Thermal capsulorrhaphy to treat shoulder instability

Adoption of new technology in sports medicine: case studies of the Gore-Tex prosthetic ligament and of thermal capsulorrhaphy

Evaluation of new technology in sports medicine is supposed to promote improvements in the care of patients. It is also supposed to prohibit technology that can harm patients. This evaluation process is not perfect and at times can promote technology that not only does not help patients but may harm them. Two examples of new sports medicine technology that were widely adopted but eventually abandoned are thermal capsulorrhaphy for treatment of shoulder instability and the Gore-Tex prosthetic ligament (W. L. Gore & Associates, Flagstaff, AZ) for patients with anterior cruciate ligament deficiency. On analysis of the quick adoption of these 2 failed procedures, certain recommendations are apparent for improvement of the evaluation process. There must be a sound rationale behind any new technology, basic science research into the theory of the medical technology, and demonstrated improvements in animal models and clinical studies that are prospective cohort studies or randomized controlled trials, and finally, there must be careful follow-up and postmarket surveillance.

Arthroscopic stabilization of posterior shoulder instability

Posterior shoulder instability is a rare and challenging condition with a complex patho-anatomy. The role of arthroscopic repair in the treatment remains poorly defined. The purpose of this study is to evaluate the result of arthroscopic stabilization procedures in patients with posterior shoulder instability. In this case series, we treated eighteen patients (19 shoulders) with posterior shoulder instability with either arthroscopic thermal capsular shrinkage (9 patients), capsulorrhaphy (3) or labral refixation (7). There were eight male and ten female patients with a mean age of 26 years. The study group included unidirectional (6 patients; PI), bi-directional (8; PII) and multidirectional posterior instability (5; MDI). The Rowe-score and DASH-score as well as subjective and objective evaluations of the patients function, range of motion, pain and instability were used as clinical outcome measurements. At a mean follow-up of 50 months, the Rowe-score improved significantly from 46 to 74 (P = 0.005). Four patients (21%) had recurrent instability after arthroscopic treatment (2 with generalized ligamentous laxity; 3 after thermal shrinkage). Analysis of postoperative DASH-scores showed a tendency toward inferior outcomes after thermal shrinkage and in patients with an a-traumatic origin of shoulder instability. We conclude that arthroscopic shoulder stabilization by either labral refixation or capsulorrhaphy is a safe and effective treatment for posterior shoulder instability. Thermal capsular shrinkage however showed poor results and should be abandoned for this indication.

Fluid temperatures during radiofrequency use in shoulder arthroscopy: a cadaveric study

Cadaveric shoulders underwent thermal capsulorrhaphy and subacromial decompression with 3 different commercially available radiofrequency (RF) devices to evaluate local and regional fluid temperatures while arthroscopic procedures were being performed. Fifteen completely thawed fresh-frozen shoulders underwent both thermal capsulorrhaphy and subacromial decompression. During thermal capsulorrhaphy, Fluoroptic mini-thermometer probes (Luxtron model 3000) were placed in the inflow bag; in the glenohumeral joint, near the inferior glenohumeral ligament; and on the RF wand. During subacromial decompression, the temperature probes were placed in the anterior and posterior subacromial space, as well as in the inflow bag and on the RF wand. All data were initially analyzed by use of analysis of variance, followed by pairwise comparison, adjusted for multiple testing by use of the Scheffé method. Mean fluid temperatures (in degrees Celsius [+/- SD]) were highest at the RF wand during both capsulorrhaphy and subacromial decompression. Mean fluid temperatures were much lower at other recorded sites. In this model, we show no deleterious elevation in arthroscopic fluid temperature while performing thermal capsulorrhaphy or subacromial decompression using any of the 3 devices at their recommended settings.

Glenohumeral instability and dislocation

Glenohumeral joint instability and dislocations are common diagnoses seen by physicians. There are many different pathologic etiologies for these conditions. A thorough understanding of the history,physical examination, pathoanatomy, and classification systems is required to make an accurate diagnosis. With the appropriate diagnosis, the clinician can choose the correct treatment and improve the patient's outcome.

Postoperative shoulder rehabilitation

This article focuses on the rehabilitation considerations for several shoulder surgeries: acromioplasty, rotator cuff repair, rotator cuff debridement, Bankart repair, thermal capsulorrhaphy, superior labral anterior posterior repair, multidirectional instability, proximal humerus fracture, surgical management of the stiff shoulder, arthroplasty,and fusion. General guidelines are presented for discussing and planning rehabilitation for patients, including exercises, timing of progression, patient education, precautions or restrictions, and expectations.

Heat-induced changes in porcine annulus fibrosus biomechanics

The intervertebral disc is implicated as the source of low-back pain in a substantial number of patients. Because thermal therapy has been thought to have a therapeutic effect on collagenous tissues, this technique has recently been incorporated into several minimally invasive back pain treatments. However, patient selection criteria and precise definition of optimum dose are hindered by uncertainty of treatment mechanisms. The purpose of this study was to quantify acute changes in annulus fibrosus biomechanics after a range of thermal exposures, and to correlate these results with tissue denaturation. Intact annulus fibrosus (attached to adjacent vertebrae) from porcine lumbar spines was tested ex vivo. Biomechanical behavior, microstructure, peak of denaturation endotherm, and enthalpy of denaturation (mDSC) were determined before and after hydrothermal heat treatment at 37 degrees C, 50 degrees C, 60 degrees C, 65 degrees C, 70 degrees C, 75 degrees C, 80 degrees C, and 85 degrees C. Shrinkage of excised annular tissue (removed from adjacent vertebrae) was also measured after treatment at 85 degrees C. Significant differences in intact annulus biomechanics were observed after treatment, but the effects were much smaller in magnitude than those observed in excised annulus and those reported previously for other tissues. Consistent with this, intact tissue was only minimally denatured by treatment at 85 degrees C for 15 min, whereas excised tissue was completely denatured by this protocol. Our data suggest that in situ constraint imposed by the joint structure significantly retards annular thermal denaturation. These findings should aid the interpretation of clinical outcomes and provide a basis for the future design of optimum dosing regimens.

Sports and performing arts medicine. 2. Shoulder and elbow overuse injuries in sports

This self-directed learning module discusses classic topics and highlights new advances in this area. This article discusses upper-limb sports injuries as part of a section of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article uses case vignettes as a vehicle to elaborate on shoulder and elbow pain in the athlete.

OVERALL ARTICLE OBJECTIVE

To discuss shoulder and elbow overuse injuries in sports.