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Radiofrequency Ablation in Osteoid Osteoma of the Finger
Radiofrequency Ablation in Osteoid Osteoma of the Finger Luis Ramos, PhD, José Ángel Santos, PhD, Genoveva Santos, MD, Salamanca, Spain, Jesús Guiral, PhD, Segovia, Spain
The occurrence of osteoid osteomas of the hand is rare and their treatment usually is surgical. A 26-year-old man with an osteoid osteoma in the proximal phalanx of the right middle finger was treated with percutaneous radiofrequency ablation. Two years later he remains free of pain and finger function is normal. (J Hand Surg 2005;30A:798 – 802. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Osteoid osteoma, phalanx, finger, percutaneous, radiofrequency.
Osteoid osteoma is a benign osteoblastic lesion characterized by a nidus of usually less than 1 cm surrounded by a zone of reactive sclerosis. It is estimated that it accounts for approximately 11% of all benign bone tumors.1 Although it generally is located in the femur and the tibia, 13% to 31% of these lesions are found in the upper extremity,2,3 and it may be present in the hand in up to 5% of cases.2,4 Percutaneous radiofrequency ablation of an osteoid osteoma in the phalanx of the hand has been performed exceptionally.5
Case Report A 26-year-old right-handed man described a 30month history of pain, swelling, and limited motion in his right middle finger. He described the pain as an
From the Departments of Orthopaedic Surgery and Radiology, University Hospital, Salamanca, Spain; and the Department of Orthopaedic Surgery, General Hospital, Segovia, Spain. Received for publication November 11, 2004; accepted in revised form March 15, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Luis Ramos, PhD, Department of Traumatología y Cirugı´a Ortopédica, Paseo de San Vicente, 108-182, 37007Salamanca, Spain; e-mail: [email protected]. Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A04-0023$30.00/0 doi:10.1016/j.jhsa.2005.03.009
798
The Journal of Hand Surgery
intense, continuous, and nocturnal ache that was controlled partially by analgesics. He never took aspirin, and there was no significant history of trauma or infection. Physical examination showed tenderness over the proximal interphalangeal joint and proximal phalanx, swelling, and decreased range of motion (Fig. 1). Anteroposterior and lateral radiographs showed a small lytic lesion in the distal metaphysis of the proximal phalanx with mild reactive-appearing periosteal bone formation (Fig. 2). A bone scan showed increased uptake (Fig. 3), and computed tomography and magnetic resonance imaging confirmed the lucent nidus in the volar aspect of the proximal phalanx and soft-tissue inflammation (Figs. 4, 5). Laboratory results were normal. By using computed tomography the nidus of the osteoid osteoma was localized. Under local anesthesia, a 1.5 mm K-wire was placed into the lesion’s center through a palmar approach between the ulnar border of the flexor tendon and the ulnar neurovascular bundle. A cannula was placed over the wire and the wire was replaced through the cannula by a straight electrode (TEW-STC; Radionics, Burlington, MA). The electrode was insulated throughout the length except for the terminal 5 mm and was heated to 75°C for 4 minutes with a radiofrequency generator (RFG3CF; Radionics) (Fig. 6). The neurovascular bundle was 6 mm from the electrode tip. The electrode and
Ramos et al / Radiofrequency Ablation in Osteoid Osteoma
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Figure 1. Initial appearance of right middle finger.
the cannula were removed and the small skin wound was closed with sterile tape. A light dressing was applied to the finger. A specimen was not obtained for histologic testing. Figure 3. Bone scan showing increased uptake.
After surgery the patient noted immediate relief of the previous finger pain, although he had transient paresthesia on the ulnar side of the finger for 2 months. Proximal interphalangeal joint motion was started immediately and the patient returned to work after 1 month. At the 2-month follow-up evaluation he was completely free of pain and had full range of motion of his finger. Two years later he remains without pain (Fig. 7). Radiographic examination showed a persistent small lytic lesion in the phalanx (Fig. 8).
Discussion
Figure 2. Posteroanterior x-ray of the proximal phalanx of the middle finger. The arrow indicates the nidus.
Approximately 6% of osteoid osteomas in the hand and half to three quarters of these are located in the phalanges, especially in the proximal phalanx.3,6 – 8 The appearance of osteoid osteoma in the hand shows certain similarities to osteoid osteoma elsewhere in the skeleton, but it can be unusual. Painless lesions and synovitis with effusion in the finger can exist.4,9 –11 Radiologically the typical aspects of osteoid osteoma are found in only 65% of cases.12 Consequently the diagnosis and treatment may be missed and delayed,6,13 especially in the distal phalanx.14 The clinical and radiographic presentation of
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The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Figure 4. Computed tomography scan in the axial plane shows a typical nidus in the volar aspect of the phalanx (arrow).
osteoid osteoma in our patient was typical. Most cases are diagnosed by history and then confirmed by clinical examination and specific imaging methods.8,15 The classic treatment of an osteoid osteoma, including those of the hand, is to remove all of the nidus by en bloc resection or curettage.3,7–9,12,14,16 –18 It can be difficult to know how much bone to remove and may necessitate using grafts, internal fixation, and postoperative immobilization. In the hand curettage may
be incomplete, leaving residual tumor cells that may explain the recurrence of the lesion.17 Other times it may be necessary to perform an arthrodesis8 or even a fingertip amputation.6,14 Percutaneous radiofrequency ablation, introduced in 1992 by Rosenthal et al,19 has primary clinical success rates between 73% and 95% with minimal complications.19,20 The procedure causes thermal necrosis of a spheric area approximately 1 cm in diam-
Figure 5. Magnetic resonance image in the axial plane on T1 shows a typical nidus on the volar surface of the phalanx (arrow).
Ramos et al / Radiofrequency Ablation in Osteoid Osteoma
801
Figure 6. Computed tomography scan shows the radiofrequency electrode within the nidus.
eter. Because the effect of the treatment is not tissue specific, no vital structures should be within 1 cm of the tip of the electrode.1,15 Because of this requirement, Torriani and Rosenthal,6 with over 250 pa-
Figure 7. Appearance of the finger 2 years after thermocoagulation.
tients treated, declined to treat osteoid osteomas of the hand and posterior elements of the spine. Barei et al1 also suggested that this technique should be used for patients with extraspinal osteoid osteomas that are not immediately adjacent to neurovascular structures. In contrast, Vanderschueren et al5 said that thermocoagulation is safe and effective at any location, and cases in the spine have been published.21–25 With the same precautions it could be performed in the phalanges of the hand. In the finger, thermal damage to digital neurovascular structures or tendons could take place because of the close proximity to the treated area.26 In our case the neurovascular bundle was more than 5 mm distant from the active portion of the electrode. The flexor tendons were less than 5 mm away, however, they remained intact. Because of the effects of the monopolar radiofrequency energy to produce joint capsular shrinkage,27 stiffness of the finger also could take place.27 Neither happened in our case. Radiofrequency ablation of osteoid osteomas in the phalanges of the hand has been published in 2 patients, including our case, and complications of technical difficulties associated with the procedure have not been reported.5 Percutaneous radiofrequency ablation of the nidus in osteoid osteomas recently has been introduced and
802
The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Figure 8. Posteroanterior x-ray 2 years after thermocoagulation.
offers advantages as compared with traditional open resection. In the phalanges of the hands the procedure could be performed on outpatients with local anesthesia and the patients could resume all daily activities immediately without casts, splints, or other external supports. A larger series of phalangeal osteoid osteomas treated with radiofrequency ablation is necessary to determine the safety and efficacy.
References 1. Barei DP, Moreau G, Scarborough MR, Neel MD. Percutaneous radiofrequency ablation of osteoid osteoma. Clin Orthop 2000;373:115–124. 2. Yildiz Y, Bayrakci K, Altay M, Saglik Y. Osteoid osteoma: the results of surgical treatment. Int Orthop 2001;25:119 – 122. 3. Bednar MS, McCormack RR Jr, Glasser D, Weiland AJ. Osteoid osteoma of the upper extremity. J Hand Surg 1993; 18A:1019 –1028. 4. Unni KK. Osteoid osteoma. In: Unni KK, ed. Dhalin’s bone tumors. General aspects and data on 11,087 cases. 5th ed. Philadelphia: Lippincott-Raven Publishers, 1996:121–130. 5. Vanderschueren GM, Taminiau AHM, Obermann WR, Bloem JL. Osteoid osteoma: clinical results with thermocoagulation. Radiology 2002;224:82– 86. 6. Torriani M, Rosenthal DI. Percutaneous radiofrequency treatment of osteoid osteoma. Pediatr Radiol 2002;32:615– 618.
7. De Smet L, Fabry G. Osteoid osteoma of the hand and carpus: peculiar presentations and imaging. Acta Orthop Belg 1995;61:113–116. 8. Allieu Y, Lussiez B. L’Ostéome ostéoïde au niveau de la main. A propos de quarante-six cas. Ann Chir Main 1988; 7:298 –304. 9. Chen SC, Caplan H. An unusual site of osteoid osteoma in the proximal phalanx of a finger. J Hand Surg 1989;14B: 341–344. 10. Walker LG, Meals RA. Painless osteoid osteoma of the phalanx. Orthopedics 1989;12:774 –776. 11. Wiss DA, Reid BS. Painless osteoid osteoma of the fingers. Report of three cases. J Hand Surg 1983;8:914 –917. 12. Allieu Y, Lussiez B, Benichou M, Cenac P. A double nidus osteoid osteoma in a finger. J Hand Surg 1989;14A:538 – 541. 13. O’Hara JP III, Tegtmeyer C, Sweet DE, McCue FC. Angiography in the diagnosis of osteoid-osteoma of the hand. J Bone Joint Surg 1975;57A:163–166. 14. Brown RE, Russell JB, Zook EG. Osteoid osteoma of the distal phalanx of the finger: a diagnostic challenge. Plast Reconstr Surg 1991;90:1016 –1021. 15. Rosenthal DI, Springfield DS, Gebhardt MC, Rosenberg AE, Mankin HJ. Osteoid osteoma: percutaneous radio-frequency ablation. Radiology 1995;197:451– 454. 16. Rex C, Jacobs L, Nur Z. Painless osteoid osteoma of the middle phalanx. J Hand Surg 1997;22B:798 – 800. 17. Soler JM, Pizà G, Aliaga F. Special characteristics of osteoid osteoma in the proximal phalanx. J Hand Surg 1997;22B: 793–797. 18. Inagaki H, Inoue G. Osteoid osteoma of the distal phalanx. Orthopedics 1999;22:1093–1094. 19. Rosenthal DI, Alexander A, Rosenberg AE, Springfield DS. Ablation of osteoid osteomas with a percutaneously placed electrode: a new procedure. Radiology 1992;183:29 –33. 20. Ambrosia JM, Wold LE, Amadio PC. Osteoid osteoma of the hand and wrist. J Hand Surg 1987;12A:794 – 800. 21. Cové JA, Taminiau AH, Obermann WR, Vanderschueren GM. Osteoid osteoma of the spine treated with percutaneous computed tomography-guided thermocoagulation. Spine 2000;25:1283–1286. 22. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR Am J Roentgenol 2000;175:1263–1266. 23. Lindner NJ, Ozaki T, Roedl R, Gosheger G, Winkelmann W, Wörtler K. Percutaneous radiofrequency ablation in osteoid osteoma. J Bone Joint Surg 2001;83B:391–396. 24. Osti OL, Sebben R. High-frequency radio-wave ablation of osteoid osteoma in the lumbar spine. Eur Spine J 1998;7: 422– 425. 25. De Berg JC, Pattynama PMT, Obermann WR, Bode PJ, Vielvoye GJ, Taminiau AHM. Percutaneous computed-tomography-guided thermocoagulation for osteoid osteomas. Lancet 1995;346:350 –351. 26. Letcher FS, Goldring S. The effect of radiofrequency current and heat on peripheral nerve action potential in the cat. J Neurosurg 1968;29:42– 47. 27. Lopez MJ, Hayashi K, Vanderby R Jr, Thabit G III, Fanton GS, Markel MD. Effects of monopolar radiofrequency energy on ovine joint capsular mechanical properties. Clin Orthop 2000;374:286 –297.
The occurrence of osteoid osteomas of the hand is rare and their treatment usually is surgical. A 26-year-old man with an osteoid osteoma in the proximal phalanx of the right middle finger was treated with percutaneous radiofrequency ablation. Two years later he remains free of pain and finger function is normal. (J Hand Surg 2005;30A:798 – 802. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Osteoid osteoma, phalanx, finger, percutaneous, radiofrequency.
Osteoid osteoma is a benign osteoblastic lesion characterized by a nidus of usually less than 1 cm surrounded by a zone of reactive sclerosis. It is estimated that it accounts for approximately 11% of all benign bone tumors.1 Although it generally is located in the femur and the tibia, 13% to 31% of these lesions are found in the upper extremity,2,3 and it may be present in the hand in up to 5% of cases.2,4 Percutaneous radiofrequency ablation of an osteoid osteoma in the phalanx of the hand has been performed exceptionally.5
Case Report A 26-year-old right-handed man described a 30month history of pain, swelling, and limited motion in his right middle finger. He described the pain as an
From the Departments of Orthopaedic Surgery and Radiology, University Hospital, Salamanca, Spain; and the Department of Orthopaedic Surgery, General Hospital, Segovia, Spain. Received for publication November 11, 2004; accepted in revised form March 15, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Luis Ramos, PhD, Department of Traumatología y Cirugı´a Ortopédica, Paseo de San Vicente, 108-182, 37007Salamanca, Spain; e-mail: [email protected]. Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A04-0023$30.00/0 doi:10.1016/j.jhsa.2005.03.009
798
The Journal of Hand Surgery
intense, continuous, and nocturnal ache that was controlled partially by analgesics. He never took aspirin, and there was no significant history of trauma or infection. Physical examination showed tenderness over the proximal interphalangeal joint and proximal phalanx, swelling, and decreased range of motion (Fig. 1). Anteroposterior and lateral radiographs showed a small lytic lesion in the distal metaphysis of the proximal phalanx with mild reactive-appearing periosteal bone formation (Fig. 2). A bone scan showed increased uptake (Fig. 3), and computed tomography and magnetic resonance imaging confirmed the lucent nidus in the volar aspect of the proximal phalanx and soft-tissue inflammation (Figs. 4, 5). Laboratory results were normal. By using computed tomography the nidus of the osteoid osteoma was localized. Under local anesthesia, a 1.5 mm K-wire was placed into the lesion’s center through a palmar approach between the ulnar border of the flexor tendon and the ulnar neurovascular bundle. A cannula was placed over the wire and the wire was replaced through the cannula by a straight electrode (TEW-STC; Radionics, Burlington, MA). The electrode was insulated throughout the length except for the terminal 5 mm and was heated to 75°C for 4 minutes with a radiofrequency generator (RFG3CF; Radionics) (Fig. 6). The neurovascular bundle was 6 mm from the electrode tip. The electrode and
Ramos et al / Radiofrequency Ablation in Osteoid Osteoma
799
Figure 1. Initial appearance of right middle finger.
the cannula were removed and the small skin wound was closed with sterile tape. A light dressing was applied to the finger. A specimen was not obtained for histologic testing. Figure 3. Bone scan showing increased uptake.
After surgery the patient noted immediate relief of the previous finger pain, although he had transient paresthesia on the ulnar side of the finger for 2 months. Proximal interphalangeal joint motion was started immediately and the patient returned to work after 1 month. At the 2-month follow-up evaluation he was completely free of pain and had full range of motion of his finger. Two years later he remains without pain (Fig. 7). Radiographic examination showed a persistent small lytic lesion in the phalanx (Fig. 8).
Discussion
Figure 2. Posteroanterior x-ray of the proximal phalanx of the middle finger. The arrow indicates the nidus.
Approximately 6% of osteoid osteomas in the hand and half to three quarters of these are located in the phalanges, especially in the proximal phalanx.3,6 – 8 The appearance of osteoid osteoma in the hand shows certain similarities to osteoid osteoma elsewhere in the skeleton, but it can be unusual. Painless lesions and synovitis with effusion in the finger can exist.4,9 –11 Radiologically the typical aspects of osteoid osteoma are found in only 65% of cases.12 Consequently the diagnosis and treatment may be missed and delayed,6,13 especially in the distal phalanx.14 The clinical and radiographic presentation of
800
The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Figure 4. Computed tomography scan in the axial plane shows a typical nidus in the volar aspect of the phalanx (arrow).
osteoid osteoma in our patient was typical. Most cases are diagnosed by history and then confirmed by clinical examination and specific imaging methods.8,15 The classic treatment of an osteoid osteoma, including those of the hand, is to remove all of the nidus by en bloc resection or curettage.3,7–9,12,14,16 –18 It can be difficult to know how much bone to remove and may necessitate using grafts, internal fixation, and postoperative immobilization. In the hand curettage may
be incomplete, leaving residual tumor cells that may explain the recurrence of the lesion.17 Other times it may be necessary to perform an arthrodesis8 or even a fingertip amputation.6,14 Percutaneous radiofrequency ablation, introduced in 1992 by Rosenthal et al,19 has primary clinical success rates between 73% and 95% with minimal complications.19,20 The procedure causes thermal necrosis of a spheric area approximately 1 cm in diam-
Figure 5. Magnetic resonance image in the axial plane on T1 shows a typical nidus on the volar surface of the phalanx (arrow).
Ramos et al / Radiofrequency Ablation in Osteoid Osteoma
801
Figure 6. Computed tomography scan shows the radiofrequency electrode within the nidus.
eter. Because the effect of the treatment is not tissue specific, no vital structures should be within 1 cm of the tip of the electrode.1,15 Because of this requirement, Torriani and Rosenthal,6 with over 250 pa-
Figure 7. Appearance of the finger 2 years after thermocoagulation.
tients treated, declined to treat osteoid osteomas of the hand and posterior elements of the spine. Barei et al1 also suggested that this technique should be used for patients with extraspinal osteoid osteomas that are not immediately adjacent to neurovascular structures. In contrast, Vanderschueren et al5 said that thermocoagulation is safe and effective at any location, and cases in the spine have been published.21–25 With the same precautions it could be performed in the phalanges of the hand. In the finger, thermal damage to digital neurovascular structures or tendons could take place because of the close proximity to the treated area.26 In our case the neurovascular bundle was more than 5 mm distant from the active portion of the electrode. The flexor tendons were less than 5 mm away, however, they remained intact. Because of the effects of the monopolar radiofrequency energy to produce joint capsular shrinkage,27 stiffness of the finger also could take place.27 Neither happened in our case. Radiofrequency ablation of osteoid osteomas in the phalanges of the hand has been published in 2 patients, including our case, and complications of technical difficulties associated with the procedure have not been reported.5 Percutaneous radiofrequency ablation of the nidus in osteoid osteomas recently has been introduced and
802
The Journal of Hand Surgery / Vol. 30A No. 4 July 2005
Figure 8. Posteroanterior x-ray 2 years after thermocoagulation.
offers advantages as compared with traditional open resection. In the phalanges of the hands the procedure could be performed on outpatients with local anesthesia and the patients could resume all daily activities immediately without casts, splints, or other external supports. A larger series of phalangeal osteoid osteomas treated with radiofrequency ablation is necessary to determine the safety and efficacy.
References 1. Barei DP, Moreau G, Scarborough MR, Neel MD. Percutaneous radiofrequency ablation of osteoid osteoma. Clin Orthop 2000;373:115–124. 2. Yildiz Y, Bayrakci K, Altay M, Saglik Y. Osteoid osteoma: the results of surgical treatment. Int Orthop 2001;25:119 – 122. 3. Bednar MS, McCormack RR Jr, Glasser D, Weiland AJ. Osteoid osteoma of the upper extremity. J Hand Surg 1993; 18A:1019 –1028. 4. Unni KK. Osteoid osteoma. In: Unni KK, ed. Dhalin’s bone tumors. General aspects and data on 11,087 cases. 5th ed. Philadelphia: Lippincott-Raven Publishers, 1996:121–130. 5. Vanderschueren GM, Taminiau AHM, Obermann WR, Bloem JL. Osteoid osteoma: clinical results with thermocoagulation. Radiology 2002;224:82– 86. 6. Torriani M, Rosenthal DI. Percutaneous radiofrequency treatment of osteoid osteoma. Pediatr Radiol 2002;32:615– 618.
7. De Smet L, Fabry G. Osteoid osteoma of the hand and carpus: peculiar presentations and imaging. Acta Orthop Belg 1995;61:113–116. 8. Allieu Y, Lussiez B. L’Ostéome ostéoïde au niveau de la main. A propos de quarante-six cas. Ann Chir Main 1988; 7:298 –304. 9. Chen SC, Caplan H. An unusual site of osteoid osteoma in the proximal phalanx of a finger. J Hand Surg 1989;14B: 341–344. 10. Walker LG, Meals RA. Painless osteoid osteoma of the phalanx. Orthopedics 1989;12:774 –776. 11. Wiss DA, Reid BS. Painless osteoid osteoma of the fingers. Report of three cases. J Hand Surg 1983;8:914 –917. 12. Allieu Y, Lussiez B, Benichou M, Cenac P. A double nidus osteoid osteoma in a finger. J Hand Surg 1989;14A:538 – 541. 13. O’Hara JP III, Tegtmeyer C, Sweet DE, McCue FC. Angiography in the diagnosis of osteoid-osteoma of the hand. J Bone Joint Surg 1975;57A:163–166. 14. Brown RE, Russell JB, Zook EG. Osteoid osteoma of the distal phalanx of the finger: a diagnostic challenge. Plast Reconstr Surg 1991;90:1016 –1021. 15. Rosenthal DI, Springfield DS, Gebhardt MC, Rosenberg AE, Mankin HJ. Osteoid osteoma: percutaneous radio-frequency ablation. Radiology 1995;197:451– 454. 16. Rex C, Jacobs L, Nur Z. Painless osteoid osteoma of the middle phalanx. J Hand Surg 1997;22B:798 – 800. 17. Soler JM, Pizà G, Aliaga F. Special characteristics of osteoid osteoma in the proximal phalanx. J Hand Surg 1997;22B: 793–797. 18. Inagaki H, Inoue G. Osteoid osteoma of the distal phalanx. Orthopedics 1999;22:1093–1094. 19. Rosenthal DI, Alexander A, Rosenberg AE, Springfield DS. Ablation of osteoid osteomas with a percutaneously placed electrode: a new procedure. Radiology 1992;183:29 –33. 20. Ambrosia JM, Wold LE, Amadio PC. Osteoid osteoma of the hand and wrist. J Hand Surg 1987;12A:794 – 800. 21. Cové JA, Taminiau AH, Obermann WR, Vanderschueren GM. Osteoid osteoma of the spine treated with percutaneous computed tomography-guided thermocoagulation. Spine 2000;25:1283–1286. 22. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR Am J Roentgenol 2000;175:1263–1266. 23. Lindner NJ, Ozaki T, Roedl R, Gosheger G, Winkelmann W, Wörtler K. Percutaneous radiofrequency ablation in osteoid osteoma. J Bone Joint Surg 2001;83B:391–396. 24. Osti OL, Sebben R. High-frequency radio-wave ablation of osteoid osteoma in the lumbar spine. Eur Spine J 1998;7: 422– 425. 25. De Berg JC, Pattynama PMT, Obermann WR, Bode PJ, Vielvoye GJ, Taminiau AHM. Percutaneous computed-tomography-guided thermocoagulation for osteoid osteomas. Lancet 1995;346:350 –351. 26. Letcher FS, Goldring S. The effect of radiofrequency current and heat on peripheral nerve action potential in the cat. J Neurosurg 1968;29:42– 47. 27. Lopez MJ, Hayashi K, Vanderby R Jr, Thabit G III, Fanton GS, Markel MD. Effects of monopolar radiofrequency energy on ovine joint capsular mechanical properties. Clin Orthop 2000;374:286 –297.