Commentary on an article by Brett P. Wiater, MD, et al.: “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”

Abstract

Chondrolysis remains a catastrophic and devastating condition of the shoulder that has had many associated but not well-proven causes. Numerous published case reports and small case series have led to difficulty in extrapolating any meaningful data with respect to the true etiology of this condition1-6. Wiater et al. were presented with a unique opportunity to review a specific cohort of patients from a single community orthopaedic surgeon as a result of a medicolegal action related to chondrolysis. They were provided complete access to the medical records on 375 intra-articular shoulder arthroscopic procedures performed by the surgeon from 1999 to 2008. A number of factors were assessed, including patient age at the time of surgery, side of surgery, date of surgery, preoperative diagnosis, type of anesthesia, procedure performed, use and type of suture anchors, use of radiofrequency, and use and location of a postoperative local anesthetic infusion catheter. They also were able to ascertain the type and concentration of local anesthetic used for postoperative analgesia and whether epinephrine was used in the infusate. Forty-nine surgical procedures (13%) were complicated by chondrolysis. Each of these forty-nine procedures was associated with intra-articular infusion of either Marcaine (bupivacaine) or lidocaine. Furthermore, none of the patients who had an arthroscopic procedure without infusion of anesthetics developed postoperative chondrolysis. Additional significant factors associated with the development of chondrolysis were arthroscopic Bankart repair, arthroscopic debridement, one or more suture anchors in the glenoid, and surgery duration. Only six shoulders had 0.25% Marcaine, but none had chondrolysis in that group. A recent systematic review of studies from peer-reviewed journals identified 100 cases of chondrolysis7. Fifty-nine percent of the cases involved post-arthroscopic use of anesthetic infusate (usually bupivacaine, with lidocaine used in only two cases). Finally, the authors of a recent study reported eighteen cases of chondrolysis related to the intra-articular infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter8. Forty-five pain pumps were used in the 113 arthroscopic procedures during the same time period. Chondrolysis developed in sixteen of thirty-two patients with a high-flow intra-articular pain pump catheter and in just two of twelve patients with a low-flow intra-articular pain pump catheter. (The pump type was not determined for the forty-fifth patient.) This information, in conjunction with the finding by Wiater et al. that the duration of surgery was correlated with the development of chondrolysis, provides a possible link between the newer, higher-flow pain pumps and the development of this condition. Given the literature to date, in conjunction with this unique article by Wiater et al., it appears reasonable to caution against the use of intra-articular infusion of anesthetics, specifically bupivacaine or higher concentrations of lidocaine. Basic science studies by Chu et al.9 and Gomoll et al.10 further highlight the potential chondrotoxic effects of bupivacaine, and these negative correlations far outweigh any possible analgesic benefits. Furthermore, the issue of the association of high-flow intra-articular pain pumps with higher rates of chondrolysis and their continued use should be carefully examined as well. The authors did not specifically analyze or hypothesize about the association between chondrolysis and suture anchors in the glenoid, and it is not intuitively clear why this association would exist, given that hundreds of thousands of these implants have been placed since their introduction in the early 1990s. In summary, Wiater et al. were provided with a unique opportunity to explore the possible causes of chondrolysis, a rare but devastating condition in the shoulder. While many unanswered questions remain, their paper, combined with the recent peer-reviewed literature, has further illuminated the role of local anesthetics and high-flow pain pumps in causing chondrolysis, and the intra-articular use of these techniques in association with shoulder arthroscopy should be avoided.