What Doctors Are Saying About Chondrolysis, Pain Pumps and Intra-articular Anesthesia

-InjuryBoard

11/28/2008- Doctors have been associating catheter delivered intra-articular pain pump anesthesia with cartilage cell toxicity. It has now become increasingly evident that pain pump infused anesthesia is detrimental to all cartilage found in articular joints. Six medical doctors had a chance to review a case presentation entitled, Bilateral Shoulder Chondrolysis Following Arthroscopy; a Report of Two Cases (Greis, et al.), and here is the substance of their letters to the Editor of the Journal & Bone Joint Surgery:

Drs. James A. Turner and Hugh Clarke At Queen Alexandria Hospital, Portsmouth, UK:

• The well known Hansen study provided a substantial association between bupivicaine with epinephrine and post arthroscopic gleno humeral chondrolysis (PAGCL)

• Scientific investigators ( Chu, et al.) exposed canine chondrocytes (cartilage cells) to bupivicaine and caused cell damage after only 15 minutes

• Another in vitro study (Piper, et al.) compared the effects of bupivicaine and ropivicaine (0.5%) on human cartilage cells and found that after 30 minutes of treatment, chondrocytes exposed to bupivicaine showed a higher rate of cell death

• Yet another study (Karpie, et al.) showed that more cartilage cells were dying when exposed to 2% instead of 1% lidocaine

• While some studies differed in the rate of cell death after exposure to anesthetic preparations, if epinephrine (a blood vessel constrictor) was part of the preparation, the cell death rate was significantly higher.

Drs. Turner and Clark concluded the following:

“Despite some variance, all the above studies including the case report 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 ( Br.) 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.”

Drs. Jonathan C. Levy and Mark Frankle of Holy Cross Orthopaedic Institute in Florida:

• According to Regan et al., there have been reports of chondrolysis following shoulder arthroscopy where intra-articular pain pumps were never used. Conversely, there are also many patients who received treatment with intra-articular pain pumps that never developed chondrolysis

• Proper evaluation is multifaceted and should involve comprehensive differential diagnoses, including inflammation, arthritis, inflammation due to bioabsorbable implants, infections, foreign body induced arthropathy, radio frequency ablation injury and chemical toxicity

However, Drs. Levy and Frankle still cautioned against using intra-articular pain pump anesthesia, stating the following:

“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. We, therefore, no longer use intra-articular pain management catheters. We minimize the use of the thermal probe in the intra-articular space…"

Drs. Patrick E. Greis and Robert T. Burks of the University of Utah (Authors) in response to Drs. Levy and Frankle:

• Doctors should always consider differential diagnoses for the cause of chondrolysis following shoulder arthroscopy. Bacterial infection might be a factor in some cases

• Chondrolysis may be multifactorial and further investigation is necessary to fully understand the problem

• However, there is a very convincing amount of literature that associate the delivery of anesthetic with indwelling catheterization and resulting cartilage cell death

• The results of one study (Hansen, et al.) showed that 36% of patients with in dwelling catheter delivery of bupivicaine suffered cartilage cell death while none of the patients who were treated without catheterization experienced cartilage problems

• Another study (Levy, et al) confirmed Hansen’s results

Drs. Greis and Burks concluded the following:

“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. 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 available, 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.”

Thus, despite slight differences of opinion, the consensus among all of the doctors is that the use of intra-articular pain pump anesthesia is a treatment risk that is too high to take.

If you or a loved one have suffered PAGCL from shoulder pain pump use, you may be entitled to compensation. Contact the shoulder pain pump attorneys of Ennis & Ennis, P.A. today by filling out a free case evaluation form on this page or call us toll free at the number listed below.