Technological innovations in shoulder surgery - delayed discovery of the risk.

 A 20 year old woman had an arthroscopic instability repair of her shoulder followed by the intra articullar infusion of local anesthetics through a pain pump. After surgery she had pain and stiffness of her shoulder. X-rays taken 10 months after surgery show joint space narrowing.

Seventeen years after her arthroscopic surgery at the age of 37 she presented to us with a very stiff shoulder. She had essentially no glenohumeral motion.  Her x-rays at that time are shown below

Because of her physically active life style she wished to proceed with a ream and run procedure.

The appearance of her humeral head and glenoid at surgery are shown below

Her glenoid was reamed to a smooth concavity

And an impaction grafted standard stemmed humeral implant was inserted.

Six days after surgery she was off pain medication and doing well with her range of motion program as shown below.

Comment: In the early 2000s the pain pump was promoted as a technological innovation in shoulder surgery.

It was not until 10 years after the introduction of the pain pump that its causative role in chondrolysis was demonstrated.

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.

As we've emphasized before (see here), two plain x-rays are necessary and sufficient to make most diagnoses of shoulder arthritis.

Here is an anteroposterior (AP) and an axillary view typical of shoulders with chondrolysis from the intraarticular infusion of local anesthetics with a pain pump.

The upper view, the AP shows an atrophic joint without sclerosis or osteophytosis, and with osteopenia and articular surface cysts.

The standardized axillary view reveals much more of the pathology: central erosion of the glenoid and shows the loss of humeral head roundness as well as the articular surface cysts.

Other posts of relevance to chondrolysis

Chondrolysis and pain pumps 1
Chondrolysis and pain pumps 2
Chondrolysis and pain pumps 3
Chondrolysis and pain pumps 4

Chondrolysis and pain pumps 5
Toxicity of local anesthetics
Risk factors for chondrolysis
x-rays in chondrolysis
x-rays in chondrolysis 2
Case 1
Case 2
Case 3

Chondrolysis - more 

More cases
Still more cases 

Even more cases
Postarthroscopic Glenohumeral Chondrolysis PAGCL JAAOS
In other joints
Post arthroscopic glenohumeral chondrolysis ?review
Chondrolysis - ?review

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Chondrolysis in a young woman - how can this be managed? Part 3

Here is the four month (still early) followup on the case we posted yesterday.

To recap, she is an athletic young woman who, when she was in her mid 20s, was diagnosed with multidirectional instability of her right shoulder. She was treated by surgeons in another state with an arthroscopic anterior and posterior capsulorrhaphy. Three years later she had a repeat surgery after which a pain pump was used to infuse local anesthetics. Eight years later she had a subacromial decompression and biceps tenodesis. At that time glenohumeral chondromalacia was identified. The shoulder was debrided and the repair sutures removed. Five months later another subacromial decompression was performed along with a distal clavicle excision. She had persistent stiffness and pain. At the time of her presentation to us - twelve years after her first surgery - she had flexion limited to 90 degrees, pain ranging from 7-10 on a scale of 10, and reported the inability to perform any of the twelve functions of the Simple Shoulder Test. 

Her x-rays showed the characteristic appearance of chondrolysis (see this link).

She and her local referring orthopaedic surgeon (a colleague of ours) convinced us to perform a ream and run procedure. Here are the immediate postoperative films.

Although her motion was improved at 6 weeks after surgery, she and her local orthopaedic surgeon decided to proceed with a manipulation under anesthesia in that she had lost some of her early range of motion.

She demonstrated the highest level of dedication to her rehabilitation program, taking it to trackside. 

She has generously allowed us to post some of her photos here.

Here are the photos she sent in at 4 months after surgery, stating that she can now perform 8 of the 12 functions of the Shoulder Test in contrast to 0/12 before surgery.

While these results are still early in the game, they are most encouraging and more than anything, they show what can be accomplished when the patient is completely dedicated to the rehabilitation program. 

It reminds of the important principle: "it is the patient and not the shoulder that we're treating". 

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Chondrolysis in a young woman - how can this be managed? Part 2

In yesterday's post (link), we presented the case of a young woman with chondrolysis after arthroscopic surgery with the postoperative infusion of local anesthetics using pain pump.

This case reminded us of another young lady in her mid 20s from out of state.  Six years prior to our visit she sustained a left shoulder dislocation when she was hit while playing basketball while in high school. The shoulder was reduced at the game. A year later she  returned to basketball but dislocated her shoulder while bench pressing. She then had an arthroscopic shoulder repair in the summer of 2008 and had the postoperative infusion of local anesthetics using pain pump for the first 2 days afterwards. She developed painful stiffness over the next two years that was refractory to an arthroscopic release. She was referred to us for consideration of a ream and run procedure.

At the time of presentation she could perform only 4 of the 12 functions of the Simple Shoulder Test, had a very stiff shoulder that was painful on all movement and these x-rays showing the characteristic appearance of chondrolysis (see link).

Because of her high level of pain and severe stiffness we recommended a total shoulder, in spite of her young age. Although we gained full passive range of motion at surgery with vigorous releases, her shoulder became stiff after surgery. We manipulated her shoulder twice, once at two months and once at four months. 

Two years after surgery she was definitely improved over her preoperative status, but continued to have issues with stiffness and pain.

Her x-rays looked fine two years after surgery.

Three years after surgery she reported "I have been doing pretty well. Low pain and maintaining movement and muscle. The main issue I have been dealing with is handling the cold weather (or as "cold" as San Diego can get) and the achy feeling I get in my shoulder, which sometimes hinders my sleeping. I am continuously encouraged by almost every person in my life to stretch it every day. I typically have pain the day after I stretch it, which I am assuming is normal and more of an ache than actual pain." She indicates that she can now perform 10 of the 12 functions of the Simple Shoulder Test.

This case, like the one posted yesterday, show the devastating effect associated with pain pump use in young women after instability repairs as well as the difficulty in regaining comfort and function for the shoulders even after an optimal surgical reconstruction. It is apparent that the chondrolysis has an adverse effect not only on the cartilage, but also on the surrounding soft tissues. 

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Click here to see the new Shoulder Arthritis Book

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Chondrolysis in a young person, managed with a ream and run

This week, we had the opportunity to meet a woman in her thirties who had had multiple prior procedures on the right shoulder, the first two were performed over a decade ago for multidirectional instability (arthroscopic anterior and posterior capsulorraphies). At least one of these included the use of a pain pump for the postoperative infusion of local anesthetics. Subsequently her shoulder became stiff and painful. About four years ago, a right shoulder subacromial decompression and biceps tenodesis were performed at which time substantial chondromalacia was noted. Next a manipulation was performed in an attempt to manage the painful stiffness. Then a repeat subacromial decompression and distal clavicle resection were performed. Finally, three years ago another manipulation was performed.

At the time of her visit with us she had a stiff painful shoulder and was unable to perform any of the 12 functions of the Simple Shoulder Test.

Her radiographs show bone on bone contact in both the AP and the axillary views as shown below, suggesting chondrolysis (noting that primary degenerative joint disease would be very unusual in a young woman).

At surgery, the loss of cartilage over the humeral head was evident.

She elected to have a ream and run procedure to avoid the potential risks associated with a total shoulder arthroplasty (glenoid component wear and loosening).

Her postoperative films are shown below. Note the absence of a plastic glenoid and the absence of bone cement. Note the humeral stem has been secured using impaction auto grafting using bone harvested from the humeral head.

Immediately after surgery, the shoulder demonstrated full assisted flexion. Stay tuned for periodic progress reports.

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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Lack of effectiveness of a subacromial pain pump infusion after arthroscopic cuff repair

Efficacy of continuous subacromial bupivacaine infusion for pain control after arthroscopic rotator cuff repair

While most surgeons are now aware of the dangers of the intra articular infusion of local anesthetics with a pain pump, some still advocate the use of pain pumps in the subacromial space after arthroscopic surgery.

These authors conducted a well done randomized controlled trial in 88 patients undergoing arthroscopic rotator cuff repair. Importantly, "the authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article."

The patients were randomized in a blinded fashion into 1 of 3 groups. Group 1 received no postoperative subacromial infusion catheter. Group 2 received a postoperative subacromial infusion catheter filled with saline solution. Group 3 received a postoperative subacromial infusion catheter filled with 0.5% bupivacaine without epinephrine. Infusion catheters were scheduled to infuse at 4 mL/h for 50 hours. They assessed postoperative pain levels  with visual analog scale scores hourly for the first 6 postoperative hours, every 6 hours for the next 2 days, and then every 12 hours for the next 3 days. Patients recorded daily oxycodone consumption for the first 5 postoperative days.
Results

Immediately postoperative, the group with no catheter had significantly lower visual analog scale scores (P = .04). There were no significant differences in visual analog scale scores among the groups at any other time point. There were no differences found among the groups regarding mean daily oxycodone consumption.

They concluded that the use of continuous bupivacaine subacromial infusion catheters resulted in no detectable pain reduction after arthroscopic rotator cuff repair based on visual analog scale scores and narcotic medication consumption.

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Chondrolysis - cases continue to be recognized

Since our publication of June 2013 in the Journal of Bone and Joint Surgery on chondrolysis, we have received communications regarding a wide variety of related cases. An interesting one relates to a young person having arthroscopic Bankart two years ago at which time an intra-articular pain pump was used. Within the first year after surgery the patient had worsening pain and range of motion with clinical and radiographic confirmation of chondrolysis. At the time of revision surgery, a retained intra-articular catheter was found in the joint. A shoulder arthroplasty is planned.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


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Glenohumeral chondrolysis caused by infusion of local anesthetic with a pain pump

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.

===
Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


See the countries from which our readers come on this post.

Chondrolysis - more

We continue to see young individuals with chondrolysis of their glenohumeral joint after a surgical procedure including the infusion of local anesthetics through a pain pump.

Here are the films of a person in their mid 20's having had an instability repair  5 years ago followed by a pain pump infusing Lidocaine for two days post surgery.

The shoulder became stiff and painful and did not respond to a capsular release. The shoulder demonstrated progressive loss of comfort and function. At presentation to us the Simple shoulder test Score was 4/12. The x-rays and MRI's showed global loss of cartilage and medial erosion of the glenoid without substantial bone response (i.e. no osteophytes).

 The patient is seeking a shoulder arthroplasty.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See from which cities our patients come.

See the countries from which our readers come on this post.