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Risk Factors for Chondrolysis of the Glenohumeral JointA Study of Three Hundred and Seventy-five Shoulder Arthroscopic Procedures in the Practice of an Individual Community Surgeon
Brett P. Wiater, MD1; Moni Blazej Neradilek, MS2; Nayak L. Polissar, PhD2; Frederick A. Matsen, III, MD1
1 Department of Orthopedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 N.E. Pacific Street, Seattle, WA 98195. E-mail address for F.A. Matsen III: matsen@u.washington.edu
2 The Mountain-Whisper-Light Statistics, 1827 23rd Avenue East, Seattle, WA 98112-2913
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the DePuy/Douglas T. Harryman II Endowed Chair for Shoulder Research. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Jeff Wihtol Law Offices).

Investigation performed at the University of Washington, Seattle, Washington
A commentary by William N. Levine, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Apr 06;93(7):615-625. doi: 10.2106/JBJS.I.01386
A commentary by William N. Levine, MD, is available here
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Abstract

Background: 

Glenohumeral chondrolysis is a complication of arthroscopic shoulder surgery characterized by the dissolution of the articular cartilage of the glenoid and the humeral head. An analysis of 375 intra-articular shoulder arthroscopic surgical procedures by an individual community orthopaedic surgeon was performed to explore which factors or combinations of factors might be associated with glenohumeral chondrolysis.

Methods: 

The occurrence of chondrolysis was correlated with several demographic and surgical variables with use of hazard ratios from Cox proportional hazards models and Kaplan-Meier survivorship curves. Sensitivity analysis was used to examine the effect of two different definitions of the date of the onset of chondrolysis.

Results: 

In this cohort, each case of documented chondrolysis was associated with the intra-articular post-arthroscopic infusion of a local anesthetic, either Marcaine (bupivacaine) or lidocaine. In an analysis of the group that received an intra-articular postoperative infusion of a local anesthetic, the risk of chondrolysis was found to be greater for those with one or more suture anchors placed in the glenoid, for younger patients, and for those who had the surgery near the end of the ten-year study period.

Conclusions: 

To our knowledge, this is the first Level-II retrospective cohort study of the factors associated with the development of post-arthroscopic glenohumeral chondrolysis. In this cohort of intra-articular shoulder arthroscopic procedures, chondrolysis was observed only in cases in which either Marcaine or lidocaine had been infused into the joint during the postoperative period. Avoiding such a postoperative infusion may reduce the risk of chondrolysis.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Frederick A. Matsen III, MD
    Posted on May 20, 2011
    Dr. Matsen and colleagues respond to Dr. Navaie
    Professor, Orthopaedic Surgery, University of Washington, Department of Orthopaedics and Sports Medicine

    We appreciate the opportunity extended to us by the Journal of Bone and Joint Surgery to comment on the letter of Dr. Navaie, Senior Vice President 
Advance Health Solutions, LLC (http://advancehealthsolutions.com/), in regard to our JBJS publication, “Risk Factors for Chondrolysis of the Glenohumeral Joint: A Study of Three Hundred and Seventy-five Shoulder Arthroscopic Procedures in the Practice of an Individual Community Surgeon.” Because of the importance of this topic, we are providing the detailed response below.

    Our goal in conducting this study was to enhance the safety of patients undergoing arthroscopic shoulder surgery by identifying risk factors for chondrolysis – an iatrogenic complication that irrevocably destroys the glenohumeral joints of young individuals – a complication that was essentially non-existent a decade ago. In Dr. Navaie’s Level IV article, “Glenohumeral Chondrolysis after Arthroscopy: A Systematic Review of Potential Contributors and Causal Pathways,”(1) she and her co-authors found 91 shoulder surgeries complicated by chondrolysis with an average age of only 28 years - this is surely a complication of arthroscopy worth avoiding! In her letter she refers to the “many patient, surgical and postoperative factors” identified in her 2009 article. On reading her article carefully, Navaie found that 59 shoulders with chondrolysis had received local anesthetics through a pain pump, 53 had implants/anchors, and 41 had the use of radiofrequency devices. Thus, chondrolysis appeared to be caused by one or more of these techniques in the arthroscopic treatment of shoulder disorders. Our study considered each of these factors and many others in a Level II Prognostic study in which the three criteria identified in her letter could be examined: 1) the covariance of a broad range of risk factors with the development of chondrolysis, 2) the precedence of these risk factors to the occurrence of chondrolysis, and 3) the minimization of sources of error by analyzing a complete set of consecutive records obtained from the arthroscopic shoulder practice of an individual surgeon – considering both patients that did and did not develop chondrolysis, a unique feature of our study.

    In her letter, Dr. Navaie expressed concern that the majority of patients receiving the intraarticular infusion of local anesthetics using a pain pump were not noted to have developed chondrolysis. Dr. Navaie suggests that this disproves the causal relationship, even though 100% of the patients in our investigation with chondrolysis had the intraarticular infusion of local anesthetics using a pain pump and even though our Figure 2 clearly demonstrates poor chondrolysis-free survivorship when a pain pump is used. The fact that all patients exposed to the risk of a complication do not develop the complication does not disprove causation: the majority of cigarette smokers do not develop lung cancer; the majority of babies ingesting lead paint do not die from this ingestion.

    In the Danish study (2) that Dr. Navaie holds up as a “more robust epidemiologic investigation,” the authors reviewed hospitalization records to search for covariates related to chondrolysis. The study group was not confined to patients having surgery of any specific type, much less arthroscopic shoulder surgery. These authors found that diabetes and orthopaedic surgery (of any type) were risk factors. Their study sheds no light on the factors contributing to the risk of post arthroscopic glenohumeral chondrolysis. In fact, this study did not even identify arthroscopic surgery as a risk factor. Furthermore, the authors state that, “The completeness of registration of pain pump treatment is unknown.” Thus, their article did not analyze cases of post-arthroscopic glenohumeral chondrolysis and is of no use in assessing the causal relationship of pain pumps in post-arthroscopic chondrolysis.

    Dr. Navaie expresses concern about selection bias in our investigation, yet the Methods section of our paper clearly demonstrates that the records assessed in this study were a complete set of validated copies of the medical records and office notes for the practice studied. While analogous studies of other practices would be of great interest, there was no selection bias within this study of the individual practice. Finally, we invite Dr. Navaie to a closer read of our paper where she will find a detailed and careful covariate (interaction) assessment involving factors such as anchors, sutures, and radiofrequency devices shown in our Tables II and III.

    In the last year we have been referred no fewer than sixteen young patients with post-arthroscopic chondrolysis. Each of them had the intra-articular infusion of local anesthetics via a pain pump, none had prominent suture anchors, and none had the intra-articular use of radiofrequency or laser energy. As yet another example, Figure 1 of the May 4, 2011 JBJS current concepts review on “Management of Glenohumeral Arthritis in the Young Adult” features, “Chondrolysis in a twenty-year-old woman associated with use of an intraarticular postoperative pain pump after shoulder arthroscopy.” To continue to deny or ignore the objective evidence supporting the causal relationship between intraarticular pain pump use and post-arthroscopic chondrolysis is to subject future patients to the avoidable risk of this permanent and devastating iatrogenic complication. A pain pump is in no way essential to arthroscopic surgery. We accept the risk of anticoagulation in certain cases of orthopaedic surgery because it has been shown to reduce the risk of a more serious problem: pulmonary embolism. In contrast, the benefit of pain pumps in the management of post arthroscopic pain is vanishingly small in comparison to the well-documented risk of a lifetime with the effects of chondrolysis. The evidence in support of patient safety is clear.

    References

    1. Solomon DJ, Navaie M, Stedje-Larsen ET, Smith JC, Provencher MT. Glenohumeral chondrolysis after arthroscopy: a systematic review of potential contributors and causal pathways. Arthroscopy. 2009;25:1329-42.

    2. Christiansen CF, Thygesen SK, Pedersen L. Incidence and risk of chondrolysis in Denmark: a nationwide population-based study. Clin Epidemiol. 2010;2:85-9.

    Maryam Navaie, Dr.P.H.
    Posted on May 20, 2011
    Leveraging Epidemiologic Principles to Drive Evidence-Based Medicine
    Senior Vice President, Advance Health Solutions, LLC, La Jolla, CA

    To the Editor:

    Research by Wiater et al. (2011;93:615-25) and its contextual premise (1) raise the importance of leveraging epidemiologic principles to ensure that evidence-based medicine rests on objectivity rather than subjectivity. Among the most salient principles of relevance are causal inference and bias.

    Inferring that a potential contributor is a true risk factor for a disease is a very complex process involving many uncertainties. Three criteria must be met before a given factor can be considered a risk factor for a particular disease: 1) the factor must be observed to covary with the disease, 2) the presence of the factor must precede the occurrence of the disease, and 3) the observed association must not be entirely due to sources of error, the involvement of other extraneous risk factors, or other problems with the study design or data analysis.

    Systematic reviews of glenohumeral chondrolysis representative of multiple practice settings and surgeons have carefully delineated many patient, surgical and post-operative factors as correlates of chondrolysis (2). In contrast, Wiater et al. make a substantial leap of faith based on a cluster of cases in a singular surgeon’s practice, attributing the risk of chondrolysis to predominately post-operative intra-articular infusion of local anesthetics, despite the fact that 76% (155/204) of the surgical procedures involving pain pumps were not associated with chondrolysis, including 60/109 (55%) with intra-articular placement. Such skewed interpretation is directly countered by more robust epidemiologic investigations that have found no linkage between chondrolysis and the use of pain pumps (3). Although the role of intra-articular pain pumps in the genesis of chondrolysis remains unsubstantiated, it is clear that this factor is neither sufficient nor necessary for the onset of the disease (4-6).

    Another principle of concern is selection bias in Wiater et al’s study given their purposive sample was identified pursuant to product liability litigation (1). Moreover, potential confounders appear to have been inadequately evaluated (7) as evidenced by a lack of interaction assessment involving factors such as proud anchors (8), sutures (8,9) and radiofrequency devices (10-13).

    Ultimately, the poor threshold of validity in Wiater et al.’s study is disconcerting, making results interpretation for health practice and policy problematic.

    References

    1. Opinion and Order delivered by Ann Aiken, Chief Judge. McClellan v. I-Flow Corp. Case 6:07-cv-01671-AA. Document 365. May 3, 2010. Available at: http://or.findacase.com/research/wfrmDocViewer.aspx/xq/fac.20100503_0000123.DOR.htm/qx

    2. Solomon DJ, Navaie M, Stedje-Larsen ET, Smith JC, Provencher MT. Glenohumeral chondrolysis after arthroscopy: a systematic review of potential contributors and causal pathways. Arthroscopy. 2009;25:1329-42.

    3. Christiansen CF, Thygesen SK, Pedersen L. Incidence and risk of chondrolysis in Denmark: A nationwide population-based study. Clin Epidemiol. 2010;2:85-9.

    4. Rothman KJ, Greenland S, Lash TL. Modern epidemiology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

    5. Savitz DA. Interpreting epidemiologic evidence: strategies for study design & analysis. New York: Oxford University Press; 2003.

    6. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. 1st ed. New York: Van Nostrand Reinhold; 1982.

    7. Levine WN. Commentary on an article by Brett P. Wiater, MD, et al.: “Risk Factors for Chondrolysis of the Glenohumeral Joint. A Study of Three Hundred and Seventy-five Shoulder Arthroscopic Procedures in the Practice of an Individual Community Surgeon.” J Bone Joint Surg Am. 2011;93:e32.

    8. McNickle AG, L'Heureux DR, Provencher MT, Romeo AA, Cole BJ. Postsurgical Glenohumeral Arthritis in Young Adults. Am J Sports Med. 2009;37:1784-91.

    9. Bailie DS, Ellenbecker T. Severe chondrolysis after shoulder arthroscopy: a case series. J Shoulder Elbow Surg. 2009;18;742-7.

    10. Coobs BR, LaPrade RF. Severe chondrolysis of the glenohumeral joint after shoulder thermal capsulorrhaphy. Am J Orthop. 2009;38:E34-7.

    11. Ciccone W, Weinstein D, Elias J. Glenohumeral chondrolysis following thermal capsulorrhaphy. Orthopedics. 2007;30:158-60.

    12. Good C, Shindle M, Kelly B, Wanich T, Warren R. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy. 2007;23:797.e1-797.e5.

    13. Levine W, Clark A, D’Alessandro D, Yamaguchi K. Chon- drolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am. 2005;87:616-21.

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