LAS VEGAS, Nevada—Small pain pumps make intra-articular infusion of local anesthetic into the shoulder joint easy and have been widely used to relieve pain after arthroscopy or other surgery, but they might also contribute to destruction of joint cartilage.

The connection between intra-articular anesthetics and chondrolysis was described by Peter T. Scheffel, MD, of Seattle, WA, who recently reported 66 cases of postarthroscopic genohumeral chondrolysis (PAGCL). Dr. Scheffel discussed these cases in a podium presentation at the American Academy of Orthopaedic Surgery 2009 meeting.¹

Severe cartilage damage seen in PAGCL

“Chondrolysis is a devastating complication that can be associated with arthroscopic surgery and post-arthroscopy infusion of local anesthetic in young individuals of either gender having surgery for instability, SLAP (superior labrum from anterior to posterior) lesions and rotator cuff disorders. In contrast to previous reports, the arthroscopic operations in this series were not limited to stabilization procedures and were not limited to cases in which bupivacaine was used,” Dr. Scheffel said.

Imaging of PAGCL associated with the use of pain-pumps after shoulder arthroscopy showed:

• complete loss of articular cartilage from the humeral head and glenoid
• joint space narrowing
• marginal erosions
• subchondral cysts of the glenoid and humeral head
• periarticular osteopenia
• bone edema
• minimal osteophytosis

“Surgeons and patients need to be aware of this potential complication of the infusion of local anesthetic after shoulder arthroscopy,” Dr. Scheffel said.

The 66 cases of chondrolysis associated with shoulder arthroscopy were followed by an intra-articular infusion of local anesthetic in 23 females and 41 males with an average age of 32.4 years. The surgeries were straightforward arthroscopies and included 28 capsular stabilizations, 18 Bankart repairs, 27 SLAP repairs, 7 rotator cuff repairs, 2 capsular repairs, 2 debridements, and 1 capsular release.

Dr. Scheffel said that joint surfaces had been normal at the time of arthroscopy in 55 patients. The infusate contained bupivacaine in one-third of the cases, lidocaine in two-thirds of the cases, and epinephrine in over half of the cases.

Dr. Scheffel said that the PAGCL pathology resembled erosive arthritis seen with autoimmune conditions such as rheumatoid arthritis or lupus more than primary degenerative joint disease.

Local anesthetics appear chondrotoxic

This study builds on work by Hansen et al², who reported a case series of 10 patients (12 shoulders) with PAGCL and found an association between PAGCL and use of intra-articular pain pump catheters delivering bupivacaine with epinephrine. More recently, Bailie et al³ reported 23 GABCL cases and advised against the use of large doses of intra-articular local anesthetics.

The mechanism behind some of these cases may have been identified by Gomoll et al⁴, who showed that in the rabbit shoulder, continuous intra-articular infusion of bupivacaine with or without epinephrine led to significant cartilage damage.

“Bupivacaine showed profound chondrotoxic effects in an experimental model that closely followed the current clinical application of postoperative pain pumps,” they concluded.

References

1. Scheffel PT. Characteristics of chondrolysis associated with intra-articular pain-pumps after shoulder surgery. Oral presentation at the American Academy of Orthopaedic Surgery 2009 meeting, Las Vegas, 27 February 2009, Presentation No: 563.
2. Hansen BP, Beck CL, Beck EP, Townsley RW. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med. 2007 Oct;35(10):1628-34.
3. Bailie DS, Ellenbecker T. Severe chondrolysis after shoulder arthroscopy: A case series. J Shoulder Elbow Surg. 2009 Jan 29.
4. 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 Aug;22(8):813-9.