Chondrolysis from pain pump infusion of local anesthetics

We recently saw a woman who had a Bankart repair for instability 15 years ago. This arthroscopic procedure was followed by 3 days of infusion of local anesthetics using a pain pump. Within a year after surgery, she developed a painful stiff shoulder, but she managed this with analgesics and exercise modification.

On presentation to us, her x-rays showed the characteristic findings of chondrolysis.

Here is an informative article on this devastating condition.

Published Evidence Demonstrating the Causation of Glenohumeral Chondrolysis by Postoperative Infusion of Local Anesthetic Via a Pain Pump 

The joint surfaces of the shoulder (glenohumeral) joint are normally covered by smooth articular cartilage.

Glenohumeral chondrolysis is the irreversible destruction of previously normal articular cartilage, occurring most commonly after shoulder surgery in young individuals. 

The reported incidence of this complication has risen rapidly since the early 2000s. As chondrolysis cannot be reversed, its occurrence can only be prevented by establishing and avoiding its causes. 

The authors analyzed all published cases of glenohumeral chondrolysis, including the relevant published laboratory data, to consolidate the available evidence on the causation of this complication by the postoperative intra-articular infusion of local anesthetic via a pain pump.

The published evidence demonstrated a causal relationship between the infusion of local anesthetic and the development of glenohumeral chondrolysis. 

The risk of this complication in shoulders receiving intra-articular infusions via a pain pump was significantly greater with higher doses of local anesthetic: twenty of forty-eight shoulders receiving high-flow infusions developed chondrolysis, whereas only two of twenty-five shoulders receiving low-flow infusions developed this complication (p = 0.0029). Eleven of twenty-two shoulders receiving 0.5% bupivacaine developed chondrolysis, whereas none of six shoulders receiving 0.25% bupivacaine developed this complication (p = 0.05). Of twenty-two shoulders infused with 0.5% bupivacaine, the eleven that developed chondrolysis had a mean pain pump delivery volume of 377 mL, whereas the eleven that did not develop chondrolysis had a mean volume of 187 mL (p = 0.003). Among shoulders in which an intra-articular pain pump was used, the risk of chondrolysis was significantly greater when suture anchors were placed in the glenoid for labral repair (p < 0.001). The effect seen with suture anchors may be due to the fact that they allow the intraarticular local anesthetic otherwise present only at the joint surface (green in the figure below)

 to gain access to the deeper tissue through the hole in the cartilage associated with the suture anchor.

It was concluded from the published evidence indicates that the preponderance of cases of glenohumeral chondrolysis can be prevented by the avoidance of the intra-articular infusion of local anesthetic via a pain pump.

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