H. Alkaduhimi, D.P. ter Meulen, M.P.J. van den Bekerom

Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery OLVG, Amsterdam, The Netherlands

Keywords: hassaninalkaduhimi@gmail.com

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 colleagues(1) 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)

Conflict of Interest

None declared.

Financial Disclosure

There is no funding for this study.


  1. P. Kashani, F. Asayesh Zarchi, H.R. Hatamabadi, A. Afshar, M. Amiri, Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation, Turk J Emerg Med, 16 (2) (2016), pp. 60–64 http://dx.doi.org/10.1016/j.tjem.2016.04.001
  2. A. Gulihar, S. Robati, H. Twaij, A. Salih, G.J.S. Taylor, Articular cartilage and local anaesthetic: a systematic review of the current literature, J Orthop, 12 (Suppl 2) (2015), pp. S200–S210 http://dx.doi.org/10.1016/j.jor.2015.10.005
  3. M. Sola, L. Dahners, P. Weinhold, A. Svetkey van der Horst, S. Kallianos, D. Flood, The viability of chondrocytes after an in vivo injection of local anaesthetic and/or corticosteroid, Bone Jt J, 97-B (7) (2015)
  4. J.C. Karpie, C.R. Chu Lidocaine exhibits dose- and time-dependent cytotoxic effects on bovine articular chondrocytes in vitro, Am J Sports Med, 35 (10) (2007), pp. 1621–1627 http://dx.doi.org/10.1177/0363546507304719
  5. L. Hovelius, H. Rahme, Primary anterior dislocation of the shoulder: long-term prognosis at the age of 40 years or younger, Knee Surg Sports Traumatol Arthrosc, 24 (2) (2016), pp. 330–342 http://dx.doi.org/10.1007/s00167-015-3980-2