Thermal capsular shrinkage: Basic science and clinical applications

Recently, the use of thermal energy to shrink the redundant glenohumeral joint capsule in patients with instability has generated a great deal of interest. Proponents assert that the procedure avoids the need for an open stabilization and it may be used as an adjunct to an open or arthroscopic capsulolabral repair. The use of nonablative thermal energy to shrink soft-tissue collagen appears to induce ultra-structural and mechanical changes at or above 60 degrees C. The microscopic changes reflect the unwinding of the collagen triple helix and loss of the fiber orientation. The fibrils contract into a shortened state and reactive fibroblasts have been shown to grow into this treated area and synthesize the collagen matrix. The biomechanical properties of the tissue do not appear to be detrimentally altered if shrinkage is limited to less than 15% and if ablation or excess focal treatment is avoided. The endpoint of optimal shrinkage is not known and clinical estimations of tissue changes and volumetric reduction are used as guides to treatment. The first clinical follow-up study was only recently published in the peer-reviewed literature and prior preliminary reports were optimistic regarding the use of thermal energy for the treatment of glenohumeral instability. Thermal capsular shrinkage has been used as an adjunct to a capsulolabral repair, as well as an isolated treatment for the disorders of internal impingement and multidirectional instability. Additional evaluation is necessary to determine the optimal quantity of energy needed for tissue shrinkage without inadvertent tissue destruction. The long-term clinical effect, mechanical properties, and durability of the newly produced collagen need to be analyzed further. The basic science and clinical applications of this newly applied technology are reviewed in this article.