0545 Electrothermal Arthroscopy (1) - Aetna Better Health

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Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:09/01/2020

Policy Number: 0545 Effective Date: Revision Date: 08/18/2020

Policy Name: Electrothermal Arthroscopy

Type of Submission – Check all that apply:

New PolicyRevised Policy* Annual Review – No Revisions Statewide PDL

*All revisions to the policy must be highlighted using track changes throughout the document.

Please provide any clarifying information for the policy below:

CPB 0545 Electrothermal Arthroscopy

This CPB has been revised to state that electrothermal arthroscopy is considered experimental and investigational for partial scapholunate ligament tears.

Name of Authorized Individual (Please type or print):

Benjamin Alouf, MD, MBA, FAAP

Signature of Authorized Individual:

Revised July 22, 2019

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Electrothermal Arthroscopy - Medical Clinical Policy Bulletins | Aetna Page 1 of 25

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Electrothermal Arthroscopy

Policy History

Last Review

08/18/2020

Effective: 06/22/2001

Next

Review: 06/10/2021

Review History

Definitions

Additional Information

Clinical Policy Bulletin

Notes

Number: 0545

Policy

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

▪ Partial scapholunate ligament tears; or

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▪ Temporomandibular joint dislocation; or

▪ 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 limited 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 injury to a part of the shoulder joint

called the labrum.

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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.

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

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back to the glenoid rim may be 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 Arthroscopy System 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 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

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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

the literature and personal clinical experience, the authors

conclude that additional experimental and clinical

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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.

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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 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

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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.

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

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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 in the treatment of volar wrist

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ganglia has yielded encouraging preliminary results; 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

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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

capsulorrhaphy is 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.

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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 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 statistically different (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 clinically different; 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.

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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.

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.

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Partial Scapholunate Ligament Tears

In a prospective study, Romero and colleagues (2020)

examined the outcomes of arthroscopic electrothermal

shrinkage for partial scapholunate (SL) ligament tears, isolated

or with associated triangular fibrocartilage complex (TFCC)

injuries. This trial included 20 patients with symptomatic

instability of SL ligament (14 of them also with TFCC wrist

injuries) treated with arthroscopic electrothermal shrinkage

using a monopolar radiofrequency probe. No patient showed

radiologic signs of static dissociation (mean SL interval =of

2.2 ± 0.6 mm; mean SL angle of 41.4° ± 6.7°) before surgery.

All participants underwent follow-up at the authors’ clinic

regularly for an average of 50.6 months (range of 29 to 80

months). The modified Mayo wrist score improved from a

mean of 59 ± 17.1 points pre-operatively to 88.3 ± 16.2 points

at the final follow-up. At the final clinical examination, a painful

Watson scaphoid shift test was found in 3 patients (15 %).

The mean flexion-extension arc was unchanged (132° ± 19°),

and mean grip strength improved 12 kg. No patient showed

radiologic signs of arthritis or instability after surgery (mean SL

interval of 1.9 ± 0.7 mm; mean SL angle of 42.7° ± 7.3°). Of

the 14 patients with combined TFCC injuries, 3 patients

continued complaining of ulnar-sided point tenderness. At the

end of the follow-up, 80 % of the subjects were satisfied or

very satisfied. The authors concluded that SL ligament and

TFCC electrothermal shrinkage effectively provided pain relief

and grip strength increase for most of the patients treated.

Level of Evidence = IV. This was a small (n = 20) study that

provided Level IV evidence; these findings need to be

validated by well-designed studies.

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 "+":

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Code Code Description

CPT codes not covered for indications listed in the CPB:

Electrothermal arthroscopy - no specific code

Other CPT codes related to the CPB:

29804 Arthroscopy, temporomandibular joint, surgical

29806 -

29828

Arthroscopy, shoulder, surgical

29843 -

29847

Arthroscopy, wrist, surgical

29848 Endoscopy, wrist surgical, with 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; with

synovectomy

29906 with debridement

29907 with subtalar arthrodesis

HCPCS codes not covered for indications listed in the CPB:

S2300 Arthroscopy, shoulder, surgical; with thermally-

induced capsulorrhaphy

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

M23.000

- M23.92

Internal derangement of knee


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M24.00 -

M25.9

Other specific joint derangements

M26.601

- M26.69

Temporomandibular joint disorders

M65.871

-

M65.879

Other synovitis and tenosynovitis of ankle and

foot

M75.00 -

M75.02

Adhesive capsulitis of shoulder

M76.60 -

M76.62

Achilles tendinitis

Numerous

options

Sprains and strains of wrist [Codes not listed

due to expanded specificity]

Numerous

options

Sprains and strains of ankle and foot [Codes

not listed due to expanded specificity]

Numerous

options

Injury, elbow, forearm, and wrist [Codes not

listed due to expanded specificity]

S03.00x+

-

S03.02x+

Dislocation of jaw

S63.511A

-

S63.519S

Sprain of carpal (joint) of wrist [partial

scapholunate ligament tears]

S76.111A

-

S76.119S

Strain of quadriceps muscle, fascia and tendon

S83.200A

-

S83.32xS

Tear of meniscus, current injury


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S83.401A

-

S83.429S

Sprain of collateral ligament of knee

S83.501A

-

S83.529S

Sprain of cruciate ligament of knee


The above policy is based on the following references:

1. An YH, Friedman RJ. Multidirectional instability of the

glenohumeral joint. Orthop Clin North Am. 2000;31

(2):275-285.

2. Anderson K, Warren RF, Altchek DW, et al. Risk factors

for early failure after thermal capsulorrhaphy. Am J

Sports Med. 2002;30(1):103-107.

3. Balding FC, Peff TC, Torg JS. Application of

electrothermal energy in arthroscopy. Arthroscopy.

1985;1(4):259-263.

4. Balduini FC, Peff TC, Torg JS. Application of

electrothermal energy in arthroscopy. Arthroscopy.

1985;1(4):259-263.

5. Cardone DA, Jacobs BC. Meniscal injury of the knee.

UpToDate [online serial]. Waltham, MA:

UpToDate; reviewed March 2017.

6. Carter TR, Bailie DS, Edinger S. Radiofrequency

electrothermal shrinkage of the anterior cruciate

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

7. Chloros GD, Wiesler ER, Poehling GG. Current concepts

in wrist arthroscopy. Arthroscopy. 2008;24(3):343-354.

8. Chu PJ, Lee HM, Chung LJ, Shih JT. Electrothermal

treatment of thumb basal joint instability. Arthroscopy.

2009;25(3):290-295.

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9. D'Alessandro DF, Bradley JP, Fleischli JE, Connor PM.

Prospective evaluation of thermal capsulorrhaphy for

shoulder instability: Indications and results, two- to five-

year follow-up. Am J Sports Med. 2004;32(1):21-33.

10. David TS, Drez DJ Jr. Electrothermally-assisted capsular

shift. IEEE Eng Med Biol Mag. 1998;17(3):102-104.

11. 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.

12. Enad JG, ElAttrache NS, Tibone JE, Yocum LA. Isolated

electrothermal capsulorrhaphy in overhand athletes. J

Shoulder Elbow Surg. 2004;13(2):133-137.

13. 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.

14. Friedberg RP. Anterior cruciate ligament injury.

UpToDate [online serial]. Waltham, MA:

UpToDate; reviewed March 2017.

15. Garcia-Lopez I, Delgado PJ, Abad JM, Garcia De Lucas F.

Thermal energy for the arthroscopic treatment of

tears of the triangular fibrocartilage of the wrist. Acta

Orthop Belg. 2012;78(6):719-723.

16. Gartsman GM, Roddey TS, Hammerman SM.

Arthroscopic treatment of bidirectional glenohumeral

instability: Two- to five-year follow-up. J Shoulder

Elbow Surg. 2001;10(1):28-36.

17. Gartsman GM, Roddey TS, Hammerman SM.

Arthroscopic treatment of multidirectional

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

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

18. Gerber A, Warner JJ. Thermal capsulorrhaphy to treat

shoulder instability. Clin Orthop. 2002;(400):105-116.

19. Gieringer RE. Arthroscopic monopolar radiofrequency

thermal capsulorrhaphy for the treatment of shoulder

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instability: A prospective outcome study with mean

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

20. 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.

21. Hanypsiak BT, Faulks C, Fine K, et al. Rupture of the

biceps tendon after arthroscopic thermal

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

22. 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.

23. Hawkins RJ, Krishnan SG, Karas SG, et al.

Electrothermal arthroscopic shoulder capsulorrhaphy:

A minimum 2-year follow-up. Am J Sports Med.

2007;35(9):1484-1488.

24. 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.

25. 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.

26. 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.

27. Imhoff AB, Roscher E, Konig U. Arthroscopic shoulder

stabilization. Differentiated treatment strategy with

Suretac, Fastak, Holmium: YAG-laser and

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

28. Indelli PF, Dillingham MF, Fanton GS, Schurman DJ.

Monopolar thermal treatment of symptomatic

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anterior cruciate ligament instability. Clin Orthop.

2003;(407):139-147.

29. 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.

30. Khan AM, Fanton GS. Electrothermal assisted shoulder

capsulorrhaphy--monopolar. Clin Sports Med. 2002;21

(4):599-618.

31. Lazarus MD, Harryman DT 2nd. Complications of open

anterior stabilization of the shoulder. J Am Acad

Orthop Surg. 2000;8(2):122-132.

32. Lephart SM, et al. Shoulder propioception and function

following thermal capsulorrhaphy. Arthroscopy.

2002;18(7):573-577.

33. Levine WN, Flatow EL. The pathophysiology of

shoulder instability. Am J Sports Med. 2000;28(6):910-

917.

34. 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.

35. 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.

36. Levy O, Wilson M, Williams H, et al. Thermal capsular

shrinkage for shoulder instability. Mid-term

longitudinal outcome study. J Bone Joint Surg Br.

2001;83(5):640-655.

37. Lubowitz JH. Thermal modification of the lax anterior

cruciate ligament using radiofrequency: Efficacy or

catastrophe? Knee Surg Sports Traumatol Arthrosc.

2005;13(6):432-436.

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

assisted capsulorrhaphy for multidirectional instability

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

Proprietary


39. Mahaffey BL, Smith PA. Shoulder instability in young

athletes. Am Fam Physician. 1999;59(10):2773-2782,

2787.

40. Mandl LA, Marin GM. Overview of surgical therapy of

knee and hip osteoarthritis. UpToDate [online serial].

Waltham, MA: UpToDate; reviewed April 2015.

41. 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.

42. McRae S, Leiter J, Subramanian K, et al. Randomized

controlled trial of arthroscopic electrothermal

capsulorrhaphy with Bankart repair and isolated

arthroscopic Bankart repair. Knee Surg Sports

Traumatol Arthrosc. 2016;24(2):414-421.

43. Medvecky MJ, Ong BC, Rokito AS, Sherman OH.

Thermal capsular shrinkage: Basic science and clinical

applications. Arthroscopy. 2001;17(6):624-635.

44. Miniaci A, McBirnie J. Thermal capsular shrinkage for

treatment of multidirectional instability of the

shoulder. J Bone Joint Surg Am. 2003;85-A(12):2283-

2287.

45. 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.

46. Mohtadi NG, Kirkley A, Hollinshead RM, et al; Joint

Orthopaedic Initiative for National Trials of the

Shoulder-Canada. Electrothermal arthroscopic

capsulorrhaphy: Old technology, new evidence. A

multicenter randomized clinical trial. J Shoulder Elbow

Surg. 2014;23(8):1171-1180.

47. Monaghan BA. Uses and abuses of wrist arthroscopy.

Tech Hand Up Extrem Surg. 2006;10(1):37-42.

Proprietary


48. Nelson BJ, Arciero RA. Arthroscopic management of

glenohumeral instability. Am J Sports Med. 2000;28

(4):602-614.

49. Noonan TJ, Tokish JM, Briggs KK, Hawkins RJ. Laser-

assisted thermal capsulorrhaphy. Arthroscopy.

2003;19(8):815-819.

50. Norlin R, Karlsson J. Shoulder instability. Review of

current trends in treatment. Scand J Med Sci Sports.

1998;8(6):394-397.

51. Nottage WM. Laser-assisted shoulder surgery.

Arthroscopy. 1997;13(5):635-638.

52. Oakes DA, McAllister DR. Failure of heat shrinkage for

treatment of a posterior cruciate ligament tear.

Arthroscopy. 2003;19(6):E1-E4.

53. 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.

54. Philippon MJ. The role of arthroscopic thermal

capsulorrhaphy in the hip. Clin Sports Med. 2001;20

(4):817-829.

55. 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.

56. Romero EC, Arias AA, Serrano DD, et al. Arthroscopic

electrothermal collagen shrinkage for partial

scapholunate ligament tears, isolated or with

associated triangular fibrocartilage complex injuries: A

prospective study. Musculoskelet Surg 2020; Mar 2

[Online ahead of print].

57. Savoie FH 3rd, Field LD. Thermal versus suture

treatment of symptomatic capsular laxity. Clin Sports

Med. 2000;19(1):63-75, vi.

58. Selecky MT, Vangsness CT Jr, Liao WL, et al. The effects

of laser-induced collagen shortening on the

biomechanical properties of the inferior glenohumeral

Proprietary


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

172.

59. Shih JT, Lee HM. Monopolar radiofrequency

electrothermal shrinkage of the scapholunate

ligament. Arthroscopy. 2006;22(5):553-557.

60. Smith DB, Carter TR, Johnson DH. High failure rate for

electrothermal shrinkage of the lax anterior cruciate

ligament: A multicenter follow-up past 2 years.

Arthroscopy. 2008;24(6):637-641.

61. Spahn G, Kirschbaum S, Klinger HM, Wittig R.

Arthroscopic electrothermal shrinkage of chronic

posterolateral elbow instability: Good or moderate

outcome in 21 patients followed for an average of 2.5

years. Acta Orthop. 2006;77(2):285-289.

62. Tibone JE, Lee TQ, Black AD, et al. Glenohumeral

translation after arthroscopic thermal capsuloplasty

with a radiofrequency probe. J Shoulder Elbow Surg.

2000;9(6):514-518.

63. Torres DE, McCain JP. Arthroscopic electrothermal

capsulorrhaphy for the treatment of recurrent

temporomandibular joint dislocation. Int J Oral

Maxillofac Surg. 2012;41(6):681-689.

64. 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. 2000;30(7):390-400.

65. Wall MS, Deng XH, Torzilli PA, et al. Thermal

modification of collagen. J Shoulder Elbow Surg. 1999;8

(4):339-344.

66. Walton J, Paxinos A, Tzannes A, et al. The unstable

shoulder in the adolescent athlete. Am J Sports Med.

2002;30(5):758-767.

67. Washington State Department of Labor and Industries,

Office of the Medical Director. Thermal shrinkage for

the treatment of shoulder instability and anterior

cruciate ligament laxity. Health Technology

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Assessment. Olympia, WA: Washington State

Department of Labor and Industries; June 3, 2003.

68. Wolf RS, Lemak LJ. Thermal capsulorrhaphy in the

treatment of multidirectional instability of the

shoulder. J South Orthop Assoc. 2002;11(2):102-109.

69. Wong KL, Williams GR. Complications of thermal

capsulorrhaphy of the shoulder. J Bone Joint Surg Am.

2001;83-A Suppl 2 Pt 2:151-155.

70. Wright RJ. Synovectomy for inflammatory arthritis of

the knee. UpToDate [online serial]. Waltham, MA:

UpToDate; reviewed April 2015.

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

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

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subject to change.

Copyright © 2001-2020 Aetna Inc.

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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 revised 08/18/2020

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http://www.aetnabetterhealth.com/pennsylvania

0545 Electrothermal Arthroscopy (1) - Aetna Better Health

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