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Turk J Emerg Med. 2017 March; 17(1): 34.
Published online 2017 February 27. doi:  10.1016/j.tjem.2016.11.006
PMCID: PMC5357092

Chondrotoxic effects of intra-articular anesthetics in shoulders

Dear editor,

With great interest we read the article of Kashani and colleagues “Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation”.1 This article that has been recently published in your journal describes the interesting results of a randomized controlled trial that compared intra-articular lidocaine with intravenous sedation for the treatment of shoulder dislocations.

Although we agree with the benefits of intra-articular sedation over local sedation, we feel that possible disadvantages of the use of intra-articular lidocaine have not been properly addressed. Kashani and colleagues1 do make note of possible chondrolytic effects of local anesthetic injections in the study limitations paragraph but state that it is uncommon.

Recent systematic reviews have reported toxic effects of intra-articular use of anesthetics.2 Sola et al. has also reported an in vivo chondrotoxic effect after a single injection of different concentrations of saline, bupivacaine, ropivacaine, triamcinolone, and a mixture of these agents in the knee joint of rats. Only an injection with a low dose of ropivacaine did not result in chondrotoxicity.3 Although the effect of bupivacaine seems to be more profound, lidocaine also has chondrotoxic effects as has been shown by Karpie and colleagues.4

Although sedation with intra-articular lidocaine may have benefits over IV sedation, there are multiple studies that report toxic effects of anesthetics on articular chondrocytes.

The objective of this letter is to warn orthopaedic and trauma surgeons in colleagues for these chondrotoxic effect and to use intra-articular local anesthetics with caution, especially in an emergency care population with patients who already suffered an injury to their shoulders' cartilage due to the dislocation. Almost two-thirds of all first-time dislocations at the age of <25 years will develop different stages of arthropathy within 25 years.5

Funding

There is no funding for this study.

Conflicts of interest

None declared.

Footnotes

Peer review under responsibility of The Emergency Medicine Association of Turkey.

References

1. Kashani P., Asayesh Zarchi F., Hatamabadi H.R., Afshar A., Amiri M. Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation. Turk J Emerg Med. 2016;16(2):60–64. [PubMed]
2. Gulihar A., Robati S., Twaij H., Salih A., Taylor G.J.S. Articular cartilage and local anaesthetic: a systematic review of the current literature. J Orthop. 2015;12(Suppl 2):S200–S210. [PubMed]
3. Sola M., Dahners L., Weinhold P., Svetkey van der Horst A., Kallianos S., Flood D. The viability of chondrocytes after an in vivo injection of local anaesthetic and/or corticosteroid. Bone Jt J. 2015;97-B(7) [PubMed]
4. Karpie J.C., Chu C.R. Lidocaine exhibits dose- and time-dependent cytotoxic effects on bovine articular chondrocytes in vitro. Am J Sports Med. 2007;35(10):1621–1627. [PubMed]
5. Hovelius L., Rahme H. Primary anterior dislocation of the shoulder: long-term prognosis at the age of 40 years or younger. Knee Surg Sports Traumatol Arthrosc. 2016;24(2):330–342. [PubMed]

Articles from Turkish Journal of Emergency Medicine are provided here courtesy of Elsevier