March 13th, 2004
AOSSM Specialty Day

FOCAL OSTEONECROSIS AND SEVERE CHONDROLYSIS FOLLOWING THERMAL CAPSULORRHAPHY

Authors:
  1. Wayne Z. Burkhead MD, W.B. Carrell Memorial Clinic, Dallas, TX
  2. Sumant G. Krishnan MD, W.B. Carrell Memorial Clinic, DALLAS, TX
  3. Daryle Ruark MD, W.B. Carrell Clinic, Dallas, TX
Objective:  The purpose of this paper is to warn surgeons of potentially catastrophic complications following thermal capsulorrhaphy of the shoulder.
Methods:  We have seen in consultation 5 cases of focal osteonecrosis and severe chondrolysis following thermal capsulorrhaphy performed elsewhere. Average age was 19.2 years at time of surgery. Dominant arm was involved in all 3 male and 2 female patients. All were throwing athletes. Thermal capsulorrhaphy was performed with bipolar thermal devices (Arthrocare in 3, Mitek Vapr in 2) in all cases. In no case was a monopolar device with temperature control utilized. Three patients also had suture anchor or suture capsulorraphy fixation. Capsular treatments included 1 isolated rotator interval, 1 anterior-inferior and interval, and 3 global treatments. Immediate and subsequent postoperative courses were characterized by pain out of proportion to procedure and intractable stiffness.
Results:  All 5 required subsequent surgeries: closed manipulation in 2, arthroscopy/capsular release in 5, biological resurfacing in 2, and glenohumeral fusion in 1. Postoperative range of motion was poor and pain relief incomplete. In 2 cases, litigation has been an issue. This condition differs from idiopathic or steroid-induced avascular necrosis: this is focal, asymmetric, and smaller. Rapidity of collapse, deformity, and pain is much greater, and glenoid changes occur simultaneously. The condition is extremely painful, rapidly progressive, and has resulted in reflex sympathetic dystrophy in 2 patients.
Conclusions:  Etiology may be focal subchondral bone death from direct application of heat combined with “super heating” of intraarticular fluid. It is difficult to determine whether this is direct thermal cartilage damage from heated fluid or direct damage to cartilage/bone vascular supply from heating the capsule. All patients were treated with bipolar thermal devices with no temperature regulation. Based on surgery videotapes, direct trauma from anchors or instrumentation was not felt to be responsible. Preoperatively informing young throwing athletes that this is a rare but potential complication is highly recommended. We believe that awareness and prevention of this complication is the most important message, and avoiding thermal capsulorrhaphy with bipolar devices is highly recommended.
Keywords:
  1. Cartilage
 Categories:
  1. CLINICAL: Shoulder - Other