Tuesday, November 29, 2011

Chondrolysis of the shoulder & pain pumps - what does the recent literature say? res ipsa loquitur

A pub med search for reports of cases of chondrolysis of the shoulder published in 2010 or later surfaced the following articles.

Glenohumeral chondrolysis: a systematic review of 100 cases from the English language literature
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. 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.

Case Reports: Two Cases of Glenohumeral Chondrolysis after Intraarticular Pain Pumps
A 19 year old NCAA Division 1 gymnast developed chondrolysis after an arthroscopic capsular plication was performed. At the time of this surgery the cartilage of the joint was noted to be intact. A bupivacane pain pump was placed in the joint. One year later she was found to have cartilage defects in the load bearing areas of the humeral head and glenoid and required a shoulder arthroplasty.
A 26 year old had an arthroscopic posterior glenoid labrum repair. A bupivacane pain pump was placed in the joint. After this surgery she became stiff and had a arthroscopic debridement. Again bupivacane pain pump was placed in the joint. One and one half years after her initial surgery, shoulder arthroplasty was required.

Chondrolysis of the Glenohumeral Joint After Infusion of Bupivacaine Through an Intra-articular Pain Pump Catheter: A Report of 18 Cases
Review of 18 patients diagnosed with chondrolysis was carried out. Patient age ranged from 16 to 39 years of age. All patients were from 2 experienced orthopaedic surgeons’ practices. All 18 patients diagnosed with glenohumeral joint chondrolysis received postoperative infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter. 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. Of the 18 patients, 14 have since undergone repeat arthroscopic procedures, and 5 have received a humeral head–resurfacing operation.

Glenohumeral chondrolysis associated with use of an intra-articular pain pump delivering local anesthetics following manipulation under anesthesia: a report of four cases
The authors report four cases of glenohumeral chondrolysis that occurred following the use of an IAPP delivering either 0.25% or 0.5% bupivacaine with epinephrine for forty-eight to sixty hours after isolated manipulation of the shoulder under anesthesia, without a surgical procedure. No patient had evidence of arthritis prior to the manipulation. Three of the four patients required shoulder arthroplasty for the chondrolysis and the fourth was considering this procedure.

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.
Chondrolysis was observed only in cases where an intraarticular pain pump was used to administer local anesthetics after an arthroscopic procedure.

In some quarters - for reasons that are unclear - there is a tendency to shy away from acknowledging the causational relationship between the use of intraarticular pain pumps and chondrolysis of the shoulder. This relationship is not diminished by the observation that there are other causes of chondrolysis - such as thermal energy or infection or birth defects or penetration of the femoral head with a guide pin. Similarly, the causational relationship between cigarette smoking and lung cancer is not diminished by the observation that there are other causes of lung cancer.

You may like to review some of the previous posts on chondrolysis, such as x-rays in chondrolysis, chondrolysis of the shoulder and 'pain pumps', and chondrolysis and pain pumps - recent article in JBJS - advisory! As well as this article and this site.

Since a pain pump is not necessary for any procedure and since its use can be associated with irreversible joint destruction, the evidence for patient safety speaks for itself.


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