The use of radiofrequency in equine orthopedic surgery

Charlotte K. Barton Orthopaedic Research Center, C. Wayne McIlwraith Translational Medicine Institute, Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO

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Laurie R. Goodrich Orthopaedic Research Center, C. Wayne McIlwraith Translational Medicine Institute, Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO

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Abstract

The use of radiofrequency energy (RFE) has become increasingly popular in equine orthopedic surgery in recent years, particularly for the debridement of cartilage lesions and soft tissue resection. However, despite considerable advancements in the technology, the safety and efficacy of RFE have continued to be questioned. While studies investigating the use of RFE for chondroplasty in the equine population are lacking, there is an abundance of research studies in the human literature assessing its effect on healthy chondrocytes, and researchers are seeking to develop guidelines to minimize collateral damage. This review article provides a concise and thorough summary of the current use of RFE in equine orthopedics, in addition to discussing the recent evidence surrounding its use for chondroplasty in both the human and equine populations.

Abstract

The use of radiofrequency energy (RFE) has become increasingly popular in equine orthopedic surgery in recent years, particularly for the debridement of cartilage lesions and soft tissue resection. However, despite considerable advancements in the technology, the safety and efficacy of RFE have continued to be questioned. While studies investigating the use of RFE for chondroplasty in the equine population are lacking, there is an abundance of research studies in the human literature assessing its effect on healthy chondrocytes, and researchers are seeking to develop guidelines to minimize collateral damage. This review article provides a concise and thorough summary of the current use of RFE in equine orthopedics, in addition to discussing the recent evidence surrounding its use for chondroplasty in both the human and equine populations.

Introduction

Tissue ablation via thermal energy generated by radiofrequency (RF) waves was first described by D’Arsonva1 in 1891. Cushing and Bovie2 developed the first electrocautery instrument in 1928 and reported on its ability to reduce bleeding while removing abnormal tissue during intracranial tumor resection. The initial use of RF was largely restricted to percutaneous tumor ablation; however, in 1986, the technology was used in orthopedic surgery for the first time to successfully perform an arthroscopic meniscectomy on a rabbit.3

The use of RF in orthopedic procedures continued to advance, and in 1998 Turner et al4 performed a histological comparison of cartilage lesions treated with RF debridement against those treated with mechanical debridement. In that study,4 the authors found superior performance of RF in all variables tested, reporting smooth debridement borders with no evidence of collateral tissue damage or chondrocyte death. Subsequent research has provided support to these findings, but some studies have raised concerns regarding the detrimental effects of RF energy (RFE) on surrounding chondrocytes and the underlying matrix. Both in vitro and in vivo studies have demonstrated that immediate chondrocyte death can occur following RFE use, penetrating 2 to 3 mm below the cartilage surface, even when used at the manufacturer’s recommended settings.5,6

In the last decade, the use of RFE in both veterinary and human orthopedics has advanced considerably, particularly for procedures involving chondroplasty, due to its ability to produce rapid smoothing of fibrillated cartilage.7 This has prompted the development of newer bipolar instruments that function at lower temperatures, thereby producing less thermal collateral injury.8 The degree to which tissues are damaged during radiosurgery is influenced by the instrument used, the electrosurgical generator settings, and the exposure time.9 While 18% of articular cartilage debridement procedures involve the use of RFE,9 there is still some controversy surrounding its use due to concerns regarding the viability of chondrocytes following exposure to RFE.

In the equine literature, desmotomy of the annular ligament and accessory ligament of the superficial digital flexor tendon utilizing RFE under tenoscopic guidance has been described.10,11 It has been reported that the use of the RF probe allowed precise tissue transection with minimal intraoperative hemorrhage or iatrogenic damage to surrounding tissues. Furthermore, the use of RFE for chondroplasty and soft tissue debridement during routine arthroscopic procedures is frequently described.1214

Mechanism of RF

RF devices deliver a high-frequency alternating current to create thermal energy enabling tissue excision and ablation.15 These instruments are divided into those utilizing monopolar energy and those utilizing bipolar energy, differing in their thermal profile and mode of action, with the latter (bipolar) presenting the safer option for use in arthroscopic procedures.

Monopolar energy passes current produced by the generator through the probe tip into the target tissue; the current then courses though the patient to the return electrode (Figure 1).15 The target tissue has a higher resistance than the rest of the circuit, and therefore ionic agitation occurs, generating heat that leads to tissue disintegration.16 Conversely, the bipolar probe contains both electrodes in the probe tip, meaning energy does not pass directly through the patient (Figure 2).

Figure 1
Figure 1

Diagram showing the mechanism of monopolar radiofrequency energy. (Reproduced from Lin C, Deng Z, Xiong J, et al. The arthroscopic application of radiofrequency in treatment of articular cartilage lesions. Front Bioeng Biotechnol. 2022;9:822286. doi:10.3389/fbioe.2021.822286. Reprinted with permission.)

Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0034

Figure 2
Figure 2

Diagram showing the mechanism of bipolar radiofrequency energy. (Reproduced from Lin C, Deng Z, Xiong J, et al. The arthroscopic application of radiofrequency in treatment of articular cartilage lesions. Front Bioeng Biotechnol. 2022;9:822286. doi:10.3389/fbioe.2021.822286. Reprinted with permission.)

Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0034

The original bipolar systems utilizing thermal energy were found to penetrate between 74% and 92% deeper into subchondral bone than monopolar systems and as a result caused significant chondrocyte death.5 These findings prompted the evolution of the technology and the development of the new generation of probes, which utilize pulsed-energy modulations to build a plasma energy field between the electrodes at the instrument tip.17 Within a conductive medium, this charged plasma layer produces enough energy to cause dissociation of the molecular bonds within tissues, enabling transection at lower temperatures with less collateral injury.18

There are currently many instruments utilizing RF on the market, and each probe differs in its power settings and guidelines for use. Devices that alter RF output to minimize the potential for thermal energy are available as either power controlled or temperature controlled. Temperature-controlled devices have the capability to monitor the temperature of the tissues at the probe tip. Once the preset temperature has been reached, the probe will reduce its power output to maintain the temperature close to the preselected setting, minimizing the risk of inadvertent thermal damage. Alternative models will sound alerts or cut off when the preset temperature is reached. The safety profile of these probes has been tested in both swine and humans for the treatment of intraductal lesions of ampullary adenoma, both confirming their safety and highlighting their potential benefit.19,20 A temperature-controlled probe, set to sound an alarm when temperatures over 30 °C were reached, was assessed for use in human knee arthroscopy, with no concerns regarding thermal damage.21 However, that study was based on clinical outcome and did not enable histological evaluation of the cartilage layer to confirm absence of injury. No studies assessing the use of temperature-controlled probes in equine arthroscopic procedures has been performed to date. Power-controlled devices produce either uniform, direct power or variable-amplitude waveforms during probe activation, with the aim of reducing thermal damage.

RF probes can be used with 2 modes of action, either ablation (cutting) or coagulation (for hemostasis). The ablate setting utilizes a high voltage to cut tissue, while the coagulation setting utilizes a lower voltage and is used to seal bleeding vessels, resulting in hemostasis. Many RF systems will have dual modes of action with both ablation and coagulation modes, which can be activated via foot pedal or controls on the probe handle (Figure 3).

Figure 3
Figure 3

Image of the Arthrex Synergy Bipolar Ablation System with ApolloRF Hook Probe, highlighting the dual mode of action and activation via foot-pedal or controls on the probe handle. The authors recommend using setting 7 for soft tissue resection to maximize efficiency and minimize activation time required for coblation (cutting). Reproduced from Arthrex with permission.

Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0034

Close adherence to the manufacturer’s recommendations is vital to ensure safe use of the instrument.

The Role of RF in Cartilage Pathology

In both human and equine populations, partial- or full-thickness cartilage lesions have traditionally been managed via arthroscopic debridement of the fibrillated cartilage. It has been shown that full-thickness cartilage lesions over 5 mm in diameter do not heal spontaneously in the horse.22 Techniques utilizing a motorized shaver to debride the fibrillated cartilage are beneficial, with good patient outcomes reported in both horses and humans alike.22,23 However, following debridement with motorized shavers, an irregular cartilage surface with uneven and rough resection margins often remains (Figure 4).24 Additionally, it is thought that the unavoidable removal of excessive healthy cartilage can lead to progression of the lesion and a thinner cartilage surface, which in some cases results in dissatisfaction with motorized resection.25 RFE has several distinct advantages over traditional shavers, specifically the property of allowing the user to rapidly smooth and contour the fibrillated cartilage and its margins without leaving surface irregularities or unstable borders.26 The superior mechanical stability of the RFE-treated cartilage defect has been reported to provide resistance to continued fibrillation and lesion progression.27 Additionally, the bipolar plasma gas layer anneals and stabilizes the cartilage surface, reducing the permeability of the matrix and decreasing the release of inflammatory mediators.28,29

Figure 4
Figure 4

Histologic images of osteochondral sections following treatment of the cartilage surface. A—Control; scale bar = 100 µm. B—Mechanical debridement. C—CoVac 50 probe coupled with ArthroCare 2000 generator. D—TAC-CII probe coupled with Vulcan EAS generator. (Reproduced from Edwards RB III, Lu Y, Uthamanthil RK, et al. Comparison of mechanical debridement and radiofrequency energy for chondroplasty in an in vivo equine model of partial thickness cartilage injury. Osteoarthritis Cartilage. 2007;15(2):169–178. doi:10.1016/j.joca.2006.06.021. Reprinted with permission.)

Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0034

Despite these well-established benefits of RFE, the concern of detrimental chondrocyte damage remains a barrier to its use in clinical cases of cartilage debridement. Studies investigating the effect of RFE on the joint environment are hindered as the temperature profile and depth of penetration following RFE exposure vary significantly with the device used, the ablation settings, the flow of irrigation fluid, and the application technique.30 This makes it difficult to make reliable comparisons between the studies and assess their relevance to clinical practice, as there is no standardized technique or instrument setting established. Additionally, much of the published literature focuses on the early first-generation RF devices, and there are limited data evaluating the effects of exposure to modern plasma RF instruments on chondrocyte and matrix viability.

In horses, RF debridement was compared with conventional mechanical shavers for the treatment of full-thickness cartilage lesions created on the articular surface of the patella. Edwards et al6 found that the plasma layer bipolar RF probe provided a smoother cartilage surface, caused less chondrocyte death, and maintained a thicker cartilage layer than mechanical debridement. The authors hypothesized that the thicker cartilage layer was due to the ability to contour the surface with RFE without removing as much healthy tissue as the motorized shaver.6 Conversely, a study performed by the same author concluded that RFE caused more severe morphological changes and chondrocyte death compared with untreated degenerative cartilage and mechanical debridement.31 The minimal clinical data and the conflicting evidence regarding the detrimental effect of RFE on chondrocyte viability largely limit the use of RF to soft tissue debridement and resection.

In human orthopedics, RFE has been evaluated in multiple prospective and retrospective clinical studies, assessing its safety and efficacy for shoulder and knee chondroplasty. The earliest of these studies32 was performed in 2002; 39 female patients with patellofemoral lesions underwent either mechanical or plasma layer chondroplasty. Follow-up evaluation at 12 and 24 months postoperatively showed the plasma layer group had better outcomes compared with the mechanical group, a significant statistical outcome. More recently, 85 RFE knee chondroplasties assessed 2 years postoperatively identified no complications related to thermal injury, with the functional outcome being correlated with the quality of chondral and meniscal tissue at the time of surgery.33 Similarly, a systematic review30 of 63 studies investigating RFE in shoulder arthroscopy concluded that the technology represents a more efficacious and economic treatment than traditional therapies; however, practitioners should be cognizant of the potential for thermal injuries.

There are limited clinical data assessing the use of RFE in the hip joint; however, 2 case reports34,35 describe the development of chondrolysis within 6 months of RF treatment of acetabular cartilage lesions. RFE use in the hip is mainly restricted to soft thermal release procedures and ligament debridement.30

RFE use in humans is largely limited to arthroscopy of the knee joint or soft tissue procedures involving debridement, resection, and techniques for thermal joint capsule shrinkage.27 While many clinical studies prove the effectiveness and safety of RF, there is limited evaluation of the long-term biochemical changes to the cartilage of treated joints, which is consequently an area requiring further investigation before RFE can be recommended. Additionally, while the importance of exposure time, probe settings, and technique on the temperature profile and resultant thermal injury has been highlighted, conclusive guidelines ensuring safe use have not been determined.

Current Evidence for Safe RF Use

As the popularity of RF techniques for chondroplasty increases, research to develop guidelines for the safe use of the technology to minimize chondrocyte damage is critical to optimize patient outcomes.

Temperature

There is a strong link between temperature and chondrocyte viability, with the percentage of viable cells decreasing significantly for each increase in temperature over 50 °C.8 At 55 °C, a 40% chondrocyte death rate has been reported, increasing to almost 100% at 65 °C.36 Restoration of chondrocyte vitality following exposure to temperatures of < 50 °C was documented after 1 week, whereas chondrocyte recovery did not occur at temperatures > 55 °C.8,37 Proteoglycan synthesis was also negatively impacted by thermal stress, with a 31% decline after 3 minutes of 50 °C temperatures.37 However, similar to chondrocyte recovery, 1 week following thermal injury, proteoglycan synthesis had restored to 69%.37

The maximum temperature of the joint fluid reached during arthroscopic use of RF probes is strongly correlated to the irrigation fluid flow rate. When no irrigation fluid flow was used, the maximum temperature reached in the joint averaged 56 and 80 °C following 1 and 2 minutes of continuous RF use respectively.38,39 These temperatures are above the threshold for immediate irreversible chondrocyte death, but when an appropriate irrigation fluid flow was used, the maximum temperature following 1 minute of continuous use was decreased to a safe 32 °C.39

Additionally, the time needed to cool to a safe temperature following RFE use was significantly longer in the no-flow state, exposing the chondrocytes to detrimental thermal stress for approximately 2 minutes longer when compared with an adequate fluid flow.39 These findings highlight the importance of maintaining a high flow of cooled irrigation fluids during arthroscopic procedures utilizing RFE to help minimize the occurrence of chondrocyte injury.3840

The authors use flow rates of 120 to 150 mL/min throughout procedures in which RF is being utilized. If available, cooled fluids can be used; however, there are currently no studies comparing the use of room temperature (22 °C) to cooled fluids in their ability to counteract the heat produced by RF probes. Similarly, no studies have assessed the benefit of utilizing active suction during RF use; however, the authors hypothesize the active removal of heated fluids may aid in reducing the risk of thermal injury. Fluid flow rates of 120 mL/min with room temperature (22 °C) saline and no active suction were found to significantly reduce intra-articular temperatures during RF use,39,40 and this practice is what the authors of this review use. Furthermore, we have not found it necessary to apply more than 5 seconds of energy at a time within the joint; therefore, this should leave an ample safety window to work within to minimize risk to cartilage.

Time

The exposure time of the articular cartilage to bipolar RFE is positively correlated with the smoothness of the treated area, but also with chondrocyte and matrix damage. Studies4143 on humans have indicated that an RFE application time of at least 15 to 20 seconds is needed to create a smooth cartilage surface, when assessed with scanning electron microscopy. The volume of glycosaminoglycan (GAG) in the matrix has been shown to decrease as exposure time increases; in 1 study,41 GAG content started at 11 µg/mg before treatment and dropped to 7 µg/mg and then 2 µg/mg after 20 and 40 seconds of application respectively.41 Shorter application times of 5 and 10 seconds have less detrimental effects on GAG content,41 but the cartilage surface remains rough and irregular, with incomplete contouring of the lesion margins.43 No studies have investigated the effect of exposure time on equine cartilage, and the variation of cartilage thickness in the human and bovine specimens used in these studies makes it difficult to reach definitive conclusions.

The authors recommend minimizing continuous exposure time where possible, and a short burst of RF activation followed by a period of joint lavage has been shown to contribute to a reduction in thermal energy. While exact guidelines for the maximal activation time do not exist, the authors limit continuous exposure time to 5 seconds or less. Ongoing research will clarify the maximum window of safety.

Clinical Application of RF in Equine Arthroscopic and Tenoscopic Surgery

While studies investigating the use of RFE for chondroplasty are lacking, multiple procedures involving soft tissue transection have been described and evaluated. These studies have found that the RF probe is a viable option for desmotomies under tenoscopic guidance, with minimal to no iatrogenic damage to surrounding tissues. The advantages of the RF probe compared with sharp transection cited in these papers include control over the activation of cutting, improved tactile handling of the instrument, minimized risk of iatrogenic damage, and reduced intraoperative hemorrhage.10,11

In 2014, Nelson et al10 described a procedure in which RF energy was compared with sharp transection for tenoscopic-guided desmotomy of the accessory ligament of the superficial digital flexor tendon (ALSDFT). In all horses, desmotomy of the ALSDFT was successfully completed with no intraoperative complications encountered (Figure 5). It was determined that no significant differences existed between the techniques when cell viability, tissue architecture, and postoperative inflammation were assessed. Mild hemorrhage during transection with RF energy in 2 of 5 limbs was noted, compared with 5 of 6 limbs with sharp transection; however, this wasn’t a statistically significant difference. The investigators concluded that RFE is a viable alternative to sharp transection of the ALSDFT under tenoscopic guidance, with minimal collateral tissue damage having been observed.10

Figure 5
Figure 5

Desmotomy of the accessory ligament of the superficial digital flexor tendon (ALSDFT) performed with the saber radiofrequency probe (A) and the tenotomy knife (B). The distal portion of the ALSDFT has been incised to expose the flexor carpi radialis (FCR) tendon. DDFT = Deep digital flexor tendon. (Reproduced from Nelson BB, Kawcak CE, Ehrhart EJ, Goodrich LR. Radiofrequency probe and sharp transection for tenoscopic-guided desmotomy of the accessory ligament of the superficial digital flexor tendon. Vet Surg. 2015;44(6):713–722. doi:10.1111/vsu.12328. Reprinted with permission from Wiley.)

Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0034

RF energy has also been described to perform desmotomy of the annular ligament.11 Many procedures employing sharp transection of the annular ligament are carried out with a closed technique, which does not allow for examination of the tendon sheath. While sharp transection under tenoscopic guidance can be performed easily, it carries the disadvantage of relative imprecision, with the potential for inadvertent tissue damage and hemorrhage. A study by McCoy and Goodrich11 described a technique in which the RF probe was used for precise and controlled transection of the annular ligament with minimal intraoperative hemorrhage (Figure 6). Authors reported minimal to no collateral damage when assessed by histopathology, and in clinical cases the technique resulted in a good outcome and prognosis for return to work.11

Figure 6
Figure 6

Desmotomy of the annular ligament. Note the spherical ablative tip over the annular ligament prior to application of radiofrequency energy (A) and following nearly complete transection of the annular ligament in a distal-to-proximal direction (B). (Reproduced from McCoy AM, Goodrich LR. Use of a radiofrequency probe for tenoscopic-guided annular ligament desmotomy. Equine Vet J. 2012;44(4):412–415. doi:10.1111/j.2042-3306.2011.00454.x. Reprinted with permission from Wiley.)

Citation: Journal of the American Veterinary Medical Association 261, 8; 10.2460/javma.23.01.0034

In a study44 investigating the outcome of 135 tenoscopic procedures for the treatment of flexor tendon lesions, RFE was utilized in 52% of cases. Initial resection of the torn tendon fibrils was performed with a motorized resector, which was then followed by further microdebridement and smoothing of the fibrillated edge with RF coblation. The RF coblation was performed on a low-energy setting and in a noncontact mode. The authors of that study found that when using a univariate analysis, there was a significantly larger proportion of horses not treated with coblation that returned to their previous level of work; however, this finding was not statistically significant in the multivariate model. They also found that using only manual debridement (no shaver or coblation) resulted in statistically better functional outcome in both the univariate and the multivariate models.44 That study was not randomized; therefore, coblation may have been used in cases with more severe tendon damage. A randomized controlled study would be required for a more accurate assessment.

The role of RF in equine arthroscopy in the published literature is limited to soft tissue dissection distant from the articular surface of the joint. In a case series12 of 18 Friesian horses undergoing extensor process fragment removal, the investigators utilized the RF probe to dissect the fragment from the underlying common digital extensor tendon in 5 cases, without report of detrimental effects. Within the fetlock joint, the bipolar RF probe was successfully used to dissect the dorsal, axial, and abaxial soft tissue attachments of fragments originating from the basilar sesamoid bones, enabling complete removal.14 They reported no complications during the procedure, and follow-up at 6 to 8 months postoperatively did not identify joint effusion or alterations in joint range of motion. Similarly, the hook bipolar RF probe was used to aid removal of fragments within the condylar fossa of the metacarpus/metatarsus by freeing the fragment from its synovial and fibrous attachments. All joints appeared grossly normal following the procedure, and the horses of racing age, at the time of reporting, had all started at least 1 race.13 As these case reports involve clinical cases, it was not possible to assess changes to the cartilage matrix as a result of using RFE. Therefore, while no detrimental effects were seen in relation to the horses’ racing performance, chondrocyte or collateral tissue injury occurring during the procedure cannot be ruled out.

The authors routinely use RFE for soft tissue resection under tenoscopic and arthroscopic guidance with excellent results. The benefits of the RFE highlighted in the review include improved visualization due to a reduction of intraoperative hemorrhage, control over the activation of cutting, and good tactile handling of the instrument. The authors are mindful of the potential of thermal injury when used intra-articularly and, through adhering to the principles discussed in this review, believe the risk of iatrogenic damage can be minimized.

Conclusions

The superiority of RFE compared with motorized resectors for the debridement of cartilage lesions has been established in multiple studies in the human arena. RFE produces a smooth cartilage surface with contoured lesion margins while removing less healthy cartilage than motorized resectors, thereby leaving a thicker cartilage layer following treatment. However, the potential for chondrocyte and matrix damage remains a concern.

There is limited evidence supporting the use of RFE for chondroplasty in the equine population; studies report conflicting evidence regarding chondrocyte damage, and clinical evidence assessing its safety and efficacy is lacking. In the human literature, plasma layer debridement, when used with appropriate settings and techniques, can be a safe and effective means to treat articular cartilage lesions within the knee. However, this is not the case for all other joints studied, and improper use of the instrument can lead to thermal injury and irreversible chondrocyte damage. Cautious use of RFE for treatment of articular cartilage is recommended until the long-term effects are evaluated.

RFE represents an attractive alternative to sharp transection of soft tissues due to benefits such as control over the activation of cutting, improved surgical access, reduced intraoperative hemorrhage, and good tactile handling of the instrument. Clinical studies report that the use of bipolar RF probes within the tendon sheath is a safe and efficacious means to perform transection of the accessory ligament of the deep digital flexor tendon and annular ligament with good outcomes. However, prior to any widespread clinical application, further controlled studies will be required to assess the debridement of flexor tendon lesions with RF coblation. The use of RFE for equine orthopedic procedures, including arthroscopic soft tissue debridement, consequently reveals promising results that reflect the need for, and desirability of, undertaking further research.

Acknowledgments

No external funding was used in this study. The authors have nothing to declare.

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