LETTERS TO THE EDITORS
Chondrotoxic Effects of Intra-articular Anesthetics in Pediatric Shoulders To the Editors: ith great interest, we read the articles of Breslin and colleagues1 and Aronson and Mistry,2 “Ultrasound-Guided Intraarticular Lidocaine Block for Reduction of Anterior Shoulder Dislocation in the Pediatric Emergency Department” and “Intraarticular Lidocaine for Reduction of Shoulder Dislocation.” Both articles have been published in your journal and give an extensive description of intra-articular lidocaine use for the treatment of shoulder dislocations and the advantages over intravenous sedation. Although we agree with most part of both articles, we feel that possible disadvantages of the use of intraarticular lidocaine have not been sufficiently addressed. Breslin and colleagues1 make note of recent concerns of possible chondrotoxic effects of local anesthetic injections on chondrocytes but state that the clinical significance of this remains unclear. Aronson and colleagues2 state that intra-articular bupivacaine has been associated with chondrolysis but disregard the potential chondrotoxic effect because of the absence of long-term studies. Several studies, however, have reported the toxic effects of intra-articular use of anesthetics.3 Chu and colleagues4 found a significant reduction in chondrocyte density 6 months after an in vivo single intra-articular injection of 0.5% bupivacaine. Dogan and colleagues5 also have found significant histological changes in rabbit knee joint articular cartilage after bupivacaine injections. Although the effect of bupivacaine seems to be more profound, lidocaine also has chondrotoxic effects, as has been shown by Karpie and Chu.6 The toxic effect of a single-dose of lidocaine on articular chondrocytes has also been confirmed in vitro.7 Although sedation with intra-articular lidocaine may have benefits over intravenous sedation, there are multiple studies that report the toxic effects of anesthetics on articular chondrocytes. The objective of this letter was to warn orthopedic and trauma surgeons for these chondrotoxic effects and to use intraarticular local anesthetics with caution,3 especially in the pediatric population with possible injured cartilage of the shoulder due to the dislocation.
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Dirk P. ter Meulen, MD Derek F.P. van Deurzen, MD Just A. van der Linde, MD Michel P.J. van den Bekerom, MD Department of Orthopedic Surgery Onze Lieve Vrouwe Gasthuis Amsterdam, the Netherlands [email protected]
DISCLOSURE The authors declare no conflict of interest.
REFERENCES 1. Breslin K, Boniface K, Cohen J. Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department [published online ahead of print May 3, 2014]. Pediatr Emerg Care. 2014;30: 217–220. 2. Aronson PL, Mistry RD. Intra-articular Lidocaine for Reduction of Shoulder Dislocation [published online ahead of print March 5, 2014]. Pediatr Emerg Care. 2014; 30:358–362. 3. Baker JF, Mulhall KJ. Local anaesthetics and chondrotoxicty: what is the evidence? [published online ahead of print March 12, 2011]. Knee Surg Sports Traumatol Arthrosc. 2012;20: 2294–2301. 4. Chu CR, Coyle CH, Chu CT, et al.In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage [published online ahead of print March 3, 2010]. J Bone Joint Surg Am. 2010;92: 599–608. 5. Dogan N, Erdem AF, Erman Z, Kizilkaya M. The effects of bupivacaine and neostigmine on articular cartilage and synovium in the rabbit knee joint [published online ahead of print February 10, 2004]. J Int Med Res. 2004;32:513–519. 6. Karpie JC, Chu CR. Lidocaine exhibits dose- and time-dependent cytotoxic effects on bovine articular chondrocytes in vitro. Am J Sports Med [published online ahead of print January 8, 2007]. 2007;35:1621–1627. 7. Dragoo JL, Braun HJ, Kim HJ, Phan HD, Golish SR. The in vitro chondrotoxicity of single-dose local anesthetics. Am J Sports Med [published online ahead of print January 31, 2001]. 2012;40:794–799.
Pediatric Emergency Care • Volume 30, Number 9, September 2014
Author Response to Letter to the Editors, “Chondrotoxic Effects of Intra articular Anesthetics in Pediatric Shoulders” To the Editors: e appreciate the concerns expressed in this letter to the editors regarding the potential chondrotoxic effects of intra-articular injection of lidocaine and bupivacaine. Certainly, the adverse effects of any therapy or procedure are an important consideration for the physician, and these adverse effects must be weighed against the potential benefits of the procedure. In the submitted letter to the editors, the authors cite several studies that support the possibility of cartilage damage from intra-articular lidocaine and other members of this class of anesthetic. However, it must be considered that these data have only demonstrated chondrotoxicity in vitro. Moreover, the chondrotoxic effects were dose and duration dependent in the study by Karpie et al1; it is unknown whether a single intra-articular injection of lidocaine in the emergency department will result in significant chondrotoxic effects. In the absence of longitudinal studies of lidocaine exposure to articular cartilage in humans, the true chondrotoxic effects remain unknown. In the emergency department, where patients with shoulder dislocations present in acute pain and need of emergent reduction, the physician must balance the needs of the patient, the time involved, and the risks of alternative methods of analgesia. In particular, the risks of procedural sedation must be weighed against the theoretical risk for cartilage damage from a single dose of intra-articular lidocaine. The risks of procedural sedation are well known and may be quite significant, including aspiration of secretions or gastric contents and respiratory depression. In weighing the risks and benefits to the patient, there are many instances where administration of intra-articular lidocaine would be in the best interests of the patient, and emergency physicians would likely favor this method of analgesia in lieu of an adverse effect with unknown incidence or long-term consequence. We thank the authors for raising this important point, and the long-term effects of
W
www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
675
Chondrotoxic Effects of Intra-articular Anesthetics in Pediatric Shoulders To the Editors: ith great interest, we read the articles of Breslin and colleagues1 and Aronson and Mistry,2 “Ultrasound-Guided Intraarticular Lidocaine Block for Reduction of Anterior Shoulder Dislocation in the Pediatric Emergency Department” and “Intraarticular Lidocaine for Reduction of Shoulder Dislocation.” Both articles have been published in your journal and give an extensive description of intra-articular lidocaine use for the treatment of shoulder dislocations and the advantages over intravenous sedation. Although we agree with most part of both articles, we feel that possible disadvantages of the use of intraarticular lidocaine have not been sufficiently addressed. Breslin and colleagues1 make note of recent concerns of possible chondrotoxic effects of local anesthetic injections on chondrocytes but state that the clinical significance of this remains unclear. Aronson and colleagues2 state that intra-articular bupivacaine has been associated with chondrolysis but disregard the potential chondrotoxic effect because of the absence of long-term studies. Several studies, however, have reported the toxic effects of intra-articular use of anesthetics.3 Chu and colleagues4 found a significant reduction in chondrocyte density 6 months after an in vivo single intra-articular injection of 0.5% bupivacaine. Dogan and colleagues5 also have found significant histological changes in rabbit knee joint articular cartilage after bupivacaine injections. Although the effect of bupivacaine seems to be more profound, lidocaine also has chondrotoxic effects, as has been shown by Karpie and Chu.6 The toxic effect of a single-dose of lidocaine on articular chondrocytes has also been confirmed in vitro.7 Although sedation with intra-articular lidocaine may have benefits over intravenous sedation, there are multiple studies that report the toxic effects of anesthetics on articular chondrocytes. The objective of this letter was to warn orthopedic and trauma surgeons for these chondrotoxic effects and to use intraarticular local anesthetics with caution,3 especially in the pediatric population with possible injured cartilage of the shoulder due to the dislocation.
W
Dirk P. ter Meulen, MD Derek F.P. van Deurzen, MD Just A. van der Linde, MD Michel P.J. van den Bekerom, MD Department of Orthopedic Surgery Onze Lieve Vrouwe Gasthuis Amsterdam, the Netherlands [email protected]
DISCLOSURE The authors declare no conflict of interest.
REFERENCES 1. Breslin K, Boniface K, Cohen J. Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department [published online ahead of print May 3, 2014]. Pediatr Emerg Care. 2014;30: 217–220. 2. Aronson PL, Mistry RD. Intra-articular Lidocaine for Reduction of Shoulder Dislocation [published online ahead of print March 5, 2014]. Pediatr Emerg Care. 2014; 30:358–362. 3. Baker JF, Mulhall KJ. Local anaesthetics and chondrotoxicty: what is the evidence? [published online ahead of print March 12, 2011]. Knee Surg Sports Traumatol Arthrosc. 2012;20: 2294–2301. 4. Chu CR, Coyle CH, Chu CT, et al.In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage [published online ahead of print March 3, 2010]. J Bone Joint Surg Am. 2010;92: 599–608. 5. Dogan N, Erdem AF, Erman Z, Kizilkaya M. The effects of bupivacaine and neostigmine on articular cartilage and synovium in the rabbit knee joint [published online ahead of print February 10, 2004]. J Int Med Res. 2004;32:513–519. 6. Karpie JC, Chu CR. Lidocaine exhibits dose- and time-dependent cytotoxic effects on bovine articular chondrocytes in vitro. Am J Sports Med [published online ahead of print January 8, 2007]. 2007;35:1621–1627. 7. Dragoo JL, Braun HJ, Kim HJ, Phan HD, Golish SR. The in vitro chondrotoxicity of single-dose local anesthetics. Am J Sports Med [published online ahead of print January 31, 2001]. 2012;40:794–799.
Pediatric Emergency Care • Volume 30, Number 9, September 2014
Author Response to Letter to the Editors, “Chondrotoxic Effects of Intra articular Anesthetics in Pediatric Shoulders” To the Editors: e appreciate the concerns expressed in this letter to the editors regarding the potential chondrotoxic effects of intra-articular injection of lidocaine and bupivacaine. Certainly, the adverse effects of any therapy or procedure are an important consideration for the physician, and these adverse effects must be weighed against the potential benefits of the procedure. In the submitted letter to the editors, the authors cite several studies that support the possibility of cartilage damage from intra-articular lidocaine and other members of this class of anesthetic. However, it must be considered that these data have only demonstrated chondrotoxicity in vitro. Moreover, the chondrotoxic effects were dose and duration dependent in the study by Karpie et al1; it is unknown whether a single intra-articular injection of lidocaine in the emergency department will result in significant chondrotoxic effects. In the absence of longitudinal studies of lidocaine exposure to articular cartilage in humans, the true chondrotoxic effects remain unknown. In the emergency department, where patients with shoulder dislocations present in acute pain and need of emergent reduction, the physician must balance the needs of the patient, the time involved, and the risks of alternative methods of analgesia. In particular, the risks of procedural sedation must be weighed against the theoretical risk for cartilage damage from a single dose of intra-articular lidocaine. The risks of procedural sedation are well known and may be quite significant, including aspiration of secretions or gastric contents and respiratory depression. In weighing the risks and benefits to the patient, there are many instances where administration of intra-articular lidocaine would be in the best interests of the patient, and emergency physicians would likely favor this method of analgesia in lieu of an adverse effect with unknown incidence or long-term consequence. We thank the authors for raising this important point, and the long-term effects of
W
www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
675
