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Knee Chondrolysis by Infusion of Bupivacaine With Epinephrine Through an Intra-Articular Pain

Pump Catheter After Arthroscopic ACL Reconstruction
Jordan Z. Buchko, Tanner Gurney-Dunlop and Jason J. Shin
Am J Sports Med 2015 43: 337 originally published online November 10, 2014
DOI: 10.1177/0363546514555667

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Knee Chondrolysis by Infusion of
Bupivacaine With Epinephrine Through
an Intra-Articular Pain Pump Catheter
After Arthroscopic ACL Reconstruction
Jordan Z. Buchko,* MD, FRCSC, Tanner Gurney-Dunlop,* MD, and Jason J. Shin,y* MD
Investigation performed at the University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Background: Postoperative knee chondrolysis caused by continuous intra-articular pain pumps infusing bupivacaine with epi-
nephrine is a rare but serious complication.
Purpose: 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.
Study Design: 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 post-
operative infusion of bupivacaine with epinephrine via an intra-articular pain pump [IAPP]) and the nonexposure group (those with-
out 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 6 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 devel-
oped chondrolysis (37.5%), while 14 patients were exposed to 0.25% bupivacaine with epinephrine and 1 developed chondrol-
ysis (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.
Conclusion: The development of knee chondrolysis was associated with the intra-articular infusion of bupivacaine with epineph-
rine 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.
Keywords: chondrolysis; bupivacaine; infusion pumps; cartilage

Chondrolysis, the rapid loss of articular cartilage of a joint,
is a debilitating condition. The etymology of chondrolysis is
y
Address correspondence to Jason J. Shin, MD, Department of
Orthopaedics, Royal University Hospital, University of Saskatchewan,
Saskatoon, SK S7N 0W8, Canada (e-mail: jasonjwshin@gmail.com).
*Department of Orthopaedics, Royal University Hospital, University of
Saskatchewan, Saskatoon, Saskatchewan, Canada.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 43, No. 2
DOI: 10.1177/0363546514555667
Ó 2014 The Author(s)
from Greek ‘‘chondros’’ for cartilage and ‘‘lysis’’ for dissolu-
tion.13 The result is significant morbidity, including pain,
decreased range of motion of the affected joint, and
impaired function. There often exists no ideal treatment
solution, especially in young active patients. Chondrolysis
has been described in several joints, including the hip,
shoulder, ankle, elbow, and knee.3,17,18,22,23,30 A review
by Provencher et al24 provides a comprehensive overview
of this clinical condition.
In recent years, much attention has been devoted to
chondrolysis of the glenohumeral joint.1,7,13-15,21,22,27 While
past reports cite thermal energy, chlorhexidine, and gentian
violet as causes of chondrolysis, these more recent reports

337
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338 Buchko et al
link the development of chondrolysis to postoperative infu-
sion of local anesthetic.20,26,29,31,33 Moreover, there are an
increasing number of published laboratory studies demon-
strating the toxic effects of local anesthetics on chondro-
cytes.2,4,8,19,28 In contrast, there have been relatively few
articles discussing chondrolysis of the knee joint.9,23,30 At
our institution, we have seen several cases of chondrolysis
of the knee joint after arthroscopic anterior cruciate liga-
ment reconstruction (ACLR). We suspect this may be asso-
ciated with the postoperative infusion of bupivacaine with
epinephrine via an intra-articular pain pump (IAPP)
catheter.
The purpose of this study is 3-fold: (1) determine if an
association exists between postoperative infusion of bupiva-
caine with epinephrine and the development of chondrolysis
in patients who have undergone arthroscopic ACLR; (2) if
this association exists, to determine if it occurs in a dose-
dependent manner; and (3) report the prevalence of postop-
erative knee chondrolysis in a local cohort of patients.
We hypothesize that the development of knee chondrol-
ysis after ACLR is associated with postoperative high-dose
intra-articular bupivacaine with epinephrine infusion.
MATERIALS AND METHODS
A retrospective cohort study was designed to investigate the
use of postoperative infusion of a local anesthetic via an
IAPP and the development of chondrolysis after arthroscopic
ACLR. Ethics approval was obtained from our institution’s
Biomedical Research Ethics Board. A retrospective chart
review was carried out in April and May 2013 on all patients
who underwent arthroscopic ACLR by a single surgeon
between January 1, 2004, and December 31, 2006. No
attempt was made to formally contact the patients at the
time of the study, and all data were collected from reviewing
the patient charts. Thirty-nine patients with severe articular
cartilage damage (defined as Outerbridge grade 3 or 4 on
arthroscopic examination) at the time of index procedure, 2
patients who experienced postoperative knee joint infection
(1 superficial and 1 septic joint infection), 4 patients with
multiligament knee injury, 8 patients with a history of con-
tralateral knee injury requiring surgery, and 17 patients
who had any previous knee surgery on the affected side
were excluded. Details pertaining to each patient, including
demographic information, date and mechanism of initial
injury, surgical procedure, graft source, equipment used,
and postoperative course, were collected. Among those who
received an IAPP, the type, volume, concentration, and
flow rate of the anesthetic agent were recorded. Patients
were grouped into 2 cohorts: the exposure group (those
who had postoperative infusion of bupivacaine with epineph-
rine via an IAPP) and the nonexposure group (those without
postoperative infusion). The records were analyzed for the
earliest evidence of unexpected knee pain and stiffness and
for evidence of chondrolysis.
The diagnosis of chondrolysis was made by the operat-
ing surgeon using the following criteria: (1) despite
uneventful initial postoperative course, unusual symptoms
of increasing pain; (2) decreasing active range of motion
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The American Journal of Sports Medicine
due to pain; and (3) evidence of generalized articular carti-
lage loss involving at least 1 entire compartment in the
knee—compared with time of index surgery—on radio-
graph, magnetic resonance imaging (MRI), and/or repeat
arthroscopic evaluation.23,32 Diffuse loss of articular carti-
lage involving at least 1 entire compartment was consid-
ered due to chondrolysis and differentiated from focal or
localized chondral lesions that may result from mechanical
damage before, during, or after surgery. Chondrolysis was
distinguished from rheumatoid or septic arthritis by the
absence of evidence of systemic disease and local inflam-
matory findings. We used the date of first symptoms sug-
gesting chondrolysis to identify the date of onset of this
condition.
Surgical Technique
All patients included in the review underwent arthroscopi-
cally assisted ACLR using ipsilateral hamstring autograft
(103 knees) or bone–patellar tendon–bone autograft (2
knees). A single surgeon performed all surgeries. After rou-
tine diagnostic arthroscopy was completed and the pres-
ence of ACL rupture confirmed, the ipsilateral graft was
harvested and prepared. The ACL footprint was then pre-
pared using a mechanical shaver, and notchplasty was rou-
tinely performed. The femoral tunnel was drilled using an
anteromedial portal, and the tibial tunnel was created
using an Acufex guide (Smith & Nephew). After the graft
was passed through the tunnels, the hamstring graft was
secured on the femoral side with an Endobutton (Smith
& Nephew) and on the tibial side with a BioRCI screw
(Smith & Nephew). The patellar tendon graft was secured
with SoftSilk screws (Smith & Nephew) on both the femo-
ral and tibial sides. No thermal energy devices were used
in any of the procedures, and a tourniquet was used for
all cases. At the end of the procedure, 99 of 105 patients
had a single intra-articular injection of either bupivacaine
(0.25% or 0.5%, 40-60 mL) or lidocaine (1%, 40-60 mL)
regardless of whether they had an IAPP placed.
Exposure
At the preoperative visit, after consenting to undergo
ACLR, all patients were offered the option of purchasing
an IAPP device (DonJoy Pain Management Pain Buster
Catheter; DJO) for postoperative analgesia. Those patients
who chose to purchase the device had an IAPP catheter
inserted at the end of the procedure. The IAPPs were
loaded with 0.25% or 0.5% bupivacaine with 1:200,000 epi-
nephrine. Choice between 0.25% and 0.5% bupivacaine
was according to local anesthetic availability in the operat-
ing room at the end of the case. The IAPPs were loaded to
275 mL and had flow rates of 5 mL/h without controlling
for joint size. The IAPPs were placed in either the suprapa-
tellar pouch or the medial gutter, and patients were
instructed to remove the device 48 hours later. In the
course of 2 days, via the IAPP, patients loaded with
0.25% and 0.5% received a total bupivacaine dose of
600 mg and 1200 mg, respectively.
Vol. 43, No. 2, 2015
TABLE 1
Patient Demographics and Concomitant Surgical Procedures Performed Between Groups
Exposure (Bupivacaine
With Epinephrine Infusion)
Patients, n 46
Age, y, mean 6 SD 23.4 6 7.3
Male/female, n 23/23
Height, cm, mean 6 SD 172.6 6 9.1
Weight, kg, mean 6 SD 77.4 6 18.5
Meniscectomy, n 14
Meniscal repair, n 15
Debridement, n 2 6
Synovectomy, n 0 1
Postoperative Rehabilitation
All patients used a postoperative brace for the first 2
weeks, which was removed for exercises and cold therapy.
Active and passive range of motion of the knee and isomet-
ric muscle exercises were initiated the day after surgery.
At 4 weeks, patients were encouraged to regain propriocep-
tion and work on full range of motion. After 3 months, run-
ning and open kinetic chain exercises were permitted. Solo
sports were permitted after 4 months, and return to con-
tact sports was allowed after 6 to 9 months. In 35 patients
who underwent concomitant meniscal repairs, rehabilita-
tion protocol was modified during the first 6 weeks where
patients were limited to partial weightbearing and the
knee range of motion was restricted to 90° of flexion.
Statistical Analysis
Data were organized in Excel (Microsoft), and analyses
were performed using GraphPad Prism version 5.01
(GraphPad Software). Data are shown as mean values (6
standard deviation). Student t test was used for continuous
variables; chi-square test and Fisher exact test were used
for categorical variables. Survival analysis was conducted
to assess association between risk factors and risk of chon-
drolysis. A Kaplan-Meier curve was created to describe the
proportion of chondrolysis-free knees in relation to the
time from surgery. The use of this approach enabled the
inclusion of all data available and eliminated an arbitrarily
established requirement for the duration of follow-up. In
all the analyses, a value of P \ .05 was considered statisti-
cally significant.
RESULTS
Of the 175 patients who underwent arthroscopic-assisted
ACLR during the study period, 105 patients meeting study
criteria were identified (Figure 1). There were 57 male and
48 female patients with a mean age at surgery of 25.5 6 8.6
(range, 13-52 years). Two patients received a bone–patellar
tendon–bone autograft, and the remaining 103 patients
had a hamstring tendon autograft for their ACLR. A total
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Knee Chondrolysis After ACLR 339
Control (No Bupivacaine
With Epinephrine Infusion) P Value
59
27.1 6 9.3 .03
33/26 .55
172.2 6 10.9 .84
82.9 6 16.0 .11
26 .15
20 .89
.26
.38
Figure 1. Flowchart of patients. ACL, anterior cruciate
ligament.
of 60 (58.3%) procedures were done on the right knee. Con-
comitant surgical procedures were performed in 84 (80.0%)
patients. Table 1 summarizes patient demographics, as
well as all concomitant surgical procedures performed.
Forty-six patients received postoperative infusion of bupi-
vacaine with epinephrine via an IAPP (exposure cohort),
while 59 patients did not (control cohort).
According to our 3 criteria for chondrolysis, 13 knees
were identified to have chondrolysis. Patients reported
symptoms of worsening pain, stiffness, and mechanical
crepitation at a mean of 13.5 6 8.5 months after the index
procedure. Eleven of 13 (84.6%) cases were seen within 24
months after initial surgery (Figure 2). All 13 patients had
radiographic features to suggest diffuse loss of cartilage at
presentation. Twelve of 13 cases had subsequent second-
look arthroscopy that revealed diffuse loss of articular car-
tilage. All 13 cases of chondrolysis were in exposure group
patients who had postoperative infusion of bupivacaine
with epinephrine via an IAPP; no control group patients
developed chondrolysis (P \ .001) (Table 2). The preva-
lence of chondrolysis in the exposure group was 28.3%
(13/46), and the number needed to harm (NNH) for
340 Buchko et al
Figure 2. Kaplan-Meier curve: proportion of knees that did
not have a diagnosis of chondrolysis. ACL, anterior cruciate
ligament.
bupivacaine with epinephrine IAPPs is 3.53. Of those who
developed chondrolysis, 2 patients had tricompartmental
cartilage loss, 1 patient had widespread chondrolysis in
the medial and lateral compartments, and the remaining
10 patients had diffuse cartilage loss isolated to a single
compartment (7 patellofemoral compartment and 3 medial
compartment) (Figures 3 and 4).
Certain factors were associated with increased risk of
developing chondrolysis. Looking at subgroup analysis, of
those in the exposure group, 32 patients were exposed to
0.5% bupivacaine with epinephrine and 12 developed chon-
drolysis (37.5%), while 14 patients were exposed to 0.25%
bupivacaine with epinephrine and 1 developed chondrolysis
(7.1%) (Table 3). Patients exposed to 0.5% bupivacaine with
epinephrine had a significantly higher prevalence of chon-
drolysis compared with those exposed to 0.25% (P = .03).
Within the cohort exposed to bupivacaine, patients who
developed chondrolysis were compared with those who did
not. Patient and surgical characteristics within the exposed
cohort are outlined in Table 4. Patients who developed chon-
drolysis were more likely female, significantly shorter in
height, and weighed less. Factors not shown to be associated
with chondrolysis include age, tourniquet time, concomitant
procedures (meniscectomy, meniscal repair, and debride-
ment), and Outerbridge grade 1 or 2 articular cartilage
damage at the time of index surgery.
Of the 12 patients who had second-look arthroscopy, 11
had a negative Lachman test when examined under anes-
thesia with intact ACL on arthroscopy. One patient had
a positive Lachman test, and arthroscopic assessment
revealed intact but lax ACL. The 1 patient who did not
have repeat arthroscopic assessment had a negative Lach-
man test, and the MRI revealed an intact ACL.
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The American Journal of Sports Medicine
TABLE 2
Number of Patients Who Developed
Knee Chondrolysis According to Cohorta
Chondrolysis No Chondrolysis
Bupivacaine (with 13 33
epinephrine) infusion
No bupivacaine (with 0 59
epinephrine) infusion
a
P \ .0001.
TABLE 3
Number of Patients Who Developed Chondrolysis
According to Bupivacaine Concentrationa
Bupivacaine Concentration Chondrolysis No Chondrolysis
0.25% 1 13
0.5% 12 20
a
P = .03.
DISCUSSION
The purpose of this study was to determine the association
between postoperative intra-articular infusion of bupiva-
caine with epinephrine and the development of knee chon-
drolysis in patients who have undergone ACLR. The
principal findings of this study showed that of the 46
patients undergoing arthroscopically assisted ACLR proce-
dures who received postoperative intra-articular infusion
of a local anesthetic, bupivacaine with epinephrine, 13
(28.3%) developed chondrolysis. There was no occurrence
of chondrolysis in knees that did not receive postoperative
bupivacaine with epinephrine infusion. In our study, we
did not identify other possible causes for the development
of chondrolysis. We only included patients who had Outer-
bridge grade 2 or better articular surface condition at the
time of the initial ACLR to avoid the possibility of attribut-
ing chondrolysis to progression of preexisting degenerative
changes of the knee. Moreover, there was no evidence of
infection, trauma, inflammatory joint disease, or thermal
or radiofrequency use in any of our patients.
Unlike glenohumeral chondrolysis, chondrolysis occur-
ring after knee surgery is an extremely rare event.23 In
2002, Hoenecke et al16 recommended continuous infusion
of 0.25% bupivacaine for 48 hours after ACLR. It was not
until 2009 when Fester and Noyes9 first reported knee
chondrolysis associated with IAPP use. All 3 patients
were female and had hamstring autograft ACLR with no
immediate postoperative problems. Development of symp-
toms ranged from 7 to 21 months, and repeat arthroscopy
or MRI showed tricompartmental cartilage loss. Slabaugh
et al30 in 2010 reported a single case of chondrolysis in
a 17-year-old girl in whom symptoms developed approxi-
mately 4 months after hamstring autograft ACLR and
a lateral meniscal repair. All 4 cases were noted to be asso-
ciated with IAPPs.
Vol. 43, No. 2, 2015 Knee Chondrolysis After ACLR 341

TABLE 4
Demographics and Surgical Findings
Within Patients Exposed to Bupivacaine

Exposed to No
Bupivacaine Chondrolysis Chondrolysis P Value

Patients, n 13 33
Age, y, mean 6 SD 21.9 6 7.1 24.0 6 7.4 .40
Males/Females, n 3/10 20/13 .047
Height, cm, mean 6 SD 167.5 6 7.5 174.8 6 8.8 .01
Weight, kg, mean 6 SD 68.6 6 8.3 81.6 6 20.2 .03
Tourniquet time, min, 62.4 6 19.9 63.5 6 15.7 .85
mean 6 SD
Meniscectomy, n 4 10 1.00
Figure 3. Anteroposterior radiograph of the left knee demon- Meniscal repair, n 3 12 .50
strating (A) a normal knee joint before anterior cruciate liga- Debridement, n 1 1 .49
Articular cartilage 6 11 .50
ment reconstruction (ACLR) and (B) chondrolysis after
damage, n
ACLR, with marked joint space narrowing of the medial
compartment.

with epinephrine had been used (compared with 12 cases

Figure 4. T2 axial magnetic resonance imaging of left knee
demonstrating marked loss of hyaline cartilage involving
the patellofemoral joint with evidence of subchondral sclero-
sis and early osteophytes in the medial facet.
In a follow-up study to the 2009 series,9 Noyes et al23
reported on 21 patients (18 ACLR, 1 medial meniscal
repair, 1 arthroscopic debridement, and 1 tibial tubercle
osteotomy for patellar realignment) who developed chon-
drolysis. Twenty of 21 patients were infused with 0.5%
bupivacaine and 1 patient was infused with 0.25% bupiva-
caine, all via an IAPP. In 2011, while Wiater et al32
reported 49 cases of glenohumeral chondrolysis after infu-
sion of 0.5% bupivacaine, they also noted that 1 of the 6
shoulders that received 0.25% bupivacaine developed chon-
drolysis. Similar to these previous reports, our cohort had
a single case of chondrolysis in which 0.25% of bupivacaine
in which 0.5% bupivacaine with epinephrine was infused,
P = .03). Our findings support a dose-dependent chondro-
toxic association with bupivacaine with epinephrine in
the pathogenesis of this condition.
In basic science studies, the dose-dependent effect of
bupivacaine on chondrocyte death has been well
described.4-6,19 Chu et al5 demonstrated, using human
and bovine chondrocytes exposed to bupivacaine, a time-
and dose-dependent reduction in viability, with longer
exposure times and higher dose/concentrations resulting
in higher chondrotoxicity. Lo et al,19 using a bovine articu-
lar disk model, came to similar conclusion showing that
local anesthetics (ie, bupivacaine, lidocaine, or ropivacaine)
have a detrimental effect on chondrocyte viability in
a dose- and time-dependent manner. The clinical implica-
tions of these findings are tremendous since adult chondro-
cytes have little or no capacity to regenerate and result in
irreversible damage, which can lead to a devastating effect
on quality of life.19
Given the concerns for the development of chondrolysis
after infusion of local anesthetic, the question arises as to
whether a single injection of local anesthetic at the time of
arthroscopy should be performed. In a rat model, Chu
et al4 demonstrated a 50% reduction in chondrocyte density
after a single injection of 0.5% bupivacaine compared with
saline controls. Although chondrolysis did not develop by 6
months (the final time point in their study), this study
clearly outlines the chondrotoxicity of bupivacaine. This
suggests that any intra-articular bupivacaine is potentially
harmful. In our study, at the end of the procedure, 99 of 105
(94.2%) patients had a single intra-articular injection of
either bupivacaine (0.25 or 0.5%, 40-60 mL) or lidocaine
(1%, 40-60 mL) regardless of whether they had an IAPP
placed. Chondrolysis was seen only in patients with an
IAPP, suggesting no harmful clinical effects of a single injec-
tion of bupivacaine. However, it remains to be seen if any
negative consequences will arise over the long term. In con-
trast to the study by Chu et al,4 a recent study by Ravnihar

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342 Buchko et al
Figure 5. Arthroscopic view of the medial tibiofemoral com-
partment of the left knee. Complete loss of articular cartilage
with exposed bone is seen, in keeping with a diagnosis of
chondrolysis. Of note, the medial meniscus is unaffected.
et al25 demonstrated that a single intra-articular injection of
15 to 20 mL of 2% lidocaine did not have any deleterious
effects on the viability, morphologic characteristics, or culti-
vation potential of chondrocytes in articular cartilage har-
vested for autologous chondrocyte implantation. More data
on the safety of single injections of local anesthetic are
required to guide clinical practice in this regard.
Some have suggested that mechanical damage, such as
that resulting from the tip of the IAPP catheter, is a poten-
tial cause of chondrolysis. While this is a possibility, we
believe it highly unlikely that the IAPP catheter played
a major role in the development of chondrolysis in our
patients. Mechanical abrasion from a prominent IAPP
catheter would most likely result in focal mechanical dam-
age, not diffuse cartilage loss as observed in our patients
(Figures 5 and 6). In addition, the short time period
(48 hours) in which the catheter is in situ and the limited
activity in immediately postoperative patients do not pro-
vide optimal conditions for extensive mechanical abrasion.
Moreover, the extensive bi- and tricompartmental damage
observed in several patients would be difficult to attribute
to mechanical damage from IAPP catheter tip alone.
Finally, the dose-dependent chondrotoxic response of chon-
drocytes to local anesthetic provides evidence that chon-
drolysis after IAPP use is more likely to be a chemical
process rather than a mechanical phenomenon. In both
0.25% and 0.5% bupivacaine with epinephrine, the same
IAPP catheter is inserted into the joint for the same dura-
tion and under identical postoperative activity restrictions.
As such, dose dependency suggests a chemical (rather than
mechanical) cause of cartilage destruction.
Our prevalence of knee chondrolysis after bupivacaine
with epinephrine infusion after ACLR was 28.3%. To our
knowledge, this is the first time that the prevalence of
knee chondrolysis after continuous intra-articular infusion
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The American Journal of Sports Medicine
of bupivacaine with epinephrine has been reported. In the
glenohumeral joint, Hansen et al12 reported a prevalence
of chondrolysis of 63% (12 of 19 shoulders) after use of an
IAPP. In a previous study, our institution reported a prev-
alence of 40.0% (18 of 45 shoulders).1 Wiater et al32
reported chondrolysis development in 45.0% (49 of 109) of
shoulders that received an IAPP. In a 2013 analysis of
published evidence, Matsen and Papadonikolakis22 identi-
fied 213 cases of glenohumeral chondrolysis. We suspect
the lower prevalence of chondrolysis in the knee is due
to the large volume of the joint compared with the shoul-
der, which allows for more diffusion and dilution of
bupivacaine/epinephrine. Moreover, because the articular
cartilage in the human knee is substantially thicker than
that on the humeral head, the knee may be more resistant
to developing chondrolysis.10,11 Anatomic variation
between sexes in joint size and cartilage thickness may
also partly explain why more female patients developed
chondrolysis than did male patients.
Our study had several similar findings to Noyes et al.23
In our cases of chondrolysis, all patients had a common fea-
ture of complete cartilage loss and subchondral bone expo-
sure in the involved compartment. The majority (92.3%) of
our patients had extensive articular cartilage loss in only 1
or 2 compartments. Tricomparmental chondrolysis was
noted in only 1 patient. Similarly, in a series of 21 cases
of knee chondrolysis, Noyes et al23 reported diffuse loss
of cartilage limited to 1 or 2 compartments in 15 (71.4%)
patients, and only 6 knees developed chondrolysis involv-
ing all 3 compartments. Because the knee joint is larger
than the glenohumeral joint and consists of 3 connected
but distinct compartments, chondrolysis secondary to
bupivacaine/epinephrine infusion via an IAPP may not
involve all 3 compartments. This is a unique feature of
knee chondrolysis. The laws of diffusion would state that
the concentration of bupivacaine/epinephrine would
change with distance—with the chondrocytes that are fur-
ther from the IAPP catheter exposed to lower concentra-
tions of the chondrotoxic substance. The operating
surgeon noted that initially in his practice, he placed the
IAPP catheter in the suprapatellar pouch but later
changed his practice to place it in the medial gutter.
Although the specific date for modifying placement of the
catheter is unknown and the exact location of the IAPP
catheter was not documented for each individual patient,
all 7 patients who developed isolated patellofemoral chon-
drolysis had surgery in 2004 and 2005 (early part of the
study period) compared with the remaining 6 patients
who had surgery in 2006 (later part of the study period).
The close proximity of the source of bupivacaine/epineph-
rine may explain the predominance of chondrolysis in the
patellofemoral and medial compartments in our patients.
Moreover, there were no cases of isolated lateral compart-
ment chondrolysis in our patients, and it was not part of the
surgeon’s practice to place the catheter in the lateral com-
partment. Further supporting the previous findings of
Noyes et al,23 we did not find any association between the
condition of the menisci or any meniscal procedures (menis-
cectomy or meniscal repair) and the subsequent develop-
ment of chondrolysis. Second-look arthroscopic procedures
Vol. 43, No. 2, 2015
Figure 6. Arthroscopic view of the right knee in a patient with isolated patellofemoral chondrolysis. (A) Patellofemoral, (B) medial
tibiofemoral, (C) reconstructed anterior cruciate ligament graft, and (D) lateral tibiofemoral.
demonstrated resilience of the menisci to the infused bupi-
vacaine with epinephrine (see the online Video Supple-
ment). Similarly, ACL integrity does not appear to be
affected by chondrolysis.
It has previously been suggested that chondrolysis be
defined as conditions that present within 12 months from
exposure to a noxious stimulus.24 However, in the study
by Noyes et al,23 patients with chondrolysis developed
noteworthy symptoms up to 24 months after their index
surgery. It is quite possible that the majority of joint chon-
drolysis will develop within 12 months, but given the large
joint volume and thickness of articular cartilage in the
knee, it may take longer to complete the process of chon-
drolysis. Consistent with this theory, patients in our study
developed symptoms at a mean of 13.5 6 8.5 months after
the index procedure, with 6 of 13 patients developing
symptoms within 12 months.
This study has several limitations. The retrospective
nature of this study is one source of weakness. However,
it would be unethical and immoral to carry out a prospec-
tive study with such a deleterious outcome. This study
was a chart review, and no attempt was made to contact
all patients to return for a clinical and radiographic review.
Our institution has previously attempted to contact and
arrange follow-up for patients for a similar study on gleno-
humeral chondrolysis, but this had to be abandoned given
poor patient follow-up (\20%) because of the young and
mobile nature of the patient population in that study
Downloaded from ajs.sagepub.com at PENNSYLVANIA STATE UNIV on May 25, 2015
Knee Chondrolysis After ACLR 343
(J.Z.B., personal communication). Given that our patient
population possessed similar characteristics, we elected
to perform a chart review only. As a result, we may poten-
tially be missing cases of chondrolysis from our analysis,
since patients who developed chondrolysis may have
moved away or not returned for follow-up. The operating
surgeon did, however, send all patients who underwent
ACLR during the study time period a letter once he real-
ized that some patients were developing chondrolysis
(most likely due to postoperative infusion of bupivacaine
with epinephrine). The letter notified them of the associa-
tion between IAPPs and chondrolysis, explained the symp-
toms of chondrolysis, and asked patients to return for
follow-up if they were having any difficulties or concerning
symptoms. Again, given the nature of this patient popula-
tion, some letters were returned as patients had moved
away, but encouragingly, several patients did return for
follow-up. Given these factors, it is possible that our data
may reflect an underestimated incidence of chondrolysis,
since some cases may have been missed. Although long-
term follow-up data were not available for many of the
patients, survival analysis was used to handle the different
follow-up times for the cohorts. Similar to previous clinical
studies on chondrolysis, we did not provide an exact date of
chondrolysis onset and instead used the date of first
postoperative symptoms as our surrogate.32 Last, the pre-
sented data reflect the experience of a single surgeon and
therefore may not be generalizable to other practices.
344 Buchko et al
Despite these limitations, this study is a cohort study
with excellent similarity in characteristics between the 2
compared groups (single surgeon performing primary
ACLR with normal articular cartilage condition). The
groups were similar in patient demographics, diagnosis,
surgical technique, rehabilitation, type of local anesthetic
used, and brand of the IAPP. As such, the present retro-
spective cohort design suggests that exposure to intra-
articular infusion of bupivacaine with epinephrine is caus-
ally associated with the development of chondrolysis.
CONCLUSION
The occurrence of knee chondrolysis is associated with the
intra-articular infusion of bupivacaine with epinephrine
postoperatively. Furthermore, the presented evidence sug-
gests that the development of chondrolysis 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.
ACKNOWLEDGMENT
The authors thank Prosanta Mondal, MSc, for his assis-
tance with statistical analysis.
A Video Supplement for this article is available in the online
version or at http://ajsm.sagepub.com/supplemental.
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