Mechanisms of Action of Noninvasive Monopolar Radiofrequency: Technology Review

Terry L. Whipple, Scott P. Steinmann

Department of Orthopaedics, Mayo Clinic, Rochester, USA..
Orthopaedic Research of Virginia, Richmond, USA.

DOI: 10.4236/ojo.2013.31006                

Abstract

Tendinosis is now understood as the result of a failed tendon healing process regardless of where it occurs in the body. Current noninvasive therapeutic alternatives are anti-inflammatory in nature and outcomes are unpredictable at best. The benefit of invasive alternatives resides in the induction of the healing response as demonstrated in pre-clinical and clinical studies in cardiology and orthopaedics. A new technology that employs noninvasivemonopolar capacitive-coupled radiofrequency (mcRF), has demonstrated the ability to raise temperatures in tendons and ligaments upwards of 50°C, the temperature threshold for collagen modulation and recruitment of macrophages, fibroblasts and Heat Shock Protein factors—without damaging the overlying structures—resulting in activation of the Wound Healing Response (WHR).

Keywords

Thermal Shrinkage; Thermoplasty; Heat-Shock; AT2, Radiofrequency; Collagen Denaturation; Tendinosis; Wound Healing Response; Tendinopathy; Microtenotomy; Antinociceptive

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	L. Bernstein, “Tendinosis of the Shoulder,” Mississippi Valley Medical Journal, Vol. 73, No. 6, 1951, pp. 155157.
[2]	R. P. Nirschl and F. A. Pettrone, “Tennis Elbow. The Surgical Treatment of Lateral Epicondylitis,” Journal of Bone & Joint Surgery, Vol. 61, No. 6A, 1979, pp. 832839.
[3]	R. P. Nirschl, “Elbow Tendinosis/Tennis Elbow,” Clini= cal Journal of Sport Medicine, Vol. 11, No. 4, 1992, pp. 851-870.
[4]	B. S. Kraushaar and R. P. Nirschl, “Tendinosis of the Elbow (Tennis Elbow). Clinical Features and Findings of Histological, Immunohistochemical, and Electron Microscopy Studies,” Journal of Bone & Joint Surgery, Vol. 81, No. 2, 1999, pp. 259-278.
[5]	N. Maffulli, K. M. Khan and G. Puddu, “Overuse Tendon Conditions: Time to Change a Confusing Terminology,” Arthroscopy, Vol. 14, No. 8, 1998, pp. 840-843. doi:10.1016/S0749-8063(98)70021-0
[6]	E. R. Cosman, B. S. Nashold and J. Ovelman-Levitt, “Theoretical Aspects of Radiofrequency Lesions in the Dorsal Root Entry Zone,” Neuro-surgery, Vol. 15, No. 6, 1984, pp. 945-950. doi:10.1227/00006123-198412000-00035
[7]	B. Avitall, M. Khan, D. Krum, et al., “Physics and Engineering of Transcatheter Cardiac Tissue Ablation,” Journal of the American College of Cardiology, Vol. 22, No. 3, 1993, pp. 921-932. doi:10.1016/0735-1097(93)90212-J
[8]	B. Avitall, D. Lafontaine, G. Rozmus, et al., “The Safety and Efficacy of Multiple Consecutive Cryo Lesions in Canine Pulmonary Veins-Left Atrial Junction,” Heart Rhythm, Vol. 1, No. 2, 2004, pp. 203-209. doi:10.1016/j.hrthm.2004.03.058
[9]	B. Avitall, A. Urbonas, D. Urboniene, G. Rozmus and R. Helms, “Linear Lesions Provide Protection from Atrial Fibrillation Induction with Rapid Atrial Pacing,” Journal of Cardiovascular Electrophysiology, Vol. 13, No. 5, 2002, pp. 455-462. doi:10.1046/j.1540-8167.2002.00455.x
[10]	E. Daoud and F. Morady, “Catheter Ablation of Ventricular Tachycardia,” Current Opinion in Cardiology, Vol. 10, No. 1, 1995, pp. 21-25. doi:10.1097/00001573-199501000-00005
[11]	M. D. Lesh, “Interventional Electrophysiology-Stateof-the-Art 1993,” American Heart Journal, Vol. 126, No. 3, 1993, pp. 686-698. doi:10.1016/0002-8703(93)90419-A
[12]	L. A. Saxon, J. M. Kalman, J. E. Olgin, M. M. Scheinman, R. J. Lee and M. D. Lesh, “Results of Radiofrequency Catheter Ablation for Atrial Flutter,” American Journal of Cardiology, Vol. 77, No. 11, 1996, pp. 1014-1016.
[13]	J. S. Brodkey, Y. Miyazaki, F. R. Ervin and V. H. Mark, “Reversible Heat Lesions with Radiofrequency Current. A Method of Stereotactic Localization,” Journal of Neurosurgery, Vol. 21, No. 1, 1964, pp. 49-53. doi:10.3171/jns.1964.21.1.0049
[14]	A. Moraci, C. Buonaiuto, A. Punzo, C. Parlato and R. Amalfi, “Trigeminal Neuralgia Treated by Percutaneous Thermocoagulation. Comparative Analysis of Percutaneous Thermocoagulation and Other Surgical Procedures,” Neurochirurgia (Stuttg), Vol. 35, No. 2, 1992, pp. 48-53.
[15]	W. H. Sweet and J. G. Wepsic, “Controlled Thermocoagulation of Trigeminal Ganglion and Rootlets for Differential Destruction of Pain Fibers. 1. Trigeminal Neuralgia,” Journal of Neurosurgery, Vol. 40, No. 2, 1974, pp. 143-156. doi:10.3171/jns.1974.40.2.0143
[16]	M. H. Seegenschmiedt and R. Sauer, “The Current Role of Interstitial Thermo-Radiotherapy,” Strahlentherapie und Onkologie, Vol. 168, No. 3, 1992, pp. 119-140.
[17]	P. L. Privalov. Stability of proteins, “Proteins Which Do Not Present a Single Cooperative System,” Advances in Protein Chemistry, Vol. 35, 1982, pp. 1-104. doi:10.1016/S0065-3233(08)60468-4
[18]	C. A. Miles, T. V. Burjanadze and A. J. Bailey, “The Kinetics of the Thermal Denaturation of Collagen in Unrestrained Rat Tail Tendon Determined by Differential Scanning Calorimetry,” Journal of Molecular Biology, 27 Vol. 245, No. 4, 1995, pp. 437-446. doi:10.1006/jmbi.1994.0035
[19]	A. Miniaci and M. J. Codsi, “Thermal Capsulorrhaphy for the Treatment of Shoulder Instability,” The American Journal of Sports Medicine, Vol. 34, No. 8, 2006, pp. 1356-1363. doi:10.1177/0363546506287824
[20]	A. M. Hill, I. T. Jones, U. Hansen, et al., “Treatment of Ligament Laxity by Electrothermal Shrinkage or Surgical Plication: A Morphologic and Mechanical Comparison,” Journal of Shoulder and Elbow Surgery, Vol. 16, No. 1, 2006, pp. 95-100.
[21]	D. A. Coons and F. A. Barber, “Thermal Medial Retinaculum Shrinkage and Lateral Release for the Treatment of Recurrent Patellar Instability,” Arthroscopy, Vol. 22, No. 2, 2006, pp. 166-171. doi:10.1016/j.arthro.2005.08.043
[22]	E. Farng, S. A. Hunt, D. J. Rose and O. H. Sherman, “Anterior Cruciate Ligament Radiofrequency Thermal Shrinkage: A Short-Term Follow-Up,” Arthroscopy, Vol. 21, No. 9, 2005, pp. 1027-1033. doi:10.1016/j.arthro.2005.05.015
[23]	N. A. Darlis, R. W. Weiser and D. G. Sotereanos, “Partial Scapholunate Ligament Injuries Treated with Arthroscopic Debridement and Thermal Shrinkage,” Journal of Hand Surgery, Vol. 30, No. 5, 2005, pp. 908-914. doi:10.1016/j.jhsa.2005.05.013
[24]	H. M. Kwon, B. K. Hong, G. J. Jang, et al., “Percutaneous Transmyocardial Revascularization Induces Angiogenesis: A Histologic and 3-Dimensional Micro Computed Tomography Study,” Journal of Korean Medical Science, Vol. 14, No. 5, 1999, pp. 502-510.
[25]	J. P. Tasto, J. Cummings, V. Medlock, R. Hardesty and D. Amiel, “Microtenotomy Using a Radiofrequency Probe to Treat Lateral Epicondylitis,” Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. 21, No. 7, 2005, pp. 851-860. doi:10.1016/j.arthro.2005.03.019
[26]	K. M. Khan, J. L. Cook, N. Maffulli and P. Kannus, “Where Is the Pain Coming from in Tendinopathy? It May Be Biochemical, Not Only Structural, in Origin,” British Journal of Sports Medicine, Vol. 34, No. 2, 2000, pp. 81-83. doi:10.1136/bjsm.34.2.81
[27]	N. Takahashi, J. P. Tasto, M. Ritter, et al., “Pain Relief through an Antinociceptive Effect after Radiofrequency Application,” American Journal of Sports Medicine, Vol. 35, No. 5, 2007; pp. 805-810. doi:10.1177/0363546506297085
[28]	C. F. Hyer, “Radiofrequency Microtenotomy of Plantar Fascia Is Effective, but Why?” Foot & Ankle Specialist, Vol. 1, No. 6, 2008, pp. 368-369.
[29]	L. J. R. Weil, J. P. Glover and L. S. S. R. Weil, “A New Minimally Invasive Technique for Treating Plantar Fasciosis Using Bipolar Radiofrequency: A Prospective Analysis,” Foot & Ankle Specialist, 2008, Vol. 1, No. 1, 2008, pp. 13-18.
[30]	N. T. Wright and J. D. Humphrey, “Denaturation of Collagen via Heating: An Irreversible Rate Process,” Annual Review of Biomedical Engineering, Vol. 4, 2002, 109-128. doi:10.1146/annurev.bioeng.4.101001.131546
[31]	A. L. Fink, “Chaperone-Mediated Protein Folding,” Physiological Reviews, Vol. 79, No. 2, 1999, pp. 425-449.
[32]	M. Jaattela, “Heat Shock Proteins as Cellular Lifeguards,” Annals of Medicine, Vol. 31, No. 4, 1999, pp. 261-271. doi:10.3109/07853899908995889
[33]	R. S. Williams, J. A. Thomas, M. Fina, Z. German and I. J. Benjamin, “Human Heat Shock Protein 70 (HSP70) Protects Murine Cells from Injury during Metabolic Stress,” Journal of Clinical Investigation, Vol. 92, No. 1, 1993, pp. 503-508. doi:10.1172/JCI116594
[34]	F. R. Sharp, S. M. Massa and R. A. Swanson, “HeatShock Protein Protection,” Trends in Neurosciences, Vol. 22, No. 3, 1999, pp. 97-99. doi:10.1016/S0166-2236(98)01392-7
[35]	J. Bao, W. Naimark, M. Palasis, R. Laham, M. Simons and M. J. Post, “Intramyocardial Delivery of FGF2 in Combination with Radio Frequency Transmyocardial Revascularization,” Catheterization and Cardiovascular Interventions, Vol. 53, No. 3, 2001, pp. 429-434. doi:10.1002/ccd.1196
[36]	N. Yamamoto, A. Gu, C. M. DeRosa, et al., “Radio Frequency Transmyocardial Revascularization Enhances Angiogenesis and Causes Myocardial Denervation in Canine Model,” Lasers in Surgery and Medicine, Vol. 27, No. 1, 2000, pp. 18-28. doi:10.1002/1096-9101(2000)27:1<18::AID-LSM3>3.0.CO;2-F
[37]	A. Hayashi, “Getting Athletes Back in the Game: A Global View,” AAOS Now, Vol. 2, No. 10, 2008, pp. 1-6.
[38]	S. Yang, “Treatment Increases Survival after Transplantation Autologous Myoblasts Pigs in Skeletal Muscle,” University of Geneva, Geneva, 2005.
[39]	D. Amiel, S. T. Ball and J. P. Tasto, “Chondrocyte Viability and Metabolic Activity after Treatment of Bovine Articular Cartilage with Bipolar Radiofrequency: An in Vitro Study,” Arthroscopy, Vol. 20, No. 5, 2004, pp. 503510. doi:10.1016/j.arthro.2004.03.018
[40]	J. P. Tasto, “The Role of Radiofrequency-Based Devices in Shaping the Future of Orthopedic Surgery,” Orthopedics, Vol. 29, No. 10, 2006, pp. 874-875.
[41]	J. P. Tasto and S. A. Ash, “Current Uses of Radiofrequency in Arthroscopic Knee Surgery,” American Journal of Knee Surgery, Vol. 12, No. 3, 1999, pp. 186-191.
[42]	E. Taverna, F. Battistella, V. Sansone, C. Perfetti and J. P. Tasto, “Radiofrequency-Based Plasma Microtenotomy Compared with Arthroscopic Subacromial Decompression Yields Equivalent Outcomes for Rotator Cuff Tendinosis,” Arthroscopy, Vol. 23, No. 10, 2007, pp. 10421051. doi:10.1016/j.arthro.2007.04.018
[43]	K. Meknas, A. Odden-Miland, J. B. Mercer, M. Castillejo and O. Johansen, “Radiofrequency Microtenotomy: A Promising Method for Treatment of Recalcitrant Lateral Epicondylitis,” The American Journal of Sports Medicine, Vol. 36, No. 10, 2008, pp. 1960-1965. doi:10.1177/0363546508318045
[44]	B. D. Zelickson, D. Kist, E. Bernstein, et al., “Histological and Ultrastructural Evaluation of the Effects of a Radiofrequency-Based Nonablative Dermal Remodeling Device: A Pilot Study,” Archives of Dermatology, Vol. 140, No. 2, 2004, pp. 204-209. doi:10.1001/archderm.140.2.204
[45]	R. Buchbinder, S. E. Green, J. M. Youd, W. J. Assendelft, L. Barnsley and N. Smidt, “Shock Wave Therapy for Lateral Elbow Pain,” Cochrane Database of Systematic Reviews, Vol. 4, 2005, Article ID: CD003524.
[46]	T. Whipple and D. Villegas, “Non-Invasive Monopolar Radiofrequency Energy for the Treatment of Tendons and Ligaments: Temperatures Achieved and Histological Outcomes Richmond,” Orthopaedic Research of Virginia, 2009.
[47]	C. Rose and N. Maffulli, “Non-Invasive Monopolar Capacitive-Coupled RF for the Treatment of Tennis Elbow: A Pilot Study,” 2009.
[48]	F. Essers, “Non-Invasive Monopolar Capacitive Coupled RF: A Safety Study,” 2009.
[49]	T. Weber and B. Kabelka, “Non-Invasive Monopolar RF for the Treatment of Tennis Elbow: 12 Months Follow-Up,” 2009 (In Preparation).
[50]	L. C. Almekinders, A. J. Baynes and L. W. Bracey, “An in Vitro Investigation into the Effects of Repetitive Motion and Nonsteroidal Antiinflammatory Medication on Human Tendon Fibroblasts,” The American Journal of Sports Medicine, Vol. 23, No. 1, 1995, pp. 119-123. doi:10.1177/036354659502300120
[51]	L. Bisset, N. Smidt, D. A. Van der Windt, et al., “Conservative Treatments for tennis Elbow Do Subgroups of Patients Respond Differently?” Rheumatology, Vol. 46, No. 10, 2007, pp. 1601-1605.
[52]	J. M. Bjordal, R. Lopes-Martins, J. Joensen, et al., “A Systematic Review with Procedural Assessments and Meta-analysis of Low Level Laser Therapy in Lateral Elbow Tendinopathy (Tennis Elbow),” BMC Musculoskeletal Disorders, Vol. 9, No. 10, 2008, pp. 9-75.
[53]	M. Loew, W. Daecke, D. Kusnierczak, M. Rahmanzadeh and V. Ewerbeck, “Shock-Wave Therapy Is Effective for Chronic Calcifying Tendinitis of the Shoulder,” The Bone & Joint Journal, Vol. 81, No. 5, 1999, pp. 863-867. doi:10.1302/0301-620X.81B5.9374
[54]	R. Buchbinder, S. Green, M. White, L. Barnsley, N. Smidt and W. J. Assendelft, “Shock Wave Therapy for Lateral Elbow Pain,” Cochrane Database of Systematic Reviews, Vol. 1, 2002, Article ID: CD003524.
[55]	R. Buchbinder, S. E. Green, J. M. Youd, W. J. Assendelft, L. Barnsley and N. Smidt, “Shock Wave Therapy for Lateral Elbow Pain,” Cochrane Database of Systematic Reviews, Vol. 4, 2005, Article ID: CD003524.
[56]	R. Buchbinder, S. E. Green, J. M. Youd, W. J. Assendelft, L. Barnsley and N. Smidt, “Systematic Review of the Efficacy and Safety of Shock Wave Therapy for Lateral Elbow Pain,” The Journal of Rheumatology, Vol. 33, No. 7, 2006, pp. 1351-1363.
[57]	M. P. Staples, A. Forbes, R. Ptasznik, J. Gordon and R. Buchbinder, “A Randomized Controlled Trial of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis (Tennis Elbow),” The Journal of Rheumatology, Vol. 35, No. 10, 2008, pp. 2038-2046.
[58]	J. H. Dunn, J. J. Kim, L. Davis and R. P. Nirschl, “Tento 14-Year Follow-Up of the Nirschl Surgical Technique for Lateral Epicondylitis,” The American Journal of Sports Medicine, Vol. 36, No. 2, 2008, pp. 261-266. doi:10.1177/0363546507308932
[59]	L. J. England, B. M. Egbert and K. Pope, “Dermal Wound Healing in an Animal Model Following Monopolar Radio Frequency Treatment,” Wound Healing Society Meeting, Chicago, 2005.