I want to thank Dr. Canale for his insightful commentary in AAOS Now regarding chondrolysis (June 2010). I agree that we must dive deeper into this area of bupivacaine toxicity. I have had patients in whom chondrolysis developed, and I have testified in pain pump litigation. This is a real issue that needs to be pushed to the forefront of clinical practice.
The fact that most busy shoulder surgeons, including some of the biggest names in our field, have experienced this outcome around the same time should be an issue of major concern. I have since stopped all local anesthetic use other than a few milliliters. Even then, I only use preservative-free and no epinephrine. I try to inject only the soft tissue and not the joints. I do not inject shoulders after surgery any longer and only use 10 mL or less after knee surgery. I stopped in 2006 after seeing my first case of chondrolysis in a young athlete.
John P. Fulkerson, MD, first looked at the toxicity of bupivacaine in 1985, but given the limited nature of his study, he concluded that “The decision to place this solution into a joint should be made only after considering established evidence, but there does not appear to be any immediate need to stop the use of intra-articular bupivacaine.” That was really the end of it until pain pumps and a sudden onslaught of chondrolysis, which immediately raised many questions.
The AAOS would do our patients and members a great service by keeping this problem in the forefront. It will continue to stimulate research in order to “first do no harm.” I certainly do not believe that doctors have been negligent in using bolus injections up until now. The package inserts of local anesthetic drugs indicate their use is approved for “local infiltration” and has no contraindication for use around cartilage or in joints.
However, I think doctors of all specialties are exposed to liability if they continue indiscriminate use at this time, given the information available in the literature. We seem to generally accept that local anesthetics cause chondrocyte death, but the mechanism of this is yet unknown. It is also unclear why chondrolysis develops in some patients but not in others. There most likely is some as yet undiscovered predisposing risk factor.
At a recent meeting where I presented a paper on this topic, some surgeons were still using pain pumps. I urge the AAOS to continue to keep this topic “hot” to make sure that all are aware, down to the last small-town general orthopaedist in the smallest rural area, of the issues involved. The AAOS should also encourage industry to refrain from marketing these devices until further research has been done. In addition, the repeated denials by the U.S. Food and Drug Administration to approve use of bupivacaine in synovial cavities, which became public information at a trial in Oregon in January 2010 must be disseminated by manufacturers to surgeons.
David S. Bailie, MD
Setting Now straight
AAOS Now welcomes reader comments and efforts to “set AAOS Now straight.” We reserve the right to edit your correspondence for length, clarity, or style. Send your letters to the Editor, AAOS Now, 6300 N. River Rd., Rosemont, IL 60018; fax them to (847) 823-8033; or e-mail them to firstname.lastname@example.org
The June 2010 issue of AAOS Now incorrectly identified a radiograph accompanying the article “Arthroscopic hip surgery helpful for athletes.” The caption should read “Fig. 1 Hip dysplasia (shown here) is a relative contraindication for arthroscopic treatment.” We regret the error.