Is Injecting Bupivacaine or Lidocaine into a Joint Malpractice?

by Chris Centeno, MD /

This week a patient sent a note that her mom was to undergo surgery and the anesthesia crew was planning on using the local anesthetic bupivacaine. She knew from reading the blog that this wasn’t a  good idea, so let’s explore just how nasty this drug is to joints and why doctors are still using it.

Local Anesthetics

A local anesthetic is a medication that is injected to make an area numb. These drugs commonly include lidocaine, bupivacaine, ropivacaine, and mepivacaine. They work by altering the body’s ability to transport the chemicals that start the nerve response, with the clear winner for the duration of action being bupivacaine (aka Marcaine). As a result, bupivacaine is very popular in anesthesiology, where the longer a part is numb, the better.

Bupivacaine Problems

About a decade-plus ago, a pump was invented to keep shoulder joints numb after surgery, which helped with post-op pain. It infused bupivacaine continuously and was hailed as a modern wonder until the patients began to show up post-op with shoulders that had no cartilage. Turns out that bupivacaine is highly toxic to cartilage cells. As a result of the additional research performed, the American Academy of Orthopedic Surgeons put out a warning in 2012, warning surgeons not to use bupivacaine in joints.

Just How Bad Is Bupivacaine?

In 2007, our lab research group did its first study to see how the common local anesthetics we used might impact stem cells. At that point, bupivacaine was a real standout. It was toxic to stem cells at almost homeopathic dilutions (i.e., a dilution of 100 or more from the amount that’s used clinically). In 2014, we followed that up with publishing a research paper that also showed the same thing. However, our research isn’t alone in its findings that bupivacaine is a really bad boy. In addition, there’s also a surprising new entrant on the list of local anesthetics not to inject into joints.

As recent as March, a research paper was published that reviewed the results of 12 studies on the effects of local anesthetics on cartilage in joints. Bupivacaine and lidocaine were found to be more chondrotoxic (cartilage killing) than mepivacaine and ropivacaine. The amount of dead cartilage cells was directly related to the dose used of the local anesthetic, and joints with arthritic cartilage were more vulnerable than normal ones. The authors concluded that the only commonly used anesthetic that can be used in concentrations that still numb the joint and won’t have an effect on cartilage cells is ropivacaine (0.1–0.2%). The paper warned that “The use of lidocaine should be avoided.” This is new info, as while we knew lidocaine had some issues, it’s still being commonly used.

Who Still Hasn’t Gotten the Memo?

As we can see from my patient’s story, there are still physicians who haven’t gotten the memo about the cartilage toxicity of local anesthetics (other than ropivacaine). From what I see, the doctors still using dangerous drugs like bupivacaine and lidocaine to numb joints are usually surgical anesthesiologists and interventional pain-management doctors performing spine injections. They both like bupivacaine for its long-acting effects and also routinely use high-dose lidocaine because it can give a dense type of numbing block. One of the likely problems is that the safe anesthetic, ropivacaine, is little known in these fields because it’s commonly used in labor and delivery and its about 10 times more expensive per unit volume. For example, a bottle of lidocaine will run a clinic a few dollars; whereas, the same bottle of ropivacaine will run $30–40.

So Is It Malpractice to Inject Bupivacaine or Lidocaine into an Arthritic Joint?

While 10 years ago the literature on the toxicity of local anesthetics in joints was just getting going, and 5 years ago it was evolving, we have enough data in 2017 to state that injecting either bupivacaine or lidocaine into an arthritic joint is medically contraindicated. This is a fancy way of saying that it shouldn’t be done. Is that malpractice? That’s more of a legal definition defined by the courts, but suffice it to say that we have enough data to give a smart attorney ample ammunition to make a case.

What Can You Do if You’re a Patient?

If you’re a patient, always ask which local anesthetic is being injected into your joint. This is true whether it’s a knee, shoulder, ankle, or spine joint, like a facet. Make sure that it’s ropivacaine and not bupivacaine nor lidocaine! The brand name for ropivacaine is Naropin, and the brand name for bupivacaine is Marcaine. Here’s a pneumonic I made up that can help you remember:

R and N are right as RaiN; all others won’t help my pain! 

In this pneumonic, R is for ropivacaine and N is for Naropin. So if you ask about the anesthetic that will be used and the name starts with an L, like lidocaine, or a B or an M, like bupivacaine or Marcaine, then that’s not the right stuff!

The upshot? In 2017 we still have doctors who haven’t gotten the memo that common local anesthetics can destroy the remaining cartilage inside arthritic joints. If you’re a physician reading this, it’s time to change anesthetics—there are no more excuses. If you’re a patient, remember my pneumonic and if a doctor tries to use a toxic anesthetic, run and find a new doctor!

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17 thoughts on “Is Injecting Bupivacaine or Lidocaine into a Joint Malpractice?

  1. Gerry ONeill

    After getting a steroid injection in my joint to reduce swelling, how long should I wait before getting synthetic cartilage injected? I know the stem cell wait is 12 weeks.

    1. Regenexx Team Post author

      Gerry,
      Do you mean a hylauronic acid injection? That would be names like Euflexxa, Hyalgan, Nuflexxa, Supatz, Orthovisc, Hylan, or Synvisc…

      1. Gerry ONeill

        Yes, I only recently realized that those two terms were used interchangeably.

        1. Regenexx Team Post author

          Gerry,
          A waiting period of a month after a Hylauronic Acid injection like Supratz, etc is needed and a 3 months waiting period after any type of steroid injection. Hope that helps.

  2. Chris Kozura

    Hey Dr. Centeno,
    Good to see you at AAOM. The story in RIT world is still that lidocaine at .5-.3% or less is going to get out of the joint or be broken down before it causes chondrotoxicity. Your thoughts? I don’t use it but its less expensive to use. Lido is what is mainly used by doctors I have been taught, but I still use Procaine w/wo preserve with no side effects, because I was taught in the neural therapy and biopuncture world first. MSDS sheets show no deliterious effects on the body with procaine but lidocaine showed possible teratogenicity, and mutagenicity- (Rats/mice)

    1. Regenexx Team Post author

      Chris,
      We haven’t used lido in joints for many years, replaced with ropiviciane. Not much data on procaine in joints.

      1. Chris

        Thanks, will look into ropivicaine.

  3. dr O

    I do not even have a bottle of Bupivacaine in my office. Dumped it over a decade ago. Lido is for skin and subcut. These lido facet test injections may be doing some harm based on the article above. Rope all the way. Dr O.

  4. Dr. Daniel Johnson

    Dr. Centeno:

    Good on you that for so long, you’ve been bringing attention to the issue of chondrotoxicity of local anesthetics.

    Questions:

    – The available research shows that ropivacaine at below 0.2% concentration has no significant effect on cell viability, which is a welcome contrast to the clear chondrotoxicity of bupivacaine or lidocaine. But I wonder about injecting even low-concentration ropivacaine into joints. In most situations, the joints receiving these injections are osteoarthritic, with sometimes significant levels of cartilage damage already present, and I worry they might be particularly sensitive to even low-concentration ropivacaine. To avoid any possibility of damage, what do you think of using no anesthetic for joint injections of PRP, HA, stem cells?

    The obvious problem is the pain of injection. Looking at hips and knee joints, intra-articular injections without anesthetic aren’t pleasant, and my feeling is that hips would be worse than knees. But I can think of many medical procedures which are more painful yet still tolerable. Would you think most patients would truly be unable to handle the pain of no-anesthetic joint injections?

    – If the pain of injection is too great for certain patients, what would you think of placing the numbing agent only outside the joint, rather than intra-articularly, in order to get some pain reduction benefit, whilst still avoiding as much as possible the possibility of joint damage? For example, with the hip, inject the anesthetic below the skin, yet far from the joint, then proceed to inject the PRP/HA/etc intra-articularly into the joint?

    Best wishes,

    Daniel Johnson

    1. Chris Centeno Post author

      Dan, we will routinely numb right up to the joint on guidance and then inject without any ropi in the joint. In maybe 5% of the patients who are intolerant, we will use up to 0.25% ropi in the joint that once it mixes with natural fluid and injectate is well below 0.2%.

  5. Mary Nelson

    I live in Mexico. My doctor used to be an anesthesiologist – semi-retired.
    He likes stem cell possibilities and is using that in his practice now.
    I have had 3 hip injections over about the last 3-4 months. I cannot say I have seen much if any improvement in hip discomfort to date.
    Then I got your email re local anesthetics actually destroying cartilage and cannot help but wonder if it was one of the problematic drugs. Lidocaine is the most likely suspect.
    What can we do now if it was? A new injection using the good anesthetic? Not even sure it is available in Mexico right now.

    1. Mary Nelson

      I just talked to my doctor about your comments re local anesthetics.
      He said the local is injected before the joint itself and more shallow than the stem cells themselves.
      Makes sense or not?

      1. Regenexx Team Post author

        Mary,
        Did you ask what type he used?

        1. Mary

          I asked and he said lidocaine. That injection hurts every time since I have gotten about 5 stem cell injections. I am getting injections into my left hip joint. Am thinking about trying at least one time w/o local.
          I am not sure he even liked my investigation. I have been reading this site for some time now. Doctors are going to have to get used to patients doing their own research!
          That is not the way most elders have been trained plus they did not have Google, etc.,

          1. Chris Centeno Post author

            What type of stem cell injections are these?

          2. Regenexx Team Post author

            Mary,
            We always say, an educated patient is an empowered patient! 5 stem cell injections is unusual, what type of stem cell injections were these?

    2. Regenexx Team Post author

      Mary,
      We wrote the blog because this issue is not commonly known by Physicians. To avoid cartilage breakdown and not kill the stem cells used, the anesthetics stated need to be avoided. But there is a significantly more needed than just the type of anesthetic used for treatment to be effective. Please see: https://regenexx.com/blog/orthopedic-stem-cell-treatment/

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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