Focal osteonecrosis and severe chondrolysis following thermal capsulorrhaphy (SS-59)

Abstract

The purpose of this paper is to warn surgeons of potentially catastrophic complications following thermal capsulorrhaphy of the shoulder. From 2000 to 2002, the senior author has seen in consultation, treated, and followed-up 5 cases of focal osteonecrosis and severe chondrolysis following thermal capsulorrhaphy performed elsewhere. The average patient age was 19.2 years at time of surgery. The dominant arm was involved in all 3 male patients and 2 female patients. All patients were throwing athletes. Thermal capsulorrhaphy was performed with bipolar thermal devices (Arthrocare in 3, Mitek Vapor in 2) in all cases. In no case was a monopolar device with temperature control utilized. Two patients also had suture anchor fixation and 1 had suture capsulorrhaphy. Areas of the capsule treated included 1 isolated rotator interval, 1 anterior-inferior and interval, and 3 global treatments of entire capsule. Postoperatively patients were immobilized from 3–6 weeks and underwent physical therapy including passive stretching. All patients immediate and subsequent postoperative courses were characterized by pain out of proportion to the procedure and intractable stiffness. All attempts to return to competitive throwing were unsuccessful. All 5 required subsequent surgeries: closed manipulation in 2, arthroscopy with capsular release in 5, biological resurfacing in 2, and glenohumeral fusion in 1. Postoperative range of motion was poor in all and pain relief incomplete. In 2 cases, litigation has been an issue. This condition differs from idiopathic or steroid-induced avascular necrosis: this osteonecrosis is focal, occasionally multi-focal, asymmetric, and osteonecrotic areas are smaller. Rapidity of collapse, deformity, and pain intensity is much greater, and changes on the glenoid surface occur simultaneously secondary to severe associated chondrolysis. The condition is extremely painful, rapidly progressive, and has resulted in reflex sympathetic dystrophy in 2 patients. The etiology of this complication may be focal subchondral bone death from direct application of heat combined with “superheating” of intra-articular fluid. It is difficult to determine whether this is direct thermal damage to the cartilage from heated fluid or direct damage to cartilage/bone vascular supply from heating the capsule. However, only the rotator interval was treated in 1 patient, which would not implicate a vascular source for avascular necrosis or chondrolysis. All patients were treated with bipolar thermal devices which have no temperature regulation. Based on surgery videotapes, direct trauma from anchors or instrumentation were not felt to be responsible. Given the young age of these patients, joint replacement is an unattractive option. Biologic resurfacing of the glenohumeral joint does offer pain relief and modest improvement in range of motion in these patients. Preoperatively informing young throwing athletes that this is a rare but potential complication is highly recommended. It is unclear whether earlier intervention with arthroscopic release would prevent progression. We believe that awareness and prevention of this complication is the most important message, and avoiding thermal capsulorrhaphy with bipolar devices is highly recommended.