0545 Electrothermal Arthroscopy - Aetna

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Electrothermal Arthroscopy

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Pol icy History Last

Review

10/10/2018

Effective: 06/22/2000

Next Review:

05/23/2019

Review History

Definitions

Additional Information

Number: 0545

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Aetna considers electrothermal arthroscopy (also known as electrothermally-

assisted capsule shift, and electrothermally-assisted capsulorrhaphy (ETAC)) of the

joint capsule, ligaments, or tendons experimental and investigational for all

indications, including any of the following because available scientific evidence

does not permit conclusions concerning the long-term effects on health outcomes

(not an all-inclusive list):

• Achilles injuries; or

• Adhesive capsulitis; or

• Ankle, hip, knee, or thumb instability; or

• Bankart lesions; or

• Bony avulsion of the capsule; or

• Deficient or thin capsule; or

• Frozen shoulder; or

• Glenohumeral joint (shoulder) instability; or

• Hill-Sachs lesions; or

• Humeral-side avulsion of the capsule; or

• Ligament tear and meniscal injury of the knee; or

• Multi-directional instability; or

• Temporomandibular joint dislocation; or

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• Wrist injuries.

See also CPB 0475 - Coblation (../400_499/0475.html).

Background

Thermal capsular shrinkage, also known as thermal capsulorrhaphy, is an

arthroscopic procedure performed under general anesthesia that utilizes thermal

energy/heat to shrink the tendons or ligaments of the synovial joint. Thermal

capsulorrhaphy purportedly increases stability of the joint. It is theorized that when

heat is applied to the tissue a molecular change occurs to the structure of collagen

(the chief component of connective tissue, tendons and bones) causing the length

of the collagen to shrink and tighten.

Examples of thermal capsular shrinkage devices include, but may not be l im i ted to :

ArthroCare system 2000 CAPS X ArthroWand; ORA-50 electrothermal system and

accessories; VULCAN EAS electrothermal arthroscopy system and

accessories;VAPR TC electrode for use with VAPR II electrosurgical system.

The shoulder joint is a ball and socket type of joint that permits a wide range of

movement. Its bony structures include the humerus and the shallow cavity (the

glenoid) of the shoulder blade, thus making it inherently unstable. A circle of

ligaments, tendons, muscles and cartilage form a capsule around the joint to

maintain stability. The glenoid labrum is the fibro-cartilage ring attached to the rim

of the glenoid cavity, and acts to stabilize the humeral head inside the glenoid. The

Bankart lesion is a specific injuryto a part of the shoulder joint called the labrum.

Shoulder instability is defined as excessive movements of the shoulder that cause

pain in daily activities or sporting activities. Dislocations occur when the head of

the humerus completely pops out of the socket, and typically are the result of a

complete dislocation with capsulo-labral avulsion, a tearing away of the labrum from

the glenoid rim. The first few times this happens, it is usually with significant, high-

energy trauma. After that, it can get easier and easier for the joint to dislocate.

Most shoulder dislocations are anterior. Subluxation is the feeling that the shoulder

slips slightly out of socket, then immediately comes back in place.

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The cause of this instability varies. Sometimes it is the result of an abnormal,

generalized hyperlaxity of the capsule usually caused by repetitive microtrauma,

such as in overhead throwing sports, racquet sports, and swimming. It can also

result from recurrent partial or full anterior dislocations of the shoulder. Aching,

heaviness, or sharp pains associated with pathologic conditions of the rotator cuff,

biceps, or labrum are common presenting complaints.

The main goal for any shoulder surgery is to stabilize the shoulder and maintain a

full, pain-free range of motion. The multiplicity of procedures that address this

problem have in common either blocking anterior displacement of the humerus

and/or tightening the joint capsule. For long-term shoulder health, anatomic

stabilization of the Bankart lesion is the first priority because it corrects uni-

directional anterior subluxation/dislocation. The Bankart procedure involves a small

incision (1 cm) into the shoulder, and a suturing of the labrum back to the glenoid.

The Bankart repair reduces pain and can be performed without causing a

significant loss of external rotation.

Anatomic re-attachment of the capsulo-labral complex alone may not successfully

stabilize the gleno-humeral joint. It has been proposed that the higher recurrence

rates seen in arthroscopic repairs that secure the capsulo-labral complex back to

the glenoid rim maybe the result of failure to treat the stretched-out capsule.

Electrothermally-assisted capsulorrhaphy (ETAC), also known as electrothermal

arthroscopy and electrothermally-assisted capsule shift, provides an easy approach

to arthroscopically advance or tighten the capsule in conjunction with arthroscopic re-

attachment procedures.

The ElectroThermal ArthroscopySystem uses high-energy radiofrequency waves

to heat the collagen fibers in the joint. This controlled thermal energy eventually

causes contraction and firming up of the soft tissue in an effort to stabilize the joint.

Initial success of this procedure appears to depend on proper patient selection,

appropriate surgical technique, attention to the rehabilitation program, and patient

compliance. Monopolar electrothermal stabilization is technically easy to perform,

and reported peri-operative complication rates have been low. Short-term,

uncontrolled studies of electrothermal arthroscopy for shoulder instability have

shown preservation of range of motion and more rapid post-operative recovery than

with open procedures. Although results of short-term studies of electrothermal

arthroscopy appear to equal or exceed other surgical procedures, longer-term

clinical outcome studies with direct comparisons with open procedures are

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necessary to determine the effectiveness of electrothermal arthroscopy. Long-term

follow-up is necessary to determine whether results for this procedure will

deteriorate over time.

In this regard, a number of investigators have commented on the need for long-

term follow-up studies of electrothermal arthroscopy for shoulder instability. Levine

et al (2001) reported that the advances in thermal treatment of the capsule have

made arthroscopic electrothermal capsulorrhaphy increasingly attractive as an

alternative to the open approach for the primary treatment of multi-directional

instability. However, the authors concluded that longer follow-ups will be necessary

before definitive statements can be made regarding the arthroscopic techniques.

Khan et al (2002) noted that monopolar electrothermal stabilization of the shoulder

shows considerable promise as a treatment alternative in athletes and patients with

recurrent instability. However, long-term follow-up is necessary to determine if

results for this procedure deteriorate over time, especially in patients with multi-

directional instability. Furthermore, Walton et al (2002) noted that “[g]ood results

have been reported with this technique in recent short-term studies” but that “[f]

urther long-term evaluations are necessary to evaluate the technique, indications,

and results of this novel method of reducing capsular volume”. Levitz et al (2001)

cautioned that it is not known how much the capsule should be shrunk or what

long-term results will show.

Current evidence supporting the use of electrothermal arthroscopy for shoulder

instability is limited to uncontrolled retrospective (Hovis et al, 2002; Lephart et al,

2002;Levitz et al, 2001; Lyons et al, 2001; Reinold et al, 2003; Joseph et al, 2003)

and prospective case series, with variable results (Fitzgerald et al, 2002; Levy et al,

2000; Mishra et al, 2001; Savoie et al, 2000; Noonan et al, 2003; and Gieringer,

2003).Most of these studies are small and of short duration, although some mid-

term results have been reported. There is a lack of adequate well-controlled long-

term clinical studies of the effectiveness and durability of electrothermal

arthroscopy, comparing outcomes of this procedure with established surgical

methods of treating shoulder instability.

In a review of the literature on electrothermal arthroscopy, Gerber and Warner

(2002) of the Harvard Shoulder Service have warned that “Currently, however, the

indications for thermal capsulorrhaphy are defined poorly, clinical outcome has not

been shown to be superior to conventional stabilization procedures, and long-term

effects on joint biology and mechanics are not known. Based on a critical review of

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the literature and personal clinical experience, the authors conclude that addi tional

experimental and clinical investigations are necessary to add this procedure to the

accepted modalities applied for the treatment of shoulder instability”.

A technology assessment of electrothermal arthroscopy prepared for the

Washington State Department of Labor and Industries (2003) concluded that, “[w]

hile researchers have published their findings in peer-reviewed journals, the

evidence comes primarily from case series studies with small study populations.

Therefore, findings do not substantially show thermal shrinkage’s efficacy or

effectiveness for the treatment of shoulder instability...”.

Recent studies by Enad et al (2004) as well as D'Alessandro et al (2004) indicated

that the long-term outcome of electrothermal arthroscopy is unsatisfactory. Enad et

al (2004) examined the effectiveness of arthroscopic electrothermal capsulorrhaphy

for the treatment of instability in overhand athletes. Electrothermal capsulorrhaphy

without labral repair was used to treat 20 symptomatic overhand athletes (15

baseball, 3 softball, and 2 volleyball). A total of 19 patients were evaluated at a

mean of 23 months. Overall Rowe results were 10 excellent, 4 good, 2 fair, and 3

poor, with a mean score of 82. The overall mean American Shoulder and Elbow

Surgeons (ASES) score was 85.7 (mean pain score, 42.2; mean score for activities

of daily living, 43.5). Two failures (10 %) required open shoulder stabilization. Ten

athletes returned to their prior level of sport, 3 returned to a lower level, and 6 were

unable to return to their sport. These preliminary results indicate that treatment of

the overhand athlete with isolated electrothermal capsulorrhaphy is favorable but

does not reproduce the success of open surgery. Overall recurrence and failure

rates were high. Instability in overhand athletes may require something other than

isolated electrothermal capsulorrhaphy to address laxity.

D'Alessandro et al (2004) reported a “high rate of unsatisfactory results” in a

published prospective evaluations of the effectiveness of arthroscopic

electrothermal capsulorrhaphy with 2 to 5 years follow-up. This non-randomized

prospective study evaluated the indications and results of thermal capsulorrhaphy

in 84 subjects with shoulder instability. Subjects underwent arthroscopic thermal

capsulorrhaphy after initial assessment, radiographs, and failure of a minimum of 3

months of non-operative rehabilitation. Outcome measures included pain, recurrent

instability, return to work/sports, and the ASES Shoulder Assessment score. After

a median duration of follow-up of 38 months, overall results were excellent in 33

participants (39 %), satisfactory in 20 (24 %), and unsatisfactory in 31 (37 %). The

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authors concluded that ”[t]he high rate of unsatisfactory overall results (37 %),

documented with longer follow-up, is of great concern”. The authors cautioned that

“[t]he enthusiasm for thermal capsulorrhaphy should be tempered until further

studies document its efficacy”.

There is also a lack of evidence of the effectiveness of electrothermal arthroscopy

for other joints, including knee, ankle and elbow. The most thoroughly studied

indication for electrothermal arthroscopy, other than shoulder instability, is anterior

cruciate ligament (ACL) laxity. Carter et al (2002) reported failure at an average of

4 months post-surgery in 11 of 18 patients with laxity of the ACL treated with

electrothermal arthroscopy. Of the 7 patients with a good result, 6 were treated for

acute laxity. The investigators concluded “[e]ven with the short-term follow-up in

our study, it is evident that thermal shrinkage using radiofrequency technology has

limited application for patients with anterior cruciate ligament laxity. Although it may

be useful in treating patients with an acutely injured native anterior cruciate

ligament, further study is needed to see if the ligament stretches out over time or is

at increased risk of reinjury.” Indelli and co-workers (2003) reported their

experience using monopolar thermal repair on 28 consecutive knees with partial

ACL tears. Based on measurements of ACL stability 2 or more years after surgery,

the authors found the results to be comparable to experience with ACL re-

constructions with allograft. The authors stated, however, that longer follow-up and

the results of other studies will better define the selection, methods, and results of

thermal repair of partial ACL tears. Oakes and McAllister (2003) stated that

although the use of thermal energy to selectively shrink tissues may ultimately

prove to be an invaluable tool, the lack of well-designed, randomized controlled

studies to firmly establish its efficacy in the treatment of partial cruciate injuries

mandates cautious use of this technique at this time. A technology assessment

prepared for the Washington State Department of Labor and Industries (2003)

concluded that there is inadequate evidence of the effectiveness of electrothermal

arthroscopy for ACL laxity.

In a review on thermal modification of the lax ACL by means of radiofrequency,

Lubowitz(2005) stated that results of shrinkage of a lax, intact native ACL using

radiofrequency seems promising, but complications of catastrophic, spontaneous

ACL rupture have been reported. The author noted that more research is needed

to define treatment techniques, indications, and selection criteria for ACL thermal

shrinkage using radiofrequency and to compare its outcomes with traditional ACL

reconstructive surgery.

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In a a multi-center study, Smith and colleagues (2008) prospectively evaluated the

mid-term results (beyond 2 years) of thermal shrinkage on both lax native ACL and

lax re-constructions and determined the effectiveness of this procedure. A total of

64 patients underwent electrothermal shrinkage for a lax ACL, both native and

previous re-constructions. They were followed-up past 2 years with KT-1000

measurements. Failure criteria were subsequent operations for instability and KT-

1000 measurements greater than 5 mm. Three patients were lost to follow-up.

Among the 61 patients followed-up past 2 years, failure occurred in 31 (50.8 %).

The failure rate for lax grafts alone was 78.9 %,and there was a failure rate of 38.1

% for lax native ligaments. The authors concluded that electrothermal shrinkage of

lax native or re-constructed ACLs is not an appropriate treatment.

Chloros et al (2008) reviewed the recent literature on arthroscopic treatment of

distal radius fractures (DRFs), triangular fibro-cartilage complex injuries, inter-

carpal ligament injuries, and ganglion cysts, including the use of electrothermal

devices. A major advantage of arthroscopy in the treatment of DRFs is the

accurate assessment of the status of the articular surfaces and the detection of

concomitant injuries. Non-randomized studies of arthroscopically assisted

reduction of DRFs show satisfactory results, but there is only 1 prospective

randomized study showing the benefits of arthroscopy compared with open

reduction-internal fixation. Wrist arthroscopy plays an important role as part of the

treatment for DRFs; however, the treatment for each practitioner and each patient

needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis

and treatment of triangular fibro-cartilage complex injuries. Type 1A injuries may

be successfully treated with debridement, whereas the repair of type 1B, 1C, and

1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer

procedure is equally effective as ulnar shortening osteotomy but is associated with

fewer complications in the ulnar positive wrist. With interosseous ligament injuries,

arthroscopic visualization provides critical diagnostic value. Debridement and

pinning in the acute setting of complete ligament tears are promising and proven.

In the chronic patient, arthroscopy can guide re-constructive options based on

cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal

devices are encouraging; however, complications have been reported, and

therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown

excellent results, a lower rate of recurrence, and no incidence of scapholunate

interosseous ligament instability compared with open ganglionectomy. Arthroscopy

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in the treatmentof volar wrist ganglia has yielded encouraging preliminary res ul ts;

however, further studies are warranted to evaluate the safety and effectiveness of

arthroscopy.

Chu and colleagues (2009) examined if radiofrequency electrothermal treatment of

thumb basal joint instability could produce clinical improvement and result in

successful functional outcomes for patients. From August 2001 to April 2006, these

researchers treated 17 thumbs with symptomatic thumb basal joint instability using

arthroscopic electrothermal shrinkage of the volar ligaments and joint capsule with

a monopolar radiofrequency probe. The sample included 11 men and 6 women

with a mean age of 35.3 years (range of 20 to 60 years). All patients underwent

regular clinical follow-up at a mean of 41 months (range of 24 to 80 months). Pain

improved in all thumbs after surgery. Thumb pinch strength significantly improved

in all thumbs after surgery (p < 0.01). All patients were satisfied with the results

and returned to their pre-injury activities. The authors concluded that by use of the

described method of arthroscopic electrothermal shrinkage of the volar ligaments

and joint capsule in patients with symptomatic thumb basal joint instability, most

patients had good subjective results and the pinch strength improved significantly in

most patients. Of 17 thumbs, 16 had satisfactory subjective and functional stability

at a minimum 2 years' follow-up. This was a small, non-controlled study; its

findings need to be validated by well-designed studies.

Torres and McCain (2012) noted that acute temporomandibular joint dislocation is a

common occurrence that is generally treated by conservative therapy. In some

patients, this can become a chronic recurrent condition. This recurrent

temporomandibular joint dislocation (RTD) can significantly decrease the patient's

quality of life and require some form of surgical intervention for correction. These

researchers examined the effectiveness of a minimally invasive alternative

treatment for RTD using operative arthroscopy. A total of 11 patients treated for

RTD between 2004 and 2010 were retrospectively analyzed. Electrothermal

capsulorrhaphy was performed using a standard double puncture operative

arthroscopy with a Hol:YAG laser and/or electrocautery. Post-operatively, the

patients were monitored for 6 months to 6 years. Of the 11 subjects, 2 suffered a

recurrence of temporomandibular dislocation and required open arthrotomy for

correction. The other 9 patients had no signs of recurrence or any significant post-

operative loss of function. The authors concluded that electrothermal

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capsulorrhaphyis an effective and minimally invasive method for the treatment of

RTD. The findings of this small, non-controlled study need to be validated by well-

designed studies.

The triangular fibro-cartilage complex (TFCC) is formed by the triangular fibro-

cartilage discus, the radio-ulnar ligaments and the ulno-carpal ligaments. Garcia-

Lopez et al (2012) evaluated the clinical and occupational outcomes of arthroscopic

treatment with electrothermal shrinkage for TFCC tears. These researches

retrospectively reviewed 162 patients. All patients had ulnar-sided wrist pain that

limited their occupational and sporting activities. The surgical technique consisted

of electrothermal collagen shrinkage of the TFCC. Pain relief, range of motion,

complications, re-operation rate, time to return to work and workers' compensation

claims were evaluated. Exclusion criteria were distal radioulnar joint instability and

association of other wrist lesions. Complete pain relief was noted in 80.3 % of the

patients, incomplete pain relief in 14.8 %, and only 4.9 % required re-operation

because of pain-persistence. The average range of motion was over 90 %

compared to the opposite hand. Worker's compensation claims were introduced by

20 patients, of which 6 did not return to their previous occupation. The authors

concluded that electrodiathermy may be a useful option for arthroscopic treatment

of TFCC tears in cases without distal radioulnar joint instability. The findings of this

study need to be validated by well-designed studies.

Mohtadi et al (2014) noted that radiofrequency technology for shoulder instability

was rapidly adopted despite limited clinical evidence and a poor understanding of

its indications. Reports of serious adverse events followed, leading to its

abandonment. These researchers presented findings from a multi-center

randomized clinical trial evaluating the safety and effectiveness of ETAC compared

with open inferior capsular shift (ICS) and reviewed the role of randomized trials in

adopting new technology. Patients (greater than 14 years) diagnosed with multi-

directional instability or multi-directional laxity with antero-inferior instability and

failed non-operative treatment were enrolled. Patients with bone lesions or labral,

biceps anchor, or full-thickness rotator cuff tears were excluded intra-operatively.

Outcomes included Western Ontario Shoulder Instability Index, function and

recurrent instability at 2 years post-operatively, and surgical times. A total of 54

subjects (mean age of 23 years; 37 women) were randomized to ETAC (n = 28) or

open ICS (n = 26). The groups were comparable at baseline, except for external

rotation at the side. At 2 years post-operatively, there were no statistically or

clinically significant differences between groups for the Western Ontario Shoulder

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Instability Index (p = 0.71), American Shoulder and Elbow Surgeons score (p =

0.43), Constant score (p = 0.43), and active range of motion. Recurrent instability

was not statisticallydifferent (ETAC, 2; open,4; p = 0.41). Electrothermally-

assisted capsulorrhaphy (23 minutes) was significantly shorter than open ICS (59

minutes) (p < 0.01) surgery. Three subjects (1 ETAC, 2 open) had stiff shoulders.

The authors concluded that at 2 years post-operatively, quality of life and functional

outcomes between groups were not clinicallydifferent;ETAC had fewer

complications and episodes of recurrence compared with open surgery. They

stated that this evidence reinforced the need to critically evaluate new technology

before widespread clinical use.

UpToDate reviews on “Overview of surgical therapy of knee and hip

osteoarthritis” (Mandl and Marin, 2015), “Synovectomy for inflammatory arthritis of

the knee” (Wright, 2015) do not mention electrothermal arthroscopy/ETAC as a

therapeutic option.

McRae and associates (2016) noted that ETAC was introduced as an adjunct to

shoulder stabilization surgery to address capsular laxity in the treatment of

traumatic anterior dislocation. No previous randomized controlled trial (RCT) has

compared arthroscopic Bankart repair with ETAC of the medial gleno-humeral

ligament and anterior band of the inferior gleno-humeral ligament versus

undergoing arthroscopic Bankart repair alone. These investigators hypothesized

that there would be no difference in quality of life (QOL) between these 2 groups.

Complication/failure rates were also compared. A total of 88 patients were

randomly assigned to receive arthroscopic Bankart repair with (n = 44) or without

ETAC (n = 44). Post-operative visits occurred at 3, 6, 12, and 24 months with

WOSI, ASES, and Constant scores completed, and rates of dislocation/subluxation

were determined. Data on 74 patients were analyzed, with the rest lost to follow-

up. There were no differences between groups at any post-surgery time points for

WOSI, ASES, or Constant scores (non-significant.); 8 patients in the no-ETAC

group and 7 in the ETAC group were considered failures (non-significant). The

authors concluded that no benefits in patient-reported outcome or recurrence rates

using ETAC were found. Mean WOSI scores 2 years post-surgery were virtually

identical for the 2 groups; ETAC could not be shown to provide benefit or detriment

when combined with arthroscopic labral repair for traumatic anterior instability of the

shoulder.

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UpToDate reviews on “Anterior cruciate ligament injury” (Friedberg, 2017) and

“Meniscal injury of the knee” (Cardone and Jacobs, 2017) do not mention

electrothermal arthroscopy as a therapeutic option.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Other CPT codes related to the CPB:

29804 Arthroscopy, temporomandibular joint, surgical

29806 - 29828 Arthroscopy, shoulder, surgical

29843 - 29847 Arthroscopy, w rist, surgical

29848 Endoscopy, w rist surgical, w ith release of transverse carpal ligament

29861 - 29863 Arthroscopy, hip, surgical

29870 - 29887 Arthroscopy, knee [not covered for electrothermal arthroscopy]

29891 - 29899 Arthroscopy, ankle

29905 Arthroscopy, subtalar joint, surgical; w ith synovectomy

29906 w ith debridement

29907 w ith subtalar arthrodesis

HCPCS codes not covered for indications listed in the CPB:

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

M23.92

M26.69

M65.879

M75.02

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M76.62

Numerous

options

Numerous

options

Numerous

options

S03.02x+

S83.32xS

The above policy is based on the following references:

1. Balding FC, Peff TC, Torg JS. Application of electrothermal energy in

arthroscopy. Arthroscopy. 1985;1(4):259-263.

2. Nottage WM. Laser-assisted shoulder surgery. Arthroscopy. 1997;13

(5):635-638.

3. Hayashi K, Thabit G 3rd, Massa KL, et al. The effect of thermal heating on

the length and histologic properties of the glenohumeral joint capsule. Am

J Sports Med. 1997;25(1):107-112.

4. Ellenbecker TS, Mattalino AJ. Glenohumeral joint range of motion and

rotator cuff strength following arthroscopic anterior stabilization with

thermal capsulorrhaphy. J Orthop Sports Phys Ther. 1999;29(3):160-167.

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5. Obrzut SL, Hecht P, Hayashi K, et al. The effect of radiofrequency energy

on the length and temperature properties of the glenohumeral joint

capsule. Arthroscopy. 1998;14(4):395-400.

6. Selecky MT, Vangsness CT Jr, Liao WL, et al. The effects of laser-induced

collagen shortening on the biomechanical properties of the inferior

glenohumeral ligament complex. Am J Sports Med. 1999;27(2):168-172.

7. Hayashi K, Massa KL, Thabit G 3rd, et al. Histologic evaluation of the

glenohumeral joint capsule after the laser-assisted capsular shift

procedure for glenohumeral instability. Am J Sports Med. 1999;27(2):162-

167.

8. Norlin R, Karlsson J. Shoulder instability. Review of current trends in

treatment. Scand J Med Sci Sports. 1998;8(6):394-397.

9. Imhoff AB, Roscher E, Konig U. Arthroscopic shoulder stabilization.

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laser and electrosurgery. Orthopade. 1998;27(8):518-531.

10. Wall MS, Deng XH, Torzilli PA, et al. Thermal modification of collagen. J

Shoulder Elbow Surg. 1999;8(4):339-344.

11. Mahaffey BL, Smith PA. Shoulder instability in young athletes. Am Fam

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12. Mishra DK, Fanton GS. Two-year outcome of arthroscopic Bankart repair

and electrothermal-assisted capsulorrhaphy for recurrent traumatic

anterior shoulder instability. Arthroscopy. 2001;17(8):844-849.

13. Balduini FC, Peff TC, Torg JS. Application of electrothermal energy in


14. Tyler TF, Calabrese GJ, Parker RD, Nicholas SJ. Electrothermally-assisted

capsulorrhaphy (ETAC): A new surgical method for glenohumeral

instability and its rehabilitation considerations. J Orthop Sports Phys Ther.

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15. David TS, Drez DJ Jr. Electrothermally-assisted capsular shift. IEEE Eng Med

Biol Mag. 1998;17(3):102-104.

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shoulder. J Bone Joint Surg Am. 2001;83-A Suppl 2 Pt 2:151-155.

17. Medvecky MJ, Ong BC, Rokito AS, Sherman OH. Thermal capsular

shrinkage: Basic science and clinical applications. Arthroscopy. 2001;17

(6):624-635.

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18. Levitz CL, Dugas J, Andrews JR. The use of arthroscopic thermal

capsulorrhaphy to treat internal impingement in baseball players.

Arthroscopy. 2001;17(6):573-577.

19. Hawkins RJ, Karas SG. Arthroscopic stabilization plus thermal

capsulorrhaphy for anterior instability with and without Bankart lesions:

The role of rehabilitation and immobilization. Instr Course Lect.

2001;50:13-15.

20. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of

multidirectional glenohumeral instability: 2- to 5-year follow-up.

Arthroscopy. 2001;17(3):236-243.

21. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of

bidirectional glenohumeral instability: Two- to five-year follow-up. J


22. Tibone JE, Lee TQ, Black AD, et al. Glenohumeral translation after

arthroscopic thermal capsuloplasty with a radiofrequency probe. J


23. Levine WN, Flatow EL. The pathophysiology of shoulder instability. Am J

Sports Med. 2000;28(6):910-917.

24. Nelson BJ, Arciero RA. Arthroscopic management of glenohumeral

instability. Am J Sports Med. 2000;28(4):602-614.

25. Lazarus MD, Harryman DT 2nd. Complications of open anterior

stabilization of the shoulder. J Am Acad Orthop Surg. 2000;8(2):122-132.

26. An YH, Friedman RJ. Multidirectional instability of the glenohumeral joint.

Orthop Clin North Am. 2000;31(2):275-285.

27. Levine WN, Prickett WD, Prymka M, Yamaguchi K. Treatment of the athlete

with multidirectional shoulder instability. Orthop Clin North Am. 2001;32

(3):475-484.

28. Khan AM, Fanton GS. Electrothermal assisted shoulder capsulorrhaphy--

monopolar. Clin Sports Med. 2002;21(4):599-618.

29. Fitzgerald BT, Watson BT, Lapoint JM. The use of thermal capsulorrhaphy

in the treatment of multidirectional instability. J Shoulder Elbow Surg.

2002;11(2):108-113.

30. Carter TR, Bailie DS, Edinger S. Radiofrequency electrothermal shrinkage

of the anterior cruciate ligament. Am J Sports Med. 2002;30(2):221-226.

31. Hanypsiak BT, Faulks C, Fine K, et al. Rupture of the biceps tendon after

arthroscopic thermal capsulorrhaphy. Arthroscopy. 2004;20 Suppl 2:77-79.

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32. Noonan TJ, Tokish JM, Briggs KK, Hawkins RJ. Laser-assisted thermal

capsulorrhaphy. Arthroscopy. 2003;19(8):815-819.

33. Wolf RS, Lemak LJ. Thermal capsulorrhaphy in the treatment of

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(2):102-109.

34. Gieringer RE. Arthroscopic monopolar radiofrequency thermal

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outcome study with mean 2-year follow-up. Alaska Med. 2003;45(1):3-8.

35. Hovis WD, Dean MT, Mallon WJ, Hawkins RJ. Posterior instability of the

shoulder with secondary impingement in elite golfers. Am J Sports Med.

2002;30(6):886-890.

36. McFarland EG, Kim TK, Banchasuek P, McCarthy EF. Histologic evaluation

of the shoulder capsule in normal shoulders, unstable shoulders, and

after failed thermal capsulorrhaphy. Am J Sports Med. 2002;30(5):636-642.

37. Gerber A, Warner JJ. Thermal capsulorrhaphy to treat shoulder instability.

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38. Walton J, Paxinos A, Tzannes A, et al. The unstable shoulder in the

adolescent athlete. Am J Sports Med. 2002;30(5):758-767.

39. Joseph TA, Williams JS Jr, Brems JJ. Laser capsulorrhaphy for

multidirectional instability of the shoulder. An outcomes study and

proposed classification system. Am J Sports Med. 2003;31(1):26-35.

40. Lyons TR, Griffith PL, Savoie FH 3rd, Field LD. Laser-assisted

capsulorrhaphy for multidirectional instability of the shoulder.

Arthroscopy. 2001;17(1):25-30.

41. Savoie FH 3rd, Field LD. Thermal versus suture treatment of symptomatic

capsular laxity. Clin Sports Med. 2000;19(1):63-75, vi.

42. Miniaci A, McBirnie J. Thermal capsular shrinkage for treatment of

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43. Reinold MM, Wilk KE, Hooks TR, et al. Thermal-assisted capsular shrinkage

of the glenohumeral joint in overhead athletes: A 15- to 47-month follow-

up. J Orthop Sports Phys Ther. 2003;33(8):455-467.

44. Anderson K, Warren RF, Altchek DW, et al. Risk factors for early failure

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47. Levitz CL, Dugas J, Andrews JR. The use of arthroscopic thermal

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48. Greis PE, Burks RT, Schickendantz MS, Sandmeier R. Axillary nerve injury

after thermal capsular shrinkage of the shoulder. J Shoulder Elbow Surg.

2001;10(3):231-235.

49. Lephart SM, et al. Shoulder propioception and function following thermal

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administer ing plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in

private practice and are neither employees nor agents of Aetna or its aff iliates. Treating providers are solely responsible

for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to

change.

Copyright © 2001-2019 Aetna Inc.

http://www.aetna.com/cpb/medical/data/500_599/0545.html 09/23/2019


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0545 Electrothermal

Arthroscopy

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania annual 10/01/2019

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