Bilateral shoulder chondrolysis following arthroscopy. A report of two cases

Efficacy of Intra-articular Versus Extra-articular Bupivacaine Injection in Arthroscopic Partial Meniscectomy: A Prospective, Randomized, Double-Blind Clinical Trial

Background

Immediate postoperative pain relief following arthroscopic partial meniscectomy remains a critical contributor to improved patient experience, early recovery of range of motion, and enhanced rehabilitation.

Purpose

To evaluate the effect of intra-articular versus extra-articular bupivacaine on pain intensity and analgesic intake after arthroscopic partial meniscectomy.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

This was a prospective double-blind, randomized clinical trial. All patients included underwent arthroscopic partial meniscectomy under general anesthesia. Patients were randomized into 2 groups, with 20 patients in each group. At the conclusion of the arthroscopic procedure, the intra-articular group received 10 mL 0.5% bupivacaine introduced intra-articularly and 10 mL isotonic saline 0.9% infiltrated subcutaneously around the portals. The extra-articular group received the isotonic saline intra-articularly and the bupivacaine around the portals. The primary outcome was the visual analog scale (VAS) for pain. Assessments were performed 0 to 0.5, 1 to 2, 2 to 4, and at 24 and 48 hours postoperatively. In addition, analgesic and narcotic consumption was monitored.

Results

There were no differences between the groups in terms of patient demographics. VAS scores for the intra-articular group were 6, 8, 3.25, 4.3, and 4.5 at 0 to 0.5, 1 to 2, 2 to 4, 24, and 48 hours postoperatively, respectively. VAS scores for the extra-articular group were 3.8, 5, 2.9, 5.2, and 5.25, respectively. No statistically significant differences were observed between the 2 groups regarding pain intensity at all time points. There was also no statistically significant difference in analgesic consumption. Dipyrone was the preferred drug by patients from the intra-articular group, while the extra-articular group preferred to use opioids and nonsteroidal anti-inflammatory drugs.

Conclusion

There were no differences in pain severity and analgesic intake between intra- or extra-articular bupivacaine administration after arthroscopic partial meniscectomy.

Damage control articular surgery: Maintaining chondrocyte health and minimising iatrogenic injury

Articular cartilage has limited intrinsic regenerative potential. The maintenance of healthy articular cartilage is essential to prevent joint degeneration and the morbidity associated with arthritis. In this review, we outline the structure and function of healthy articular cartilage. We summarise some of the recent literature outlining the influence of surgical factors on chondrocyte health. These factors include mechanical injury from instrumentation and drilling, drying, and the influence of irrigation fluids, antimicrobial solutions and local anaesthetics. We demonstrate that there is scope for improving cartilage viability at the time of surgery if simple chondroprotective measures are routinely adopted.

Nonbiologic Injections in Sports Medicine

Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability. A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.

Pain Management After Outpatient Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Effective postoperative pain management after shoulder arthroscopy is a critical component to recovery, rehabilitation, and patient satisfaction.

PURPOSE

This systematic review provides a comprehensive overview of level 1 and level 2 evidence regarding postoperative pain management for outpatient arthroscopic shoulder surgery.

STUDY DESIGN

Systematic review.

METHODS

We performed a systematic review of the various modalities reported in the literature for postoperative pain control after outpatient shoulder arthroscopy and analyzed their outcomes. Analgesic regimens reviewed include regional nerve blocks/infusions, subacromial/intra-articular injections or infusions, cryotherapy, and oral medications. Only randomized control trials with level 1 or level 2 evidence that compared 2 or more pain management modalities or placebo were included. We excluded studies without objective measures to quantify postoperative pain within the first postoperative month, subjective pain scale measurements, or narcotic consumption as outcome measures.

RESULTS

A combined total of 40 randomized control trials met our inclusion criteria. Of the 40 included studies, 15 examined nerve blocks, 4 studied oral medication regimens, 12 studied subacromial infusion, 8 compared multiple modalities, and 1 evaluated cryotherapy. Interscalene nerve blocks (ISBs) were found to be the most effective method to control postoperative pain after shoulder arthroscopy. Increasing concentrations, continuous infusions, and patient-controlled methods can be effective for more aggressively controlling pain. Dexamethasone, clonidine, intrabursal oxycodone, and magnesium have all been shown to successfully improve the duration and adequacy of ISBs when used as adjuvants. Oral pregabalin and etoricoxib administered preoperatively have evidence supporting decreased postoperative pain and increased patient satisfaction.

CONCLUSION

On the basis of the evidence in this review, we recommend the use of ISBs as the most effective analgesic for outpatient arthroscopic shoulder surgery.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.

PERSPECTIVE

This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Preemptive Local Anesthesia in Ankle Arthroscopy

BACKGROUND

Complex anesthesia is increasingly used in order to reduce postoperative pain and accelerate rehabilitation. The aim of this study was to evaluate the efficacy and safety of preemptive local anesthesia combined with general or spinal anesthesia in ankle arthroscopy.

METHODS

From January 2014 to February 2016, 80 ankle anterior arthroscopies were performed. Patients were randomly assigned to one of 4 groups, depending on the type of anesthesia: A, general and local preemptive; B, spinal and local preemptive; C, general and placebo; D, spinal and placebo. After general or spinal anesthesia, each patient randomly received an injection of 7 mL of a mixture of local anesthetics or the same amount of normal saline. After 2, 4, 8, 12, 16, 24, 48, and 72 hours following the release of the tourniquet, the pain intensity level was measured with a visual analog scale (VAS). The use of additional analgesics and any adverse effects were also noted.

RESULTS

Preemptive local anesthesia (groups A and B) resulted in a significantly lower level of pain intensity during the first 24 hours after surgery. Until 8 hours after the release of the tourniquet, the pain intensity level was statistically lower in the groups A, B, and D in comparison to C. During hospitalization, none of the patients from groups A and B received on-demand ketoprofen intravenously. No side effects of local anesthetic agents were observed. Two patients had transient numbness and paresthesia in the field of sensory nerve innervation of the dorsal intermediate cutaneous nerve of the foot.

CONCLUSION

Preemptive operative site infiltration with a mixture of local anesthetics performed in ankle arthroscopy was a safe procedure. It reduced the level of intensity of postoperative pain and the amount of analgesics used.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Analgesic control after hip arthroscopy: a randomised, double-blinded trial comparing portal with intra-articular infiltration of bupivacaine

The optimum anaesthetic and analgesic management following hip arthroscopy is yet to be determined. There is, in addition, some concern over the use of intraarticular local anaesthetic. We compared the analgesic efficacy of intra-articular infiltration compared with portal infiltration of bupivacaine following hip arthroscopy. Patients were randomised to receive either 10 ml of 0.25% bupivacaine either into the joint or around the portal sites following completion of surgery. 73 patients were recruited (40 intra-articular). The portal infiltration group required significantly more rescue analgesia immediately after surgery (2.33 mg vs.0.57 mg, p=0.036). Visual Analogue Scale pain scores were not significantly different at 1 and 2 hours following surgery, but at 6 hours the portal group had significantly lower VAS scores (p=0.0036). We believe that the initial pain following surgery results from capsular injury and this explains the need for more rescue analgesia in the portal infiltration group. Further work is needed to establish the ideal regimen. A combination of portal and intra-articular infiltration may be the most efficacious.

Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder

BACKGROUND

Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice.

MATERIALS AND METHODS

A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis.

RESULTS

Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient.

CONCLUSIONS

This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Glenohumeral kinematics after soft tissue interposition graft and glenoid reaming: A cadaveric study

BACKGROUND

The management of young patients with glenohumeral arthritis is controversial. Resurfacing of the glenoid with biologic interposition and reaming of the glenoid have been suggested as potential treatment options. The goal of this study was to determine the change in glenohumeral contact pressures in interposition arthroplasty, as well as glenoid reaming in an arthritis model. We hypothesized that interposition with meniscal allograft will lead to the best normalization of contact pressure throughout the glenohumeral range of motion.

MATERIALS AND METHODS

Eight fresh-frozen cadaveric shoulders were tested in static positions of humeral abduction with a compressive load. Glenohumeral contact area, contact pressure, and peak force were determined sequentially for (1) intact glenoid (2) glenoid with cartilage removed (arthritis model) (3) placement of lateral meniscus allograft (4) placement of Achilles allograft (5) arthritis model with reamed glenoid.

RESULTS

The arthritis model demonstrated statistically higher peak pressures than intact glenoid and glenoid with interpositional allograft. Meniscal and Achilles allograft lowered mean contact pressure and increased contact area to a level equal to or more favorable than the control state. In contrast, the reamed glenoid did not show any statistical difference from the arthritis model for any of the recorded measures.

CONCLUSION

Glenohumeral contact pressure is significantly improved with interposition of allograft at time zero compared to an arthritic state. Our findings suggest that concentric reaming did not differ from the arthritic model when compared to normal. These findings favor the use of allograft for interposition as a potential treatment option in patients with glenoid wear.

Delaying shoulder motion and strengthening and increasing achilles allograft thickness for glenoid resurfacing did not improve the outcome for a 30-year-old patient with postarthroscopic glenohumeral chondrolysis

Although interposition soft-tissue (biologic) resurfacing of the glenoid with humeral hemiarthroplasty has been considered an option for end-stage glenohumeral arthritis, the results of this procedure are highly unsatisfactory in patients less than 40 years old. Achilles tendon allograft is popular for glenoid resurfacing because it can be made robust by folding it. But one reason that the procedure might fail in younger patients is that the graft is not initially thick enough for the young active patient. Most authors report folding the graft only once to achieve two-layer thickness. We report the case of a 30-year-old male who had postarthroscopic glenohumeral chondrolysis that was treated with Achilles tendon allograft resurfacing of the glenoid and humeral hemiarthroplasty. An important aspect of our case is that the tendon was folded so that it was 50–100% thicker than most allograft constructs reported previously. We also used additional measures to enhance allograft resiliency and bone incorporation: (1) multiple nonresorbable sutures to attach the adjacent graft layers, (2) additional resorbable suture anchors and nonresorbable sutures in order to more robustly secure the graft to the glenoid, and (3) delaying postoperative motion and strengthening. However, despite these additional measures, our patient did not have an improved outcome.

Sonographically guided therapeutic injections in the meniscoid lesion in patients with anteromedial ankle impingement syndrome

We describe a sonographically guided technique to perform therapeutic injections for anteromedial ankle impingement syndrome. Scans are carried out using a high-frequency small footprint linear array transducer, positioned along the anteromedial aspect of the tibiotalar joint. A 25 gauge needle is advanced under direct sonographic guidance into the "meniscoid lesion" (area of scarring), and a standardized therapeutic mixture is injected extra-articularly. Image-guided injections have a positive influence on clinical decision making by improving patient management, increasing the accuracy of diagnosis, and decreasing patient pain. Sonography allows confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes.

LEVELS OF EVIDENCE

Therapeutic, Level V, Expert Opinion.

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.

Rapid chondrolysis of the knee after partial lateral meniscectomy in professional athletes

BACKGROUND

Postoperative knee joint chondrolysis is a rare but serious complication. The aim of our study is to report the clinical presentation, the early, mid and long-term outcomes of rapid chondrolysis after a partial lateral meniscectomy in elite athletes.

METHODS

Clinical records of 10 consecutive cases of rapid chondrolysis after partial lateral meniscectomy in eight professional athletes were retrospectively reviewed. There were seven males and one female with a mean age of 25.2 years (range 20-32 years) at index procedure. An initial conservative approach to its treatment was attempted in all cases. Arthroscopic lavage was advocated in two cases. Patients were clinically reviewed at last follow-up with comparative X-rays, a subjective IKDC, a Lysholm and Tegner scale.

RESULTS

All patients resumed their pre-injury level of activity at a mean 8 (±2.45) months after the index procedure. At a mean of 82 (±36) months of follow-up, the mean subjective IKDC, Lyshom and Tegner scale were respectively 82.64 (±8.61), 86.6 (±6.44), 9 (±1.41). All knees demonstrated joint space narrowing scored Kellgren and Lawrence II (n=1) III (n=4) or IV (n=5) on conventional radiographs.

CONCLUSION

By reviewing the common factors in each of these cases we believe that rapid chondrolysis occurs primarily due to the excessive loading of the articular cartilage in the lateral compartment of the knee. In this series, although the results in the medium term were good, the long-term outcome must be guarded due to the high rate of radiographic osteoarthritis of the lateral compartment seen in this population.

STUDY DESIGN

Retrospective case series, Level IV.

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.

Thermal stress potentiates bupivacaine chondrotoxicity

PURPOSE

The primary objective of this study was to determine whether thermal stress potentiates the chondrotoxic effect of bupivacaine, resulting in decreased articular chondrocyte viability compared with exposure to bupivacaine alone.

METHODS

Bovine articular cartilage explants and cultured chondrocytes were treated with a range of thermal exposures (10 to 20 minutes at 37°C to 65°C) to create time/temperature viability curves and to determine threshold conditions for cell death. A second set of experiments was performed to determine whether subthreshold thermal stress potentiates bupivacaine toxicity. Explants were exposed to 37°C or 55°C for 10 or 20 minutes, and cultured chondrocytes were exposed to 37°C or 45°C for 10 or 20 minutes. Thirty minutes later, the explants and chondrocytes were treated with either 0.9% normal saline solution or 0.5% bupivacaine for 30 minutes. Chondrocyte viability was quantified 24 hours after treatment.

RESULTS

There was a temperature- and time-dependent decrease in chondrocyte viability above the thermo-toxicity threshold in both intact cartilage explants and cultured chondrocytes (55°C and 45°C, respectively; P < .05). Chondrocyte viability in cartilage explants was significantly lower after treatment with thermal stress for 10 or 20 minutes followed by bupivacaine for 30 minutes compared with treatment with bupivacaine at 37°C (bupivacaine and 55°C for 10 minutes, 0.09% ± 0%; bupivacaine and 55°C for 20 minutes, 0.08% ± 0%; bupivacaine and 37°C for 10 minutes, 37.4% ± 1.2% [P < .001]; and bupivacaine and 37°C for 20 minutes, 47.1% ± 0.8% [P < .001]). A similar trend was seen in cultured chondrocytes, although it was not statistically significant (P > .05).

CONCLUSIONS

Thermal stress potentiates the chondrotoxic effects of bupivacaine in intact cartilage, leading to decreased chondrocyte viability compared with exposure to bupivacaine alone.

CLINICAL RELEVANCE

Intra-articular injection of bupivacaine after arthroscopic procedures during which cartilage is exposed to elevated temperatures, such as with prolonged use of radiofrequency probes, may increase the risk of chondrocyte toxicity.

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.

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.

Bupivacaine and triamcinolone may be toxic to human chondrocytes: a pilot study

BACKGROUND

Intraarticular injections of corticosteroids combined with local anesthetics are commonly used for management of chronic pain symptoms associated with degenerative joint diseases and after arthroscopic procedures. Several studies suggest chondrotoxicity of local anesthetics whereas others report chondroprotective and cytotoxic effects of corticosteroids on cartilage. Given the frequency of use of these agents, it is important to know whether they are in fact toxic.

QUESTIONS/PURPOSES

We asked whether (1) bupivacaine and triamcinolone acetonide, alone and combined, were chondrotoxic to chondrocytes in culture; (2) buffering of the reagents diminished toxicity of the bupivacaine and triamcinolone; and (3) the presence of the superficial layer of articular cartilage protects against toxicity.

MATERIALS AND METHODS

We obtained cartilage from three patients undergoing arthroplasty. To address triamcinolone acetonide, bupivacaine, and combinatorial toxicity to human chondrocytes, we set up monolayer chondrocyte cultures (n = 8 wells per condition). The question of buffering was addressed by performing the same assays as above, but the reagents were buffered. An MTT assay was used to assess chondrocyte survival in the monolayer. We harvested 21 articular plugs from each of three patients (total 63 plugs) and exposed them to the same reagents as above, including the buffered reagents. A Live/Dead assay was used to determine chondrocyte survival.

RESULTS

Triamcinolone acetonide, bupivacaine, and their combination were toxic to human chondrocytes in the monolayer comparisons. The addition of buffering did not mitigate chondrocyte death. With the intact superficial layer in the plug group, bupivacaine was not toxic as compared with for the control group; all the other reagents (triamcinolone, combination bupivacaine/triamcinolone, buffered bupivacaine, buffered triamcinolone, and buffered combination) produced chondrotoxicity.

CONCLUSIONS

Triamcinolone induced chondrotoxicity in the articular plug and monolayer culture, whereas bupivacaine induced chondrotoxicity only in monolayer culture. The combined used of triamcinolone and bupivacaine did not show additive chondrocyte death in any arm. Buffering of bupivacaine increased its chondrotoxicity.

CLINICAL RELEVANCE

Although not necessarily reflecting in vivo conditions, our data suggest physicians should be cognizant of the potential in vitro chondrotoxicity of bupivacaine and triamcinolone when contemplating intraarticular administration.

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.

In vitro assessment of human chondrocyte viability after treatment with local anaesthetic, magnesium sulphate or normal saline

PURPOSE

Local anaesthetic agents are often used as an intra-articular analgesic following arthroscopic procedures. However, there is increasing evidence of a potential toxic effect to chondrocytes within the articular cartilage. The aim of this study was to compare the effect on human chondrocyte viability of treatment with bupivacaine, levobupivacaine and ropivacaine. The second aim was to compare the effect on chondrocyte viability of the local anaesthetics with magnesium, a potential alternative analgesic agent.

METHODS

Chondrocytes were exposed to one of the local anaesthetic agents (levobupivacaine 0.13, 0.25, 0.5%; bupivacaine 0.13, 0.25, 0.5%; ropivacaine 0.19, 0.38, 0.75%), normal saline or 10% magnesium sulphate for 15 min. Cells exposed to cell culture media served as controls. Twenty-four hours after exposure, cell viability was assessed using the CellTiter 96® AQueous One Solution Cell Proliferation Assay.

RESULTS

There was no significant difference in chondrocyte viability after treatment with either normal saline or magnesium sulphate. With the exception of 0.13% levobupivacine, all local anaesthetic treatment showed significantly greater toxic effects than either normal saline or magnesium sulphate. Statistically significant dose-dependent responses of decreasing cell viability were found with increasing local anaesthetic concentration.

CONCLUSIONS

A dose-dependent reduction in chondrocyte viability after treatment with common local anaesthetic agents was confirmed. Local anaesthetic agents had a greater deleterious effect on chondrocytes than did 10% magnesium sulphate. These findings suggest the need for continuing caution with the use of intra-articular local anaesthetic. Magnesium sulphate is a potential alternative intra-articular analgesic agent.

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.

Human chondrocyte viability after treatment with local anesthetic and/or magnesium: results from an in vitro study

PURPOSE

We aimed to assess the effect on chondrocyte viability of adding magnesium to a variety of commonly available local anesthetic agents.

METHODS

Human chondrocytes were grown under standard culture conditions. Cells were exposed to a local anesthetic agent with the addition of magnesium (10%, 20%, or 50%). Cells were also exposed to the varying concentrations of magnesium and 0.9% saline solution. Untreated cells served as controls. The CellTiter 96 AQueous One Solution Cell Proliferation Assay was used to assess for cell viability 24 hours after exposure. One-way analysis of variance was used to test for statistical significance.

RESULTS

Magnesium sulfate alone was no more toxic than normal saline solution (P > .3) compared with untreated cells. The addition of magnesium to the local anesthetic agents resulted in greater cell viability than when cells were treated with a local anesthetic alone (lidocaine [P = .033], levobupivacaine [P = .007], bupivacaine [P < .001], and ropivacaine [P < .001]).

CONCLUSIONS

Our findings support the use of magnesium either alone or in combination with a local anesthetic rather than a local anesthetic alone, and this represents a potential strategy for the reduction of chondrocyte toxicity associated with intra-articular local anesthetic administration after arthroscopy.

CLINICAL RELEVANCE

The addition of magnesium to a local anesthetic results in a reduced toxic effect to the articular chondrocyte. This may represent a potential approach to intra-articular analgesia.

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.

Case reports: two cases of glenohumeral chondrolysis after intraarticular pain pumps

BACKGROUND

Acute idiopathic chondrolysis in young adults is rare. The etiology often is unknown and outcomes can be devastating owing to rapid development of painful secondary osteoarthritis. There have been some recent reports of chondrolysis after arthroscopic shoulder procedures. Animal and laboratory data suggest chondrolysis is related to the use of intraarticular pain pumps, although there is no conclusive evidence that this is causative in patients.

CASE DESCRIPTION

We present two cases of young adults with chondrolysis of the humeral head after intraarticular pain pump use with humeral head resurfacing and biologic glenoid resurfacing.

LITERATURE REVIEW

Several authors report glenohumeral chondrolysis after shoulder arthroscopy involving the use of bupivacaine pain pumps. In addition, experimental animal studies have confirmed the presence of chondrolysis after bupivacaine infusion.

PURPOSES AND CLINICAL RELEVANCE

These cases provide additional evidence of an important association between postarthroscopic chondrolysis of the glenohumeral joint and the use of bupivacaine pain pumps.

Complications in shoulder arthroscopy

Shoulder arthroscopy is generally a safe and effective method for treating a wide variety of shoulder pathology. Fortunately, complications following shoulder arthroscopy are rare, with reported rates between 4.6% and 10.6%.¹⁻⁷ These rates may be underestimated, as underreporting of complications and varying definitions of the term complication are likely. During shoulder arthroscopy, complications may occur at numerous points. The surgeon must be aware of potential problems and take necessary measures to prevent them. This article describes common complications after arthroscopic shoulder surgery. Although failure of treatment and postoperative stiffness are undesirable outcomes, they are not described.

Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: a report of 18 cases

PURPOSE

To report on our experience of patients who received infusion of bupivacaine with epinephrine after arthroscopic glenoid labral repair surgery and in whom glenohumeral joint chondrolysis subsequently developed, as well as to determine the incidence of such chondrolysis in our surgeons' patient populations.

METHODS

A retrospective chart review of 18 patients diagnosed with chondrolysis was carried out. All patients were from 2 experienced orthopaedic surgeons' practices. Details of their clinical course were obtained and summarized. These data were compared with all other arthroscopies completed by the 2 surgeons to determine the incidence of chondrolysis.

RESULTS

All 18 patients diagnosed with glenohumeral joint chondrolysis received postoperative infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter (IAPPC). None of the patients received thermal energy as part of their procedure. None of the patients had evidence of glenohumeral joint infection, although an extensive workup was frequently undertaken. Clinically, patients presented with a stiff, painful shoulder. Examination showed decreased range of motion of the affected shoulder. Radiographs and magnetic resonance imaging showed joint space narrowing, as well as subchondral sclerosis and cyst formation. Of the 18 patients, 14 have since undergone repeat arthroscopic procedures, and 5 have received a humeral head-resurfacing operation. Within the same time period, there were 113 arthroscopies, with 45 pain pumps used. Chondrolysis developed in 16 of 32 patients with high-flow IAPPCs and 2 of 12 patients with low-flow IAPPCs (1 patient's IAPPC flow rate was not documented).

CONCLUSIONS

Although we cannot establish a causal link, the development of glenohumeral chondrolysis may be related to the intra-articular infusion of bupivacaine with epinephrine postoperatively. We thus caution against the use of IAPPCs.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Glenohumeral chondrolysis after shoulder arthroscopy associated with continuous bupivacaine infusion

PURPOSE

To determine the incidence of glenohumeral chondrolysis associated with the use of a continuous-infusion device in shoulder arthroscopy.

METHODS

A consecutive series of patients undergoing arthroscopic glenohumeral surgery with a postoperative continuous-infusion pump inserted into either the glenohumeral joint or subacromial space were evaluated for chondrolysis. Two pump types were used: group 1 received 100 mL of 0.5% bupivacaine without epinephrine infused at 2.08 mL/h, and group 2 received 270 mL of 0.5% bupivacaine without epinephrine infused at 4.16 mL/h.

RESULTS

We followed up 65 patients at a mean of 40 months. Of these, 29 had glenohumeral catheters (13 in group 1 and 16 in group 2) and 36 had subacromial catheters (19 in group 1 and 17 in group 2). The overall postoperative Constant, American Shoulder and Elbow Surgeons, Rowe, Single Assessment Numeric Evaluation, and Simple Shoulder Test scores were 84, 87, 77, 86, and 10, respectively, in those with glenohumeral catheters and 93, 94, 95, 89, and 11, respectively, in those with subacromial catheters. Three glenohumeral catheter patients were diagnosed with chondrolysis, all in group 2.

CONCLUSIONS

Chondrolysis developed in 3 of 16 patients (19%) with glenohumeral joint infusion of 0.5% bupivacaine without epinephrine at 4.16 mL/h for 65 hours. No patient using a 2.08-mL/h reservoir for 48 hours into the glenohumeral joint and no patient with a subacromial infusion device had chondrolysis. Clinical symptoms and radiographic evidence of chondrolysis developed before 12 months after surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Glenohumeral chondrolysis after arthroscopy: a systematic review of potential contributors and causal pathways

PURPOSE

This systematic review provides (1) a synthesis of existing clinical evidence that helps identify factors associated with the development of glenohumeral chondrolysis after arthroscopy (PAGCL), (2) a consolidated conceptualization of potential causal pathways that elucidate proposed mechanisms leading to PAGCL, and (3) a summary of implications for practice, policy, and future research.

METHODS

A computerized literature review using an iterative search process identified 245 publications in English between January 1960 and April 2009. After we applied inclusion and exclusion criteria, 35 articles were stratified into 4 categories of factors related to PAGCL: (1) patient factors, (2) surgical factors (preoperative and intraoperative), (3) postoperative factors, and (4) causal pathways.

RESULTS

The majority of studies (61%) focused on surgical factors correlated with PAGCL, and most were laboratory based (n = 21). Publications involving human subjects were descriptive case reports (n = 15), not epidemiologic studies. A total of 88 patients (91 shoulder surgeries) with PAGCL were identified in case reports. The majority of patients (55%) was male, and the mean age was 27.9 years (range, 13.1 to 64 years). Among patients, 68% (n = 53) had implants/anchors, 67% (n = 59) received local anesthetics through a pain pump, and 45% (n = 41) had surgeries involving radiofrequency devices. The causal pathways to PAGCL likely involve initiating and secondary cartilage injury due to mechanical, thermal, or chemical events. The result is a cascade of interactive cellular responses that may include inflammation and chondrocyte apoptosis causing disturbance of cellular metabolism with subsequent loss of the gliding surface, congruity, and synovial fluid, leading to increased friction and accelerated wear that ultimately yield PAGCL.

CONCLUSIONS

The literature is limited to correlates, rather than true risk factors, for PAGCL. Well-designed epidemiologic studies that examine various exposures in relation to health outcomes, while controlling for potential confounders, are needed to determine relative risks that allow causal inference, thereby facilitating sound practice and policy decision making.

LEVEL OF EVIDENCE

Level IV, systematic review.

Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis

Shoulder arthroscopy has become a routine outpatient surgery. Pain control is a limiting factor for patient discharge after surgery, and several modalities are used to provide continued analgesia postoperatively. Regional anesthetic blocks and shoulder pain pumps are common methods to provide short-term pain control. Shoulder pain pumps can be used either in the subacromial space or within the glenohumeral joint. Several clinical studies suggested--which was confirmed by a bovine and rabbit cartilage study--that there is significant chondrotoxicity from bupivacaine, a local anesthetic commonly used in pain pumps. Postarthroscopic glenohumeral chondrolysis is a noninfectious entity associated with factors including use of radiofrequency thermal instruments and intra-articular pain pumps that administer bupivacaine, but there have been no cases reported with subacromial pain pump placement. Treatment options are difficult in a young patient with postarthroscopic glenohumeral chondrolysis, and understanding the literature with regard to risk factors is paramount to counseling patients and preventing this devastating complication.