Rafael Inigo Pavlovich, MD, PhD, FACS*,
*Head of the Knee Center Orthopedica
Javier Lozano Pardinas,MD,
CEO of CYMOT!
Centro Medico de Rio Suites 6 & 7
Proyecto Rio Sonora,
Hermosillo, Sonora, Mexico CP 83280
Radio frequency and meniscal tissue have been related to resection in arthroscopic meniscectomy procedures. Radio frequency as a thermal source of energy appeared as an effective cutting tool around the 1980’s. As this form of energy was further studied, it has evolved from a cutting device to a bio-stimulator of biologic events, leading to healing processes throughout the inflammatory cascade and neovascularization- neocollagenization process where numerous growth factors are involved to help even avascular zones along with traditional or innovative stabilization methods for meniscal suture. In this review, the evolution of radio frequency from the times of meniscectomy to newer indications to boost the healing process is revised: Radio frequency and meniscus repair, from a taker, to a giver- a new paradigm.
The time of meniscectomies, when surgeons proudly showed the meniscus that had been removed, are gone. The importance of the meniscus has been established without any doubt and so is the fact of preserving this tissue as much as possible.
Meniscal tissue is highly reactive to injury; therefore it starts the repair process when proper conditions are present.
Meniscal tissue is not only important due to its mechanical properties, but also for its proprioceptive role in the knee joint (1, 2.)
There are three conditions to consider when thinking in meniscal repair:
The first one is where the injury is located within the body of the meniscus. Sir Thomas Annandale is considered the first ever to repair a meniscal injury and he published it in 1885( 3) In 1936, King (4) recognized that the meniscus can be repaired as long as the injury is located near the synovial rim. Smillie declared that the meniscus could regenerate itself after a total meniscectomy, a fact that later proved wrong. In 1948, Fairbanks (5) gave a detailed description of the degenerative changes that appear after a total meniscectomy. The importance of this tissue was reconfirmed in the 1960’s by Appel (6 ) and Johnson( 7) who reckoned the procedure was not innocuous . It was not until Arnockzky (8 )demonstrated the organization and distribution of the circulation through the body of the meniscus in his classic paper on meniscal vascularity, thus classifying the three areas as red, pink and white, based on blood supply.
Currently, there is a trend to repair only the vascular and transitional zone; however, there are some mechanisms to make this avascular area attain some degree of healing.
Stabilizing Meniscal Fragments
In order to heal , the meniscus requires some degree of immobilization; therefore, a large number of paraphernalia of meniscal devices is now on the market. It is generally known that a primary stabilization is a must; otherwise, bridging of collagen fibers would be impossible. From primary suture published for the first time by Annandale in 1855, numerous methods raised the need of less invasive ways. Then the arrows, darts, screws, etc. appeared on the stage; even cyanoacrilate (9 )that eventually proved to be cytotoxic (by producing aldehyde radicals) were part of the general effort to solve the challenge, although which is the ideal tensile strength to help the meniscus remain in place and have a chance to heal in view of material fatigue and the ultimate breakage of the suture components, is still controversial. Nevertheless, vertical sutures remain the golden standard for meniscus fixation (10).
In the search for developing a solid primary fixation, many concepts were conceived and much expectation was created, such as the promise of a “meniscal welding” where meniscal fragments were bonded by a dye of 1-8 naftilamide under a low energy cold L.A.S.E.R beam that polymerized the monomer researched by R.W. Jackson (11).
Biologic Response to Healing
With the advent of knowledge in tissue engineering and gene manipulation, great efforts have been poured into how Mother Nature awakens the magic of the repair process. The most basic attempt to stimulate these factors are the rasping or refreshing of the tissue, allowing bleeding and the shedding of growth factors embedded within which are the ultimate responsible for the tissue changes towards the repair process (12)
Refreshing the tissue has being a common procedure in general orthopedic surgery like in bone mal union, where a bed of blood must be formed to once again restart bone consolidation.
To reproduce the same concept in the meniscal tissue repair technique, there are a number of devices such as banana, rasp, burr, or even the shaver to refresh the meniscal borders. By 1983, Ghadially (13) found that myofibroblasts were present in the tear of the meniscal cartilage.
In 1985 Webber (14) was the first in establishing a correlation between fibroblast proliferation and growth factors such as fibronectin, FGF, all being members of a super family of TGF-B, and all of these factors were found in a hematoma .
Then, in 1986, research turned on how to purvey vascular nutrition to a wound in order to foster healing, and it was found that suturing a synovial flap to the meniscal rupture, rendered good results on histology in an animal study with swine and lambs (15).
In 1988, Arnockzky recommended that a blood clot was to be adhered to the wound in order to create a biologic scaffold, reporting good results (16. )
More recent evidence shows that in summary, some members of TGF-ß , like BMP , play a significant role in the meniscal repair process, which has being a subject of research by Spindler and Collier (17,18)
The highest ranking in meniscal healing are reported in patient to whom an ACL reconstruction was performed simultaneously . In these persons nearly a 100% rate of success was attained. The endosteal blood in contact with the wound will render growth factors to promote the healing process.
Mechanical Damage in the Meniscus Tissue Leading to the Release of Repairing Cytokines
Ochi (20) developed a new technique for meniscal repair by rasping the meniscus surface in the avascular zone with the purpose of eliciting a healing response.
This procedure stimulates the induction of vascularity with the end result of a healed avascular zone injury. Attempting to study the schedule of events of cytokine appearance, he created complete 5 mm longitudinal injuries in the avascular area of the anterior segment of both medial menisci in rabbits. He proceeded to perform a rasp of approximately 0.5 mm. in depth on the meniscal surface, from the parameniscal area to the actual injury site. On the sham side, the meniscus was left intact to serve as a control group .Postoperatively, at 1, 7, 14, 28, 56, and 112 days, four rabbits were slaughtered to analyze both menisci. An IHC dye with monoclonal antibodies was applied to quantify cytokine expression of IL-1, TGF-B, PDGF and proliferating nuclear antigen PCNA.
A positive ratio was found in four rabbits in IL-1, TGF-1, PDGF, and PCNA in the rasped surface that reach its peak at 1, 7, 14, and 7 days, respectively, after the surgery and which thereafter declined gradually. Although there were differences as regards cytokine appearance, the positive ratio was higher in the rasp than in the control group.
Yuji (21) reports a way to treat meniscal ruptures by rasping as a mean to attain vascularity and, eventually, a healing response with good results. Forty-eight ruptured menisci on 47 patients whose ages ranged from 14-47, the average age being 24 years, were controlled by second view arthroscopy. The interval from the time of injury to the time of surgery ranged from 3 weeks to thirteen years. There were 35 lateral meniscus and 44 medial ruptures associated with ACL.
Twenty-eight of them had a complete longitudinal rupture, the average length being 14.4 mm. (Range 10-33 mm.) The distance form the capsule ranged from 1 to 9 mm. (Average 5 mm.) Thirty-four menisci (71%) healed completely (no visible mark); ten (21%) healed in an incomplete manner; and four did not show any change or healing (8%).
It is interesting to find out that even if the meniscus itself is slightly damaged when receiving the radio frequency pulses, there is evidence that this very tissue exhibits a great capacity of recovery within a period ranging from six to twelve weeks (22,23,24,25 )
D’arsonval (26 )was the first to publish the physiologic effect of alternate current in humans in 1893; however, the invention of the sparkling gap or spark generator was due to two achievers that changed the face of the surgery forever: William Bovie, and Harvey Cushing, a neurosurgeon from Harvard . That early technology prevented the high rate of mortality of brain surgeries due to excess bleeding.
Radio frequency is the result of elevating the cycles per second measured in Hertz of the alternating poles of an electromagnetic field. Typically, less than 10,000 Hertz or cycles per second is considered low frequency current, which has deleterious effects on nerves and heart, leading to arrhythmia and spastic contractions. Radio frequency comprises beyond 10,000 and up to 300 mega hertz.
R.I. Pavlovich, Strobbel et al. (28) described the effects of low and high frequency currents on human tissues. More than eighty years have elapsed since R.F. was first use in brain surgery. RF has being a useful tool that exists in virtually every operating room around the world to cut and coagulate. Its applications comprise a wide array of indications, from general surgery, to oncology and cosmetic surgery (29,30,31)
High frequency currents were introduced to meniscectomy by Schosheim and Caspari in a study in rabbits .The curve of the necrosis line after the application of RF was around 30 microns, followed by a disappearance of the necrosis line along with hypercelullarity, around six weeks, that increased until the 12th week. After six months, the meniscus resembled a normal one on a histological exam.
Later on, Miller(33) reported a histology study in human menisci after the exposal to R.F due to a meniscectomy . The average necrosis line was 29 microns. Two biopsies taken at 7 and 21 months revealed that no harm was demonstrable and that by the exam data, these could not be distinguished from a normal meniscus. In 1992, Bert (34) reported a six year follow-up study on meniscectomies with R.F in humans. The study consisted in 21 patients with meniscal biopsies at 6 months and 4 years, showing normal meniscal tissue on HE and Trichromic Masson dye.
The true importance of these studies is that properly applied R.F. is safe and that the meniscus can recover fully from the insult.
The first cases on meniscal repair with the use of R.F, with second arthroscopic views was reported in arthroscopy in 1998. The use of R.F instead of meniscal rasping based in the former studies showing hypercelullarity, resulted in the total healing of neglected cases of bucket handle tear after five years of a blocked knee .RI Pavlovich (35)
More studies followed the first report and a clinical report of 60 patients with 18 second views in a multi-centric study resulted in an 88% of anatomical healing (presented at Whistler, Canada, Continuing Medical Education, University of British Columbia, 2001). The study showed biopsies taken at three and six months with HE and Masson dye (36).
In order to research two thermal energy sources related to meniscal repair, a study comparing R.F and L.A.S.E.R was presented at the ICRS in San Diego, 2006 Meeting . The study presented the effect of meniscal repair in Wistar rats with an artificial rupture that was on the avascular area sutured with a non-absorbable suture. R.F and L.A.S.E.R pulses with a sham group compared the healing of meniscal ruptures. RF showed more stimulation against LASER in synovial invasion and repair, whereas poor results were seen in the control group.(37)
We now know, that the exposure of the meniscal tissue to R.F follows a predictable pattern of damage and recovery with capabilities for fibroblast proliferation during this recovery period, with a return of the normal anatomy and histology within a 6 to 12 week period (A study in Barbados sheep as the Doctoral Thesis at the University Complutensis of Madrid, 2006)( 38). This study follows the events of the damage-recovery period and identifies the main stakeholder in the repair process, which is the synovial tissue, that acts like a “Tidal wave” effect, by first invading, and then, eventually withdrawing from the spot, leaving behind a normal and healthy tissue (39).
In a special issue by the J Sports Medicine and Arthroscopy Review on RF applied to Orthopedics, the author (40) presents the surgical technique as well as some results that encourage its use and the study of R.F basic sciences for a proper application on tissues.
The paper suggests that RF can be used as a successful alternative to fibrin, blood clot and vascular access channels to promote and boost healing processes in some avascular areas of the rupture. More recently Hatayama(41 ) investigated histological changes in the meniscus of rabbits after meniscal repair via radio frequency energy (RFE). He analyzed Twenty Japanese white rabbits that underwent bilateral knee arthrotomies and a longitudinal tear was made in the avascular area of both medial menisci. On the right knees, RFE treatment (60 degrees C and 40 W) was performed on the femoral surface of the meniscal tear in a monopolar mode. On the left knees, the meniscus was left untreated as a control. The rabbits were slaughtered at 0, 1, 2, 4, or 12 weeks after surgery and all medial menisci were examined histologically. The expression of autocrine motility factor in meniscal fibrochondrocytes was examined by immunohistochemical analysis, after histological examination at baseline showed fusion of collagen fibers in the tear. Failure of fusion was found in 2 of 4 menisci at 2 weeks and 1 of 4 menisci at 4 and 12 weeks, respectively. One week after surgery, the specimens showed an acellular area as a result of fibrochondrocyte death. The acellular area expanded deeper until 4 weeks and was decreased at 12 weeks. On the femoral surface of the RFE-treated area, fibroblast proliferation was found at 2 weeks, and fibroblasts had invaded into the meniscus tissue from the meniscal surface at 12 weeks. Immunohistochemical analysis showed that the expression of autocrine motility factor in RFE-treated menisci was significantly higher than that in control menisci after 1 to 12 weeks. It was concluded that the RFE treatment at 60 degrees C and 40 W fused the collagen fibers in the meniscal tear in rabbits just after surgery. After RFE treatment, an acellular area developed as a result of fibrochondrocyte damage. RF caused fibroblast proliferation at 2 weeks. The acellular area was reduced by cell repopulation at 12 weeks. Its clinical relevance is that RF may induce fibroblast proliferation for meniscal repair.
Radio frequency is a source of thermal energy successfully proved as a tool for meniscectomy, a time honored procedure . As we understand the value of meniscal tissue through mechanical and clinical studies over the years, more care is taken to preserve as much tissue as possible through different approaches to attain good healing of the meniscal body.
The meniscus, a highly reactive structure, is stimulated in various ways to produce repair cytokines as a result of a controlled damage, which can be exerted in several ways such as rasping or shaving of the tissue. Avascular areas represent a challenge, since the chance of a good repair process is rather poor, otherwise having to resect precious tissue that will be missed eventually on a long term basis.
Radio frequency in this new fashion provides some advantages since the tissue is stabilized at the same point in which it is stimulated to awaken a healing response even in some avascular areas. It can be used as a good match to sutures or any method of mechanical stabilization.
RF on meniscus is safe and easy to apply. It should always be insisted that eager surgeons embark in the study of basic sciences behind new sciences on the market, understanding that “Not all new things are good, but rather that all good things were once new”.
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