Thermal Capsulorraphy:
What is Thermal Capsulorraphy?
This is a new technique, which is known by several other names, such as: thermal capsular shrinkage, radiofrequency thermal shrinkage, and thermal capsular shift, uses thermal energy to shrink tissues. This can be done completely arthroscopically - enabling us to do some types of surgery arthroscopically that used to be done with a big incision before. Its most common use right now is in the shoulder to treat various types of shoulder instability.
How is it used in the shoulder?
A thermal probe is inserted through one of the "portals" created during arthroscopy. This probe is then used to heat parts of the shoulder capsule and ligaments to shrink them and therefore make them more tight. By tightening these structures, the shoulder becomes stable.
Doesn't heating the tissue hurt it?
Yes and no. Heating tissue (particularly collagen) causes some changes in its molecular structure. However, if you heat the tissue to the appropriate temperature (not too hot, not too cold), we can take advantage of these changes - they cause the length of the collagen to shrink. This does weaken the collagen to a degree. After time (weeks to months after surgery), the collagen regains its strength, while (hopefully) maintaining its new shortened characteristics.
Is thermal capsulorraphy painful?
No, actually quite the opposite! Patients typically experience much less pain than with other "open procedures" (eg. open capsular shift, Bankart reconstruction, etc). Often my problem in treating patients with this method is that they feel too good, too soon, and want to get back to strenuous activities before their shoulder has completely recovered.
How long have surgeons been doing this?
Arthroscopic surgeons have been using thermal energy to shrink tissues in the shoulder for several years. Indeed, the first person to describe its use in shoulder instability was Hippocrates - thousands of years ago! In the last decade, lasers were the primary method for performing this shrinkage. The problem was, however, that it was difficult to control the tissue temperature using the laser and often the tissue became too hot, and therefore was burned instead of shrunk. Newer instruments have become available in the last few years which have made this procedure safer and more efficacious. These instruments use radiofrequency energy to heat the tissue by causing its molecules to vibrate. In addition, a thermocouple on the end of the probe measures the tissue temperature and turns off the device if the tissue gets too hot.
What are the risks of thermal shrinkage in the shoulder?
Probably the most important risk is injury to a nerve that travels right underneath the shoulder capsule (the "axillary nerve"). This nerve can get injured by the heat produced in the shrinking process. Surgeons who are experienced in this technique utilize certain methods to help minimize this risk. Still, even in the hands of the best surgeons, the risk is probably about 1-5%. The good news is that the nerve usually recovers fully from this injury - it is just "stunned" and not permanently burned. The other risks are the same for any arthroscopic procedure - infection, excess swelling in the shoulder - these however are usually very unlikely and/or treated easily.
How well does this procedure work?
Because this procedure (using the newer probes) is relatively new, most of the studies that have been done on it have not yet been published in journals - only reported at conferences. These studies typically have followed patients for 2 years. So far, the results have been variable - approximately an 60-80% success rates for various types of shoulder instability. These studies are continuing to follow patients who have had the thermal shrinkage so that we can be sure the procedure is still successful at, say, 5 years after surgery.
In my opinion, there are limited indications for this procedure. I typically use it for only special types of instability, when I don't think more extensive surgery, such as an "arthroscopic Bankart" reconstruction, is necessary.
What is the rehabilitation afterwards?
Usually patients feel well enough to return to work (desk job, etc) within several days, depending whether other procedures besides the thermal capsulorraphy were performed. The shoulder is placed in an immobilizer for approximately 4 weeks - this allows the tissues inside to heal appropriately. Less immobilization risks stretching out the repair. After that, motion is begun - some people will regain all their motion quickly on their own, others might need gentle physical therapy.
- Dr. Laith Farjo
Telephone:
(810) 299-8550