Thermal Capsulorrhaphy toTreat Internal Impingement in Baseball Players
Abstract & Commentary
Synopsis: This retrospective study compared 2 groups of throwing athletes with internal impingement. One group was treated by traditional techniques (arthroscopic debridement with labral repair where necessary) and compared to a group of patients with similar pathology, but in which monopolar thermal capsulorrhaphy was used in addition to traditional techniques.
Source: Levitz CL, et al. The use of arthroscopic thermal capsulorrhaphy to treat internal impingement in baseball players. Arthroscopy. 2001;17(6):573-577.
The repetitive throwing motion of baseball pitchers can exacerbate glenohumeral (GH) laxity. This can lead to secondary internal impingement associated with rotator cuff and labral tears in addition to excessive capsular laxity. The results following arthroscopic debridement and labral repair have been disappointing and often prohibit the athlete from returning to the same level of play. Levitz and colleagues believe that poor outcomes result from the failure to address GH laxity. Thermal capsulorrhaphy with monopolar radiofrequency energy (mRFE; Oratec Interventions, Menlo Park, Calif.) has been shown to produce joint capsular shrinkage potentially reducing GH translation. Reducing GH translation with mRFE was used in a group of overhead athletes in an effort to reduce the time required to return to competition and increase the likelihood that they would return to their preinjury level.
In a retrospective study over 2 sequential time periods, 51 patients in a nonheat-probe (NHP) group were treated with the standard arthroscopic technique, and 31 patients in a heat-probe (HP) group were treated with the standard arthroscopic technique and a mRFE device. The majority of cases in both groups consisted of cuff and labral debridement, but the HP group had a greater proportion of SLAP repairs. Mean time for return to competition was 7.2 months in the NHP group and 8.4 months in the HP group. At 20 months postsurgery, 67% of the NHP group and 90% of the HP group returned to competition (P = 0.01). The patients in the HP group used a sling for 2 weeks longer and had a slower progression through stretching exercises than the NHP group.
Levitz et al conclude that because mRFE addresses the inherent pathophysiological problem of GH laxity associated with internal impingement, it not only improves clinical outcomes but also prevents reinjury. In the short term, standard arthroscopic techniques in conjunction with mRFE allow throwing athletes with internal impingement to return to the same level of competition.
Comment by Brian J. Cole, MD, MBA
Arthroscopic debridement and labral repair for baseball pitchers with shoulder instability can alleviate pain, but return to high-level competition remains unpredictable. Radiofrequency energy provides a relatively easy solution for the arthroscopic management of capsular laxity associated with shoulder instability, especially when compared to the skill set required for suture plication techniques. With return to play as the most important early-term variable, Levitz et al have done an excellent job of demonstrating the effectiveness of mRFE as an adjuvant to standard arthroscopic techniques in 2 seemingly comparable groups with a single surgeon quite skilled in these techniques. The results make a strong case that mRFE does reduce GH laxity in the short-term. Recent interest in the use of sutures to manage the rotator interval and capsular laxity in addition to emerging data that question the longer-term efficacy of thermal modification of collagen suggest that further study is needed. A prospective investigation comparing mRFE to suture plication in the management of GH laxity with longer-term follow-up should help answer this question.
Author Acknowledgments: Dr. Cole would like to thank Shane Nho, MS, for his help in preparing the manuscript.