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Rapid Chondrolysis of the Knee After Anterior Cruciate Ligament ReconstructionA Case Report
Mark A. Slabaugh, MD; Nicole A. Friel, BS; Brian J. Cole, MD, MBA
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. 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 commercial entities (Arthrex, Genzyme, Zimmer, DePuy, Regentis).

Investigation performed at the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jan 01;92(1):186-189. doi: 10.2106/JBJS.I.00120
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Extract

Chondrolysis is a devastating complication of surgery on any joint, resulting in the rapid and extensive destruction of the articular cartilage. Associated with this destruction is an equally large inflammatory response that causes adhesions in the lining of the involved joint. The inflammatory response manifests as arthrofibrosis and is typically seen within six months after the operation. Management of this unique complication is difficult because most patients are very young and have active lifestyles. Chondrolysis causes more immediate symptoms of pain and limited range of motion than does osteoarthritis, which often takes years to become symptomatic.
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    Brian J. Cole, MD, MBA
    Posted on February 17, 2010
    Dr. Cole responds to Drs. Noyes and Fester
    Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois

    Dr. Noyes in his Letter to the Editor in this issue has appropriately corrected our statement in our article entitled, “Rapid Chondrolysis of the Knee After Anterior Cruciate Ligament Reconstruction: A Case Report” (1) that there were no prior published reports of knee chondrolysis following the use of an intra-articular pain pump. In fact, Fester and Noyes (2) reported 3 cases in the American Journal of Sports Medicine in June, 2009. Unfortunately, given the length of time between submission (prior to June, 2009), editing, and publishing, we did not update the bibliography of our case report prior to it being published in its final form in February of 2010. This was an unintentional oversight and we appreciate the correction.

    In our patient, tri-compartmental arthritis developed and all surfaces were involved at the time of definitive treatment. This is quite similar to the presentation in the Fester and Noyes (2) article. As a side note, while there were bioabsorbable screws used at the time of our patient’s initial ACL reconstruction, there was no evidence of a directly associated intra-articular process related to screw placement nor was there significant tunnel widening or osteolysis present that would suggest that the screw might have played some role in the development of chondrolysis. We too remain concerned about the risks of prolonged exposure of articular cartilage to local anesthetics. Notably, however, there have been very few reports in the knee with most being reported in the glenohumeral joint after intra-articular procedures were performed. In addition, the use of these devices within the subacromial space is also associated with a paucity of adverse events.

    As noted previously, there may be some genetic pre-disposition to chondrolysis in some individuals and for unknown reasons the glenohumeral joint seems to be at higher risk. Thousands of the intra-articular pain pumps have been used, yet the reported incidence of chondrolysis is certainly not of epidemic proportions. It is possible that a dilutional aspect due to a larger potential space and postoperative hematoma formation may reduce the chances of chondrotoxicity of the knee relative to the shoulder. In addition, the greater thickness of the articular surfaces may provide some degree of relative protection for the knee. At this time, given these and other reports, surgeons should consider alternative measures to achieve post-operative pain relief following intra-articular procedures. In addition, surgeons treating patients with similar clinical histories should consider reporting these cases so that we can appropriately document the specific circumstances related to this devastating complication.

    References

    1. Slabaugh MA, Friel NA, Cole BJ. Rapid chondrolysis of the knee after anterior cruciate ligament reconstruction: a case report. J Bone Joint Surg Am. 2010;92:186-9.

    2. Fester EW, Noyes FR. Postoperative chondrolysis of the knee: 3 case reports and a review of the literature. Am J Sports Med. 2009;37:1848-54.

    Frank R. Noyes, MD
    Posted on February 04, 2010
    Letter to the Editor
    Cincinnati SportsMedicine and Orthopaedic Center, Cincinnati, Ohio

    To the Editor:

    We wish to comment on the recent article entitled, “Rapid Chondrolysis of the Knee after Anterior Cruciate Ligament Reconstruction: A Case Report” (1). Slabaugh et al. report on a 17 year old female who developed tricompartmental chondrolysis (and subsequent arthritis) following the use of an intra-articular bupivacaine pain pump catheter (IA-BPPC). The patient had no other etiological factors and her clinical course was similar to the occurrence of severe chondrolysis of the glenohumeral joint after an IA-BPPC. Slabaugh et al. report to their knowledge the absence of any other published cases of knee chondrolysis with use of an IA-BPPC.

    In fact, we reported and had published the first cases of knee chondrolysis after pain pump use in three patients in 2009 (2). We have now had occasion to evaluate and examine a total of 7 cases of severe knee chondrolysis referred to our center and one of the cases represents the same case that Slabaugh reported. All of the patients have in common an ACL reconstruction (except for one patient who had a diagnostic arthroscopy for anterior knee pain). Five of the 7 patients had an IA-BPPC with a concentration of 0.5 cc bupivacaine with or without epinephrine infusion over 2-3 days at flow rates of between 2 and 5 cc/hr. Dose and flow rate for 2 patients was not available. There was no use of a thermal probe or other factors to explain the severe knee chondrolysis. The latent period before the onset of knee pain, swelling and functional limitations ranges from 5 months to 24 months. Six of the 7 have had a subsequent surgery.

    All seven knees showed severe chondrolysis and loss of articular cartilage in all three compartments except for two knees with relative sparing of the lateral tibiofemoral compartment. The patellofemoral joint typically showed the greatest loss of articular cartilage presumably due to the intra-articular catheter location in the superolateral portal. All patients were young with an average age of 23.7 years, and all have moderate to severe symptoms with activities of daily living. The treatment dilemma, similar to young patients with glenohumeral chondrolysis, is the existence of extensive loss of joint articular cartilage, a highly symptomatic state, and the limited temporizing operative procedures to buy time prior to total joint arthroplasty. Slabaugh et al. reported their patient improved with medial and lateral tibiofemoral osteochondral grafting procedures and a valgus tibial osteotomy. This patient is among the most severely affected and was only able to walk for a few minutes before experiencing severe pain. At present, she is improved from the operative procedure, however, still has a 30-minute walking tolerance (from one end of a shopping mall to the other). This level of functional limitations, similar to the other patients, represents an intolerable life style in the long term for a patient to accept. It appears likely that the majority of these patients will undergo total joint arthroplasty in their twenties or early thirties.

    We previously discussed in detail the in-vitro and in-vivo studies on chondrotoxicity of bupivacaine and there are now numerous publications in the literature (2). The cause of the joint chondrolysis (chondrocyte death and subsequent cartilage matrix deterioration and loss) is the chondrotoxic effect of bupivacaine. However, the occurrence and extent of joint chondrocyte death and articular cartilage loss is multi-factorial and includes bupivacaine volume, concentration, hours of infusion and dilution effects. These factors may explain a lower incidence of knee chondrolysis in comparison to the smaller size shoulder joint, however, it is also likely that more IA-BPPC devices have been used in the shoulder joint. Undoubtedly there are other susceptibility factors to explain why some patients who had an IA-BPPC did not develop either knee or shoulder chondrolysis.

    There may also exist of subset of patients who had an IA-BPPC and may be partially affected and will later develop knee arthritis symptoms. This appears to have occurred in one of our 7 patients who initially returned to sports activities, however, subsequently developed knee joint pain and swelling at 24 month postoperatively and then had a rapid progression to severe tricompartmental loss of articular cartilage. Accordingly, clinicians are advised to document any use of an IA-BPPC in patients who present within a few years of knee joint surgery and show symptomatic unexplained joint articular cartilage deterioration.

    The views expressed in this article/letter are those of the author and do not reflect the official policy of the United States Air Force, Department of Defense or the U.S. Government.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Slabaugh MA, Friel NA, Cole BJ. Rapid chondrolysis of the knee after anterior cruciate ligament reconstruction: a case report. J Bone Joint Surg Am. 2010;92:186-9.

    2. Fester EW, Noyes FR. Postoperative chondrolysis of the knee: 3 case reports and a review of the literature. Am J Sports Med. 2009;37:1848-54.

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