Knee chondrolysis by infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter after arthroscopic ACL reconstruction.
BACKGROUND
Postoperative knee chondrolysis caused by continuous intra-articular pain pumps infusing bupivacaine with epinephrine is a rare but serious complication.


OBJECTIVE
To determine the association between postoperative intra-articular infusion of bupivacaine with epinephrine and the development of knee chondrolysis in patients who have undergone arthroscopic anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that the development of knee chondrolysis after ACLR is associated with postoperative high-dose intra-articular bupivacaine with epinephrine infusion.


METHODS
Cohort study; Level of evidence, 3.


METHODS
In this retrospective cohort study, the charts of all patients treated with arthroscopic ACLR by a single surgeon between January 1, 2004, and December 31, 2006, were reviewed. Patients with severe articular cartilage damage at the time of the index procedure, with known knee joint infection, inflammatory arthritis, multiligament knee injury, bilateral knee injury, or any previous knee surgery, were excluded. Patients were grouped into 2 cohorts: the exposure group (those who had postoperative infusion of bupivacaine with epinephrine via an intra-articular pain pump [IAPP]) and the nonexposure group (those without postoperative infusion).


RESULTS
A total of 105 patients met the inclusion and exclusion criteria. There were 57 male and 48 female patients with a mean age at surgery of 25.5 ± 8.6 years (range, 13-52 years). The exposure group consisted of 46 patients and the control group of 59 patients. Thirteen of 46 patients (28.3%) who received an IAPP developed chondrolysis. There were no cases of chondrolysis in the control group. Of those in the exposure group, 32 patients were exposed to 0.5% bupivacaine with epinephrine and 12 developed chondrolysis (37.5%), while 14 patients were exposed to 0.25% bupivacaine with epinephrine and 1 developed chondrolysis (7.1%). Patients exposed to 0.5% bupivacaine with epinephrine had a significantly higher incidence of chondrolysis compared with those exposed to 0.25% (P = .03). Patients with chondrolysis had severe pain and limitations in daily activity.


CONCLUSIONS
The development of knee chondrolysis was associated with the intra-articular infusion of bupivacaine with epinephrine postoperatively. Furthermore, the presented evidence suggests that this occurs in a dose-dependent manner. The risk of knee chondrolysis might be reduced by avoidance of intra-articular infusion of bupivacaine with epinephrine. We recommend against continuous intra-articular infusion of local anesthetic postoperatively.
Department of Orthopaedics, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Jordan Z
JZ
Buchko
Department of Orthopaedics, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Tanner
T
Gurney-Dunlop
Department of Orthopaedics, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada jasonjwshin@gmail.com.
Jason J
JJ
Shin
D000293:Adolescent; D000328:Adult; D000779:Anesthetics, Local / Q000008:administration & dosage; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D018771:Arthralgia / Q000188:drug therapy; D001182:Arthroscopy / Q000379:methods; D002045:Bupivacaine / Q000008:administration & dosage*; D002357:Cartilage Diseases / Q000209:etiology*; D002358:Cartilage, Articular / Q000473:pathology; D015331:Cohort Studies; D004837:Epinephrine / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007270:Injections, Intra-Articular / Q000009:adverse effects; D007718:Knee Injuries / Q000601:surgery; D007719:Knee Joint / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D011184:Postoperative Period; D012189:Retrospective Studies; D055815:Young Adult
D000779:Anesthetics, Local; D002045:Bupivacaine; D004837:Epinephrine
bupivacaine; cartilage; chondrolysis; infusion pumps