Monday, January 23, 2012

Chondrolysis - JBJS "current concepts review" - questions left unanswered

Those interested in chondrolysis of the shoulder may enjoy reading a letter by Benjamin Busfield, entitled "Questions left unanswered".

Some of the key points in his letter are summarized here:
(1) Apples and Oranges "Review articles tend to review existing literature, not re-classify the data. Why group pediatric hip chondrolysis cases with PAGCL patients? This is very likely two different pathologies presenting in vastly different patient populations. This also begs the issue of the authors merging of the terms chondrolysis and PAGCL. The term PAGCL, as I correctly stated in my initial letter to the editor that was disputed in the author reply, was indeed a term coined by Beck and Hansen.PAGCL was a new diagnosis in the shoulder at that time that occurred after arthroscopy and was associated with use of intra-articular pain pumps with local anesthetics. Numerous subsequent retrospective studies have confirmed this association in both the knee and the shoulder, and numerous laboratory studies have demonstrated the chondrotoxicity of local anesthetics. For obvious reasons, no prospective study can ethically be performed for patients receiving intra-articular pain pumps and local anesthetics to give us the highest level of evidence."

(2) The Evidence: "I find the inconsistent conclusion of this article and the grouping of all chondrolysis cases to be questionable, which creates significant concern as it has been published in our most respected journal. The advent of intra-articular pain pumps with local anesthetics in the 1990’s directly correlated with the development of PAGCL cases. All recent authors on this topic recommend against the use of intra-articular pain pumps and local anesthetics." See our post on "res ipsa".

(3) Disclosure: "It seems that both the “Joint Chondrolysis” CCR and the Solomon et al. paper were both co-authored by members of this corporation (Advance Health Solutions).  Regarding Advance Health Solutions, what is the nature of this corporation that is now co-authoring articles in our Orthopedic literature? .. I am concerned about possible bias on the part of Advance Health Solutions. Clearly an article that minimizes the role of pain pumps and local anesthetics as a cause of PAGCL would be looked upon favorably by the defense counsels of the pain pump manufacturers and could assist in deflecting blame toward their products. As the Orthopedic literature has committed to do with changes in the author disclosure forms, it is appropriate that we have complete transparency with regards to potential bias. The disclosure statement for the “Joint Chondrolysis” CCR states that none of the authors “received payments or services, either directly or indirectly (i.e., via his or her institution)” but there is disclosure of a “financial relationship” in the “thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work.” There were no conflicts of interest reported in the Solomon et al. paper in 2009, the other paper on chondrolysis with contributions from Advance Health Solutions and largely the same authors as the “Joint Chondrolysis” CCR. If Advance Health Solutions has had pain pump manufacturers as clients with confidentiality agreements, are the company and Dr. Maryam Navaie held to our literature standard of full disclosure for publications? Are corporations also subject to the disclosure standards?" See also our post regarding disclosure in the CCR.

(4)  Disclosure: Dr. Busfield is a medicolegal consultant for plaintiffs in chondrolysis litigation

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