Glenohumeral chondrolysis associated with use of an intra-articular pain pump delivering local anesthetics following manipulation under anesthesia: a report of four cases

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.

Regional anesthesia for shoulder surgery

Regional anaesthesia should be the preferred technique for analgesia in shoulder surgery, which is a frequent procedure in the daily practice of anaesthesiologists. The use of ultrasound guidance enables the visualization of the relevant nerve structures and the adjacent anatomical details. Low volumes of local anaesthetics reduce the incidence of inadvertent blockade of the phrenic nerve with subsequent respiratory impairment. The additional administration of dexmedetomidine to local anaesthetics prolonges the duration of analgesia with a minimal increased incidence of haemodynamic side effects. An optimal workflow is associated with economical advantages due to an improved use of operation rooms. Attention have to be paid regarding intraoperative hypotension, cerebral hypoperfusion and complications due to positioning.

Glenohumeral Osteoarthritis: The Role for Orthobiologic Therapies: Platelet-Rich Plasma and Cell Therapies

The glenohumeral (GH) joint ranks third on the list of the large joints that are most commonly affected by osteoarthritis, after the knee and the hip. General nonsurgical modalities, including changes in daily activities, physical therapy, pharmacotherapy, and corticosteroid injections, constitute the mainstay of treatment. Most of these options, however, have shown moderate and short-term effectiveness. Arthroplasty techniques have proven to be successful for elderly patients. Nevertheless, replacement options are not optimal for younger patients because their functional demands are higher and prostheses have a finite life span. This has led to the search for new nonoperative treatment options to target this subgroup of patients. It has been suggested that orthobiologic therapies, including platelet-rich plasma (PRP) and cell therapies, present great promise and opportunity for the treatment of GH osteoarthritis. Despite the promising results that have been shown by cell therapies and PRP for treating degenerative joint conditions, additional studies are needed to provide more definitive conclusions.

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.

Use of the On-Q Pain Pump in Alveolar Bone Grafting: Effect on Hospit Length of Stay

Objective

Alveolar bone grafting (ABG) with iliac crest bone graft can be associated with significant pain at the donor site. The On-Q pain pump has been shown to be efficacious in treating postsurgical pain. The aim of this study was to compare the length of postoperative hospital stay in patients undergoing ABG who received the On-Q pain pump at the iliac crest donor site (On-Q+) with that of patients who did not receive the On-Q pain pump (On-Q-).

Design

A retrospective, cohort study, approved by institutional review board, was performed. Thirty-one consecutive patients in the On-Q- group were compared with 38 consecutive patients in the On-Q– group. The two cohorts were assessed for length of stay. Statistical analysis was performed using the Fisher exact probability test.

Setting

Tertiary care academic medical center.

Patients

Sixty-nine patients with cleft lip and/or cleft palate (CL/P) undergoing secondary ABG with iliac crest bone graft were operated on between May 1993 and January 2014.

Main Outcome Measure

Length of postoperative hospital stay.

Result

Mean length of stay in the On-Q– patients was 0.52 days versus 0.37 days for the On-Q– patients. This difference between the two cohorts was not statistically significant (P = .234).

Conclusion

Although there is a trend toward a shorter length of stay in our patients who received the On-Q pump, this finding was not statistically significant. Given the expense and additional burden of care associated with the device, we have become more selective in its utilization.

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.

Articular cartilage and local anaesthetic: A systematic review of the current literature

BACKGROUND

Chondrolysis involves the breakdown of cartilage following arthroscopic surgery, most commonly affecting the glenohumeral joint.

METHODS

This review summarises all clinical and laboratory studies regarding local anaesthetic (LA) and its association with chondrolysis. We identified 289 papers, 41 of which met our inclusion criteria and were included in the final review.

RESULTS

Bupivacaine, lidocaine, ropivacaine and levobupivacaine are all toxic to cartilage. Intra-articular infusions confer a greater toxicity to cartilage than single injections.

CONCLUSIONS

Intra-articular LA pain pumps carry a high risk of chondrolysis and should be avoided. Further studies are indicated to assess long-term single exposure LA implications.

Knee chondrolysis by infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter after arthroscopic ACL reconstruction

BACKGROUND

Postoperative knee chondrolysis caused by continuous intra-articular pain pumps infusing bupivacaine with epinephrine is a rare but serious complication.

PURPOSE

To determine the association between postoperative intra-articular infusion of bupivacaine with epinephrine and the development of knee chondrolysis in patients who have undergone arthroscopic anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that the development of knee chondrolysis after ACLR is associated with postoperative high-dose intra-articular bupivacaine with epinephrine infusion.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In this retrospective cohort study, the charts of all patients treated with arthroscopic ACLR by a single surgeon between January 1, 2004, and December 31, 2006, were reviewed. Patients with severe articular cartilage damage at the time of the index procedure, with known knee joint infection, inflammatory arthritis, multiligament knee injury, bilateral knee injury, or any previous knee surgery, were excluded. Patients were grouped into 2 cohorts: the exposure group (those who had postoperative infusion of bupivacaine with epinephrine via an intra-articular pain pump [IAPP]) and the nonexposure group (those without postoperative infusion).

RESULTS

A total of 105 patients met the inclusion and exclusion criteria. There were 57 male and 48 female patients with a mean age at surgery of 25.5 ± 8.6 years (range, 13-52 years). The exposure group consisted of 46 patients and the control group of 59 patients. Thirteen of 46 patients (28.3%) who received an IAPP developed chondrolysis. There were no cases of chondrolysis in the control group. Of those in the exposure group, 32 patients were exposed to 0.5% bupivacaine with epinephrine and 12 developed chondrolysis (37.5%), while 14 patients were exposed to 0.25% bupivacaine with epinephrine and 1 developed chondrolysis (7.1%). Patients exposed to 0.5% bupivacaine with epinephrine had a significantly higher incidence of chondrolysis compared with those exposed to 0.25% (P = .03). Patients with chondrolysis had severe pain and limitations in daily activity.

CONCLUSION

The development of knee chondrolysis was associated with the intra-articular infusion of bupivacaine with epinephrine postoperatively. Furthermore, the presented evidence suggests that this occurs in a dose-dependent manner. The risk of knee chondrolysis might be reduced by avoidance of intra-articular infusion of bupivacaine with epinephrine. We recommend against continuous intra-articular infusion of local anesthetic postoperatively.

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.

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.

Multimodal pain management in orthopedics: implications for joint arthroplasty surgery

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.

The 2012 Chitranjan Ranawat award: intraarticular analgesia after TKA reduces pain: a randomized, double-blinded, placebo-controlled, prospective study

BACKGROUND

Postoperative pain after total knee arthroplasty remains one of the most important challenges facing patients undergoing this surgery. Providing a balance of adequate analgesia while limiting the functional impact of regional anesthesia and minimizing opioid side effects is critical to minimize adverse events and improve patient satisfaction.

QUESTIONS/PURPOSES

We asked whether bupivacaine delivered through an elastomeric device decreases the (1) patients' perception of pain after TKA; (2) narcotic consumption; and (3) narcotic-related side effects as compared with a placebo.

METHODS

In this prospective, double-blind, placebo-controlled study, all patients received standardized regional anesthesia, a preemptive and multimodal analgesic protocol, and a continuous intraarticular infusion at 5 mL/hour through an elastomeric infusion pump. The patients were randomized to receive either an infusion pump filled with (1) 300 mL of 0.5% bupivacaine, the experimental group (n = 75); or (2) 300 mL of 0.9% normal saline solution, the control group (n = 75). Data concerning postoperative pain levels through a visual analog scale, postoperative opioid consumption, opioid-related side effects, and complications were collected and analyzed.

RESULTS

Patients in the experimental group receiving the bupivacaine reported a reduction in pain levels in highest, lowest, and current visual analog scale scores compared with the placebo group on the first postoperative day and highest visual analog scale score on postoperative Day 2 along with a 33% reduction in opioid consumption on postoperative Day 2 and a 54% reduction on postoperative Day 3.

CONCLUSION

In patients undergoing TKA, continuous intraarticular analgesia provided an effective adjunct for pain relief in the immediate postoperative period without the disadvantages encountered with other analgesic methods.