Electrothermal chondroplasty--monopolar

The Arthroscopic Application of Radiofrequency in Treatment of Articular Cartilage Lesions

Articular cartilage lesion is a common disease to be treated by arthroscopic surgery. It will eventually progress to osteoarthritis without proper management, which can affect patients’ work and daily life seriously. Although mechanical debridement and laser have been used clinically for its treatment, due to their respective drawbacks, radiofrequency has drawn increasing attention from clinicians as a new technique with more advantages. However, the safety and efficacy of radiofrequency have also been questioned. In this article, the scope of application of radiofrequency was reviewed following an introduction of its development history and mechanism, and the methods to ensure the safety and effectiveness of radiofrequency through power and temperature control were summarized.

RFE based chondroplasty in wrist arthroscopy indicates high risk for chrondocytes especially for the bipolar application

Background

The application of radiofrequency energy (RFE) has become widespread for surgical performed chondroplasty especially due to the anticipated sealing effect, however the safety of this procedure in the wrist remains unclear. The purpose of this study was to investigate the subchondral temperature during radiofrequency energy (RFE) application simulating chondroplasty in an arthroscopic setting of the wrist.

Methods

A chondroplasty of the lunate fossa was performed during an arthroscopy setting on 14 cadaver arms using monopolar or biopolar RFE. The temperature was recorded simultaneously from 7 predefined anatomical landmarks.

Results

The mean temperature for both application modes did not exceed more than 30°C at all measured points, except for the lunate fossa. The highest subchondral measured peak temperature was 49.35°C (monopolar) and 69.21°C (bipolar) in the lunate fossa. In addition, the temperature decreased for both radiofrequency (RF) devices depending on the distance of the sensors to the RF-probe.

Conclusion

It remains to be questionable how safe RFE can be used for chondroplasty in wrist arthroscopy under continuous irrigation and constant movement to obtain the desired sealing effect. However, the bipolar device should be applied with more caution since peak temperature in the lunate fossa almost reached 70°C even under continuous irrigation.

The acute effect of bipolar radiofrequency energy thermal chondroplasty on intrinsic biomechanical properties and thickness of chondromalacic human articular cartilage

Radio frequency energy (RFE) thermal chondroplasty has been a widely-utilized method of cartilage debridement in the past. Little is known regarding its effect on tissue mechanics. This study investigated the acute biomechanical effects of bipolar RFE treatment on human chondromalacic cartilage. Articular cartilage specimens were extracted (n = 50) from femoral condyle samples of patients undergoing total knee arthroplasty. Chondromalacia was graded with the Outerbridge classification system. Tissue thicknesses were measured using a needle punch test. Specimens underwent pretreatment load-relaxation testing using a spherical indenter. Bipolar RFE treatment was applied for 45 s and the indentation protocol was repeated. Structural properties were derived from the force-time data. Mechanical properties were derived using a fibril-reinforced biphasic cartilage model. Statistics were performed using repeated measures ANOVA. Cartilage thickness decreased after RFE treatment from a mean of 2.61 mm to 2.20 mm in Grade II, II-III, and III specimens (P < 0.001 each). Peak force increased after RFE treatment from a mean of 3.91 N to 4.91 N in Grade II and III specimens (P = 0.002 and P = 0.003, respectively). Equilibrium force increased after RFE treatment from a mean of 0.236 N to 0.457 N (P < 0.001 each grade). Time constant decreased after RFE treatment from a mean of 0.392 to 0.234 (P < 0.001 for each grade). Matrix modulus increased in all specimens following RFE treatment from a mean 259.12 kPa to 523.36 kPa (P < 0.001 each grade). Collagen fibril modulus decreased in Grade II and II-III specimens from 60.50 MPa to 42.04 MPa (P < 0.001 and P = 0.005, respectively). Tissue permeability decreased in Grade II and III specimens from 2.04 ∗10(-15) m(4)/Ns to 0.91 ∗10(-15) m(4)/Ns (P < 0.001 and P = 0.009, respectively). RFE treatment decreased thickness, time constant, fibril modulus, permeability, but increased peak force, equilibrium force, and matrix modulus. While resistance to shear and tension could be compromised due to removal of the superficial layer and decreased fibril modulus, RFE treatment increases matrix modulus and decreases tissue permeability which may restore the load- bearing capacity of the cartilage.

The use of radiofrequency energy for arthroscopic chondroplasty in the knee

We present a review of the current literature surrounding the use of radiofrequency energy for arthroscopic chondroplasty in the knee. This review article summarizes basic science, clinical efficacy, and recent advances in the understanding of radiofrequency energy use for the treatment of chondral lesions. Laboratory evidence of increased mechanical stability and decreased release of inflammatory mediators associated with the use of radiofrequency energy chondroplasty is described with clinical evidence of decreased pain and increased functional scores when compared with mechanical chondroplasty. We re-examine concerns about the immediate side effects of radiofrequency energy use, including damage to local structures, in light of new potentially contradictory results, as well as the progression of techniques and probe design. However, although reported complications are few, because the quality of clinical evidence about safety and efficacy remains low, we suggest cautious and judicious use of this technology until future research has clearly defined the long-term clinical outcomes and risks.

Comparison of mechanical debridement and radiofrequency energy for chondroplasty in an in vivo equine model of partial thickness cartilage injury

OBJECTIVE

The purpose of this study was to develop a long-term model of cartilage injury that could be used to compare the effects of radiofrequency energy (RFE) and mechanical debridement as a treatment.

METHODS

Partial thickness fibrillation of patellar cartilage was created in 16 mature ponies. Three months after the initial surgery all injured patellae were randomly selected to receive one of the four treatments (n = 8/treatment): (1) control, (2) mechanical debridement with a motorized shaver, (3) TAC-CII RFE probe, and (4) CoVac 50 RFE probe. The ponies were euthanized 22 months after treatment. Macroscopic appearance of the cartilage surface was scored, vital cell staining was used to determine chondrocyte viability and light microscopy was used to grade the morphometric changes within the cartilage. Mechanical properties (aggregate modulus, Poisson's ratio and permeability) also were determined and compared to normal uninjured cartilage.

RESULTS

There were no differences in the cartilage surface scores among the treatment groups and control samples (P > 0.05). The maximum depth of cell death and the percentage of dead area in control and mechanical debridement groups were significantly less than those in both RFE groups. There were no significant differences in maximum depth and the percentage of dead area between the two RFE treatment groups. Histologic scores demonstrated better cartilage morphology for the control and mechanical debridement groups than those of RFE groups. However, even with full thickness chondrocyte death, the matrix in the RFE treated sections was still retained and the mechanical properties of the treated cartilage did not differ from the mechanical debridement group.

CONCLUSION

RFE caused greater chondrocyte death and more severe morphological changes compared to untreated degenerative cartilage and mechanical debridement in this model.

Treatment of grade III femoral chondral lesions: mechanical chondroplasty versus monopolar radiofrequency probe

PURPOSE

Articular cartilage defects are commonly found on the femoral condyle, and their treatment with thermal energy is thought to provide a smoother surface, sealing the damaged articular cartilage and possibly decreasing the progression of these lesions. Reports of femoral avascular necrosis (AVN) developing after bipolar thermal chondroplasty are worrisome. The purpose of this study was to compare the effects on subchondral bone and the early clinical effectiveness of mechanical shaving versus mechanical shaving plus monopolar radiofrequency (MRF) on grade III femoral chondromalacia.

TYPE OF STUDY

Randomized, prospective, controlled trial.

METHODS

In this trial 60 subjects were treated by either mechanical shaving alone (n = 30) or mechanical shaving plus MRF (n = 30). Preoperative and 12-month postoperative magnetic resonance imaging (MRI) evaluations and Tegner, Lysholm, Cincinnati, International Knee Documentation Committee, and visual analog scale assessments at 12 and 24 months were obtained.

RESULTS

Of the subjects, 56 were available for the final analysis (28 treated by shaver and 28 treated by shaver plus MRF). Baseline demographics were similar between treatment groups. Postoperative MRI findings were similar between groups, including no incidents of AVN. At a mean of 19 months postoperatively, Tegner, Lysholm, Cincinnati, International Knee Documentation Committee, and visual analog scale assessments improved significantly from pretreatment levels in both groups. No difference in mean improvement was observed between groups.

CONCLUSIONS

The primary endpoint was to look for AVN. No subchondral bone effects attributable to either mechanical shaving or radiofrequency energy were noted. The secondary endpoint was a clinical evaluation. Both groups showed significant improvements in pain and function outcomes with no discernible differences between groups. The use of monopolar radiofrequency as an adjuvant to mechanical chondroplasty with a shaver for the treatment of grade III chondral lesions did not affect MRI findings or pain and function outcomes when compared with mechanical chondroplasty by use of a shaver only.

LEVEL OF EVIDENCE

Level II, randomized controlled trial with confidence intervals not reported.

Comparison of techniques for determination of chondrocyte viability after thermal injury

OBJECTIVE

To compare 2 methods of quantitating chondrocyte viability and to determine chondrocyte response to thermal injury over time.

SAMPLE POPULATION

108 stifle joints from 54 adult rats.

PROCEDURES

Cartilage from the distal aspect of the femur was treated ex vivo with radiofrequency energy at a probe setting that would result in immediate partial-thickness chondrocyte death; untreated sections served as controls. Explants were cultured, and cell viability was compared by use of lactate dehydrogenase (LDH) histochemical staining and calcein AM and ethidium homodimer-1 confocal laser microscopy (CLM) cell viability staining. Terminal deoxynucleotidyl transferase-mediated X-dUTP nick end labeling (TUNEL) was used to detect apoptosis. All labeling studies were performed 0, 1, 3, 7, 14, and 21 days after treatment.

RESULTS

In the treated tissues, a greater percentage of viable cells were found with CLM, compared with LDH staining. This result contrasted that of control tissues in which LDH staining indicated a greater percentage of live cells than CLM. The greatest number of TUNEL-positive chondrocytes was present at day 3, declining at later time intervals.

CONCLUSIONS AND CLINICAL RELEVANCE

CLM and LDH histochemistry techniques yield different absolute numbers of live and dead cells, resulting in differing percentages of live or dead cells with each technique. These differences may be related to the enzymes responsible for activation in each technique and the susceptibility of these enzymes to thermal injury. Results of TUNEL indicate that apoptosis contributes to chondrocyte death after thermal injury, with a peak signal identified 3 days after insult.

Ex vivo investigation of the use of hydrothermal energy to induce chondrocyte necrosis in articular cartilage of the metacarpophalangeal and metatarsophalangeal joints of horses

OBJECTIVE

To evaluate the use of hydrothermal ablation of articular cartilage for arthrodesis in horses through investigation of the effects of joint lavage with physiologic saline (0.9% NaCI) solution (80 degrees C) for various treatment times on chondrocyte viability in the articular cartilage of the metacarpophalangeal and metatarsophalangeal joints of cadaveric horse limbs. Sample Population-7 pairs of metacarpophalangeal and 8 pairs of metatarsophalangeal joints from 8 Thoroughbreds.

PROCEDURE

The horses were euthanatized for reasons unrelated to musculoskeletal disease. On a random basis, 1 joint of each pair underwent intra-articular lavage for 5, 10, or 15 minutes with heated saline solution (80 degrees C); the other joint underwent sham treatment of similar duration with saline solution at 22 degrees C (control). Cartilage samples from the distal articular surface of metacarpus III (or metatarsus III), the proximal surface of the proximal phalanx, and the lateral and medial proximal sesamoid bones were assessed for chondrocyte viability via confocal microscopy and viability staining following enzymatic digestion.

RESULTS

Compared with the control joints, findings of both viability assays indicated that the percentage of sites containing viable chondrocytes in heat-treated joints was decreased. Treatment hazard ratios of 0.048 (confocal microscopy) and 0.2 (digestion assay) were estimated. Histologically, periarticular soft tissues had minimal detrimental effects after heat treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Ex vivo intra-articular lavage with saline solution at 80 degrees C resulted in the death of almost all articular chondrocytes in the joint. This technique may be a satisfactory method for extensive cartilage ablation when performing arthrodesis by minimally invasive techniques.