Gravity Fluid Flow More Accurately Reflects Joint Fluid Pressure Compared With Commercial Peristaltic Pump Systems in a Cadaveric Model

Improving visualization in shoulder arthroscopy

Arthroscopic shoulder procedures are one of the most common procedures used to restore function through minimally invasive techniques. With the demand for shoulder arthroscopic procedures comes the need for safe, effective, and efficient surgery that maximizes patient outcomes while minimizing complications. Many variables contribute to visualization in shoulder arthroscopy including vascular anatomy, blood pressure control, arthroscopic pump systems, turbulence control, epinephrine, and tranexamic acid. Furthermore, patient positioning can have a dramatic effect on visualization with both the beach chair position and lateral decubitus positioning having various strengths and weaknesses depending on the intended procedure being performed. The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy.

Tourniquet-less arthroscopic anterior cruciate ligament reconstruction: a technical guide & narrative review of the evidence

Arthroscopic anterior cruciate ligament reconstruction (ACLR) is often performed with the use of a thigh tourniquet. Surgeons believe this helps improve visualisation and reduce operative time. However, tourniquet use has been associated with many complications including increased pain, neurovascular injury, venous thromboembolism, haematoma formation, and others. In this article, we describe a method allowing comparable arthroscopic visualisation to be achieved without the aid of a tourniquet for ACLR procedures. The literature evidence relating to this technique as well as tourniquet use for ACLR is also reviewed. Tourniquet-less ACLR can be achieved through the combined application of hypotensive anaesthesia, intravenous tranexamic acid, and use of adrenaline-supplemented irrigation fluid and local anaesthetic. Performing ACLR without a tourniquet avoids the risks associated with its use and reduces the severity of post-operative haemarthrosis which may contribute to the patient's pain and limit their ability to perform their rehabilitation exercises.

Fundamentals of Arthroscopy Fluid Management and Strategies to Safely Improve Visualization

Arthroscopy has become increasingly relevant to various subspecialties within the orthopaedic surgery. From a patient safety standpoint and surgical efficiency standpoint, it is critical to know the fundamental concepts of fluid management such as those related to the fluid, pressure, and flow. A satisfactory field of view during arthroscopy can be achieved with the use of gravity-dependent or automated fluid management systems. Fluid management parameters and their physiological impact on the patient should be continuously monitored to avoid morbidity or delayed recovery. Local and systemic complications can occur from careless use of techniques that improve visualization such as tourniquet, epinephrine-diluted irrigation, and controlled hypotensive anesthesia. The purpose of this article is to review the fundamental concepts of fluid management in arthroscopy and the techniques to safely improve arthroscopic visualization.

Effects of Temperature and Volume of Intraoperative Normal Saline Irrigation on Postoperative Pain, Swelling, and Serum Markers of Inflammation in Patients After Elective, Arthroscopic, Single-Bundle Surgical Reconstruction of the Anterior Cruciate Ligament: A Retrospective, Single-Center Study

BACKGROUND Arthroscopic single-bundle surgical reconstruction of the anterior cruciate ligament (ACL) is often performed electively after 3 weeks of mobilization therapy. The present single-center retrospective study aimed to investigate the effects of temperature and volume of intraoperative normal saline irrigation on postoperative pain and swelling and on serum markers of inflammation following elective, arthroscopic, single-bundle surgical reconstruction of the ACL. MATERIAL AND METHODS Clinical data from 716 patients with non-acute ACL injuries who met the criteria between March 2015 and May 2020 were retrospectively analyzed. The patients were broken into 5 groups, depending on the volume or temperature of intraoperative irrigation with normal saline. At specific times after surgery, pain, knee swelling, and skin temperature were assessed. Postoperative levels of serum C-reactive protein (CRP), interleukin (IL)-1, IL-6, and IL-10 also were measured. RESULTS Visual analog scale (VAS) scores for pain, rates of swelling, and skin temperature differed significantly among the 5 groups at all postoperative time points (P<0.001). The VAS scores(P=0.322) and ratings for swelling (P=0.245), and skin temperature (P=0.093) were not significantly different among the volume groups. There were no significant differences in the VAS scores (P=0.055), swelling ratings (P=0.570), or skin temperatures (P=0.321) among the groups that received irrigation with normal saline at different temperatures. There were no significant differences in postoperative serum levels of CRP, IL-1, IL-6, or IL-10 among the groups (P>0.05). CONCLUSIONS Irrigation with different volumes and temperatures of normal saline did not have a significant effect on postoperative pain, swelling, or serum markers of inflammation.

Accuracy of arthroscopic fluid pump systems in shoulder surgery: a comparison of 3 different pump systems

BACKGROUND

Extra-articular fluid extravasation is a known complication during shoulder arthroscopy. The risk and amount of extravasation to a large degree is dependent on the fluid pressure delivered to the surgical site. Accurate measurement, knowledge, and control of the pressure delivered is thus important to surgeons, anesthetists, and the patient. The purpose of this study was to compare the pressure measurement accuracy of 3 arthroscopic fluid pumps, with 2 of them having 2 different settings.

METHODS

Twenty-five patients (n = 5 per group) undergoing shoulder arthroscopy were selected. Three different arthroscopic fluid pumps (ConMed 24K, Stryker Crossflow, Arthrex Dual Wave) were tested in 5 different operational settings (Stryker, standard and dynamic mode; ConMed, with and without TIPS; Arthrex Dual Wave). In each operation, the set pump pressures and the subsequently delivered intra-articular surgical site fluid pressures were measured by a spinal needle connected to an anesthetic standard pressure transducer attached to the anesthetic machine. Independent measures of the surgical site pressures were obtained before multiple portals were created or extravasation had occurred. Measurements were taken at the beginning of surgery.

RESULTS

Measurements of the mean intra-articular pressure were found to not be significantly different from the set pressure for the ConMed 24K with TIPS (0.98 ± 0.02-fold) and Stryker Crossflow in standard mode (0.98 ± 0.02-fold). However, actual pressure was significantly greater than the set pressure for the ConMed 24K without TIPS (by 1.30 ± 0.13-fold), Stryker Crossflow in dynamic mode (by 1.82 ± 0.08-fold), and Arthrex Dual Wave (by 2.19 ± 0.06-fold).

CONCLUSION

Independently measured intra-articular pressure can be more than double the set pressure for some arthroscopic pumps. Measuring intra-articular pressure can thus aid in adjusting the set pressure. This could minimize the risk of intraoperative complications.

Carbon dioxide gas endoscopy of the deep gluteal space

The treatment of hip and pelvic pain associated with abnormalities of the deep gluteal space has evolved and increasingly involves endoscopic techniques with a saline expansion medium. This investigation presents a surgical technique utilizing carbon dioxide as the insufflation medium for deep gluteal space endoscopy in 17 cadaveric hips. This technique was successful in 94% (16/17) of the hips, allowing for visualization of the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, branch of the inferior gluteal artery crossing the sciatic nerve, piriformis muscle, hamstring tendon origin, and lesser trochanter. Our experience suggests that gas expansion presents several advantages over fluid expansion.

Fluid retention after shoulder arthroscopy: gravity flow vs. automated pump-a prospective randomized study

BACKGROUND

Soft tissue fluid retention due to irrigation is relatively common after shoulder arthroscopy. The objective of this study was to compare fluid retention of 2 irrigation systems of shoulder arthroscopy: gravity flow irrigation and automated pump.

METHODS

Patients undergoing shoulder arthroscopy were enrolled prospectively and randomized into 2 groups using gravity flow system (GFS) or automated pump system (APS) for irrigation. Net weight gain was the primary outcome measurement to determine periarticular fluid retention. Change in deltoid diameter and postoperative pain were also compared.

RESULTS

Forty-two patients were included in the study. There were no statistically significant differences between the GFS and APS groups regarding demographics, surgical procedures, duration of surgery, or the amount of irrigation fluid used. The APS group had greater weight gain per hour (1.46 ± 0.36 kg/h vs. 1.1 ± 0.38 kg/h) than the GFS group. A strong correlation was found between the amount of fluid used and the weight gain in both the GFS and APS groups. But a strong correlation between duration of surgery and weight gain was found in the APS group only. The APS group also had a greater mean deltoid diameter increase (3.33 ± 1.56 cm vs. 2.1 ± 1.44 cm) and a higher postoperative first-hour visual analog pain scale score (5.81 ± 2 vs. 3.62 ± 1.6).

CONCLUSION

APS causes more fluid retention than GFS in shoulder arthroscopy when used for equal duration in similar procedures. Use of APS, prolongation of surgery, and increased amounts of irrigation fluid increase weight gain as a result of fluid retention.

Extravasation of fluid in arthroscopic shoulder surgery requiring prolonged intubation: a case report

Background

Shoulder arthroscopy is a safe and effective procedure with a low complication rate. Although rare, there are potentially life-threatening risks such as fluid extravasation causing airway compromise.

Case presentation

We report the case of a 65-year-old female treated with an arthroscopic rotator cuff repair who had significant extravasation of arthroscopic fluid causing severe facial and neck swelling. Overnight intubation was required for respiratory monitoring until the edema had resolved enough to allow safe extubation.

Conclusion

This case highlights the risk factors and clinical course of a patient with airway compromise caused by extravasation of fluid during shoulder arthroscopy. Although shoulder arthroscopy is a safe procedure, surgeon familiarity with the risk factors for this complication and close monitoring can aid in its identification and allow for appropriate treatment.

Editorial Commentary: To Pump or Not to Pump? Gravity Versus Fluid Pumps for Shoulder and Knee Arthroscopy

Recent studies and our clinical experience have supported the safety and efficacy of various arthroscopic pumps for use in practice. Different pump designs are to be used in different ways. Although gravity flow can lead to constant low pressure in a cadaveric knee or shoulder, it may not provide optimal visualization or performance to best complete your surgical procedure. To take the best care of our patients, understanding basic fluid pump design and understanding what pump design resides in your operating room is important for all practicing arthroscopists.