The Devastating Complications Of Pagcl And Cartilage Death

After routine shoulder surgeries, many patients are being diagnosed with PAGCL

. This is a rare but very serious condition resulting in the death of shoulder cartilage. As the condition becomes more commonplace, the amount of research has increased exponentially.

One interesting study is called, Glenohumeral Chondrolysis After Shoulder Arthroscopy With Thermal Capsulorrhaphy by C. Good, M. Shindle, B. Kelly, T. Wanich, R. Warren - Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 23, Issue 7, Pages 797.e1-797.e5. Here is an excerpt:

Glenohumeral chondrolysis is a rare but devastating complication that can occur after shoulder arthroscopy and thermal capsulorrhaphy. We retrospectively reviewed the medical records and imaging studies of 8 patients in whom glenohumeral chondrolysis developed after shoulder arthroscopy in which thermal energy was used. Of the 8 patients, 5 had previous thermal capsulorrhaphy for the diagnosis of instability. Two patients were diagnosed with instability with associated labral tears and underwent labral repair with thermal capsular shrinkage. One patient was diagnosed with a labral tear and underwent labral debridement with an extensive glenohumeral synovectomy via a thermal probe. No patients had evidence of chondral damage at their index arthroscopy, and none received postoperative pain pumps. In all patients, radiographic evidence of chondrolysis developed and repeat arthroscopy was performed to confirm the diagnosis. Open surgical stabilization has not been known to have this complication, and it is speculated that heating of the joint fluid at the time of arthroscopy from any source plays a role in cartilage death. Further studies are warranted to determine whether adequate outflow during shoulder arthroscopy where the fluid volume is relatively small will aid in avoiding complications associated with the use of heat sources.

Another interesting study is called, Effect of Radiofrequency Energy on Glenohumeral Fluid Temperature During Shoulder Arthroscopy by Christopher R. Good, MD, Michael K. Shindle, MD, Matthew H. Griffith, MD, Tony Wanich, MD and Russell F. Warren, MD - The Journal of Bone and Joint Surgery (American). 2009;91:429-434. Here is an excerpt: Background: Reports of glenohumeral chondrolysis following arthroscopy have raised concern about the deleterious effects that thermal devices may have on articular cartilage. The purpose of this study was to investigate the effects of flow and duration of treatment with a thermal device on temperatures within cadaveric glenohumeral joint specimens. It was hypothesized that the use of a thermal device during surgery increases the temperature of fluid within the joint to >45C, which has been shown to cause chondrocyte death.

Results: Temperatures of >45C occurred in every trial. The average maximum temperatures in all no-flow conditions were significantly higher than those in the trials with flow. Higher temperatures were measured by the anterior probe in all trials. When the heating had been applied adjacent to the glenoid, without tissue contact, the time needed to cool to a safe temperature was significantly longer in the no-flow states (average, 140.5 seconds) than it was in the 50% flow states (average, 12.5 seconds) or the 100% flow states (average, 8.5 seconds).

Conclusions: Use of a thermal probe during arthroscopy may cause joint fluid temperatures to reach levels high enough to cause chondrocyte death. Maintaining adequate fluid-pump flow rates may help to lower joint fluid temperatures and protect articular cartilage.

Clinical Relevance: The use of radiofrequency devices according to the manufacturer's recommendations in situations similar to clinical scenarios can result in exposure of chondrocytes to temperatures high enough to cause their death (>45C). While this complication is rare, this study emphasizes that care must be taken when using these devices; precautions include minimization of direct chondrocyte exposure and maintenance of adequate flow rates.

If you found either of these excerpts interesting, please read the studies in their entirety. We all owe a debt of gratitude to the people doing this research.

by: Mont Wrobleski

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