The influence of the irrigating solution on articular cartilage in arthroscopic surgery: A systematic review

Abstract

Arthroscopic surgery has become an important and popular orthopedic procedure for numerous joint disorders. Continuous irrigation is performed to replace synovial fluid for optimal joint distension and clear visualization of the synovial cavity. Irrigation solutions may, however, negatively impact articular cartilage and chondrocyte viability. This systematic review aims to compare different irrigating solutions and their properties to determine whether one is superior in its effects on articular cartilage and chondrocytes. Methods: A systematic literature review was conducted. The online databases: Embase, Medline, HealthStar, Emcare and PubMed were searched from 1946 to August 2018. Methodological index for non-randomized studies (MINORS) was used to assess methodological quality of the included studies. Results: Sixteen studies met the inclusion/exclusion criteria and were included in this review. Although the studies used different criteria to define superiority, solution superiority was based on results that focused on articular cartilage and chondrocyte viability. Seven of the sixteen included studies compared Ringer's/ lactate solution or Ringer's lactate to normal saline. Three found Ringer's solution or Ringer's lactate to be superior to saline, whereas, three studies found no significant differences and one study found Ringer's lactate to be inferior to saline only when their osmolarities differed. Four studies compared ionic to non-ionic solutions. Two of the four studies demonstrated non-ionic solutions to be superior, one had demonstrated no significant differences between solutions, while one had mixed results. Six of the sixteen included studies compared differing osmolarities. One found no statistically significant differences between solutions of differing osmolarities, whereas, the remaining five studies found superiority with hyperosmolarity. Two of the sixteen included studies examined the effects of different temperatures. Both studies concluded that the use of a warmer (more physiological) temperature is more ideal. Two of the sixteen studies included in this review compared solutions with differing pH levels. Both studies concluded on the importance of utilizing the more physiological solutions for arthroscopic procedures. Conclusion: Ringer's Lactate and Ringer's Solution as well as non-ionic solutions may have merit over the use of the normal saline for irrigation. Hyperosmolarity, warmer solutions and ones with more physiological pH values may be beneficial when considering potential effects on articular cartilage and chondrocytes. The current review demonstrated trends found in the current literature, which require human studies-preferably high quality RCTs-to make recommendations that aid surgeons in making the best decision regarding the ideal irrigation solution to use on their patients.

The efficacy of intraarticular viscosupplementation after arthroscopic partial meniscectomy: a randomized controlled trial

“…During arthroscopic surgery, continuous irrigation is performed for the visualization of the knee joint. However, irrigating fluids, such as saline, are known to negatively influence articular cartilage, [3] as they can alter the ideal environment of the knee joint by changing the temperature, osmolarity, and pH of the synovial fluid [4]. Their use during arthroscopic surgery may cause an increased removal of proteoglycans from the knee joint, exposing articular cartilage to possible mechanical damage [5].…”

A Hyperosmolar Saline Solution Fortified with Anti-Inflammatory Components Mitigates Articular Cartilage Pro-Inflammatory and Degradative Responses in an In Vitro Model of Knee Arthroscopy

“…Hyperosmolar synovial fluid (404 mOsm/L; pH 7.7) is diluted and displaced by an isotonic irrigation fluid such as normal saline (308 mOsm/L; pH 5) or lactated Ringer’s solution (273 mOsm/L; pH 6.5). 1,2 Chondrocytes are sensitive to fluctuations in osmolarity, temperature, and pH; this transition may influence the articular cartilage extracellular matrix composition by altering cytoskeletal organization, gene expression, protein synthesis, and calcium signaling. 2-6 Thus, there is strong interest in developing and validating solutions that can maintain and protect the joint, rather than disrupt it.…”

“…1,2 Chondrocytes are sensitive to fluctuations in osmolarity, temperature, and pH; this transition may influence the articular cartilage extracellular matrix composition by altering cytoskeletal organization, gene expression, protein synthesis, and calcium signaling. 2-6 Thus, there is strong interest in developing and validating solutions that can maintain and protect the joint, rather than disrupt it. 3,7-12…”

Temporary application of ox muzzle drainage in knee arthroscopic surgery

“…Do not apply a tourniquet During arthroscopy, the synovium and fat pad may need to be partially removed to visualize the anterior part of the menisci. [4,5] However, the bleeding caused by excision of part of the synovium and fat pad results in knee joint effusion, anterior knee pain and affected surgical eld of vision [4] . Therefore, su cient out ow of lavage uid in the knee joint cavity can make the eld of vision clear without stasis in the joint cavity.Drainage is widely used in orthopedic interventions and will, theoretically, remove the initial hemarthrosisSome studies have reported that drains prevent effusions and painful irritation of the knee by reducing synovial irritation, It promotes uid ow out of the joint [5,6] .…”