Cassie M. Fleckenstein

The development of postoperative knee chondrolysis after intra-articular pain pump infusion of an anesthetic medication: a series of twenty-one cases.

BACKGROUND Postoperative chondrolysis in the knee joint caused by continuous intra-articular pain pumps infusing bupivacaine is a serious complication that severely affects function. We report the clinical course of a series of twenty-one patients who were referred to our clinic with this complication. METHODS A physical examination and a review of medical records were conducted. The condition of the articular cartilage was determined from operative notes, photographs, magnetic resonance images, and radiographs. Knee function was assessed with the Cincinnati Knee Rating System. RESULTS The study group included eighteen female and three male patients ranging in age from fourteen to forty-two years. The index procedures, all done elsewhere, included eighteen anterior cruciate ligament reconstructions, one meniscal repair, one arthroscopy, and one tibial tubercle osteotomy. An intra-articular high-flow-volume pump (200 to 270 mL) was used in ten patients, and a low-flow-volume pump (90 to 120 mL) was used in ten patients; the flow rate in the remaining patient was not documented. The devices used 0.5% bupivacaine in twenty knees and 0.25% in one knee, with 1:200,000 epinephrine added in eleven knees. Knee symptoms affecting daily activities occurred at a mean of 9 ± 7 months after the index procedure. Extensive chondrolysis with loss of articular cartilage of all three knee compartments occurred in six knees. In ten knees, two compartments were affected, and in five knees, one compartment was abnormal. All patients had marked limitations and pain with daily activities, and nineteen patients underwent forty-one subsequent surgical procedures. CONCLUSIONS Severe postoperative knee chondrolysis occurred after the use of a high or low-flow-volume pump infusing intra-articular bupivacaine, producing disabling knee symptoms. A variety of operative procedures failed to alleviate symptoms. Although this study does not define the incidence of knee chondrolysis after intra-articular bupivacaine pain-pump infusion, the severe complications reported here warrant its use to be contraindicated.

Predictors of Outcome After Nonoperative and Operative Treatment of Adhesive Capsulitis

Background: Few studies regarding adhesive capsulitis have concurrently evaluated nonoperative and operative treatment. Purpose: The objectives were to evaluate the efficacy of operative and nonoperative treatment of adhesive capsulitis and to determine predictors of clinical outcome. Study Design: Cohort study; Level of evidence, 3. Methods: At minimum 24 months’ follow-up, 85 patients underwent self-assessment using the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) score, including 24 patients treated operatively. Results: Mean number of yes responses on the SST improved from 4.0 ± 2.7 at initial presentation to 9.9 ± 2.8 at final follow-up (P < .0001). Patients who received nonoperative treatment and patients who underwent surgery demonstrated similar improvements on the SST. For the entire cohort, forward elevation and external rotation at the side improved from 119° ± 20° to 152° ± 15° and from 29° ± 18° to 46° ± 11° (P < .0001), respectively, between initial presentation and discharge from treatment. Internal rotation to the back improved from the gluteal area to the thoracolumbar junction (P < .0001). Improvements in forward elevation and external rotation were greater for patients undergoing surgery. After nonoperative treatment, patients with diabetes had a lower final SST than patients without diabetes (P < .05). For the entire cohort, initial SST predicted final SST (P < .05), and a shorter duration of symptoms predicted a higher final ASES score (P < .05). Younger patients (P < .001) and those with a lower initial SST (P < .05) were more likely to undergo surgery. Conclusions: A multimodal nonoperative treatment program is effective for most patients with adhesive capsulitis. Patients who do not improve, including those with diabetes, respond well to manipulation and arthroscopic release. Residual motion deficits at discharge from treatment do not appear to affect longer-term clinical outcome.

Glenohumeral chondrolysis associated with use of an intra-articular pain pump delivering local anesthetics following manipulation under anesthesia: a report of four cases.

Glenohumeral chondrolysis is a devastating condition characterized by rapid dissolution of the articular cartilage surfaces of the glenoid and the humeral head. Patients typically present with a painful stiff joint, and radiographs demonstrate joint space narrowing and subchondral cystic changes. Because most cases of glenohumeral chondrolysis have occurred following arthroscopic shoulder surgery, the term “post-arthroscopic glenohumeral chondrolysis” (PAGCL) has been used to describe this condition. Several causative factors have been implicated, including suture anchors that are prominent or that become loose1, excessive intra-articular use of thermal heat2-4, and intra-articular pain pump (IAPP) catheters delivering local anesthetics5-10. Most of the patients described developed glenohumeral chondrolysis following arthroscopic stabilization procedures in which one or more suture anchors were employed, with or without adjunctive use of thermal heat, and in which an IAPP was placed at the conclusion of the procedure to deliver local anesthetics for postoperative analgesia. To the best of our knowledge, glenohumeral chondrolysis developing after the use of an IAPP and without arthroscopy has not been described previously. We report four cases of glenohumeral chondrolysis that occurred following the use of an IAPP delivering either 0.25% or 0.5% bupivacaine with epinephrine for forty-eight to sixty hours after isolated manipulation of the shoulder under anesthesia, without a surgical procedure. In all four patients, the initial treatment, including manipulation and placement of an IAPP (AmbIT; Sorenson Medical Products, West Jordan, Utah), was done elsewhere by the same orthopaedic surgeon between March 2006 and August 2007. One of the four patients was treated with a subsequent prosthetic shoulder arthroplasty by another surgeon prior to referral to the senior author (S.S.H.). Each of the four patients in this series was informed that data concerning his or her case were submitted for publication, and verbal …

Glenohumeral Chondrolysis: Part I—Clinical Presentation and Predictors of Disease Progression

PURPOSE The objective of this 2-part study is to report on the etiology, clinical findings, and predictors of disease progression (part I) and the results of treatment (part II) in a group of patients with glenohumeral chondrolysis. METHODS Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed up since their initial presentation before arthroplasty (group 1), and 20 patients were referred either for management of complications arising after prosthetic arthroplasty or for evaluation only (group 2). RESULTS Thirty-seven patients received an intra-articular pain pump (IAPP) delivering bupivacaine, and 3 patients had prominent suture anchors or tacks. Symptoms related to chondrolysis developed in patients at a mean of 9.8 months (range, 1 to 34 months) after the index procedure. Radiographs showed joint space obliteration in 30 of 40 patients at most recent follow-up or before arthroplasty. Of the patients receiving an IAPP delivering bupivacaine, the majority received 0.5% with epinephrine. Higher bupivacaine dose (P < .05) and female gender (P < .05) were associated with a longer interval to onset of symptoms. In addition, a shorter interval to onset of symptoms predicted the need for subsequent surgery (P < .05) and a shorter interval to second-look arthroscopy (P < .001). CONCLUSIONS Post-arthroscopic glenohumeral chondrolysis is a devastating and rapidly evolving condition that most often strikes young patients. The use of IAPPs delivering local anesthetics should be abandoned because nearly all cases of glenohumeral chondrolysis in this series were associated with their use. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Glenohumeral chondrolysis: part II--results of treatment.

PURPOSE The objective of this 2-part study is to report on the etiology and disease progression (part I) and results of treatment (part II) of glenohumeral chondrolysis. METHODS Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed since their initial presentation and before prosthetic shoulder arthroplasty (group 1), and 20 patients were referred either for management of complications arising after shoulder arthroplasty or for evaluation only (group 2). All patients underwent standardized clinical and radiographic examination and completed shoulder-specific self-assessment questionnaires at initial presentation and after prosthetic shoulder arthroplasty for patients in group 1. RESULTS Thirty of 40 patients underwent subsequent arthroscopy for debridement, chondroplasty, capsular release, or a combination of these procedures. Of these, 23 patients (77%) required additional surgery, comprising 18 prosthetic shoulder arthroplasties performed at a mean 13 months of follow-up (range, 3 to 33 months), as well as 5 repeated arthroscopies. At most recent follow-up, 15 of 20 patients in group 1 had undergone shoulder arthroplasty, with improvements in active forward elevation from 92.6° to 140.0° (P < .0001), active abduction from 81.6° to 131.3° (P < .0001), active external rotation from 22.1° to 49.3° (P < .0001), and active internal rotation from the gluteal region to the T12 spinous process (P < .001). Pain scores improved from 6.4 to 3.4 (P < .01), and self-assessed outcome also improved significantly. Twelve patients in group 2 underwent shoulder arthroplasty, so overall 27 of 40 patients (68%) underwent prosthetic shoulder arthroplasty for chondrolysis at a mean of 32 months (range, 9 to 66 months) after the index procedure. CONCLUSIONS Postarthroscopic glenohumeral chondrolysis is a devastating condition that strikes young patients, responds poorly to arthroscopic interventions, and often requires shoulder arthroplasty within a few years. Patients can expect improved range of motion and outcome after shoulder arthroplasty, but pain relief is often incomplete. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Chondrolysis of the Glenohumeral Joint: Level of Evidence and Additional Analyses

r i u u p s b t F r 8 P N T o the Editor: We have studied the article “Chondrolysis of the Glenohumeral oint After Infusion of Bupivacaine Through an Intra-articular ain Pump Catheter: A Report of 18 Cases” by Anderson et al.1 nd are writing comment to both on the Level of Evidence asigned to that study and to report additional analyses based on the resented data. The authors explicitly note that during the study ime period, there were 113 glenohumeral arthroscopies, with 45 ain pumps used. As such, the study actually compares 2 cohorts f surgeries, a cohort that was exposed to the use of an intrarticular pain pump and a non-exposed cohort. Because the priary outcome measured is whether shoulders had chondrolysis fter surgery, the study by Anderson et al. appears to be a retropective cohort study or retrospective comparative study that proides Level II (IIb) evidence rather than Level IV evidence typially ascribed to a case series report.2 The authors found glenohumeral chondrolysis in 18 of 45 houlders that received an intra-articular pain pump after arhroscopic shoulder surgery. In contrast, chondrolysis did not evelop in any of the 68 shoulders undergoing arthroscopic houlder surgery without an intra-articular pain pump during he same time frame. The authors did not calculate the statisical significance of the difference in chondrolysis incidence etween the shoulders receiving an intra-articular pain pump nd those that did not, even though this analysis is readily erformed by use of the published data, as shown in Table 1. By use of the Fisher exact test, the calculated P value for a -tailed analysis of these data is P .0001. In other words, the ikelihood that chance alone could explain the observed distriution of chondrolysis is less than 1 in 10,000. Because the xpected sample size in at least 1 cell is small (typically defined s 5), the Fisher exact test is a more appropriate statistical test or comparing these proportions than the 2 test.3 Other statistics can also be used to summarize the results of retrospective cohort study. The odds ratio represents the odds f chondrolysis in the pain pump group divided by the odds of hondrolysis in the no pain pump group. Because no cases of hondrolysis were observed in the no pain pump group, the enominator of the odds ratio is 0 and the odds ratio is infinite. hen this situation arises, published statistical corrections can e implemented to compute a finite odds ratio. One such orrection is the logit method,4 which involves adding 0.5 to ach cell and then performing the conventional odds ratio stimation. By use of this method, the odds ratio is 92.2 (95% onfidence interval [CI], 5.4 to 1,583). Another statistic is the isk difference between the pain pump and no pain pump roups. The risk of chondrolysis in the intra-articular pain a

Early Results of Concurrent Arthroscopic Repair of Rotator Cuff and Type II Superior Labral Anterior Posterior Tears

Background: Recent reports on concurrent arthroscopic rotator cuff and type II superior labral anterior posterior (SLAP) repair have raised concerns over postoperative stiffness and patient satisfaction. However, it is unclear if the observed stiffness relates to the repair of degenerative SLAP tears in older adults, the surgical technique, the postoperative rehabilitation, or to a combination of these factors. Purpose: The purpose of this study was to evaluate the outcome and repair integrity of concurrent arthroscopic rotator cuff and type II SLAP repair. Study Design: Case series. Methods: Of 11 patients identified, 7 had a full-thickness rotator cuff tear and 4 had a high-grade partial thickness tear that was completed. A cannula placed through the rotator cuff tear improved the trajectory for posterior suture anchor placement during SLAP repair. Postoperative rehabilitation employed continuous passive motion to prevent stiffness. Results: At minimum of 1-year follow-up, mean yes responses on the Simple Shoulder Test improved from 5.4 to 10.7 (out of 12; P < .01), and mean American Shoulder and Elbow Surgeons scores improved from 40 to 87 (out of 100; P < .01). Mean forward elevation improved from 148° to 161° (P < .01) and external rotation from 58° to 67° (P < .01). Magnetic resonance imaging, obtained at most recent follow-up in 10 patients, demonstrated a healed SLAP tear in all patients and a persistent rotator cuff defect in 1 patient. Conclusions: Arthroscopic rotator cuff repair can be successfully combined with type II SLAP repair in relatively young patients who have sustained traumatic injury to their shoulders. Allowing early passive motion may help prevent postoperative stiffness without compromising rotator cuff healing.

Reliability of a New Clinical Instrument for Measuring Internal and External Glenohumeral Rotation

Background: The shoulder plays a critical role in many overhead athletic activities. Several studies have shown alterations in shoulder range of motion (ROM) in the dominant shoulder of overhead athletes and correlation with significantly increased risk of injury to the shoulder and elbow. The purpose of this study was to measure isolated glenohumeral joint internal/external rotation (IR/ER) to determine inter- and intraobserver reliability of a new clinical device. Hypothesis: (1) Inter- and intraobserver reliability would exceed 90% for measures of glenohumeral joint IR, ER, and total arc of motion; (2) the dominant arm would exhibit significantly increased ER, significantly decreased IR, and no difference in total arc of motion compared with the nondominant shoulder; and (3) a significant difference exists in total arc between male and female patients. Study Design: Case series. Level of Evidence: Level 4. Methods: Thirty-seven subjects (mean age, 23 years; range, 13-54 years) were tested by 2 orthopaedic surgeons. A single test consisted of 1 arc of motion from neutral to external rotation to internal rotation and back to neutral within preset torque limits. Each examiner performed 3 tests on the dominant and nondominant shoulders. Each examiner completed 2 installations. Results: Testing reliability demonstrated that neither trial, installation, nor observer were significant sources of variation. The maximum standard deviation was 1.3° for total arc of motion and less than 2° for most other measurements. Dominant arm ER was significantly greater than nondominant arm ER (P = 0.02), and dominant arm IR was significantly less than nondominant arm IR (P = 0.00). Mean total rotation was 162°, with no significant differences in total rotation between dominant and nondominant arms (P = 0.34). Mean total arc of motion was 45° greater in female subjects. Differences in total arc of motion between male and female subjects was statistically significant (P < 0.00). Conclusion: This simple, clinical device allows for both inter- and intraobserver reliability measurements of glenohumeral internal and external rotation.