Radiofrequency Wand Research Articles

Arthroscopic Debridement and Resection of a Bennett Lesion in a Collegiate Baseball Pitcher

Background: Overhead throwing athletes are predisposed to ossification along the superior to inferior posterior glenoid rim, termed thrower's exostosis or a Bennett lesion. These lesions can result in posterior shoulder pain during throwing and decreased shoulder range of motion, and they can be associated with posterior labral tears and undersurface rotator cuff tears. In this video technique, we describe the arthroscopic debridement and resection of a symptomatic unstable Bennett lesion in a collegiate baseball pitcher who had unsuccessful nonoperative treatment. Indications: Currently, there is no standard treatment algorithm for Bennett lesions. Arthroscopic intervention is typically indicated in overhead throwers who have unsuccessful nonoperative protocols, including stretching of the posterior capsule, strengthening of the rotator cuff, and injections. Technique Description: In the lateral decubitus position, standard posterior viewing and anterior working arthroscopic portals are created followed by diagnostic arthroscopy. A high anterior accessory portal is created to view the posterior labrum and evaluate for tears. The location of the Bennett lesion is determined using a switching stick or probe. In this case, an accessory posterior viewing portal and capsulotomy are created under spinal needle visualization and a 70° scope is utilized for an improved view. Through the capsulotomy, a motorized shaver and radiofrequency wand is used to work along the posterior inferior glenoid neck to expose the lesion. Once the lesion is fully demarked, a hooded bur is utilized to debride the entirety of the lesion back to the smooth bony surface of the glenoid neck. After resection, the capsule is left open to avoid overtightening the posterior capsule in overhead throwing athletes. Results: Arthroscopic debridement and resection of a symptomatic Bennett lesion in a collegiate baseball pitcher allowed the patient to return to pain-free pitching at the same level of collegiate play the following season. Discussion/Conclusion: An unstable Bennett lesion can be a source of pain in the overhead throwing athlete. If nonoperative treatment modalities fail to resolve symptoms, arthroscopic debridement and excision of this lesion utilizing a posterior capsulotomy and accessory posterior viewing portal as described in this video technique is a safe and effective surgical option. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Use of Novel Radiofrequency Wand for the Application of the Biceps Tenotomy and Subacromonical Bursectomy

Rotator cuff tears in patients can lead to a surgical intervention to relieve the pain and improve the function of the shoulder joint. In the majority of cases, the rotator cuff repair is completed arthroscopically and requires the ability for soft-tissue resection and visualization to restore the anatomic structures to their native state. With the advent of a radiofrequency wand, the technical aspects of a biceps tenotomy from the insertion point on the glenoid can be completed, along with the ability to resect, ablate, and coagulate tissue, using a single instrument. Although bone resection is completed with a bone cutting shaver and/or burr, the soft-tissue dissection can be completed in a precise and efficient manner.

A retrievable rescue stent graft and radiofrequency positioning for rapid control of noncompressible hemorrhage.

Noncompressible hemorrhage of the torso remains a challenging surgical dilemma. Stent graft repair requires endovascular expertise, imaging, and inventory that are not available within the critical window of massive hemorrhage. We developed a retrievable stent graft for rapid hemorrhage. We further investigated a radiofrequency (RF) positioning approach as a possible alternative to the logistics of fluoroscopy. A retrievable stent graft was constructed with a novel "petal and stem" design from nitinol and covered with a sleeve of electrospun polyurethane. The stent graft was tested using an in vitro model of simulated hemorrhage. Next, the stent graft was examined in vivo using a porcine model of noncompressible hemorrhage. The stent was examined for hemorrhage control in a porcine model of either aortic or caval injury. An RF reader was assembled from an Arduino processor while RF tags were affixed to the ends of the stent graft. Detection accuracy of a handheld RF wand for an RF tag was quantified both in vitro and through tissue. The retrievable RESCUEstent graft was deployed within minutes and rapidly controlled traumatic hemorrhage angiographically in both aortic injury (n = 3) and caval injury (n = 2). Stent grafts were easily recaptured in both models in under 15 seconds. The LED light of a handheld RF detector illuminated when positioned directly over an RF tag. The RF detection approach revealed positioning accuracy to within 1 cm of the intended target, despite tissue interference. This study demonstrates the rapid deployment and retrieval of a RESCUE stent graft as well as the ability to tamponade injuries of the aorta and cava. In addition, this study demonstrates the feasibility of RF tags to guide stent placement through tissue. More rigorous models are needed to define the effectiveness of this approach in the setting of vascular injury and shock.

Radiographic and anatomic landmarks to approach the anterior capsule in hip arthroscopy.

Hip arthroscopy (HA) is considered to be a very difficult and demanding surgical procedure, special instruments, an image intensifier and a fracture table or hip distractor are required to access the hip joint, the most common and worldwide used HA technique is entering blindly to the central compartment with the use of fluoroscopy and continuous distraction; with the potential danger if performed in unskillful hands of labral penetrations, labral resections and scuffing of the femoral head cartilage. Our technique describes the arthroscopic management of femoroacetabular impingement (FAI), performing a preoperative planning using radiographic and anatomic landmarks to approach the anterior capsule without the use of fluoroscopy. Access to the hip joint is made extra-articularly from the peritrochanteric compartment palpating the greater trochanter and posteriorly penetrating the iliotibial band sliding the arthroscopic sheath and obturator from the trochanteric border to the anterior femoral neck to visualize the anterior capsule bursa and anterior capsule fibers and posteriorly following our previous landmarks perform an anterior oblique Inverted ‘T’ or ‘H’ capsulotomy with a radiofrequency wand to access the cam-type impingement and distraction is made under direct controlled arthroscopic vision. Our technique in HA aiming the anterior capsule using radiographic and anatomic landmarks is safe, reliable and reproducible in FAI with big cams, deep sockets and cases with mild arthritis where the capsule is thick, stiff and calcified.

Recent NICE guidance of interest to surgeons

COMMENT ON Hariharan D, Lobo DN. Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl 2013; 95: 87–92 doi 10.1308/003588413X13511609957218 I read with interest the review by Hariharan and Lobo in which they discuss the incidence of retained surgical items and the seriousness of outcomes to patients, particularly when sponges are retained. Clearly, this issue has not been resolved and requires attention. The authors rightfully point out that the surgical count, a primary preventive measure, has limitations. Discrepancies in the count are a common event and the sensitivity of the surgical count is only 77%. 1 We conducted a healthcare failure mode and effect analysis that identified potential failures in the processes of preventing retained sponges. 2 Distraction and multitasking were the most frequent causes, and are especially difficult, if not impossible, to eliminate. In their algorithm, Hariharan and Lobo propose using a standardised count process, the surgeon confirming the final count, and the use of radiography if the surgical count is incorrect. This poses a challenge clinically. In addition to the limitations of the count, the sensitivity of intraoperative radiography for detection of a retained surgical item is only 67%. 3 If we rely on these two interventions, we will not likely eliminate retained surgical items. The more sensitive postoperative survey images are taken outside of the operating theatre. This would require tremendous expense and a return trip to theatre if an item is identified. The algorithm would be enhanced by including methodological wound exploration by the surgeon, to search for sponges prior to closure, and a hard stop when a count is reported as being incorrect. We should also comprehensively evaluate adjunct technology. There are currently three adjunct technologies available to supplement the current processes for prevention of retained sponges. Hariharan and Lobo provide a comprehensive review of the evidence regarding two: the barcoded counting system and the radiofrequency identification system. The third, a radiofrequency (RF) detection system, involves low energy RF chips sewn into sponges and a scanner for detection of the sponges. Two scanners are available: a wand that is passed over the patient and a mat that is placed under the patient. Studies have found the sensitivity and specificity of the RF wand to be 100%, even in morbidly obese subjects. 4,5 The mat is slightly less sensitive for detection in morbidly obese than in non-morbidly obese patients (97% vs 100%). 5 RF technology has been shown to be highly effective in reconciling miscounts and preventing retained sponges. 6,7 In a study including 2,285 patients, no retained sponges occurred while using the RF technology within the 12 months of data collection. 7 I thank Hariharan and Lobo for highlighting a very important patient safety issue. Through teamwork and effective communication, we can improve patient care. However, as we cannot eliminate distraction and multitasking, we should evaluate adjunct technology to determine its applicability in the prevention of retained sponges.

Assessment of Radiofrequency Device Sensitivity for the Detection of Retained Surgical Sponges in Patients With Morbid Obesity

Retained surgical sponges are serious medical errors that result in negative patient outcomes. A radiofrequency (RF) mat for the operating room bed has recently been introduced to detect the presence of a retained surgical sponge. The study objectives were to evaluate the sensitivity and specificity of the RF mat for the detection of surgical sponges through the torso of individuals with varying body habitus and to compare the sensitivity of the RF mat with that of the RF wand. We hypothesized that the sensitivity and specificity of the RF technology would be comparable to published findings of the manual sponge count by operating room personnel. A prospective, crossover, double-blinded study design was used. Participants served as their own controls. SETTING Large Midwestern academic medical center. In total, the first phase of the study enrolled 203 participants, including 129 (63.5%) with morbid obesity. One hundred seventeen of 203 participants were also enrolled in the second phase of the study. The study participants reclined in a supine position on top of an RF mat. Four surgical sponges were sequentially placed on top of the torso in locations approximating the abdominal quadrants. The torso was scanned for sponges. In a subset of participants, 4 surgical sponges were sequentially placed underneath the torso, and an RF wand was passed over the abdomen. Overall, 812 readings were obtained with the RF mat, and 468 readings were obtained with the RF wand. Twelve false-negative readings were obtained with the RF mat, exclusively in participants with super morbid obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] >50.0). Overall, the sensitivity of the RF mat was 98.1%, and the specificity of the RF mat was 100.0%. In the subset of 117 participants in whom the RF wand was also used, the sensitivity and specificity of the wand were each 100.0%. The sensitivity and specificity of RF device technology are much higher than those of surgical sponge counts or published findings on the use of intraoperative radiographs to identify retained surgical sponges. The RF wand is more sensitive than the RF mat in individuals with morbid obesity.

Potential Healing of Meniscal Injuries in the Avascular Zone after Radiofrequency Stimulation (SS-34)

Meniscal repair in the white-white zone has a high incidence of failure due to poor vascularity. Radiofrequency application has been shown to increase the angiogenic capabilities of fibroblasts in chronic tendinopathies. The purpose of this study was to evaluate the effect of radiofrequency (RF) stimulation, in conjunction with suture repair, on the healing of tears in the white-white zone of the meniscus. 54 New Zealand white rabbits underwent surgically induced meniscal injuries within the avascular (white-white) region. Rabbits were then divided into three treatment groups: no repair (N=6), suture repair only (N=15) and suture repair in conjunction with RF treatment (N=33). Radiofrequency was applied using a 0.8 mm radiofrequency wand at level 4 for 500 milliseconds. Rabbits were then sacrificed at 9, 28 and 84 days for gross, histological and biochemical examination by two blinded observers. Biochemical analyses included evaluation of cell proliferation (3H-thymidine) as well as mitogenic (IGF-1, bFGF) and angiogenic (VEGF, αV) factors. Of specimens repaired with radiofrequency combined with suture, 19 (58%) showed increased gross morphologic and histological healing compared to controls. Two meniscal explants treated with RF had complete histological healing. No significant healing was seen in specimens that had either no repair or repair with suture alone. Biochemically, at nine days, the rate of 3H-thymidine for meniscal tears treated with suture repair + RF was 590±80 cpm/mg dry tissue. This value was approximately 40% greater than the menisci treated with suture repair only, which had a value of 380±30 cpm/mg (p < 0.05). Normal, unrepaired meniscal tissue had a 3H-thymidine incorporation rate of 250±35 cpm/mg. Semiquantitative RT-PCR analysis showed that at nine days post-repair, the RF-treated menisci had significantly increased mR.N.A expression of IGF-1, bFGF, VEGF and αV relative to untreated repairs. By day 28 and 84, the levels appeared equivalent between all treatment groups (p > 0.05). This study demonstrated that in our animal model, radiofrequency application in adjunct to suture repair of white-white meniscal tears led to a significantly increased healing response both in vitro and in vivo. Although the mechanism by which RF stimulation improves the healing response is not completely understood, our biochemical analyses suggest that it may enhance cellular proliferation as well as the mitogenic and angiogenic capability of the meniscal fibroblast.

Nonablative 4-MHz Dual Radiofrequency Wand Rejuvenation Treatment for Periorbital Rhytides and Midface Laxity

To evaluate the wrinkle-reducing effects of 4-MHz radiofrequency (RF) energy applied to human periorbital, frontal, and midface facial skin using clinical wrinkle grading, patient self-satisfaction survey, and limited histologic studies. Thirty-two patients, ranging from 29 to 71 years of age with skin types varying from class I to class III using the Fitzpatrick Wrinkle Classification system, underwent 8 weekly treatment sessions of nonablative RF therapy on the periorbital, frontal, and midface regions and were subjected to follow up for 6 months after treatment. Pretreatment and post-treatment evaluations were compared. Two female subjects gave informed consent for RF treatment for the right upper eyelid and no treatment for left upper eyelid. Specimens from both upper eyelids then underwent histologic examination using light and transmission electron microscopy. Pre- and post-RF treatment evaluation by 3 independent observers using the Fitzpatrick wrinkle classification system showed progressive improvements in wrinkle score at 1-, 3-, and 6-month intervals (p < 0.01). Self-evaluation of 32 patients using a 9-point rating scale after application of RF treatment also showed improving satisfaction (p < 0.01). The most commonly noted adverse reaction was transient erythema (62.5%) lasting from a few hours to a day. Transmission electron microscopy (25,000×) showed scattered diffuse changes in collagen fibril architecture with a shift from smaller-diameter collagen fibers in the untreated samples to larger-diameter fibers in the treated samples and a loss of distinct fibril borders. Four-megahertz dual RF wand delivery rejuvenation treatment produces a reduction in periorbital and midface rhytides.

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.

Arthroscopic Treatment of Chronic Anterior Instability of the Shoulder in Marfan’s Syndrome

We present a case of recurrent anterior shoulder dislocation in a patient with Marfan’s syndrome who presented with hyperlaxity that has been treated arthroscopically. We discuss abnormal findings at arthroscopic evaluation, including complete absence of the mid anterior capsule, which left the subscapularis uncovered, and we hypothesize that repetitive trauma to the capsule was not followed by a normal process of remodeling because of a lack of competent elastic fibers and a poor capacity for soft tissue healing. The inferior insertion of the labrum and the inferior glenohumeral ligament seemed normal through the large volume of the pouch. We performed arthroscopic reconstruction of the capsule through dissection of its anteroinferior part with a radiofrequency wand from the glenoid rim and the subscapularis, followed by superior drift of the capsule. The Weitbrecht foramen was then closed with 2 nonresorbable No. 4 sutures, and the capsule was reinserted to the labrum with 2 anchors. A final suture closed the remaining hole in the rotator interval. At 16-month follow-up, the patient emphasized her satisfaction with the results; she was able to keep up with her regular schedule of leisure sports and swimming, painlessly, with no limitations or new episodes of instability.

Meniscal Debridement With an Arthroscopic Radiofrequency Wand Versus an Arthroscopic Shaver: Comparative Effects on Menisci and Underlying Articular Cartilage

Meniscal debridement with an arthroscopic radiofrequency (RF) wand versus an arthroscopic shaver and their comparative effects on menisci and underlying articular cartilage were studied. When repair is not feasible, degenerative or post-traumatic meniscal tears often need debridement. Six fresh bovine knees were harvested, the tibial plateau was dissected free from the femoral articulation and placed in a saline bath at 28 degrees C, with 10% to 15% of the posterior horn of menisci debrided arthroscopically, and the surfaces debrided using a basket punch plus shaver, punch plus RF wand, RF wand alone, and untreated control. Treatment time of each case was 24 seconds at wand power 7. We characterized an injury zone, as well as viability and metabolic activity of meniscal cells and tibial articular cartilage chondrocytes. Chondrocyte viability of the tibial articular surface was 96% to 98%. We saw no differences in viability or injury zone (0 to 150 microm) among debrided groups or versus the control for any experimental surface, with no significant difference in metabolic activity in menisci debrided surfaces versus control. Meniscal viability was variable with analyses showing substantial levels (150 to 500 microm) of cell death in debrided and control groups. Metabolic activity in treated meniscus was lower than in cartilage specimens. No significant differences were observed among treatment groups versus control. Focal areas of chondrocyte cell death were not seen. Meniscal samples showed cell death (150 to 500 mum) throughout the tissue. Debridement of menisci with a bipolar RF wand produces levels of cell injury and death similar to those of debridement with a basket punch mechanical shaver. The RF wand did not harm underlying articular surfaces and produced a precise cut to the meniscal surface.

In Vitro Effects of 3 Common Arthroscopic Instruments on Articular Cartilage

The purpose of this study was to compare chondroplasty performed with an ExoJet high-pressure fluid-driven burr (Mitek, Norwood, MA), a mechanical shaver, and a bipolar radiofrequency (RF) wand on articular cartilage-covered condyles taken from sheep cadavers that were induced to have an osteoarthritic-like condition, and corresponding healthy control tissue. Experimental designed animal cadaveric, biochemical, and histologic study. Sheep condyles were used as a source of articular cartilage. Femurs were extracted approximately 1 hour postmortem and a transverse section of the condyles was made. Half of the samples were treated to induce an osteoarthritic-like condition. The condyles were then subjected to chondroplasty performed with the ExoJet high-pressure fluid-driven burr, a mechanical shaver, and a bipolar RF wand under sterile saline solution by an experienced orthopaedic surgeon. Twenty cross-sections from each condyle were examined by confocal microscopy to measure smoothness and depth of tissue damage to the articular cartilage caused by each of the 3 instruments. The ExoJet high-pressure fluid-driven burr and the bipolar RF wand left a smoother surface on the articular cartilage compared with the mechanical shaver. Additionally, the ExoJet fluid-burr caused slightly less tissue damage to the cartilage than the bipolar RF wand, both of which were less damaging than the shaver. Orthopaedists have multiple choices for surgical instruments used on cartilage. However, the effect on the integrity of the cartilage left remaining at the knee was previously unknown. Based on this study, a fluid-burr appears to leave the cartilage with a smaller zone of injury than does the RF wand or shaver. It also leaves the cartilage surface smoother than the shaver. During surgical procedures, minimizing cartilage breakdown and smooth remaining surfaces are desired because they minimize the vulnerable tissue to further destruction. A fluid burr leaves cartilage with less injury and with a smoother surface than do more traditional surgical instruments. This information should help surgeons in their selection of currently available surgical instruments and should aid engineers in the design of future instruments that function to modify articular cartilage.

Histologic findings of disc, end plate and neural elements after coblation of nucleus pulposus: an experimental nucleoplasty study

Background context Partial removal of the nucleus has been shown to decompress herniated discs, relieving pressure on nerve roots and, in some cases, offering relief from disc pain. The nucleoplasty technique builds on earlier surgical approaches that helped validate the strategy of intranuclear tissue removal. Nucleoplasty, a new minimally invasive procedure using patented coblation technology, combines coagulation and ablation for partial removal of the nucleus pulposus to decompress the disc. Purpose To determine if histologic changes of the intervertebral discs and surrounding tissues occur after nucleoplasty. Study design A light microscopic study of intervertebral disc and adjacent neural tissues after disc decompression by nucleoplasty in pig cadavers. Methods Light microscopy was used to examine disc and neural tissues in two pig cadaveric specimens (T12 to sacrum). Nucleoplasty was performed by 1) advancing a radiofrequency wand to a predetermined depth in the disc (ablation), and 2) withdrawing the wand to the starting point (coagulation). Discs and adjacent tissues were removed from treated and nontreated segments, and examined under light microscopy. Results Histologic examination revealed no evidence of direct mechanical or thermal damage to the surrounding tissues. There was clear evidence of coblation channels with clean coagulation borders of the nucleus pulposus. Normal histologic findings of the annulus and end plate, with normal neural elements of the spinal cord and nerve roots at the level of the procedure, were observed. Conclusions The histologic findings of this study suggest that the nucleoplasty achieves volumetric removal of target disc tissue without overt thermal or structural damage to the adjacent tissues. Further studies in live animals will be needed to assess the effects of nucleoplasty on the annulus, end plate and neural tissues under physiologic conditions, including assessment of cell viability.