic scar tissue. Clinical outcomes were obtained using a visual analog scale (VAS) and the modified Macnab criteria before and at 2 days, 2 and 6 weeks, and 3, 6, and 12 months after surgery.

RESULTS

The data of 20 and 16 patients who underwent OM-RLD and BE-RLD, respectively, were evaluated. The demographic and perioperative data were comparable between the groups. During the year following the surgery, in the BE-RLD group, the VAS scores at each point were significantly improved over the baseline and remained improved up to 2 weeks after surgery (p < 0.05); however, no statistical difference between the two groups was observed after 6 weeks of surgery (p > 0.05). According to the modified Macnab criteria on the follow-up, the excellent or good satisfaction rates reported at 2 weeks, 6 weeks, 6 months, and 12 months after surgery were 81.25%, 81.25%, 75%, and 81.25%, respectively, in the BE-RLD group, and 50%, 75%, 75%, and 80%, respectively, in the OM-RLD group.

CONCLUSION

BE-RLD yielded similar outcomes to OM-RLD, including pain improvement, functional improvement, and patient satisfaction, at 1 year after surgery. However, faster pain relief, earlier functional recovery, and better patient satisfaction were observed when applying BE-LRD.

TRIAL REGISTRATION

Retrospectively registered.

Cost-effectiveness analysis of Coblation versus mechanical shaver debridement in patients following knee chondroplasty

Background

To compare costs and outcomes following knee chondroplasty with Coblation versus mechanical shaver debridement (MSD) in patients with grade III articular cartilage lesions of the knee.

Methods

A decision-analytic model was developed to compare costs and outcomes of the two methods from a US payer perspective. We used published clinical data from a single-center randomized clinical trial (RCT) designed to compare outcomes between Coblation and MSD in patients with grade III articular cartilage lesions of the medial femoral condyle. Following primary knee chondroplasty, patients experienced either treatment success (no additional surgery required) or required a revision over the 4 year follow-up period. Costs associated with the initial chondroplasty, physical therapy sessions through the 6 week postoperative period, and revision rates at 4 years post-surgery were estimated using 2018 US Medicare Physician Fee Schedule. Sensitivity analyses including a 10 year time horizon and threshold analyses were performed to test the robustness of the model.

Results

The estimated total cost per patient was $4614 and $7886 for Coblation and MSD, respectively, resulting in cost-savings of $3272 in favor of Coblation, making it a dominant strategy because of lower costs and improved clinical outcomes. Threshold analysis showed that Coblation remained dominant even when revision rates were assumed to increase from the base case rate of 14–66%. Sensitivity analyses showed that cost-saving results were insensitive to variations in revision rates, number of physical therapy sessions and the time horizon used.

Conclusion

Coblation chondroplasty is a cost-saving procedure compared with MSD in the treatment of patients with grade III articular cartilage lesions of the knee.

Comparison Between 2 Types of Radiofrequency Ablation Systems in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Background:

Radiofrequency ablation is commonly used in arthroscopic rotator cuff repair (RCR). New technology devices incorporating a plasma bubble may generate lower intra-articular temperatures and be more efficient.

Purpose:

To compare a plasma ablation device with a standard ablation device in arthroscopic RCR to determine which system is superior in terms of intra-articular heat generation and diathermy efficiency.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

This was a single-center randomized controlled trial. The inclusion criteria were adult patients undergoing primary RCR. Patients were randomized preoperatively to the standard ablation group (n = 20) or plasma ablation group (n = 20). A thermometer was inserted into the shoulder joint during surgery, and the temperature, surgery, and diathermy times of radiofrequency ablation were measured continually.

Results:

No significant differences were found between the standard ablation group and plasma ablation group for maximum temperature (38.20°C and 39.38°C, respectively; P = .433), mean temperature (31.66°C and 30.64°C, respectively; P = .757), minimum temperature (21.83°C and 23.45°C, respectively; P = .584), and baseline temperature (28.49°C and 29.94°C, respectively; P = .379). Similarly, no significant differences were found for surgery time (74 and 75 minutes, respectively; P = .866) and diathermy time (10 minutes for both; P = .678). Seven patients registered transient high temperatures greater than 45°C.

Conclusion:

There was no difference between plasma ablation and standard ablation in terms of intra-articular temperature in the joint and diathermy efficiency. Transient high intra-articular temperatures occurred in both groups.

Registration:

ACTRN1261300056970 (Australian New Zealand Clinical Trials Registry).

Analysis of parameters influencing intraarticular temperature during radiofrequency use in shoulder arthroscopy

PURPOSE

The aim of this study was to analyze the influence of several factors on the temperature in the work chamber during shoulder arthroscopy procedures in order to identify danger zones when using radiofrequency.

METHODS

Intraarticular temperature was measured intraoperatively using system with special probe that directly measured the temperature in 22 patients. Data collection was prospective. The main parameters studied were the measurement of the temperature depending on: localization of the procedure (glenohumeral or subacromial), the use of coagulation or ablation, the number of portals, the pressure of the arthropump, the time of use, the blood pressure and the temperature of the operating room.

RESULTS

Ninety-three recordings were made. No complications were identified. Addition of a portal reduces the average elevation of 3.8 °C (p < 0.05). Ambient temperature above 19.15 °C with two portals leads to an average increase of 13.3 °C (p < 0.05). Increasing the pressure of the arthropump of 10 mmHg increases the temperature of 0.8 °C (p < 0.05). No significant difference was found on the change in blood pressure, location and mode of use.

CONCLUSIONS

These results show the interest of controlling these factors when performing shoulder arthroscopy procedure. This study identifies situations of high joint risk when using radiofrequency and thus to prevent secondary complications such as burns and massive chondrolyses.