Postsurgical glenohumeral arthritis in young adults

FactFinders for patient safety: Preventing local anesthetic-related complications: Local anesthetic chondrotoxicity and stellate ganglion blocks

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential local anesthetic-related complications. Evidence in support of the following facts is presented. (1) Chondrotoxicity: Which Local Anesthetics are Safest for Intraarticular Injection? -- There are drug-, concentration-, and time-dependent chondrotoxic effects that vary between local anesthetics. Current evidence related to commonly used local anesthetics indicates that with exposure to equivalent volumes, bupivacaine, at concentrations of 0.5 % or higher, is the most chondrotoxic agent, while ropivacaine, at concentrations equal to or less than 0.5 %, is the least chondrotoxic in vitro. There is minimal published evidence that confirms these findings in vivo. (2) Minimizing Risks with Stellate Ganglion Blocks -- Evidence suggests that fluoroscopic or ultrasound guidance reduces the risk and increases the accuracy of SGB. Utilizing ultrasound guidance has the added benefit of soft tissue visualization, especially vascular structures, which has the potential to prevent adverse outcomes when compared to the fluoroscopic technique.

Dexamethasone Does not Compensate for Local Anesthetic Cytotoxic Effects on Tenocytes: Morphine or Morphine Plus Dexamethasone May Be a Safe Alternative

Purpose

The purposes of this in vitro study were to investigate whether the addition of dexamethasone can compensate for any cytotoxic effects of the amide-type local anesthetics (LA) bupivacaine and ropivacaine and whether morphine and morphine-6-glucuronide (M6G) may be a safe alternative for peritendinous application.

Methods

Biopsies of human biceps tendons (n = 6) were dissected and cultivated. Cells were characterized by the expression for tenocyte markers, collagen I, biglycan, tenascin C, scleraxis, and RUNX via reverse transcriptase-polymerase chain reaction and immunohistochemistry. Tenocytes were incubated with bupivacaine, ropivacaine, morphine, M6G, or a saline control with and without addition of dexamethasone for 15, 60, or 240 min. Cell viability was determined by quantifying the presence of adenosine-triphosphate.

Results

Significant time-dependent cytotoxic effects were observed for LA after all exposure times. After 15, 60, and 240 minutes, cell viability decreased to 81.1%, 49.4% and 0% (P < .001) for bupivacaine and to 81.4%, 69.6%, and 9.3% (P < .001) for ropivacaine compared to saline control. Dexamethasone did not compensate for these cytotoxic effects. Cell viability was not affected after 15, 60-min exposures to morphine and M6G but decreased significantly (P < .001) after 240 minutes compared to saline control. However, in combination with dexamethasone, tenocyte viability was significantly increased at all times for morphine (P < .01) and at 15 and 60 minutes for M6G (P < .01).

Conclusions

The results showed that amide-type LA have a time-dependent cytotoxic effect on human tenocytes in vitro, which could not be compensated for by dexamethasone, whereas morphine and M6G had no cytotoxic effects on tenocytes after 15 and 60 minutes. The addition of dexamethasone to morphine and M6G had a positive effect on viability, which increased significantly compared to the opioids.

Clinical Relevance

It is known that amide-type local anesthetics used for local joint analgesia have chondrotoxic side-effects. The combined application of morphine and dexamethasone may be a safe alternative.

Heat-Related Complications from Radiofrequency and Electrocautery Devices Used in Arthroscopic Surgery: A Systematic Review

Purpose

To investigate the occurrence of heat-related complications from radiofrequency and electrocautery devices in patients undergoing arthroscopic surgery.

Methods

A systematic review was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting complications after arthroscopy using electrosurgery devices were included. Only English- and Dutch-language articles were included. Basic science/nonclinical studies/human cadaveric studies and animal studies were excluded. Article selection was performed by 2 separate reviewers. Interobserver agreement of the selection procedure was determined by Cohen’s kappa. All included articles were critically appraised using an adapted version of the ROBINS-I tool.

Results

Twenty-five studies were included in this systematic review. A total of 309 cases of heat-related complications were identified. Chondrolysis was present in 45 cases and dermal burns in 15 cases. Axillary nerve injuries were reported in 197 cases of arthroscopic adhesive capsulitis release. However, it was unclear whether these injuries were directly related to the overheating of the arthroscopic fluid. No one specific risk factor for thermal complications was identified, but related factors included the leakage of the arthroscopy fluid, use of a thermal device continuously for a long period of time, proximity of the thermal device to the tissue, intra-articular local anesthetic injection or the use of intra-articular pain pumps, and certain surgical procedures, such as thermal capsulorrhaphy, capsular release, and synovectomy.

Conclusions

The most common heat-related complications in arthroscopy are dermal burns and chondrolysis. Risk factors include leakage of arthroscopy fluid, use of a thermal device, intra-articular anesthetics/pain pumps, and performing specific surgical procedures.

Level of Evidence

Systematic review of level III-IV studies.

An anthropometric evaluation of the scapula, with emphasis on the coracoid process and glenoid fossa in a South African population

The exact dimensions of the scapula, including the coracoid process and glenoid fossa, are fundamental in the patho-mechanics of the glenohumeral joint (GHJ); as these structures act as initiators of shoulder movement. The aim of the study was to evaluate the anthropometric parameters of the GHJ, with emphasis on the coracoid process and glenoid fossa. The morphometric (Linear Tools 2012, 0-150mm, LIN 86500963) and morphological parameters of a total of one hundred and sixty-four (n = 164) dry bone scapulae [Right (R): 80; Left (L): 84, Male (M): 68; Female (F): 96] were recorded. Results: (i) Shape of glenoid fossa: Type 1: (R) 16.5%, (L) 11.0%; Male (M) 20.1%, Female (F) 7.3%; Type 2: (R) 14.0%, (L) 15.2%; (M) 18.3%, (F) 11.0%; Type 3: (R) 18.3%, (L) 25.0%; (M) 27.4%, (F) 15.9%. (ii) Notch type: Type 1: (R) 1.7%, (L) 7.3%; (M) 6.7%, (F) 2.4%; Type 2: (R) 47.0%, (L) 43.9%; (M) 59.2%, (F) 31.7%. (iii) Vertical diameter of glenoid fossa (VD) (mm): (R) 35.2 ± 3.1, (L) 34.9 ± 3.0; (M) 35.3 ± 3.2, (F) 34.6 ± 2.8. (iv) Horizontal diameter 1 (HD1) of glenoid fossa (mm): (R) 18.4 ± 3.3, (L) 17.5 ± 2.9; (M) 18.2 ± 3.3, (F) 17.4 ± 2.6. (v) Horizontal diameter 2 (HD2) of glenoid fossa (mm): (R) 24.5 ± 2.9, (L) 23.6 ± 2.6; (M) 24.2 ± 2.7, (F) 23.7 ± 2.8. (vi) Length of coracoid process (CL) (mm): (R) 41.7 ± 4.7, (L) 41.5 ± 4.9; (M) 42.1 ± 4.7, (F) 40.7 ± 4.8. (vii) Width of coracoid process (CW) (mm): (R) 13.3 ± 1.9, (L) 14.2 ± 11.9; (M) 13.1 ± 1.9, (F) 15.1 ± 14.5. (viii) Coracoglenoid distance (CGD) (mm): (R) 27.4 ± 8.3, (L) 28.2 ± 3.5; (M) 28.2 ± 7.4, (F) 27.0 ± 3.4. In the present study, Type 3 (oval) was observed to be the predominant glenoid fossa shape with a higher incidence in male individuals and on the right side. Although only notch Types 1 (without a notch) and 2 (with one notch) were observed in this study, Type 2 (one notch) was the most prevalent, presenting with a significant p-value (p = 0.019), suggesting that notch Type 1 (without a notch) and 2 (with one notch) are common findings in the right and left side of individuals. The findings observed in this study may provide knowledge regarding the role of the coracoid parameters in etiology of subcoracoid impingement while knowledge on the glenoid fossa parameters and variations are essential for evaluation in shoulder arthroplasty for glenoid fractures and anterior dislocations, and for glenoid prosthesis designs for the South African population.

Rotator cuff repair with all-suture anchors: a midterm magnetic resonance imaging evaluation of repair integrity and cyst formation

BACKGROUND

This study investigated the feasibility and safety of all-suture anchors in arthroscopic rotator cuff repair.

METHODS

All patients were diagnosed with a rotator cuff tear by ultrasound or magnetic resonance imaging (MRI). Patients with partial tears, massive tears, subscapularis tears, or previous shoulder surgery, were excluded. MRI and clinical outcome were investigated in all patients at 1.58 years (range, 1.0-2.0 years) after rotator cuff repair with all-suture anchors (prospective case series). Integrity of the cuff repair, cyst formation (encapsulated fluid signal around the anchor), ingrowth of the bone into the anchor, and integrity of the bone tunnel border were evaluated for 47 anchors. Clinical results were evaluated using the Constant-Murley score.

RESULTS

An MRI evaluation was performed in 20 patients at 1.58 years (range, 1.0-2.0 years) after rotator cuff repair with all-suture anchors. MRI evaluation showed a very small rim of fluid around 10% of the anchors. None of the anchors showed cyst formation with fluid diameter more than twice the anchor diameter. In approximately 90% of the anchors, no fluid could be detected between the anchors and the edge of the bony tunnel. Full rotator cuff integrity was seen in 19 patients. Only 1 patient sustained a retear. Clinical results comparable with an arthroscopic rotator cuff repair using classic anchors were seen.

CONCLUSIONS

This prospective clinical cohort study shows promising early radiographic and clinical results after arthroscopic rotator cuff repair using all-suture anchors.

Etiology of Shoulder Arthritis in Young Patients

The manifestation of glenohumeral arthritis in the young adult is a devastating occurrence that can be difficult to manage. This review details the many underlying etiologies including genetic causes, congenital abnormalities, glenohumeral instability, posttraumatic lesions, postcapsulorraphy arthropathy, osteonecrosis, intraarticular pain pump postoperative use, radiofrequency/thermal capsulorraphy treatments, septic arthritis/infection, and inflammatory arthropathies. Although each of these potential causes have been well-studied, their contributions to the development of glenohumeral arthritis in the young person has not been described extensively.

Treatment of Articular Cartilage Injuries in the Glenohumeral Joint

Articular cartilage injuries in the glenohumeral joint present a unique and difficult problem for the patient and surgeon alike. Various etiologies exist for the development of these cartilage lesions; therefore, treatment options are vast and must be chosen thoughtfully, especially in the young, active patient. Across all treatment modalities, the goal is for the patient to regain lasting function and mobility while decreasing pain.

Management of Articular Cartilage Defects in the Glenohumeral Joint

Articular cartilage defects are not often encountered in the glenohumeral joint. These lesions are typically found in patients with shoulder trauma, recurrent instability, or previous surgical treatment. Diagnosis can be difficult; these defects are often found incidentally during arthroscopic or open surgical management of other pathology. Initial management of isolated glenohumeral chondral defects is nonsurgical and includes physical therapy and/or corticosteroid injections. If nonsurgical treatment is unsuccessful, patients may undergo surgery. Because these lesions occur infrequently, few studies have documented surgical techniques and outcomes. Surgical strategies include arthroscopic débridement, microfracture surgery, osteochondral autograft or allograft transplantation, autologous chondrocyte implantation, and particulated juvenile allograft cartilage implantation.

Single-dose local anesthetics exhibit a type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and cartilage: a systematic review of the current literature

PURPOSE

Many studies have shown that local anesthetics may impede chondrocyte metabolism. However, the influence of a single-dose local anesthetics is controversial. The aim of this metaanalysis was to review the literature for studies investigating the cytotoxic effects of single-dose local anesthetics on chondrocytes and cartilage.

METHODS

A comprehensive literature search was performed using established search engines (Medline, Embase) to identify studies, investigating the influence of single-dose local anesthetics on cartilage. The systematic analysis included the influence on histology, cell viability, morphology, and matrix production depending upon dose, exposure time, and type of local anesthetics.

RESULTS

Twelve studies with four different local anesthetics were included in this metaanalysis. Bupivacaine and lidocaine were found to be more chondrotoxic than mepivacaine and ropivacaine. The amount of dead cells increased in a substance-, dose-, and time-dependent process. Osteoarthritic cartilage seems to be more vulnerable compared to intact cartilage. The toxic effects occur first in the superficial cartilage layers and include damage to membrane integrity, mitochondrial DNA, and nuclear changes. There is no study that could show a significant chondrotoxic effect with low concentrations of bupivacaine (0.0625%), ropivacaine (0.1 and 0.2%), and mepivacaine (0.5%).

CONCLUSIONS

The cytotoxicity of local anesthetics on chondrocytes is dependent on dose, time, and type of local anesthetics. Single-dose intra-articular administration of local anesthetics impede chondrocyte metabolism and should be performed only with low concentrations for selected diagnostic purposes and painful joints. The use of lidocaine should be avoided.

LEVEL OF EVIDENCE

II.

Past and present of interposition arthroplasties for joint repair with special tribute to the contribution by Vittorio Putti

Several techniques have been proposed to restore the compromised function of a joint. These include the arthroplasty by placing various tissues or materials between the articular surfaces. An important contribution to the diffusion of arthroplasty techniques was made by Vittorio Putti, head of the Rizzoli Orthopedic Institute in Bologna from 1912 to 1940. Interposition arthroplasty is still used for some non-weight-bearing joints, such as wrist and elbow, and gives good results. This type of surgery has been further developed by the improvement in biomaterials, biomechanical studies and the regenerative medicine. This paper describes the development starting from a historical survey particularly focused on Putti's contribution and ending with the state of the art of regenerative medicine in the treatment of joint diseases. Level of evidence V.

Osteochondral Allografts in Shoulder Surgical Procedures

The use of fresh osteochondral allografts has become popular in many joint-preserving orthopaedic procedures and shows early promising results within the shoulder. Distal tibial allograft contains a stout cartilaginous layer that appears to have highly congruent curvature and concavity to the glenoid, which makes for an optimal allograft option for instability. In the setting of large Hill-Sachs lesions, the use of a humeral-head osteochondral allograft is essential to restore geometry, stability, and mechanics of the native glenohumeral joint. One must be cautious with the treatment of glenoid chondral lesions with osteoarticular grafting procedures because of the depth of the glenoid compared with the depth of subchondral bone on the graft necessary to achieve a press fit, and advanced imaging is recommended when planning an operative intervention. Optimizing joint-preservation treatment with osteochondral allografts will rely on the long-term results of these procedures, and careful patient selection, preoperative discussion, and realistic expectations are necessary.

Effects of Multiple Intra-articular Injections of 0.5% Bupivacaine on Normal and Osteoarthritic Joints in Rats

PURPOSE

To determine the in vivo effects of multiple local anesthetic injections of 0.5% bupivacaine on normal and osteoarthritic articular cartilage.

METHODS

Rats with normal knee joints received an intra-articular injection of 0.9% saline solution or 0.5% bupivacaine in their right knees joint once a week for 5 consecutive weeks, starting 4 weeks after the beginning of the experiment. Rats were humanely killed at 8, 16, and 24 weeks. In a parallel experiment, rats underwent anterior cruciate ligament transection to induce osteoarthritic changes. These rats were subjected to the same protocol as those with normal knee joints, starting 4 weeks after the procedure. Static weight-bearing tests were performed on both hind limbs to evaluate changes in weight-bearing ability throughout the experiments. Rats were humanely killed at 8 and 16 weeks. Cell viability was assessed with confocal microscopy, using samples from the distal femur. Histologic assessment of osteoarthritis was performed using samples from the tibial plateau based on the Osteoarthritis Research Society International (OARSI) cartilage histopathology assessment system (i.e., OARSI score).

RESULTS

Static weight-bearing tests showed no significant changes after intra-articular injection of saline solution or bupivacaine, and bupivacaine injection did not increase weight bearing compared with saline solution injection, regardless of whether there were osteoarthritic changes. There were also no significant differences in cell viability, cell density, or OARSI scores between the saline solution and bupivacaine groups at each time point, regardless of whether osteoarthritic changes were induced.

CONCLUSIONS

This study suggested that single or intermittent intra-articular bupivacaine injections might not have deleterious effects on either osteoarthritic or normal joints.

CLINICAL RELEVANCE

There is no strong evidence that intra-articular bupivacaine injection induces degenerative changes in articular cartilage. Therefore, these results may apply to normal and osteoarthritic joints.

Shoulder arthroplasty for chondrolysis

BACKGROUND

Chondrolysis is a rare complication after shoulder arthroscopy leading to early joint destruction. Shoulder arthroplasty may be considered for end-stage chondrolysis, but concerns exist about implant survivorship, given the younger age of this population. This study aimed to assess pain relief, function, and survivorship of shoulder arthroplasty for chondrolysis and to assess risk factors for failure.

METHODS

Between January 2000 and January 2013, 26 consecutive shoulders with chondrolysis were treated at our institution with shoulder arthroplasty. All shoulders had a prior arthroscopic procedure that predated a phase of rapid joint destruction. Twenty-three shoulders were followed up for a minimum of 2 years or until reoperation (mean, 4.0 years; range, 0.7-8.6 years). The mean age of the patients was 40 years (range, 21-58 years). Outcome measures included pain, range of motion, postoperative modified Neer ratings, American Shoulder and Elbow Surgeons scores, complications, and reoperations.

RESULTS

At most recent follow-up, only 14 of 23 shoulders had no or mild pain. Overall pain scores improved from 4.7 to 2.6 points. Abduction and external rotation improved significantly. Five shoulders required reoperation, 2 for glenoid loosening and 1 each for infection, instability, and stiffness. Subjectively, 8 patients rated their shoulder as much better, 7 as better, 4 the same, and 4 worse. Most recent American Shoulder and Elbow Surgeons scores averaged 64 points (range, 20-95 points).

CONCLUSIONS

Shoulder arthroplasty for the treatment of chondrolysis improves pain and range of motion. However, patient satisfaction is variable. Early follow-up shows a higher than expected rate of reoperation (25%). Patients undergoing shoulder arthroplasty for chondrolysis should be counseled appropriately about expectations after surgery.

Evaluation of satisfaction and durability after hemiarthroplasty and total shoulder arthroplasty in a cohort of patients aged 50 years or younger: an analysis of discordance of patient satisfaction and implant survival

BACKGROUND

Shoulder arthroplasty in individuals aged 50 years or younger reportedly leads to worse outcomes than in older patients. Current methods of determining survivorship may be inadequate and may not reflect actual patient definitions of satisfaction. The purpose of this study is to evaluate and contrast the survival of patient satisfaction and implant survival in the youngest reported patients undergoing either a primary hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) using a third-generation stemmed prosthesis.

METHODS

Outcomes in 71 patients aged 50 years or younger who were treated with primary HA or TSA were evaluated for patient satisfaction and implant survival rates. Patient satisfaction survival was based on yes or no answers to 2 binary questions regarding willingness to undergo surgery again and whether surgery improved the patient's shoulder.

RESULTS

The Kaplan-Meier patient satisfaction survival rates at 5 years were 71.6% (95% confidence interval [CI], 46%-87%) for HAs and 95% (95% CI, 81%-99%) for TSAs. Multivariable regression analysis implicated postoperative pain as the primary causative factor for failure of patient satisfaction in all patients. In contrast, the implant survival rates at 5 years were 89% (95% CI, 69%-96%) for HAs and 95% (CI, 85%-100%) for TSAs.

CONCLUSIONS

Patients aged 50 years or younger who undergo shoulder arthroplasty have declining rates of self-reported satisfaction despite high implant survival rates, and this finding highlights the discordance between patient satisfaction and implant survival. Primary TSA outperforms HA in both implant survival and patient satisfaction survival rates at short-term follow-up. Future studies and registries must incorporate measurements of patient satisfaction and not just revision rates to truly interpret outcomes.

Surgical options for the young patient with glenohumeral arthritis

Young patients with glenohumeral arthritis are an ongoing treatment challenge. They typically have high demands of their shoulders, require long-term durability due to their young age, and often have altered local anatomy, through their disease process (instability arthropathy, juvenile rheumatoid arthritis, etc.) or from previous surgery (capsulorraphy arthropathy, chondrolysis, etc.). Workup to evaluate underlying causes of early arthritis, and to exclude infectious causes are necessary. When nonoperative management fails, arthroscopic debridement, hemiarthroplasty (isolated, with glenoid reaming, or with biological interposition), and total shoulder arthroplasty are treatment options available to the treating surgeon. Debridement or hemiarthroplasty can provide pain relief for a subset of patients, but results have not been reproducible across the literature and have not been durable over time. Total shoulder arthroplasty provides the most reliable pain relief, but long-term glenoid loosening and wear continue to lead to high revision rates in this patient population.

Performance Comparison of a Pretied Suture Knot With Three Conventional Arthroscopic Knots

PURPOSE

To compare the knot characteristics of a pretied suture knot with 3 of the most commonly used arthroscopic knots tied with various high-strength sutures.

METHODS

Three commonly used arthroscopic knots (surgeon's knot, Seoul Medical Center, and Duncan loop) tied with no. 2 high-strength sutures were compared with a pretied knot secured with either 1, 2, or 3 reversed half hitches (RHAPS). An orthopaedic sports medicine surgeon and fellow tied a total of 120 knots. All knot combinations were tested for strength, knot bulk, cyclic loop elongation, ultimate loop elongation, and ultimate strength.

RESULTS

All pretied configurations had statistically significant improved strength (P = .048, P ≤ .001, and P < .001) versus all other knot groups with mean ± standard deviation loads of 206.3 ± 37.5, 285.6 ± 68.6, and 357.6 ± 61.1 N, respectively. The pretied knot with 1, 2, or 3 RHAPs has significantly smaller volume than the arthroscopic knots in all suture materials. All pretied knot configurations demonstrated no significant difference in cyclic loop elongation compared with standard arthroscopic knots; however, they had a statistically significant lower ultimate loop elongation (P = .001 for each pretied knot configuration).

CONCLUSIONS

Compared with other commonly tied arthroscopic knots using no. 2 high-strength suture, the pretied knot with doubled no. 1 high-tensile-strength suture tied with 1, 2, or 3 RHAPs results in a statistically significantly improved strength. The pretied knot has an equivalent cyclic loop elongation and lower ultimate loop elongation with all RHAP configurations. The pretied knot with 2 or 3 RHAPs has a significantly higher ultimate strength than all combinations of arthroscopic knots excluding one. The pretied knot with 1, 2, or 3 RHAPs has significantly less knot volume than all other knots tested and offers a more reproducible knot.

CLINICAL RELEVANCE

The pre-tied knot offers equivalent or improved strength while having a smaller knot volume.

Surgical Treatment Options for Glenohumeral Arthritis in Young Patients: A Systematic Review and Meta-analysis

PURPOSE

The aim of this study was to compare surgical treatment options for young patients with glenohumeral arthritis.

METHODS

A systematic review of the English-language literature was conducted by searching PubMed, EMBASE, and Scopus with the following term: "(shoulder OR glenohumeral) AND (arthritis OR osteoarthritis) AND (young OR younger)." Studies that reported clinical or radiological outcomes of nonbiologic surgical treatment of generalized glenohumeral arthritis in patients younger than 60 years of age were included. Data were extracted to include study and patient characteristics, surgical technique, outcome scores, pain relief, satisfaction, functional improvement, return to activity, health-related quality of life, complications, need for and time to revision, range of motion, and radiological outcomes. Study quality was assessed with the Modified Coleman Methodology Score.

RESULTS

Thirty-two studies containing a total of 1,229 shoulders met the inclusion criteria and were included in the review. Pain scores improved significantly more after total shoulder arthroplasty (TSA) than after hemiarthroplasty (HA) (P < .001). Patient satisfaction was similar after HA and TSA. Revision surgery was equally likely after HA, TSA, and arthroscopic debridement (AD). Complications were significantly less common after AD than after HA (P = .0049) and TSA (P < .001). AD and TSA afforded better recovery of active forward flexion and external rotation than did HA. At radiological follow-up, subluxation was similarly common after HA and TSA.

CONCLUSIONS

According to current Level IV data, TSA provides greater improvement of pain and range of motion than does HA in the surgical treatment of young patients with glenohumeral arthritis. AD is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Subacromial pain pump use is safe after arthroscopic rotator cuff repair

BACKGROUND

Intra-articular pain pumps with local anesthetics have been implicated as a potential cause of post-arthroscopic glenohumeral chondrolysis (PAGCL) of the shoulder. In short-term studies, subacromial pain pump use is effective and safe without association with PAGCL. Patients with full thickness rotator cuff tears may be at high risk of PAGCL given disruption of the tendinous integrity which may allow intra-articular infusion of local anesthetics. We hypothesized that subacromial pain pump use after arthroscopic rotator cuff repair would not result in PAGCL.

METHODS

We analyzed a consecutive series of 34 patients treated with subacromial pain pump placement after arthroscopic rotator cuff repair and subacromial decompression for full thickness rotator cuff tears. Thirty patients met inclusion criteria of greater than 12-month follow-up with an average age of 51 (28-68). All patients had the subacromial pain pumps placed under arthroscopic visualization and infused 0.25% bupivacaine without epinephrine at 2 cc/h for 48 h. All patients had clinical examinations and radiographic studies performed more than 1 year after surgery.

RESULTS

Patients had an average rotator cuff size of 1.6 cm and fixation was performed with bioabsorbable suture anchors. All patients had at least 150° of abduction and forward flexion at latest follow-up without palpable crepitus and no patients had any evidence of joint space narrowing on post-operative radiographs.

CONCLUSION

Subacromial pain pump use after arthroscopic rotator cuff repair is safe. Despite probable lack of a water-tight seal from repair, there were no cases of PAGCL.

LEVEL OF EVIDENCE

IV.

Postoperative imaging of bioabsorbable anchors in rotator cuff repair

BACKGROUND

Bioabsorbable anchors may lead to osteolysis and cyst formation. However, the prevalence of these outcomes is not known for rotator cuff repairs.

PURPOSE

To evaluate cyst formation after placement of bioabsorbable anchors for rotator cuff repairs and to verify whether bioabsorbable anchors degraded as intended and preserved bone stock for possible revision compared with metal anchors. The null hypothesis was that the rate and severity of cyst formation around the anchor are negligible.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between April 2008 and November 2011, a total of 209 patients (85 men, 124 women) underwent rotator cuff repair with bioabsorbable suture anchors (113 with polylactic acid enantiomers [PLLA] and 96 with poly-D,L-lactide from L-lactide and D-lactide [PLDLA]); the patients underwent magnetic resonance imaging (MRI) evaluation more than 10 months after surgery. The fluid signal around the anchor on T2-weighted MRI scans was graded as follows: grade 0, no fluid around anchor; grade 1, minimal fluid around anchor; grade 2, local fluid around anchor; grade 3, fluid collection around entire length of anchor with cyst diameter less than twice the anchor diameter; and grade 4, cyst diameter larger than grade 3. The integrity of repairs was also evaluated.

RESULTS

Cysts were observed in 97 instances (46.4%). There were 41 grade 1 cases (19.6%), 16 grade 2 (7.7%), 22 grade 3 (10.5%), and 18 grade 4 (8.6%). Healing of repaired tendon was observed in 131 patients (62.7%). There was no statistical difference in healing rate between patients with and without cyst formation (66.1% vs 58.8%; P = .276). Altered anchor shape and absorption were not observed in most of the patients. However, in 12 patients (6 with PLLA and 6 with PLDLA anchors), T2-weighted scans showed that the signal intensity of anchors had changed since surgery, which could indicate that absorption had taken place; nonetheless, even in these 12 patients, anchors were clearly visible on T1-weighted scans.

CONCLUSION

Osteolysis and cyst formation are common complications following the use of bioabsorbable anchors in rotator cuff repairs. Considering that adequate absorption of anchors and preservation of bone stock are the reasons for using bioabsorbable anchors, use of these anchors should be reconsidered because of possible interference with revision surgery.

Inhibition of chondrocyte and synovial cell death after exposure to commonly used anesthetics: chondrocyte apoptosis after anesthetics

BACKGROUND

An intra-articular injection of local anesthetics is a common procedure for diagnostic and therapeutic purposes. It has been shown that these agents are toxic to articular cartilage and synovial tissue in a dose- and time-dependent fashion, and in some cases, they may lead to postarthroscopic glenohumeral chondrolysis (PAGCL). However, the role of apoptosis in cell death is still unclear, and the potential role of apoptosis inhibition in minimizing chondrocyte and synovial cell death has not been reported.

PURPOSE

(1) To quantify the degree of apoptotic cell death in chondrocytes and synovial cells exposed to local anesthetics, and (2) to determine whether caspase inhibition could reduce cell death.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human chondrocytes and synovial cells were expanded in vitro and exposed to normal saline, 0.5% bupivacaine, 0.5% ropivacaine, 1% lidocaine, or 1:1000 epinephrine for 90 minutes. Apoptosis was then detected at 1, 3, 5, and 7 days after exposure using terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) and immunohistochemistry. Apoptosis was then inhibited using the pan-caspase inhibitor z-vad-fmk. Results were normalized to normal saline controls and analyzed by generalized regression models and pairwise confidence intervals.

RESULTS

Analysis of cumulative chondrocyte apoptosis relative to controls after anesthetic exposure demonstrated more than 60% cell death with 0.5% bupivacaine and 1:1000 epinephrine. The greatest chondroprotective effect of caspase inhibition occurred with 0.5% ropivacaine. Similarly, in synovial cells, epinephrine was also very cytotoxic; however, 1% lidocaine induced the most apoptosis. Synovial cells exposed to 0.5% ropivacaine were again most sensitive to protective caspase inhibition.

CONCLUSION

Local anesthetics induce chondrocyte and synovial cell apoptosis in a time-dependent fashion, with peak apoptosis occurring 5 days after exposure. Both chondrocytes and synovial cells are most sensitive to caspase inhibition after exposure to 0.5% ropivacaine.

CLINICAL RELEVANCE

Apoptosis inhibition may be an effective strategy in minimizing chondrocyte and synovial cell death after exposure to anesthetics. Further investigation is clinically warranted.

Topographic analysis of the glenoid and proximal medial tibial articular surfaces: a search for the ideal match for glenoid resurfacing

BACKGROUND

Current knowledge is lacking concerning the appropriate site of osteochondral allograft harvest to match glenoid shape for the purposes of glenoid resurfacing. This has led to difficulty with adequate restoration of the geometry of the glenoid with currently available techniques.

HYPOTHESIS

The medial tibial plateau will provide a suitable osteochondral harvest site because of its concavity and anatomic similarity to the glenoid.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Computed tomography (CT) was performed on 4 cadaveric proximal tibias and 4 scapulae, allowing for 16 glenoid-tibial comparative combinations. Three-dimensional CT models were created and exported into point-cloud models. A local coordinate map of the glenoid and medial tibial plateau articular surfaces was created. Two zones of the medial tibial articular surface (anterior and posterior) were quantified. The glenoid articular surface was defined as a best-fit circle of the glenoid articular surface maintaining a 2-mm bony rim. This surface was virtually placed on a point on the tibial articular surface in 3D space. The tibial surface was segmented, and its 3D surface orientation was determined with respect to its surface. The 3D orientation of the glenoid surface was reoriented so that the direction of the glenoid surface matched that of the tibial surface. The least distances between the point-clouds on the glenoid and tibial surfaces were calculated. The glenoid surface was rotated 360° in 1° increments, and the mean least distance was determined at each rotating angle.

RESULTS

When the centroid of the glenoid surface was placed on the medial tibial articular surface, it covered approximately two-thirds of the anterior or posterior tibial surfaces. Overall, the mean least distance difference in articular congruity of all 16 glenoid-medial tibial surface combinations was 0.74 mm (standard deviation, ±0.13 mm). The mean least distance difference of the anterior and posterior two-thirds of the medial tibial articular surface was 0.72 mm (±0.13 mm) and 0.76 mm (±0.16 mm), respectively. There was no significant difference between the anterior and posterior two-thirds of the tibia with regard to topographic match of the glenoid (P = .187).

CONCLUSION

The findings suggest that the medial tibial articular surface provides an appropriate anatomic match to the glenoid articular surface. Both the anterior and posterior two-thirds of the medial tibial articular surface are potential sites for osteochondral graft harvest.

CLINICAL RELEVANCE

This method can be applied to future studies evaluating the ideal sites of graft harvest to treat zonal glenoid bone wear and/or loss.

Glenohumeral chondrolysis: part I--clinical presentation and predictors of disease progression

PURPOSE

The objective of this 2-part study is to report on the etiology, clinical findings, and predictors of disease progression (part I) and the results of treatment (part II) in a group of patients with glenohumeral chondrolysis.

METHODS

Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed up since their initial presentation before arthroplasty (group 1), and 20 patients were referred either for management of complications arising after prosthetic arthroplasty or for evaluation only (group 2).

RESULTS

Thirty-seven patients received an intra-articular pain pump (IAPP) delivering bupivacaine, and 3 patients had prominent suture anchors or tacks. Symptoms related to chondrolysis developed in patients at a mean of 9.8 months (range, 1 to 34 months) after the index procedure. Radiographs showed joint space obliteration in 30 of 40 patients at most recent follow-up or before arthroplasty. Of the patients receiving an IAPP delivering bupivacaine, the majority received 0.5% with epinephrine. Higher bupivacaine dose (P < .05) and female gender (P < .05) were associated with a longer interval to onset of symptoms. In addition, a shorter interval to onset of symptoms predicted the need for subsequent surgery (P < .05) and a shorter interval to second-look arthroscopy (P < .001).

CONCLUSIONS

Post-arthroscopic glenohumeral chondrolysis is a devastating and rapidly evolving condition that most often strikes young patients. The use of IAPPs delivering local anesthetics should be abandoned because nearly all cases of glenohumeral chondrolysis in this series were associated with their use.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Glenohumeral chondrolysis: part II--results of treatment

PURPOSE

The objective of this 2-part study is to report on the etiology and disease progression (part I) and results of treatment (part II) of glenohumeral chondrolysis.

METHODS

Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed since their initial presentation and before prosthetic shoulder arthroplasty (group 1), and 20 patients were referred either for management of complications arising after shoulder arthroplasty or for evaluation only (group 2). All patients underwent standardized clinical and radiographic examination and completed shoulder-specific self-assessment questionnaires at initial presentation and after prosthetic shoulder arthroplasty for patients in group 1.

RESULTS

Thirty of 40 patients underwent subsequent arthroscopy for debridement, chondroplasty, capsular release, or a combination of these procedures. Of these, 23 patients (77%) required additional surgery, comprising 18 prosthetic shoulder arthroplasties performed at a mean 13 months of follow-up (range, 3 to 33 months), as well as 5 repeated arthroscopies. At most recent follow-up, 15 of 20 patients in group 1 had undergone shoulder arthroplasty, with improvements in active forward elevation from 92.6° to 140.0° (P < .0001), active abduction from 81.6° to 131.3° (P < .0001), active external rotation from 22.1° to 49.3° (P < .0001), and active internal rotation from the gluteal region to the T12 spinous process (P < .001). Pain scores improved from 6.4 to 3.4 (P < .01), and self-assessed outcome also improved significantly. Twelve patients in group 2 underwent shoulder arthroplasty, so overall 27 of 40 patients (68%) underwent prosthetic shoulder arthroplasty for chondrolysis at a mean of 32 months (range, 9 to 66 months) after the index procedure.

CONCLUSIONS

Postarthroscopic glenohumeral chondrolysis is a devastating condition that strikes young patients, responds poorly to arthroscopic interventions, and often requires shoulder arthroplasty within a few years. Patients can expect improved range of motion and outcome after shoulder arthroplasty, but pain relief is often incomplete.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The effect of local anaesthetics on synoviocytes: a possible indirect mechanism of chondrolysis

PURPOSE

While the effect of local anaesthetics on chondrocyte viability is widely documented, the effect of these medications on synoviocytes is largely unknown. The purpose of this study was to understand the effect of 0.5 % bupivacaine and 0.5 % bupivacaine with epinephrine on synoviocyte viability, cytokine and growth factor release, and breakdown product formation.

METHODS

Rabbit fibroblast-like synoviocyte (Type B) cultures were perfused with 0.5 % bupivacaine or 0.5 % bupivacaine with epinephrine (1:200,000) for 24 h. Cell viability was evaluated using a two-colour fluorescence assay. The supernatant was analysed using multiplex inflammatory and matrix metalloproteinase assays.

RESULTS

Synoviocytes treated for 24 h with 0.5 % bupivacaine with epinephrine demonstrated a significant decrease in viability (31.3 ± 19.4 % cell death) when compared with synoviocytes cultured in control media (3.8 ± 1.3 % cell death, p = 0.000) and those cultured in 0.5 % bupivacaine alone (12.6 ± 11.1 % cell death, p = 0.003). No significant decrease in cell viability was observed in synoviocytes treated with 0.5 % bupivacaine compared to those in control media (12.6 ± 11.1 % vs 3.8 ± 1.3 % cell death, p = 0.194). Significantly greater amounts of MMP-1 (47.0 ± 9.2 pg/ml) and MMP-3 (250.0 ± 68.8 pg/ml) were observed in 0.5 % bupivacaine cultures compared with controls (14.3 ± 14.3, p = 0.023 and 72.0 ± 84.9, p = 0.045, respectively).

CONCLUSIONS

0.5 % bupivacaine with epinephrine caused a significant increase in cell death of the synoviocytes, while 0.5 % bupivacaine alone produced cell injury and a significant release of matrix metalloproteinases, which may also lead to indirect injury of the surrounding chondrocytes. These results may help explain the onset of chondrolysis observed in patients who have been treated with intra-articular local anaesthetics.

Rotator cuff healing after continuous subacromial bupivacaine infusion: an in vivo rabbit study

BACKGROUND

The objective of this study was to evaluate the effects of continuous subacromial bupivacaine infusion on supraspinatus muscle and rotator cuff tendon healing using gross, biomechanical, and histologic analyses.

MATERIALS AND METHODS

Thirty-three New Zealand White rabbits underwent unilateral supraspinatus transection and rotator cuff repair (RCR). Rabbits were assigned to 1 of 3 groups: (1) RCR only, (2) RCR with continuous saline infusion for 48 hours, or (3) RCR with continuous 0.25% bupivacaine with epinephrine (1:200,000) infusion for 48 hours. Rabbits were euthanized postoperatively at 2 weeks (for histologic assessment) or 8 weeks (for biomechanical and histologic assessment).

RESULTS

Tensile testing showed a significantly higher load to failure in intact tendons compared with repaired tendons (P < .01); however, no statistical differences were detected among RCR only, RCR saline, and RCR bupivacaine groups. Histologically, the enthesis of repaired tendons showed increased cellularity and disorganized collagen fibers compared with intact tendons, with no differences between treatment groups. Muscle histology demonstrated scattered degenerative muscle fibers at 2 weeks in RCR saline and RCR bupivacaine groups, but no degeneration was noted at 8 weeks.

CONCLUSIONS

The healing supraspinatus tendons exposed to bupivacaine infusion showed similar histologic and biomechanical characteristics compared with untreated and saline-infused RCR groups. Muscle histology showed fiber damage at 2 weeks for the saline and bupivacaine-treated groups, with no apparent disruption at 8 weeks, suggesting a recovery process. Therefore, subacromial bupivacaine infusion in this rabbit rotator cuff model does not appear to impair muscle or tendon after acute injury and repair.

Effect of radiofrequency use on hip arthroscopy irrigation fluid temperature

PURPOSE

The purpose of this study was to determine operating parameters for joint fluid lavage using radiofrequency (RF) in maintaining intra-articular temperatures ≤50°C in the hip joint and to then quantify the influence of flow rate on maintaining safe intra-articular temperatures.

METHODS

Fiberoptic intra-articular thermometers at radial distance intervals of 1, 2, 5, and 10 mm, spanning cross-sectional areas of 3.14, 12.56, 78.5, and 314.1 mm(2), respectively, from the RF probe were used in 3 human hip cadaveric specimens at room temperature, with 9 trials per variable, using a 3-portal technique with a capsule release. Using a new Dyonics RF System continuously at the superior capsulolabral junction for 90 seconds, continuous temperatures were recorded at 50 mm Hg inflow and variable outflow intervals: no flow and 5, 15, and 30 seconds. Lavages were 1 second in duration on suction. Statistical comparison was through multivariate regression analysis and a logistic model.

RESULTS

Temperatures reached ≥50°C at 5-mm radial distance from the probe in all but the 5-second pulse lavage group. Elevated temperatures were reached within 1 to 2 seconds locally (1- to 2-mm radial distance) and at a radial distance of 5 mm in the 15-, 30-, and 0-second lavage groups. Logistic regression revealed a reduction in the odds that temperatures ≥50°C will occur as flow frequency increases every 30 (odds ratio = 0.68, P = .086); 15 (odds ratio = -1.22, P = .0067); and 5 (odds ratio = -4.26, P < .0001) seconds.

CONCLUSIONS

Increasing-interval pulsed irrigation is effective in maintaining intra-articular temperature profiles below 50°C during use of continuous RF ablation. Five-second-interval pulsed lavage is the longest flow interval identified during which fluid 5 mm radially from the RF device never reached temperatures >50°C.

CLINICAL RELEVANCE

Clinical guidelines for using the RF ablation include: meticulous technique, intermittent use, good inflow and outflow, and pulsed lavage at frequent intervals.

Operative treatment of chondral defects in the glenohumeral joint

PURPOSE

The objectives of this study were to conduct a systematic review of clinical outcomes after cartilage restorative and reparative procedures in the glenohumeral joint, to identify prognostic factors that predict clinical outcomes, to provide treatment recommendations based on the best available evidence, and to highlight literature gaps that require future research.

METHODS

We searched Medline (1948 to week 1 of February 2012) and Embase (1980 to week 5 of 2012) for studies evaluating the results of arthroscopic debridement, microfracture, osteochondral autograft or allograft transplants, and autologous chondrocyte implantation for glenohumeral chondral lesions. Other inclusion criteria included minimum 8 months' follow-up. The Oxford Level of Evidence Guidelines and Grading of Recommendations Assessment, Development and Evaluation (GRADE) recommendations were used to rate the quality of evidence and to make treatment recommendations.

RESULTS

Twelve articles met our inclusion criteria, which resulted in a total of 315 patients. Six articles pertained to arthroscopic debridement (n = 249), 3 to microfracture (n = 47), 2 to osteochondral autograft transplantation (n = 15), and 1 to autologous chondrocyte implantation (n = 5). Whereas most studies reported favorable results, sample heterogeneity and differences in the use of functional and radiographic outcomes precluded a meta-analysis. Several positive and negative prognostic factors were identified. All of the eligible studies were observational, retrospective case series without control groups; the quality of evidence available for the use of the aforementioned procedures is considered "very low" and "any estimate of effect is very uncertain."

CONCLUSIONS

More research is necessary to determine which treatment for chondral pathology in the shoulder provides the best long-term outcomes. We encourage centers to establish the necessary alliances to conduct blinded, randomized clinical trials and prospective, comparative cohort studies necessary to rigorously determine which treatments result in the most optimal outcomes. At this time, high-quality evidence is lacking to make strong recommendations, and decision making in this patient population is performed on a case-by-case basis.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Local anaesthetics and chondrotoxicty: What is the evidence?

PURPOSE

Recent reports have suggested that local anaesthetic agents have a toxic effect on articular chondrocytes. This is despite the widespread intra-articular use of local anaesthetic agents following arthroscopic procedures for a number of years.

METHODS

We have reviewed the available basic science literature focusing on the studies assessing the effect of exposing articular chondrocytes to local anaesthetic agents. We attempt to highlight the key findings and, where possible, extrapolate the laboratory findings to the operating theatre.

RESULTS

Basic science reports are analysed according to their setting of either in vitro, ex vivo or in vivo and according to cell line. A majority of work to date has been done using in vitro models. Only a small number of in vivo models using animal cell lines have been used and the best of these have conflicting results with regard lasting toxicity secondary to local anaesthetic exposure.

CONCLUSIONS

Numerous reports suggest a toxic effect of local anaesthetic agents on articular chondrocytes, however, further work is warranted to establish the precise mechanism of toxicity and whether or not single bolus administration results in long-term deleterious outcomes. Determining the ideal in vitro model will help in extrapolating laboratory data to the operating theatre.

The development of postoperative knee chondrolysis after intra-articular pain pump infusion of an anesthetic medication: a series of twenty-one cases

BACKGROUND

Postoperative chondrolysis in the knee joint caused by continuous intra-articular pain pumps infusing bupivacaine is a serious complication that severely affects function. We report the clinical course of a series of twenty-one patients who were referred to our clinic with this complication.

METHODS

A physical examination and a review of medical records were conducted. The condition of the articular cartilage was determined from operative notes, photographs, magnetic resonance images, and radiographs. Knee function was assessed with the Cincinnati Knee Rating System.

RESULTS

The study group included eighteen female and three male patients ranging in age from fourteen to forty-two years. The index procedures, all done elsewhere, included eighteen anterior cruciate ligament reconstructions, one meniscal repair, one arthroscopy, and one tibial tubercle osteotomy. An intra-articular high-flow-volume pump (200 to 270 mL) was used in ten patients, and a low-flow-volume pump (90 to 120 mL) was used in ten patients; the flow rate in the remaining patient was not documented. The devices used 0.5% bupivacaine in twenty knees and 0.25% in one knee, with 1:200,000 epinephrine added in eleven knees. Knee symptoms affecting daily activities occurred at a mean of 9 ± 7 months after the index procedure. Extensive chondrolysis with loss of articular cartilage of all three knee compartments occurred in six knees. In ten knees, two compartments were affected, and in five knees, one compartment was abnormal. All patients had marked limitations and pain with daily activities, and nineteen patients underwent forty-one subsequent surgical procedures.

CONCLUSIONS

Severe postoperative knee chondrolysis occurred after the use of a high or low-flow-volume pump infusing intra-articular bupivacaine, producing disabling knee symptoms. A variety of operative procedures failed to alleviate symptoms. Although this study does not define the incidence of knee chondrolysis after intra-articular bupivacaine pain-pump infusion, the severe complications reported here warrant its use to be contraindicated.

The in vitro chondrotoxicity of single-dose local anesthetics

BACKGROUND

The administration of amide-type local anesthetics to cartilaginous tissues has revealed potential chondrotoxicity.

PURPOSE

This study evaluated whether administration of single doses of 1% lidocaine, 0.25% bupivacaine, and 0.5% ropivacaine resulted in decreased chondrocyte viability or cartilage matrix degradation in vitro.

STUDY DESIGN

Controlled laboratory study.

METHODS

Monolayer human chondrocytes and intact cartilage samples were cultured for 1 week in media. Each drug was delivered in a custom bioreactor over its clinical duration of action. A Live/Dead Viability/Cytotoxicity Assay was used to determine the ratio of dead to live cells for monolayer chondrocyte cultures compared with controls. Damage to the cartilage extracellular matrix (ECM) in en bloc cartilage samples was evaluated by analysis of DNA, glycosaminoglycan (GAG), and collagen content.

RESULTS

Chondrocytes treated for 3 hours with a single dose of 1% lidocaine exhibited significantly more cell death (7.9%) compared with control media (2.9%; P < .001). No significant difference in cell death was observed in chondrocytes treated for 6 hours with 0.25% bupivacaine (2.7%) versus controls (2.8%; P = .856) or cells treated for 12 hours in 0.5% ropivacaine (2.9%) versus controls (2.4%; P = .084). There was no significant difference in GAG expression (P = .627) or DNA-normalized GAG expression (P = .065) between the intact cartilage treatment groups; however, the DNA-normalized GAG expression was markedly lower in cartilage cultures treated with 1% lidocaine (3.36 ± 1.15) compared with those in control media (7.61 ± 3.83).

CONCLUSION

The results of this in vitro study indicate that a single-dose administration of 1% lidocaine resulted in a significant decrease in chondrocyte viability when compared with control cultures.

CLINICAL RELEVANCE

Single-dose injections of 1% lidocaine may be significantly chondrotoxic, and further investigation regarding in vivo chondrotoxicity appears warranted.

Surgical treatment options for the young and active middle-aged patient with glenohumeral arthritis

The diagnosis and treatment of symptomatic chondral lesions in young and active middle-aged patients continues to be a challenging issue. Surgeons must differentiate between incidental chondral lesions from symptomatic pathology that is responsible for the patient's pain. A thorough history, physical examination, and imaging work up is necessary and often results in a diagnosis of exclusion that is verified on arthroscopy. Treatment of symptomatic glenohumeral chondral lesions depends on several factors including the patient's age, occupation, comorbidities, activity level, degree of injury and concomitant shoulder pathology. Furthermore, the size, depth, and location of symptomatic cartilaginous injury should be carefully considered. Patients with lower functional demands may experience success with nonoperative measures such as injection or anti-inflammatory pharmacotherapy. When conservative management fails, surgical options are broadly classified into palliative, reparative, restorative, and reconstructive techniques. Patients with lower functional demands and smaller lesions are best suited for simpler, lower morbidity palliative procedures such as debridement (chondroplasty) and cartilage reparative techniques (microfracture). Those with higher functional demands and large glenohumeral defects will usually benefit more from restorative techniques including autograft or allograft osteochondral transfers and autologous chondrocyte implantation (ACI). Reconstructive surgical options are best suited for patients with bipolar lesions.

Progressive osteolysis and surface chondrolysis of the proximal humerus following influenza vaccination

Influenza vaccination is a common annual event among individuals in the United States. Complications, although infrequent, are usually mild and self-limiting. This article describes the case of a 46-year-old man who experienced progressive osteolysis and surface chondrolysis of the proximal humerus following routine influenza vaccination. The patient presented with shoulder pain and limited range of motion 3 weeks following vaccination in the deltoid area. No skin changes were noted, inflammatory markers were normal, and the patient's pain and disability persisted despite nonsteroidal anti-inflammatory drugs and occupational therapy. Plain radiographs revealed a small lytic area involving the greater tuberosity of the humeral head. Magnetic resonance imaging (MRI) showed abnormal uptake and cystic changes involving the greater tuberosity of the humeral head; repeat MRI at 5 months showed progression in the cystic changes. Diagnostic arthroscopy of the shoulder revealed a hyperemic joint capsule and extensive, full-thickness chondrolysis of the humeral head. Cystic biopsy demonstrated inflammatory cells and granulation tissue, consistent with foreign body response. Cultures were negative. Surgical debridement of the cystic areas and resurfacing of the humeral head yielded a good outcome. To our knowledge, this is the first reported complication of influenza vaccination requiring surgical intervention. Physicians need to be aware of the potential for osteolysis and chondrolysis, which may require aggressive forms of management.

Joint chondrolysis

Although the disease was first described in the hip, reports of chondrolysis in nearly all diarthrodial joints have since emerged with considerable variations in the literature.Despite speculation among clinicians and researchers about the implicit causal pathways and etiologic contributors associated with chondrolysis, definitive answers remain elusive.The term chondrolysis has been applied to varied levels of joint cartilage destruction from focal chondral defects to diffuse cartilage loss, revealing a lack of consistency in the application of diagnostic criteria to guide differential disease classification.Differentiating between the various potential etiologies associated with chondrolysis provides opportunities for the prevention of the disease.

All-arthroscopic biologic total shoulder resurfacing

The treatment of advanced, bipolar glenohumeral osteoarthritis in the young patient is particularly challenging because of the expected failure of a traditional shoulder arthroplasty within the patient's lifetime. We have had early success performing osteochondral allograft resurfacing of the humeral head articular surface and glenoid articular surface, and we describe a new all-arthroscopic technique for performing this procedure. In the context of our new procedure, we have reviewed the available literature on the topic of biologic resurfacing with osteochondral allograft and have provided an overview of the relevant findings. Although only short-term follow-up data are available, our results in young patients have been promising in terms of regained motion, minimal pain, and accelerated rehabilitation. We believe that this new arthroscopic biologic shoulder resurfacing technique has the potential to be superior to other available treatments for this patient population because it preserves bone stock, limits damage to surrounding structures, and allows for early rehabilitation. Although longer-term follow-up is needed, early results have been greatly encouraging.

Effects of local anesthetics on articular cartilage

BACKGROUND

Recent basic science studies have demonstrated local anesthetic chondrotoxicity in vivo and in vitro in both human and animal cartilage. Clinically, chondrolysis associated with the use of intra-articular local anesthetic pain pumps has been described by several groups. This has raised concern regarding the clinical use of intra-articular local anesthetics.

METHODS

The authors undertook a review of the current orthopaedic literature on local anesthetic chondrotoxicity and its potential relationship to clinical chondrolysis.

RESULTS

Local anesthetics such as bupivacaine, lidocaine, and ropivacaine are chondotroxic to human articular cartilage in vitro, although ropivacaine is less so. The evidence suggests that there is a greater risk for chondrolysis with a longer exposure to a higher concentration of local anesthetic, such as with a pain pump, than with a single injection. However, late cellular and metabolic changes are seen after even a single injection of bupivacaine in animal models, and the loss of an intact cartilage matrix also leads to more extensive chondrocyte death. Some studies suggest that additives and the pH of the local anesthetic solution may also play a role in chondrotoxicity.

CONCLUSION

Intra-articular local anesthetics should be used with caution, especially continuous infusions of bupivacaine and lidocaine at high concentrations in joints with compromised cartilage. The consequences of a single intra-articular injection of local anesthetic remains unclear and requires further investigation.

CLINICAL RELEVANCE

Intra-articular use of local anesthetics may have lasting detrimental effects on human articular cartilage and chondrocytes, although the clinical relationship between local anesthetic exposure and chondrolysis requires further study.

Thermal shrinkage for shoulder instability

Thermal capsular shrinkage was popular for the treatment of shoulder instability, despite a paucity of outcomes data in the literature defining the indications for this procedure or supporting its long-term efficacy. The purpose of this study was to perform a clinical evaluation of radiofrequency thermal capsular shrinkage for the treatment of shoulder instability, with a minimum 2-year follow-up. From 1999 to 2001, 101 consecutive patients with mild to moderate shoulder instability underwent shoulder stabilization surgery with thermal capsular shrinkage using a monopolar radiofrequency device. Follow-up included a subjective outcome questionnaire, discussion of pain, instability, and activity level. Mean follow-up was 3.3 years (range 2.0-4.7 years). The thermal capsular shrinkage procedure failed due to instability and/or pain in 31% of shoulders at a mean time of 39 months. In patients with unidirectional anterior instability and those with concomitant labral repair, the procedure proved effective. Patients with multidirectional instability had moderate success. In contrast, four of five patients with isolated posterior instability failed. Thermal capsular shrinkage has been advocated for the treatment of shoulder instability, particularly mild to moderate capsular laxity. The ease of the procedure makes it attractive. However, our retrospective review revealed an overall failure rate of 31% in 80 patients with 2-year minimum follow-up. This mid- to long-term cohort study adds to the literature lacking support for thermal capsulorrhaphy in general, particularly posterior instability.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s11420-010-9187-7) contains supplementary material, which is available to authorized users.

Antinociceptive activity of pre- versus post-operative intra-articular bupivacaine in goats undergoing stifle arthrotomy

OBJECTIVE

To evaluate the peri-operative analgesic efficacy of intra-articular bupivacaine administered before or after stifle arthrotomy.

STUDY DESIGN

Prospective, randomized, blind, placebo-controlled experimental trial.

ANIMALS

Thirty-nine healthy goats.

METHODS

The goats were allocated randomly to one of three intra-articular treatment groups: group PRE (bupivacaine before and saline after surgery), group POST (saline before and bupivacaine after surgery) and group CON (saline before and after surgery). Anaesthesia was maintained with a constant end-tidal sevoflurane of 2.5%. Intra-operatively heart rate (HR), respiratory rate and mean arterial blood pressure (MAP) after critical surgical events (CSE) were recorded and compared with pre-incision values. Propofol requirements to maintain surgical anaesthesia were recorded. Flunixin was administered for 5 days. Post-operative pain assessment at 20 minutes, 2 hours, 4 hours after recovery and on day 2 and 3 included a multidimensional pain score (MPS), a lameness score and mechanical nociceptive threshold (MNT) testing. Rescue analgesia consisted of systemic opioids. Data were analysed using Kruskal-Wallis, Mann-Whitney, Friedman or chi-square tests as appropriate.

RESULTS

Intra-operatively, group PRE had lower HR and MAP at several CSEs than groups POST/CON and required less propofol [0 mg kg(-1) (0-0 mg kg(-1))] than group POST/CON [0.3 mg kg(-1) (0-0.6 mg kg(-1))]. Post-operatively, group POST had significantly higher peri-articular MNTs than groups PRE and CON up to 4 hours after recovery. No treatment effect was detected for MPS, lameness scores and rescue analgesic consumption at any time point.

CONCLUSIONS AND CLINICAL RELEVANCE

Pre-operative intra-articular bupivacaine provided notable intra-operative analgesia in goats undergoing stifle arthrotomy but did not reduce post-operative pain. Post-operative intra-articular bupivacaine provided a short lasting reduction of peri-articular hyperalgesia without affecting the requirements for systemic analgesia. Multimodal perioperative pain therapy is recommended to provide adequate analgesia for stifle arthrotomy in goats.

Risk factors for chondrolysis of the glenohumeral joint: a study of three hundred and seventy-five shoulder arthroscopic procedures in the practice of an individual community surgeon

BACKGROUND

Glenohumeral chondrolysis is a complication of arthroscopic shoulder surgery characterized by the dissolution of the articular cartilage of the glenoid and the humeral head. An analysis of 375 intra-articular shoulder arthroscopic surgical procedures by an individual community orthopaedic surgeon was performed to explore which factors or combinations of factors might be associated with glenohumeral chondrolysis.

METHODS

The occurrence of chondrolysis was correlated with several demographic and surgical variables with use of hazard ratios from Cox proportional hazards models and Kaplan-Meier survivorship curves. Sensitivity analysis was used to examine the effect of two different definitions of the date of the onset of chondrolysis.

RESULTS

In this cohort, each case of documented chondrolysis was associated with the intra-articular post-arthroscopic infusion of a local anesthetic, either Marcaine (bupivacaine) or lidocaine. In an analysis of the group that received an intra-articular postoperative infusion of a local anesthetic, the risk of chondrolysis was found to be greater for those with one or more suture anchors placed in the glenoid, for younger patients, and for those who had the surgery near the end of the ten-year study period.

CONCLUSIONS

To our knowledge, this is the first Level-II retrospective cohort study of the factors associated with the development of post-arthroscopic glenohumeral chondrolysis. In this cohort of intra-articular shoulder arthroscopic procedures, chondrolysis was observed only in cases in which either Marcaine or lidocaine had been infused into the joint during the postoperative period. Avoiding such a postoperative infusion may reduce the risk of chondrolysis.

SARL: shoulder acronyms. A review of the literature

Acronyms are words formed by taking the first initial or other parts of words from a compound term. They are designed to help communicate ideas efficiently. In the literature pertaining to shoulder surgery, a variety of acronyms have been offered for normal anatomic states, physical examination findings, pathologic conditions, surgical techniques, and outcome instruments, with new acronyms offered each year. The purpose of this article is to review and clearly define acronyms used by shoulder specialists.

Glenohumeral chondrolysis: a systematic review of 100 cases from the English language literature

HYPOTHESIS

Chondrolysis can be a devastating complication of shoulder arthroscopy. We undertook a review of the 100 cases reported in the English language to test the hypothesis that common factors could be identified and that the identification of these factors could suggest strategies for avoiding this complication.

MATERIALS AND METHODS

We systematically reviewed the English language literature and identified 16 articles reporting 100 shoulders in which postsurgical glenohumeral chondrolysis had developed.

RESULTS

The average reported patient age was 27 +/- 11 years at the time of surgery; 35 were women. The most common indications for surgery were instability (n = 68) and superior labrum anteroposterior lesions (n = 17). In 59 cases, chondrolysis was reported to be associated with the use of intra-articular pain pumps. The infusate was known to include bupivacaine in 50 shoulders and lidocaine in 2. Radiofrequency capsulorrhaphy was performed in 2 shoulders.

DISCUSSION

Fifty-nine percent of the reported cases of glenohumeral chondrolysis occurred with the combination of arthroscopic surgery and postarthroscopy infusion of local anesthetic. The arthroscopic operations observed with chondrolysis were not limited to stabilization procedures, and the infused anesthetic was not limited to bupivacaine.

CONCLUSION

In that postoperative infusion of local anesthetic and radiofrequency may not be essential to the success of shoulder arthroscopy, surgeons may wish to consider the possible risks of their use.