Thursday, November 3, 2011

Chondrolysis & pain pumps - recent article in JBJS - advisory!

The most recent volume of the JBJS (93, Issue 21) presents an article by Provencher et al on Joint Chondrolysis. This article traces the history of this condition 'that results in substantial pain and morbidity, leading to impairment of the affected joint in often young and otherwise active patients'.

As pointed out by the authors, this condition has been recognized in the hip, knee, and ankle from a wide variety of causes. Recently, chondrolysis of the shoulder has become a recognized cause of the destruction of the joint surfaces of the shoulder after arthroscopy combined with pain pump infusion of local anesthetics or thermal energy.

What is curious about this article is that four of the six authors hold positions with Advance Health Solutions, a company that lists as clients "National law firms representing pharmaceutical, medical device and biotechnology corporations". The Advance Health Solutions website states "the Journal of Bone and Joint Surgery publishes an article entitled 'Current Concepts Review: Joint Chondrolysis' authored by the staff and members of the Health Professional Advisory Committee members at Advance Health Solutions in collaboration with Rush University Medical Center". One of the authors is President and CEO of this company. Another of the authors' CV indicates that he has consulted with a law firm that defends manufacturers of pain pumps. A second curious aspect of this article is that it seems to downplay the role of pain pumps in the causation of chondrolysis of the shoulder.

Due presumably to the date of its submission, the Provencher article did not have the opportunity to consider the article by Wiater et al, Risk Factors for Chondrolysis of the Glenohumeral Joint, the abstract of which is reproduced here:

Background: Glenohumeral chondrolysis is a complication of arthroscopic shoulder surgery characterized by the dissolution of the articular cartilage of the glenoid and the humeral head. An analysis of 375 intra-articular shoulder arthroscopic surgical procedures by an individual community orthopaedic surgeon was performed to explore which factors or combinations of factors might be associated with glenohumeral chondrolysis.

Methods: The occurrence of chondrolysis was correlated with several demographic and surgical variables with use of hazard ratios from Cox proportional hazards models and Kaplan-Meier survivorship curves. Sensitivity analysis was used to examine the effect of two different definitions of the date of the onset of chondrolysis.

Results: In this cohort, each case of documented chondrolysis was associated with the intra-articular post-arthroscopic infusion of a local anesthetic, either Marcaine (bupivacaine) or lidocaine. In an analysis of the group that received an intra-articular postoperative infusion of a local anesthetic, the risk of chondrolysis was found to be greater for those with one or more suture anchors placed in the glenoid, for younger patients, and for those who had the surgery near the end of the ten-year study period.

Conclusions: To our knowledge, this is the first Level-II retrospective cohort study of the factors associated with the development of post-arthroscopic glenohumeral chondrolysis. In this cohort of intra-articular shoulder arthroscopic procedures, chondrolysis was observed only in cases in which either Marcaine or lidocaine had been infused into the joint during the postoperative period. Avoiding such a postoperative infusion may reduce the risk of chondrolysis.

Serrato et al published another recent article not included in the Provencher study: Glenohumeral Chondrolysis Associated with Use of an Intra-Articular Pain Pump Delivering Local Anesthetics Following Manipulation Under Anesthesia: A Report of Four Cases. This article concludes with the paragraphs: Chondrolysis progresses rapidly, even in patients fifty to sixty years old. Three of our four patients (Cases 2, 3, and 4) underwent prosthetic shoulder arthroplasty at a mean of twenty-six months after the use of an IAPP (intra articular pain pump). In many cases of glenohumeral chondrolysis, multiple factors could be acting synergistically to cause the condition, and could help explain why some patients do not develop chondrolysis following the use of an IAPP. However, the essential factor for the development of most of the current cases of chondrolysis, except those related to loose or proud suture anchors, appears to be the use of an IAPP.
The four cases reported here confirm that the other cited risk factors need not be present. To the best of our knowledge, this series represents the only cases of glenohumeral chondrolysis arising in the absence of any other known causative factors besides the use of an IAPP catheter delivering local anesthetics. These cases reinforce the mounting evidence that IAPP catheters can cause articular cartilage injury in the glenohumeral joint.


In view of these recent articles, it is important that the article by Provencher et al not distract from the data supporting the causational relationship between pain pumps and chondrolysis of the glenohumeral joint of the shoulder.

Patient safety is the overriding concern.


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