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Offering insights from their clinical experience, the panelists discuss the technology of Coblation® therapy and its potential value in treating other conditions.
Dr. Eickmeier: How does this technology work and how does the body react to the Topaz® therapy?
Dr. Werber: Coblation technology is a bipolar radiofrequency-based technology that works at low temperatures, approximately 40º to 70º C, to create a plasma field which disassociates the membrane of the cells. Accordingly, one does not see necrosis. There is a release of elemental atoms of hydrogen and oxygen but there is also a stimulation of growth factors, which initiates angiogenesis, leading to a formation of new bloood vessels within the tissue.
Dr. Eickmeier: Dr. McGlamry, can you discuss the differences between the Topaz procedure and needling of the plantar fascia?
Dr. McGlamry: In order to understand needling or simple penetration of the fascia versus the Topaz procedure, one should review the animal model studies that were done in the early days of Coblation therapy.6,7 In these studies, researchers showed that there was only local disruption with the needling versus more volumetric tissue effect with the Topaz. When looking at the histologic sections of that tissue at three to four weeks and then again at three to four months, there had been no change in the tissue that had the sham treatment or what I am interpreting as needling. With the Topaz treatment, you saw marked inflammation at three to four weeks, neovascularization and disruption of the sheets of tissue typically seen for tendon or fascia.
|  | | “The Topaz is a great treatment on its own and has potential use adjunctively in some patients who have failed to respond, even after you have done all the right mechanical things conservatively and/or surgically”
— Michael McGlamry, DPM |
Interestingly enough, by 90 days after the initial treatment with needling, you really had no change at all in the tissue appearance. However, 90 days after the initial treatment with Coblation therapy, there was a new organization of sheets of tissue that was consistent with relatively normal organization for tendon or fascia.
Can Coblation Therapy Be Helpful In Treating Tendonosis?
Dr. Eickmeier: In addition to plantar fasciosis, what other types of pathologies are you currently using the Topaz for?
Dr. Werber: In addition to plantar fasciosis, I typically use Topaz for multiple forms of tendonosis. Lately, I have been using it for second MPJ pathology to treat some of the synovitis.
Let us talk about tendonosis first. Using the Achilles tendon as an example, you want to localize the area of pain. Typically I utilize an MRI study or ultrasound study so I have an anatomic idea of the pathology’s location. I also try to correlate that with the patient’s pain.
I will anesthetize the patient with either intravenous (IV) sedation or a local anesthetic. I will use a traditional surgical approach with prep and drape. I make a small incision (about 2 cm) that overlays the area of pathology and dissect down to the tendon to isolate the pathology. Typically, you see the changes within the tendons and possibly some longitudinal tearing. You may see quite a bit of tenosynovitis, a lot of fluid buildup and/or some yellowing of the tendon. If there is quite a bit of thickening in nodule formation, I debride this nodule and then use the Topaz in greater matrix.
|  | | “In addition to plantar fasciosis, Coblation therapy has given us added tools in treating Achilles tendonitis, peroneal tendonitis and posterior tendonitis.”
— Bruce Werber, DPM |
The matrix is of varying depths, going across and creating a rectangular pattern. Then I go along the sides of the tendon and sometimes reflect the tendon so I can go on the inferior surface. I flush the surgical site and perform a fairly minimal closure of the deep tissue. I close over the paratenon and perform a traditional closure from there.
I do not use steroids but I do typically use some Marcaine proximally and a bulky dressing. I keep the patient either in a posterior splint or cam walker-type device. I do not want a lot of pressure on the wound and keep patients partially weightbearing with crutches. I do not prescribe nonsteroidal antiinflammatory drugs (NSAIDs) afterward. I just use a mild analgesic. Patients very rarely require any pain medication.
Dr. Eickmeier: Dr. McGlamry, on the same note, can you discuss your experience with using the Topaz for tendonosis of the foot and ankle?
Dr. McGlamry: I have usually employed this procedure for patients who have failed to respond to conservative care. For example, I consider this modality for patients who have had chronic peroneal tendonitis and have not responded to valgus wedging of the orthotic, antiinflammatories or injections.
When you get the MRI and there is no obvious tear within the tissue, I now regard these patients as being chronic non-responders with tendinosis. At this point, we offer them the option of Coblation therapy. We will go in and, through a minimally invasive approach, isolate the point of maximum tenderness. Through an approximately 2 cm incision, we will open up and expose the area of the tendon, isolate it and create the treatment grid using the Topaz. We have been very successful with this.
|  | | “I get patients back into shoes following the fasciosis procedure with Topaz in two weeks and back into an orthotic or at least an additional OTC arch support.”
— Michael McGlamry, DPM |
I have also had experience using the Topaz procedure in patients who have had chronic tibialis posterior tendon dysfunction. We have done rearfoot stabilization procedures on patients who continue to have some residual symptoms. For these patients, we will go back and perform a Topaz procedure and see a fairly marked reduction in their remaining tendonosis-type symptoms.
In my view, the Topaz is a great treatment on its own and has potential use adjunctively in some patients who have failed to respond, even after you have done all the right mechanical things conservatively and/or surgically.
Can The Topaz Procedure Be Beneficial With Other Conditions?
Dr. Eickmeier: Dr. Werber, you had mentioned that you are using the Topaz procedure for other applications. Can you elaborate on that?
Dr. Werber: Using Coblation technology in arthroscopy has been very beneficial for doing synovectomies versus using a shaver. There is less post-arthroscopic bleeding and tremendous response within the joint.
|  | | “Whether you are treating plantar fasciosis or any of the tendons in the foot and ankle, the Topaz procedure seems to offer a very low risk with almost immediate pain relief in most of these patients. ”
— Bruce Werber, DPM |
I have looked at my outcomes with ankle arthroscopy and now look at early stages of second MPJ pathology before there really is capsular rupture. Maybe there is a different way to treat this. Typically, I would do a metatarsal osteotomy such as a Weil metatarsal osteotomy and then I would use the Topaz. I would use a small arthroscope, a 2.7 scope. Even though it is an open arthrotomy, I would have the arthroscope. I could visualize underneath and to the plantar portion of the capsule, and see quite a bit of synovitis.
I would use the Topaz wand to ablate that synovitis. You do get some capsular shrinkage, some tightening. However, it seems as if utilizing the Topaz procedure has improved my outcomes in repairing the second MPJ and stabilizing it. Certainly, you need to incorporate more mechanical correction around the capsule as you are closing but I have noticed improved patient function and certainly decreased postoperative discomfort.
Why One Should Avoid Post-Op NSAIDs After Coblation Therapy
Dr. Eickmeier: Dr. McGlamry, you had mentioned that you do not give patients NSAIDs, that you hold NSAIDs after this procedure. Can you please expand upon why that is?
Dr. McGlamry: From a basic physiology standpoint, the first phase of wound healing is inflammation. We do not want to blunt that response. Use of antiinflammatories in general is strongly discouraged following Coblation therapy. We want to take advantage of that inflammation, which is the first stage into getting neovascularization into tissue and providing relief of symptoms.
We do continue with other things, such as night splints and orthotics, that are helpful postoperatively, but we specifically have patients, whether they are being treated for tendonosis or fasciosis, avoid antiinflammatories. As Dr. Werber mentioned, we avoid steroid injection postoperatively to achieve the full benefit of the inflammatory response toward healing.
Other Pertinent Points To Consider
Dr. Eickmeier: What types of complications have you seen with the Topaz procedure?
Dr. McGlamry: The complications I have seen have been very limited. In a couple of larger patients, I have seen some minimal dehiscence. I have had no nerve entrapments. My personal experience reflects the experience of James P. Tasto, MD.6,7 I have seen no postoperative ruptures of the shell or any tendons that I have treated with the Topaz procedure.
I am fairly aggressive with postoperative recovery. I get patients back into shoes following the fasciosis procedure with Topaz in two weeks and back into an orthotic or at least an additional over-the-counter (OTC) arch support. For example, when it comes to the treatment of the Achilles tendonosis, I get patients in a full weightbearing, cam walker three to five days post-op and back in shoes at three to four weeks. In spite of fairly aggressive post-op rehab, I have seen no other complications with the exception of some superficial, small percentage of dehiscence.
Dr. Werber: I have to agree with Dr. McGlamry. Whether you are treating plantar fasciosis or any of the tendons within the foot and ankle, this procedure seems to offer a very low risk with almost immediate pain relief in most of these patients.
In addition to plantar fasciosis, Coblation therapy has given us added tools in treating Achilles tendonitis, peroneal tendonitis and posterior tendonitis. Now we have another minimally invasive procedure to offer our patients to resolve these complaints. Just a few years ago, there were open procedures in which we were suturing tendon and doing tendon grafting. Now we have much simpler, quicker post-op rehab using Coblation therapy.
For further reading, see “What The Future Holds For Podiatric Care” in the August 2005 issue of Podiatry Today, “Is Microdebridement A Viable Option For Treating Tendinosis?” in the May 2006 issue or “Should You Change Your Approach To Plantar Fasciosis?” in the November 2006 issue.
Also check out the archives at www.podiatrytoday.com. |
1. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003; 93(3):234-237.
2. Yu JS, Spigos D, Tomczak R. Foot pain after a plantar fasciotomy: an MR analysis to determine potential causes. J Comput Assist Tomogr 1999; 23(5):707-712.
3. Hammer DS, Adam F, Kreutz A, Rupp S, Kohn D, Seil R. Ultrasonographic evaluation at 6-month follow-up of plantar fasciitis after extracorporeal shock wave therapy. Arch Orthop Trauma Surg 2005; 125(1):6-9.
4. Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Foot Ankle Int 2004; 25(5):290-297.
5. Weil LS, Jr., Roukis TS, Weil LS, Borrelli AH. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg 2002; 41(3):166-172.
6. Takahashi N, Tasto JP, Ritter M, Ochiai N, Ohtori S, Moriya H et al. Pain relief through an antinociceptive effect after radiofrequency application. Am J Sports Med 2007; 35(5).
7. Tasto JP. The use of bipolar radiofrequency microtenotomy in the treatment of chronic tendinosis of the foot and ankle. Techniques in Foot and Ankle Surgery 2006; 5(2):110-116.
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