Summary
An increasing number of case reports and scientific research has shown an association between the use of intra-articular pain pumps and the development of arthritis in young athletes who have undergone routine arthroscopic surgery.
Analysis
There are increasing reports of young patients developing arthritis after routine outpatient arthroscopic surgery. Early reports focused on potential risk factors including the use of thermal devices, the content of the irrigation fluid used during surgery, intrinsic patient factors and the use of intra-articular anesthetics. Laboratory data and clinical reports increasingly rest the blame on the prolonged use of intra-articular local anesthetic, most commonly administered through pain pumps.
Pain pumps have been used safely in outpatient, ambulatory surgery to decrease post-operative pain for a variety of procedures. These devices administer a steady state dosage of local anesthetic to the surgical site to control a patient's pain for the initial one to three days after surgery. The advantages of pain pumps is in achieving effective pain control in an outpatient setting with little or no need for narcotic pain medications and their associated complications. Proponents of this type of analgesia cite cost savings through shortened hospital stays and the relative safety of local anesthesia. Alternative modalities include regional anesthesia which may last for up to 12 to 18 hours after surgery, inpatient stays to control pain and the use of non-steroidal antiinflammatory or narcotic pain medications.
Although never approved for use within patients' joints after surgery, pain pumps were sold with an interested market in outpatient ambulatory surgery centers performing arthroscopic orthopaedic surgery. Subsequent reports of chondrolysis, or spontaneous, diffuse cartilage death within a joint, began to emerge predominately in young patients undergoing arthroscopic shoulder surgery to repair sports- or accident-related injuries. While cases occurring in patients undergoing knee surgery are rare, there are growing numbers of published cases involving the shoulder joint.
Evidence now suggests that the acidity of certain local anesthetics is chondrotoxic, literally causing chondrocyte cell death and the subsequent rapid onset of articular cartilage breakdown. The length of time of exposure, joint volume (the shoulder is a smaller joint than the knee), and type of anesthetic all play a role in the toxicity of pain pumps to cartilage. This cascade of events leads to the rapid onset of cartilage matrix breakdown and painful, debilitating joint pain and stiffness.
Arthritis in the shoulder is relatively uncommon with 40,000 shoulder replacements being performed per annum in the United States. This is in contrast to 450,000 knee and 230,000 hip replacements performed each year. The phenomenon of rapidly progressing shoulder arthritis in young patients was, therefore, alarming. Presently, current shoulder replacement techniques while able to relieve patient pain, inadequately address the high functional demands of the young active patient. Many of these patients treated at a young age with a shoulder replacement will require further shoulder reconstructive surgery in the future. There is impetus to develop biologic solutions to this problem, but the field is emerging.
Pain pumps have been used safely in outpatient, ambulatory surgery to decrease post-operative pain for a variety of procedures. These devices administer a steady state dosage of local anesthetic to the surgical site to control a patient's pain for the initial one to three days after surgery. The advantages of pain pumps is in achieving effective pain control in an outpatient setting with little or no need for narcotic pain medications and their associated complications. Proponents of this type of analgesia cite cost savings through shortened hospital stays and the relative safety of local anesthesia. Alternative modalities include regional anesthesia which may last for up to 12 to 18 hours after surgery, inpatient stays to control pain and the use of non-steroidal antiinflammatory or narcotic pain medications.
Although never approved for use within patients' joints after surgery, pain pumps were sold with an interested market in outpatient ambulatory surgery centers performing arthroscopic orthopaedic surgery. Subsequent reports of chondrolysis, or spontaneous, diffuse cartilage death within a joint, began to emerge predominately in young patients undergoing arthroscopic shoulder surgery to repair sports- or accident-related injuries. While cases occurring in patients undergoing knee surgery are rare, there are growing numbers of published cases involving the shoulder joint.
Evidence now suggests that the acidity of certain local anesthetics is chondrotoxic, literally causing chondrocyte cell death and the subsequent rapid onset of articular cartilage breakdown. The length of time of exposure, joint volume (the shoulder is a smaller joint than the knee), and type of anesthetic all play a role in the toxicity of pain pumps to cartilage. This cascade of events leads to the rapid onset of cartilage matrix breakdown and painful, debilitating joint pain and stiffness.
Arthritis in the shoulder is relatively uncommon with 40,000 shoulder replacements being performed per annum in the United States. This is in contrast to 450,000 knee and 230,000 hip replacements performed each year. The phenomenon of rapidly progressing shoulder arthritis in young patients was, therefore, alarming. Presently, current shoulder replacement techniques while able to relieve patient pain, inadequately address the high functional demands of the young active patient. Many of these patients treated at a young age with a shoulder replacement will require further shoulder reconstructive surgery in the future. There is impetus to develop biologic solutions to this problem, but the field is emerging.
Analyses are solely the work of the authors and have not been edited or endorsed by GLG.
