Chondrotoxic effects of intra-articular anesthetics in shoulders

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 intraarticular 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 intraarticular 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.