J Knee Surg
DOI: 10.1055/a-2198-8131
Original Article

Making the Case for Hyperosmolar Saline Arthroscopic Irrigation Fluids: A Systematic Review of Basic Science, Translational, and Clinical Evidence

Lasun O. Oladeji
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
2   Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
,
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
2   Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
,
Keiichi Kuroki
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
2   Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
,
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
2   Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
,
1   Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
2   Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
› Author Affiliations

Abstract

Commonly used isotonic arthroscopic irrigation fluids, such as normal saline or lactated Ringer's, were initially formulated for intravenous administration so they do not replicate the physiologic properties of healthy synovial fluid. Synovial fluid plays an important role in regulating joint homeostasis such that even transient disruptions in its composition and physiology can be detrimental. Previous studies suggest that hyperosmolar solutions may be a promising alternative to traditional isotonic fluids. This manuscript sought to systematically review and synthesize previously published basic science, translational, and clinical studies on the use of hyperosmolar arthroscopic irrigation fluids to delineate the optimal fluid for clinical use. A systematic literature search of MEDLINE/PubMed and Embase databases was performed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) guidelines. The search phrases were: (“cartilage” AND “hyperosmolar”); (“arthroscopy” OR “arthroscopic” AND “hyperosmolar”). The titles, abstracts, and full texts were screened for studies on hyperosmolar solutions and articular cartilage. Study quality was assessed, and relevant data were collected. A meta-analysis was not performed due to study heterogeneity. A risk of bias assessment was performed on the included translational and clinical studies. There were 10 basic science studies, 2 studies performed in translational animal models, and 2 clinical studies included in this review. Of the basic science studies, 7 utilized a mechanical injury model. The translational studies were carried out in the canine shoulder and equine stifle (knee) joint. Clinical studies were performed in the shoulder and knee. Multiple basic science, translational, and clinical studies highlight the short-term safety, cost-effectiveness, and potential benefits associated with use of hyperosmolar solutions for arthroscopic irrigation. Further work is needed to develop and validate the ideal formulation for a hyperosmolar irrigation solution with proven long-term benefits for patients undergoing arthroscopic surgeries.



Publication History

Received: 08 September 2023

Accepted: 24 October 2023

Accepted Manuscript online:
25 October 2023

Article published online:
22 November 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Molina CS, Thakore RV, Blumer A, Obremskey WT, Sethi MK. Use of the national surgical quality improvement program in orthopaedic surgery. Clin Orthop Relat Res 2015; 473 (05) 1574-1581
  • 2 Shah NV, Solow M, Kelly JJ. et al. Demographics and rates of surgical arthroscopy and postoperative rehabilitative preferences of arthroscopists from the Arthroscopy Association of North America (AANA). J Orthop 2018; 15 (02) 591-595
  • 3 Durrant LA, Archer CW, Benjamin M, Ralphs JR. Organisation of the chondrocyte cytoskeleton and its response to changing mechanical conditions in organ culture. J Anat 1999; 194 (Pt 3): 343-353
  • 4 Sardana V, Burzynski J, Scuderi GR. The influence of the irrigating solution on articular cartilage in arthroscopic surgery: a systematic review. J Orthop 2019; 16 (02) 158-165
  • 5 Teeple E, Karamchedu NP, Larson KM. et al. Arthroscopic irrigation of the bovine stifle joint increases cartilage surface friction and decreases superficial zone lubricin. J Biomech 2016; 49 (13) 3106-3110
  • 6 Amin AK, Huntley JS, Bush PG, Simpson AHRW, Hall AC. Osmolarity influences chondrocyte death in wounded articular cartilage. J Bone Joint Surg Am 2008; 90 (07) 1531-1542
  • 7 Bush PG, Hall AC. The osmotic sensitivity of isolated and in situ bovine articular chondrocytes. J Orthop Res 2001; 19 (05) 768-778
  • 8 Harris JD, Brand JC, Rossi MJ, Leland JM, Lubowitz JH. Iatrogenic arthroscopic cartilage injury: arthroscrapes result from iatrogenesis imperfecta. Arthroscopy 2020; 36 (08) 2041-2042
  • 9 Amin AK, Simpson AHRW, Hall AC. Iatrogenic articular cartilage injury: the elephant in the operating theatre: the surgeons' role in chondroprotection. Bone Joint J 2017; 99-B (12) 1555-1556
  • 10 Compton J, Slattery M, Coleman M, Westermann R. Iatrogenic articular cartilage injury in arthroscopic hip and knee videos and the potential for cartilage cell death when simulated in a bovine model. Arthroscopy 2020; 36 (08) 2114-2121
  • 11 Vega J, Golanó P, Peña F. Iatrogenic articular cartilage injuries during ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2016; 24 (04) 1304-1310
  • 12 Stafford GH, Malviya A, Villar RN. Fluid extravasation during hip arthroscopy. Hip Int 2011; 21 (06) 740-743
  • 13 Gupta S, Manjuladevi M, Vasudeva Upadhyaya KS, Kutappa AM, Amaravathi R, Arpana J. Effects of irrigation fluid in shoulder arthroscopy. Indian J Anaesth 2016; 60 (03) 194-198
  • 14 Khan F, Padmanabha S, Shantaram M, Aravind M. Airway compromise due to irrigation fluid extravasation following shoulder arthroscopy. J Anaesthesiol Clin Pharmacol 2013; 29 (04) 578-579
  • 15 Abutalib RA, Alamri AJ, Aqel SA, Alhumaidi IM, Almohini IA. Acute respiratory distress and hyperchloremic metabolic acidosis as a result of massive irrigation fluid extravasation after arthroscopic shoulder surgery: a case report and recommendations for preventable complications. Am J Case Rep 2020; 21: e926357
  • 16 Memon M, Kay J, Gholami A, Simunovic N, Ayeni OR. Fluid extravasation in shoulder arthroscopic surgery: a systematic review. Orthop J Sports Med 2018; 6 (05) 2325967118771616
  • 17 Ekhtiari S, Haldane CE, de Sa D, Simunovic N, Ayeni OR. Fluid extravasation in hip arthroscopy: a systematic review. Arthroscopy 2017; 33 (04) 873-880
  • 18 Aguilera-Bohórquez B, Cantor E, Ramos-Cardozo O, Pachón-Vásquez M. Intraoperative monitoring and intra-abdominal fluid extravasation during hip arthroscopy. Arthroscopy 2020; 36 (01) 139-147
  • 19 Verma M, Sekiya JK. Intrathoracic fluid extravasation after hip arthroscopy. Arthroscopy 2010; 26 (9, Suppl) S90-S94
  • 20 Farhan-Alanie MMH, Hall AC. Temperature changes and chondrocyte death during drilling in a bovine cartilage model and chondroprotection by modified irrigation solutions. Int Orthop 2014; 38 (11) 2407-2412
  • 21 Amin AK, Huntley JS, Patton JT, Brenkel IJ, Simpson AHRW, Hall AC. Hyperosmolarity protects chondrocytes from mechanical injury in human articular cartilage: an experimental report. J Bone Joint Surg Br 2011; 93 (02) 277-284
  • 22 Eltawil NM, Howie SEM, Simpson AHRW, Amin AK, Hall AC. The use of hyperosmotic saline for chondroprotection: implications for orthopaedic surgery and cartilage repair. Osteoarthritis Cartilage 2015; 23 (03) 469-477
  • 23 Amin AK, Huntley JS, Simpson AHRW, Hall AC. Increasing the osmolarity of joint irrigation solutions may avoid injury to cartilage: a pilot study. Clin Orthop Relat Res 2010; 468 (03) 875-884
  • 24 Eltawil NM, Ahmed S, Chan LH, Simpson AHRW, Hall AC. Chondroprotection in models of cartilage injury by raising the temperature and osmolarity of irrigation solutions. Cartilage 2018; 9 (03) 313-320
  • 25 Lin Y, Zhou C, Liu Z. et al. Room temperature versus warm irrigation fluid used for patients undergoing arthroscopic shoulder surgery: a systematic review and meta analysis. J Perianesth Nurs 2020; 35 (01) 48-53
  • 26 Pan X, Ye L, Liu Z, Wen H, Hu Y, Xu X. Effect of irrigation fluid temperature on core body temperature and inflammatory response during arthroscopic shoulder surgery. Arch Orthop Trauma Surg 2015; 135 (08) 1131-1139
  • 27 Capito NM, Cook JL, Yahuaca B, Capito MD, Sherman SL, Smith MJ. Safety and efficacy of hyperosmolar irrigation solution in shoulder arthroscopy. J Shoulder Elbow Surg 2017; 26 (05) 745-751
  • 28 Capito NM, Smith MJ, Stoker AM, Werner N, Cook JL. Hyperosmolar irrigation compared with a standard solution in a canine shoulder arthroscopy model. J Shoulder Elbow Surg 2015; 24 (08) 1243-1248
  • 29 Oladeji LO, Stoker AM, Stannard JP, Cook JL. Use of a hyperosmolar saline solution to mitigate proinflammatory and degradative responses of articular cartilage and meniscus for application to arthroscopic surgery. Arthroscopy 2020; 36 (12) 3050-3057
  • 30 Oladeji LO, Stannard JP, Smith MJ. et al. Prospective randomized controlled clinical trial comparing hyperosmolar saline to standard isotonic irrigation fluid for arthroscopic knee surgery: initial clinical outcomes. J Knee Surg 2023; 36 (10) 1087-1094
  • 31 Oladeji LO, Stoker AM, Stannard JP, Cook JL. 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. Cartilage 2021; 13 (2_suppl): 1646S-1653S
  • 32 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
  • 33 Jadad AR, Moore RA, Carroll D. et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996; 17 (01) 1-12
  • 34 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
  • 35 Hooijmans CR, Rovers MM, de Vries RBM, Leenaars M, Ritskes-Hoitinga M, Langendam MW. SYRCLE's risk of bias tool for animal studies. BMC Med Res Methodol 2014; 14: 43
  • 36 Arabiyat AS, Chen H, Erndt-Marino J. et al. Hyperosmolar ionic solutions modulate inflammatory phenotype and sGAG loss in a cartilage explant model. Cartilage 2021; 13 (2_suppl): 713S-721S
  • 37 Bush PG, Hodkinson PD, Hamilton GL, Hall AC. Viability and volume of in situ bovine articular chondrocytes-changes following a single impact and effects of medium osmolarity. Osteoarthritis Cartilage 2005; 13 (01) 54-65
  • 38 Huang Y, Zhang Y, Ding X, Liu S, Sun T. Osmolarity influences chondrocyte repair after injury in human articular cartilage. J Orthop Surg Res 2015; 10: 19
  • 39 Hayden LR, Stoker AM, Johnson PJ, McCracken MJ. The use of a hyperosmolar irrigation solution is safe in an equine stifle joint model but does not reduce joint swelling. Am J Vet Res 2022; 83 (10) ajvr.22.04.0074
  • 40 Karim A, Hall AC. Hyperosmolarity normalises serum-induced changes to chondrocyte properties in a model of cartilage injury. Eur Cell Mater 2016; 31: 205-220
  • 41 Bush PG, Hall AC. Regulatory volume decrease (RVD) by isolated and in situ bovine articular chondrocytes. J Cell Physiol 2001; 187 (03) 304-314
  • 42 Bush PG, Hall AC. The volume and morphology of chondrocytes within non-degenerate and degenerate human articular cartilage. Osteoarthritis Cartilage 2003; 11 (04) 242-251
  • 43 Haupt U, Völkle D, Waldherr C, Beck M. Intra- and retroperitoneal irrigation liquid after arthroscopy of the hip joint. Arthroscopy 2008; 24 (08) 966-968
  • 44 Zhuang C, Yang R, Xu Y. et al. The safety assessment of irrigation fluid management for shoulder arthroscopy and its effect on postoperative efficacy. Orthop Surg 2023; 15 (08) 2016-2024