JBJS -- Letters to the Editor for Greis et al., 90 (6) 1338-1344

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Letters to the Editor to:

Case Reports:
Patrick E. Greis, Alexander LeGrand, and Robert T. Burks
Bilateral Shoulder Chondrolysis Following Arthroscopy. A Report of Two Cases
J Bone Joint Surg Am 2008; 90: 1338-1344 [Full text] [PDF]

Letters to the Editor: Submit a response to this article

Electronic letters published:

An Association Between Chondrolysis and Use of Certain Intra-articular Anesthetic Agents.: James A Turner, Hugh Clarke (25 September 2008)

Drs. Greis and Burks respond to Drs. Levy and Frankle: Patrick E Greis, M.D., Robert T. Burks, M.D. (11 July 2008)

Chondrolysis following shoulder arthroscopy: a multitude of contributing factors: Jonathan C. Levy, MD, Mark Frankle, MD (16 June 2008)

An Association Between Chondrolysis and Use of Certain Intra-articular Anesthetic Agents. 25 September 2008

James A Turner,
SpR Trauma and Orthopaedics
Queen Alexandra Hospital, Portsmouth, UK,
Hugh Clarke
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Re: An Association Between Chondrolysis and Use of Certain Intra-articular Anesthetic Agents.

jimturner{at}doctors.org.uk James A Turner, et al.

To the Editor:
We read with interest the case report on bilateral shoulder chondrolysis following arthroscopy(1). The authors' conclusion that the intra-articular bupivicaine pump was the probable cause of the chondrolysis is supported by a number of recent studies not referenced in the paper.
Hansen et al (2) in a level four case series provided evidence that use of bupivicaine with epinephrine was substantially associated with gleno-humeral chondrolysis following arthroscopy.
Chu et al (3) elegantly demonstrated the chondrolytic effects of bupivicaine after only 15-30 min of exposure in a canine model. These results are supported by those obtained from another in-vitro experiment comparing the effects of ropivicaine and bupivicaine (0.5%) on human chondrocytes(4). After 30 minutes of treatment, chondrocytes exposed to bupivicaine exhibited a significantly higher rate of necrosis. In another study, the rate of chondrocyte cell death was found to be higher when exposed to 2% lidocaine compared to 1% lidocaine (5).
However, a more recent laboratory study evaluating the in vitro chondrotoxicity of anaesthetic formulations provides conflicting evidence. The authors found that human chondrocyte necrosis rates with bupivicaine (0.25% & 0.5%) and lidocaine (1%) were similar when compared to controls (6). It was only after 48 hours of infusion that the rates significantly increased. The authors also found that all local anaesthetic solutions that included epinephrine had a significantly higher cell death rate when compared to solutions without epinephrine.
Despite some variance, all the above studies including the case report(1) add to the growing evidence to support the hypothesis that bupivicaine and lidocaine cause chondrocyte cell death. We support the authors caution against the use of a bupivicaine infusion into the shoulder and suggest that if it is going to be used,a concentration of 0.25% or even 0.125% will minimise the risk of damage, and that epinephrine should not be added.
On a more general note, we would also caution that a single injection of lidocaine or bupivicaine into any other joint poses a risk a chondrolytic effect. We recommend use of soft tissue infusion of local anaesthetic into the skin incisions rather than the joint itself to obviate any risk.
The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
References:
1.Patrick E. Greis, Alexander LeGrand, and Robert T. Burks Bilateral Shoulder Chondrolysis Following Arthroscopy. A Report of Two Cases J Bone Joint Surg Am 2008; 90: 1338-1344
2. Hansen BP, Beck CL, Beck EP, Townsley RW. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med. 2007;35:1628-34.
3. Chu CR, Izzo NJ, Papas NE, Fu FH. In vitro exposure to 0.5% bupivacaine is cytotoxic to bovine articular chondrocytes. Arthroscopy. 2006;22:693-9.
4. Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity in human articular chondrocytes. J Bone Joint Surg Am. 2008;90:986-91.
5. Karpie JC, Chu CR. Lidocaine exhibits dose- and time-dependent cytotoxic effects on bovine articular chondrocytes in vitro. Am J Sports Med. 2007;35:1621-7.
6. Dragoo JL, Korotkova T, Kanwar R, Wood B. The effect of local anaesthetics administered via pain pump on chondrocyte viability. Am J Sports Med. 2008;36:1484-8.

Drs. Greis and Burks respond to Drs. Levy and Frankle 11 July 2008

Patrick E Greis, M.D.
University of Utah, Salt Lake City, Utah,
Robert T. Burks, M.D.
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Re: Drs. Greis and Burks respond to Drs. Levy and Frankle

patrick.greis{at}hsc.utah.edu Patrick E Greis, M.D., et al.

Drs. Levy and Frankle raise the issue of considering the differential diagnosis for chondrolysis following shoulder arthroscopy. We would agree that all causes of this problem must be considered when evaluating these patients. Missing an indolent infection could certainly result in a poor long term outcome of any further treatments if not recognized. Additionally, we would agree that chondrolysis may be multifactorial and that a complete understanding of this problem remains a work in progress requiring further investigation.
However, there remains a very substantial and convincing body of literature associating indwelling intra-articular catheters and the infusion of bupivacaine and chondrolysis, which we feel needs to be acknowledged. The recent work by Hansen et al.(1) clearly points towards this as the offending agent, as do the cases reported on which were the basis of our report(2). In the work by Hansen, 63% of patients with an indwelling intra-articular cathetor and infusion of bupivacaine developed chondrolysis in a series of patients undergoing arthroscopic stabilization. No patients without the catheter developed this problem. The authors could find no other consistent features of the procedures which would explain this problem. Additionally, in the recent article written by Levy et al.(3), they noted that 9 of 11 of their patients with chondrolysis had an indwelling catheter for pain relief using bupivacaine. In the remaining two patients, no information was available on this issue. We would hazard to guess that it is likely that they too had a pain pump used in the intra-articular position. Taken in sum, the reports by Hansen et al.(1), Levy et al.(3), and our present case report detail 27 shoulders with chondrolysis, 25 of which had a confirmed intra-articular catheter infusing bupivacaine (with no information available on the other(2).
In addition to the recent clinical data, the basic science work on bupivacaine and lidocaine chondrocyte toxicity makes the argument for this as a prime causal agent compelling(4-5). The purpose of our case report was to call attention to this as an issue, in an effort to stop the use of indwelling intra-articular catheters with bupivacaine infusions following shoulder arthroscopy. We feel there is more than enough information avalable, at this time, to make this recommendation. We agree with the recommendations by Drs. Levy and Frankle to try and minimize other potential causative factors in chondrolysis, but hope to bring attention to what we feel is a major player in this problem so as to hopefully avoid further potential harm.
References:
1. Hansen BP, Beck CL, Beck EP, Townsley RW. Postarthroscopic Glenohumeral Chondrolysis. Am J Sports Med. 2007;35:1628-34.
2. Greis PE, LeGrand A, Burks RT. Bilateral Shoulder Chondrolysis Following Arthroscopy. A Report of Two Cases. J Bone Joint Surg Am. 2008;90:1338-44.
3. Levy JC, Virani NA, Frankle MA, Pupello DR, Hamelin JA. Young Patients with shoulder chondrolysis following arthroscopic sholder surgery treated with total shoulder arthroplasty. J Shoulder Elbow Surg. 2008;17:380-88.
4. Chu CR, Izzo NJ, Papas NE, Fu FH. In vitro exposure to 0.5% bupivacaine in cytotoxic to bovine articular chondrocytes. Arthroscopy. 2006;22:693-9.
5. Gomoll Ah, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: an experimental model investigating chondrotoxicity in the rabbit shouder. Arthroscopy. 2006;22:813-9.

Chondrolysis following shoulder arthroscopy: a multitude of contributing factors 16 June 2008

Jonathan C. Levy, MD,
Shoulder & Elbow Surgeon
Holy Cross Orthopaedic Institute, Fort Lauderdale, FL,
Mark Frankle, MD
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Re: Chondrolysis following shoulder arthroscopy: a multitude of contributing factors

jonlevy123{at}yahoo.com Jonathan C. Levy, MD, et al.

To The Editor:
It is with great interest that we read the recent case report by Greis, et al.(1). The cases they report are devastating complications following arthroscopy. While the report suggests that the indwelling continuous pain pump was a probable causative factor, we wish to re-emphasize that this clinical entity is still poorly understood. It typically presents with a patient complaining of pain and stiffness following shoulder arthroscopy. These patients subsequently develop rapid radiographic changes, with joint space narrowing, periarticular erosion and eventual subchondral bone loss.
Proper evaluation of these patients requires consideration of a differential diagnosis that includes inflammatory mediated arthropathy (i.e. rheumatoid arthritis, juvenile rheumatoid arthritis, etc); exaggerated inflammatory response to bioabsorbable implants(2,3); infectious arthropathy(4,5) (including low virulent organisms like Propionibacterium acnes); mechanical arthropathy from retained foreign body or implants used(6); and finally, chondrocyte injury from either the use of radiofrequency ablation(7,8,9) or the chemical toxicity of drugs(10).
An appropriate work up for each case requires consideration of each potential diagnosis in an effort to identify treatable conditions such as a low grade infection or inflammatory arthritis. To assume that a patient has developed chondrolysis from a chemical toxicity (i.e. bupivicaine), may result in a failure to identify treatable conditions.
Clearly, there are reported cases in the literature of chondrolysis following shoulder arthroscopy where intra-articular pain pumps were never used(6,8). There are also many patients who were treated with an intra-articular pain pump that never developed chondrolysis(11).
We believe chondrolysis following shoulder arthroscopy has a multitude of contributing factors including the use of normal saline(12,13), radiofrequency ablation(7), bioabsorbable implants(2,3,6), low-grade infection(5), and the use of indwelling pain catheters(9). While there may be cases that seem to have a clear cut link between one of these causative factors and the complication of chondrolysis, one must remember the multitude of factors that may play causative roles.
The current understanding of chemical toxicity leading to chondrolysis has focused on one group of drugs, the -caine derivatives. However, the effects of dose, preservatives, duration of exposure, delivery method, and patient related factors predisposing such a reaction remain unclear. Mechanical factors such as thermal injury, chondral scuffing during arthroscopy, and abrasion from foreign body likely play a role, as does an exaggerated biologic response from bioabsorable implants.
Until the individual and cumulative effects of these factors are clarified, efforts should be made at avoiding chondral injury and chondrocyte toxicity. As discussed in our recent experience with this patient population, we have modified our current practice of shoulder arthroscopy in effort to avoid potential contributors to chondrolysis(5). We, therefore, no longer use intra-articular pain management catheters. We minimize the use of the thermal probe in the intra-articular space. We preferentially use bio-inert anchors (metal or PEEK) for capsulorrhaphy procedures.
The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Encore Medical). Also, a commercial entity (Encore Medical) paid or directed in any one year, or agreed to pay or direct, benefits of less than $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
References:
1. Greis, PE, LeGrand A, Burks, RT. Bilateral shoulder chondrolysis following arthroscopy. A report of two cases. J Bone Joint Surg Am 2008;90:1338-1344.
2. Bennett WF. Bioabsorbable soft tissue fasteners: failure mode an exaggerated inflammatory response? Arthroscopy. 1998;14:449-50.
3. Edwards DJ, Hoy G, Saies AD, Hayes MG. Adverse reactions to an absorbable shoulder fixation device. J Shoulder Elbow Surg. 1994;3:230-33.
4. Topolski MS, Chin PY, Sperling JW, Cofield RH. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elbow Surg. 2006;15(4):402-6.
5. Levy JC, Virani NA, Frankle MA, Cuff D, Pupello DR, Hamelin JA. Young patients with shoulder chondrolysis following arthroscopic shoulder surgery treated with total shoulder arthroplasty. J Shoulder Elbow Surg. 2008;17(3):380-8.
6. Athwal GS, Shridharani SM, O�Driscoll SW. Osteolysis and arthropathy of the shoulder after use of bioabsorbable knotless suture anchors. A report of four cases. J Bone Joint Surg Am. 2006;88:1840-45.
7. Edwards RB 3rd, Lu Y, Nho S, Cole BJ, Markel MD. Thermal chondroplasty of chondromalacic human cartilage. An ex vivo comparison of bipolar and monopolar radiofrequency devices. Am J Sports Med. 2002;30:90-7.
8. Levine WN, Clark AM Jr, D'Alessandro DF, Yamaguchi K. Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am. 2005;87:616-21.
9. Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy. 2007;23:797.e1-5.
10. Gomoll AH, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: an experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy. 2006;22(8):813-9.
11. Yamaguchi K, Sethi N, Bauer GS. Postoperative pain control following arthroscopic release of adhesive capsulitis: a short-term retrospective review study of the use of an intra-articular pain catheter. Arthroscopy. 2002;18(4):359-65.
12. Reagan BF, McInerny VK, Treadwell BV, Zarins B, Mankin HJ. Irrigating solutions for arthroscopy. A metabolic study. J Bone Joint Surg Am. 1983;65(5):629-31.
13. Bulstra SK, Kuijer R, Eerdmans P, van der Linden AJ. The effect in vitro of irrigating solutions on intact rat articular cartilage. J Bone Joint Surg Br. 1994;76(3):468-70.