subject: Issues Impacting The Development Of Pagcl And Chondrolysis [print this page] What impact does cartilage disease, decreased density, or increased dosing of medicine have in regard to the development of chondrolysis? One interesting study that examines chondrolysis is called, Postoperative Articular Chondrolysis of the Upper Lumb After Joint Irrigation with Chlorhexidine: Nine Cases by M. Valverde; N. Deblock; M. Chammas; B. Coulet; and Y. Allieu - Journal of Bone and Joint Surgery - British Volume, Vol 86-B, Issue SUPP I, 43. Here is an excerpt: Purpose: Operative wounds are commonly washed with a more or less diluted antiseptic solution to prevent infection or to treated overt infection. Chlorhexidine is widely used. We report the cases of nine patients who developed joint destruction attributed to peroperative irrigation with a chlorhexidine solution.
Material and methods: Nine patients (three men and six women) who had undergone surgery in another facility were referred to our unit for unexplained postoperative chondrolysis. The joint localisations were: wrists (n=7) after surgery for a dorsal arthrosynovial cyst (mean age 37 years); elbow (n=1) after surgery for epicondylalgia (age 49 years); shoulder (n=1) after arthroscopy for sub-acromial impingement (age 51 years).
Results: Four of the nine patients underwent surgical treatment: a four-bone arthrodesis with scaphoidectomy was used for the three patients with mediocarpal involvement and a shoulder arthrodesis was performed in one patient. The pathology study demonstrated cartilage defects filled with dense strongly hyalinised acellular tissue. Bacteriological specimens were all negative.
Discussion: The chondrolytic effect of chlorhexidine, a member of the biguanide family, was first reported in 1986 with a few cases described with knee involvement. Experimentally, there would be a dose-dependent effect. The mechanism involves a disorganisation of the cell membrane with cartilaginous necrosis and ostocartilaginous resorption. Individual predisposition cannot be ruled out.
Another interesting study is called, Long-Term Effects of Bupivacaine on Cartilage in a Rabbit Shoulder Model by Andreas H. Gomoll, MD, Adam B. Yanke, Richard W. Kang, MD, MS, Susan Chubinskaya, PhD, James M. Williams, PhD, Bernard R. Bach, MD and Brian J. Cole, MD, MBA - Am J Sports Med January 2009 vol. 37 no. 1 72-77. Here is an excerpt: Background Previous investigations have reported on the chondrotoxicity of bupivacaine in short-term in vivo and in vitro models. This study was designed to provide additional information on the long-term effects of bupivacaine infusion on articular cartilage in an established rabbit shoulder model.
Hypothesis Infusion of bupivacaine into the rabbit shoulder will have long-term deleterious effects on articular cartilage. Study Design Controlled laboratory study.
Methods Thirty-six rabbits were randomized into 3 groups and were infused over 48 hours with saline (S), bupivacaine alone (B), or bupivacaine with epinephrine (B+E) into the glenohumeral joint. Animals were sacrificed after 3 months, and tissue samples were analyzed with live/dead cell assay, proteoglycan (PG) synthesis and content assays, and conventional histological evaluation.
Conclusions No permanent impairment of cartilage function was detected 3 months after intra-articular infusion of bupivacaine. Cartilage metabolism was increased, indicating a possible reparative response. This suggests that, at least in the model used, articular cartilage has the ability to recover from the chondrotoxic effects of bupivacaine infusion. Before extrapolating these results to human cartilage, other factors including underlying cartilage injury or disease, decreased chondrocyte density, and increased bupivacaine dosing need to be taken into account.
Clinical Relevance Bupivacaine toxicity has recently been implicated in the development of chondrolysis after arthroscopic shoulder procedures, but these findings suggest that additional noxious stimuli might be required before permanent damage ensues.
If you found either of these excerpts interesting, please read them in their entirety. We all owe a debt of gratitude to these researchers.
