Fluid Extravasation in Hip Arthroscopy: A Systematic Review

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

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.

Arthroscopic iliopsoas tenotomy after total hip arthroplasty: safe method for the right patient

PURPOSE

To evaluate the outcome of arthroscopic treatment for iliopsoas impingement after total hip arthroplasty (THA) 2 years after surgery using patient reported outcomes (PROM).

METHODS

In this study 12 patients (13 hips) were included from a local hip arthroscopy registry. Patients completed web-based PROMs preoperatively and at a minimum of 2 years postoperatively. The PROMs included the International Hip Outcome Tool short version (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analog Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery.

RESULTS

The mean age was 64.4 years (±15.1SD), mean body mass index (BMI) was 26.6 (±4.3SD), mean follow-up time was 49.8 months (±25SD). Comparing PROMs preoperatively with 2-year follow up showed an improvement for many of the PROMs used. The PROMs scores were iHOT-12 (24.9 vs 34.5, p = 0.13), HAGOS subscales (symptoms 38.2 vs 54.5, p = 0.05; pain 36 vs 53, p = 0.04; sport 14.1 vs 35.1, p = 0.03; daily activity 31 vs 47.5, p = 0.04; physical activity 21.8 vs 24, p = 0.76; quality of life 24 vs 35, p = 0.03), EQ-VAS (57.9 vs 58, p = 0.08), EQ-5D (0.34 vs 0.13, p = 0.07) and VAS for overall hip function (43.1 vs 46.2, p = 0.14). In total, 10 out of the 12 patients (83%) were satisfied with the intervention.

CONCLUSION

Patients undergoing surgery for iliopsoas impingement after previous THA showed improved self-reported hip function where most patients were satisfied with treatment.

Calculating Intraoperative Fluid Deficit to Prevent Abdominal Compartment Syndrome in Hip Arthroscopy

Abdominal compartment syndrome (ACS) is a rare but potentially fatal complication that can occur during hip arthroscopy. This usually occurs as a result of arthroscopic fluid passing into the retroperitoneal space through the psoas tunnel. From the retroperitoneal space, the fluid can then enter the intraperitoneal space through defects in the peritoneum. Previous studies have identified female sex, iliopsoas tenotomy, pump pressure, and operative time as potential risk factors for fluid extravasation. We present a method to measure intraoperative fluid deficit during hip arthroscopy to alert surgeons to possible ACS. Our proposed technique requires diligent intraoperative monitoring of fluid output through various suction devices, including suction canisters, puddle vacuums, and suction mats. The difference is then calculated from the fluid intake from the arthroscopic fluid bags. If the difference is greater than 1500 mL, then the anesthesiologist and circulating nurse are instructed to examine the abdomen for distension every 15 minutes. This, combined with other common symptoms such as hypotension and hypothermia, should alert the surgical team to the development of ACS. Despite limitations to this technique, this approach offers an objective method to calculate intra-abdominal fluid extravasation.

Feasibility Study to Determine if Microfracture Surgery Using Water Jet Drilling Is Potentially Safe for Talar Chondral Defects in a Caprine Model

OBJECTIVE

Surgical microfracture is considered a first-line treatment for talar osteochondral defects. However, current rigid awls and drills limit access to all locations in human joints and increase risk of heat necrosis of bone. Using a flexible water jet instrument to drill holes can improve the reachability of the defect without inducing thermal damage. The aim of this feasibility study is to determine whether water jet drilling is potentially safe compared with conventional microfracture awls by studying side effects and perioperative complications, as well as the quality of cartilage repair tissue.

DESIGN

Talar chondral defects with 6-mm diameter were created bilaterally in 6 goats (12 samples). One defect in each goat was treated with microfracture created with conventional awls, the contralateral defect was treated with holes created with 5-second water jet bursts at a pressure of 50 MPa. Postoperative complications were recorded and after 24 weeks analyses were performed using the ICRS (International Cartilage Repair Society) macroscopic score and modified O'Driscoll histological score.

RESULTS

Several practical issues using the water jet in the operating theatre were noted. Water jet drilling resulted in fibrocartilage repair tissue similar to the repair tissue from conventional awls.

CONCLUSIONS

These results suggest that water jet drilling gives adequate fibrocartilage repair tissue. Furthermore, the results highlight essential prerequisites for safe application of surgical water jet drilling: stable water pressure, water jet beam coherence, stable positioning of the nozzle head when jetting, and minimizing excessive fluid extravasation.

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.

Arthroscopic Debridement of Intrapelvic Abscess With Coexistent Septic Hip in an Adult Female: A Technical Note

The aim of this study was to describe the technique for debridement of an intrapelvic abscess through an arthroscopic approach. We present a 24-year-old female with an obturator internus muscle abscess that extended across the obturator membrane and into the hip joint. Decompression of the intrapelvic abscess through hip arthroscopy was planned after close examination of preoperative images. Intrapelvic space was safely accessed by hip arthroscopy. The patient was asymptomatic and had normalized biomarkers at 6 months; however, the abscess recurred at 1 year postoperation. Details of the technique for intrapelvic access and anatomic structures at risk are described in this study.

Intra-abdominal Fluid Extravasation: Is Endoscopic Deep Gluteal Space Exploration a Risk Factor?

Background

The extravasation of fluid into the intra-abdominal space is recognized as a possible complication of hip arthroscopic surgery/endoscopy. The exposure of anatomic areas to elevated pump pressures and high volumes of irrigation fluid increases the risk of fluid leakage into anatomic spaces around the hip joint, especially to the abdomen and pelvis.

Purpose

To estimate the incidence and risk factors related to intra-abdominal fluid extravasation (IAFE) after hip endoscopy or arthroscopic surgery.

Study Design

Cohort study; Level of evidence, 2.

Methods

A prospective study was carried out between June 2017 and June 2018. A total of 106 hip procedures (endoscopy or arthroscopic surgery) performed for extra- or intra-articular abnormalities were included. Before and after surgery, in the operating room, ultrasound was performed by a trained anesthesiologist to detect IAFE. The hepatorenal (Morison pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. Patients were monitored for 3 hours after surgery to assess for abdominal pain. The data collected included maximum pump pressure, duration and volume of irrigation fluid (Ringer lactate), total surgical time, and traction time.

Results

The incidence of IAFE was 31.1% (33/106; 95% CI, 23.1%-40.5%). The frequency of IAFE was 52.9% (9/17) in cases with isolated extra-articular abnormalities and 15.9% (7/44) in cases with isolated femoroacetabular impingement; in cases with both extra- and intra-articular abnormalities, the frequency was 37.8% (17/45). An intervention in the subgluteal space was identified as a risk factor for IAFE (odds ratio, 3.62 [95% CI, 1.47-8.85]). There was no statistically significant difference between groups (with vs without IAFE) regarding total surgical time, maximum pump pressure, or fluid volume. Postoperative abdominal pain was found in 36.4% (n = 12) of cases with IAFE compared with 2.7% (n = 2) of cases without extravasation (P < .001). No patient with IAFE developed abdominal compartment syndrome.

Conclusion

IAFE was a frequent finding after hip arthroscopic surgery/endoscopy in patients with extra-articular abnormalities. Exploration of the subgluteal space may increase the risk of IAFE. Pain and abdominal distension during the immediate postoperative period were early warning signs for IAFE. These results reinforce the need for careful intraoperative and postoperative monitoring by the surgeon and anesthesiologist to identify and avoid complications related to IAFE.

Intra-abdominal Pressure Changes During Hip Arthroscopy: A Prospective Multicenter Study

PURPOSE

To evaluate intra-abdominal pressure changes during hip arthroscopy and define its relationship with other patient related variables.

METHODS

A prospective multicenter study evaluating intra-abdominal pressure (IAP) in patients undergoing arthroscopic treatment of femoroacetabular impingement was performed. The IAP was measured indirectly by a bladder catheter (AbViser Autovalve Intra-abdominal pressure monitor) and documented every 30 minutes during the entire procedure. The following risk factors were analyzed: traction time, duration surgery, previous abdominal surgery, capsule repair, psoas tenotomy, and surgical approach.

RESULTS

One hundred and five patients with symptomatic femoroacetabular impingement that underwent hip arthroscopy met the inclusion criteria. There were significant differences in the IAP between the preoperative measurement of IAP and the IAP at different time points during surgery (P < .01). The IAP increased continuously from the commencement of surgery (considered as time point from portal establishment) until the first 60 minutes. After first 60 minutes of surgery, the IAP did not increase significantly. There were no significant associations between increased IAP and the risk factors analyzed.

CONCLUSIONS

IAP increases significantly during the first 60 minutes of hip arthroscopy; it then stabilizes for the duration of surgery before decreasing just after the completion of surgery. The highest recorded IAP was not associated with additional complications. No symptomatic intra-abdominal hypertension was documented. Finally, patient- and procedure-specific risk factors did not predict changes in IAP. Systemic monitoring of IAP during the hip arthroscopy procedure can easily and effectively be done, allowing the surgeon to early detect any significant change.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A Systematic Summary of Systematic Reviews on the Topic of Hip Arthroscopic Surgery

BACKGROUND

There is a rapidly growing body of literature on the topic of hip arthroscopic surgery.

PURPOSE

To provide an overall summary of systematic reviews published on the indications, complications, techniques, outcomes, and information related to hip arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all hip arthroscopic surgery-related systematic reviews published between January 2000 and May 2018 was performed using PubMed, MEDLINE, and the Cochrane Library. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 837 articles were found, of which 85 met the inclusion criteria. Included articles were summarized and divided into 6 major categories based on the subject of the review: femoroacetabular impingement (FAI), non-FAI indications, surgical technique, outcomes, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on hip arthroscopic surgery can provide surgeons with a single source for the most current synopsis of the available literature. As the prevalence of orthopaedic surgeons performing hip arthroscopic surgery increases, updated evidence-based guidelines must likewise be advanced and understood to ensure optimal patient management.

Modified Shelf Acetabuloplasty Endoscopic Procedure With Allograft for Developmental Hip Dysplasia Treatment

Hip dysplasia has been identified as one of the leading causes of osteoarthritis. However, hip arthroscopy alone, in the setting of hip dysplasia, remains controversial. In borderline hip dysplasia, with lateral center-edge angle (LCEA) between 18° and 25°, good outcomes have been reported with appropriate capsular and labral management. However, in severe hip dysplasia, with LCEA below 18°, there is an acetabular bony structural deficiency that must be addressed. Even with the potential benefit of hip arthroscopy in addressing intra-articular injuries related to the instability, it cannot be used for soft-tissue procedures. Periacetabular osteotomy remains the gold standard to address that matter; however, its invasive nature along with the long recovery time leaves some patients unwilling to undergo this procedure. New minimally invasive endoscopic procedures, derived from open techniques, describe acetabular autologous bone grafting as an alternative. Donor-side morbidity is always a concern when using autografts; we believe that the use of bone allograft will decrease this potential issue and make the procedure itself less invasive. This Technical Note will describe a type of endoscopic shelf acetabuloplasty using an allograft iliac bone graft.

Editorial Commentary: Caveat Flexor-To Release or Not to Release the Iliopsoas, That Is the Question

In nonarthritic patients with femoroacetabular impingement syndrome, borderline dysplasia, and symptomatic iliopsoas snapping, arthroscopic iliopsoas fractional lengthening carries a significant risk of postarthroscopic instability. The iliopsoas is a dynamic stabilizer of the anterior hip. Thus, although statistically significant and clinically important improvements in hip function have the potential to be achieved with iliopsoas fractional lengthening, surgeons must be supremely confident in their ability to perform a secure capsular plication, labral preservation (not debridement), comprehensive cam correction, avoidance of intra-abdominal fluid extravasation, release of all iliopsoas tendon bands (if bifid or trifid), and ensure that femoral version is normal or low, neck-shaft angle is not excessively valgus, the dysplasia magnitude is no more than mild, and that there is no excessive soft tissue hypermobility. If these goals can be met, then excellent outcomes can be achieved. If not, then an iliopsoas fractional lengthening should not be performed.

Hip arthroscopy for femoroacetabular impingement

The purpose of this article is to give a general overview of femoroacetabular impingement (FAI) and how it could be treated arthroscopically, with some details about indications, the procedure itself and some of the complications associated with the surgery.

FAI is a dynamic condition of the hip that can be a source of pain and disability and could potentially lead to arthritis.

When symptomatic, and if conservative treatment fails, FAI can be addressed surgically.

The goal of surgical treatment for FAI is to recreate the spherical contour of the femoral head, improve femoral offset, normalize coverage of the acetabulum, repair/reconstruct chondral damage and repair/reconstruct the labrum to restore normal mechanics and joint sealing.

Advances in equipment and technique have contributed to an increase in the number of hip arthroscopy procedures performed worldwide and have made it one of the more common treatment options for symptomatic FAI.

Hip arthroscopy is a procedure with an extremely steep and long learning curve.

Cite this article: EFORT Open Rev 2018;3:121-129. DOI: 10.1302/2058-5241.3.170041

Arthroscopy After Traumatic Hip Dislocation: A Systematic Review of Intra-articular Findings, Correlation With Magnetic Resonance Imaging and Computed Tomography, Treatments, and Outcomes

PURPOSE

To describe the literature concerning patient demographic characteristics and intra-articular injury seen at arthroscopy after traumatic hip dislocation, describe the reported computed tomography (CT) and magnetic resonance findings with arthroscopic correlation, and describe the reported arthroscopic treatments performed with complications and outcomes.

METHODS

A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for assessment of arthroscopy after hip dislocation. Three databases were searched, and study screening and data abstraction were performed in duplicate.

RESULTS

Thirty-one heterogeneous case series and case reports were included in the analysis from the initial search yielding 780 results, including reports of 151 patients who underwent arthroscopy after traumatic hip dislocation. A wide spectrum of intra-articular injury was reported, with a high prevalence of labral tears, intra-articular bodies, ligamentum teres injuries, and chondral damage. CT had a sensitivity of 87.3% for detecting intra-articular fragments; however, 43.3% of patients who had a preoperative CT scan with negative findings for intra-articular fragments did show fragments at arthroscopy. Magnetic resonance had a sensitivity of 95.0% for detecting labral tears. There were no major complications directly attributed to arthroscopic surgery. A total of 75 of 151 patients were followed up for a median of 2 years after surgery, with osteoarthritis reported in 4.0% and avascular necrosis in 2.7%.

CONCLUSIONS

In patients with traumatic hip dislocation, heterogeneously reported previously published cases show that arthroscopy reveals a broad spectrum of intra-articular damage amenable to arthroscopic intervention. CT is not sensitive in the detection of intra-articular bodies in all cases. Although no serious periprocedural adverse events were reported, only 49.7% of patients had reported follow-up data, and further prospective studies would be necessary to show the safety and efficacy of arthroscopy in comparison with conventional treatment algorithms of hip dislocation.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Editorial Commentary: Safe Innovation? Arthroscopy After Traumatic Hip Dislocation

Hip arthroscopy can be helpful relative to conventional imaging when diagnosing (and treating) intra-articular injuries after a hip dislocation, but more evidence is required before adopting this approach diagnostic and therapeutic strategy.

Warming of Irrigation Fluids for Prevention of Perioperative Hypothermia During Arthroscopy: A Systematic Review and Meta-analysis

PURPOSE

To determine whether warming of irrigation fluids (32°C-40°C) compared with using room-temperature irrigation fluids (20°C-22°C) decreases the risk of perioperative hypothermia (<36°C) for patients undergoing shoulder, hip, or knee arthroscopy.

METHODS

One reviewer, with the assistance of a medical librarian, searched the following databases: PubMed, Embase, Cochrane Central, SPORTDiscus, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Level I and II studies involving shoulder, hip, or knee arthroscopy were included. Two reviewers screened the abstracts and titles. Two reviewers assessed the risk of bias of selected studies using The Cochrane Collaboration tool. Meta-analyses were conducted on the following outcomes: hypothermia, lowest temperature, maximum temperature drop, and shivering.

RESULTS

Seven studies of patients undergoing arthroscopy were included in the qualitative synthesis (5 shoulder studies, 1 hip study, and 1 knee study; 501 patients). The study involving knee arthroscopy was excluded from the meta-analyses because of insufficient data and high clinical heterogeneity (surgical site distal to the core, not involving extravasation of large amounts of fluid). The remaining 6 studies were included in 1 or more meta-analyses: hypothermia (5 shoulder and 1 hip study), lowest temperature (3 shoulder and 1 hip study), maximum temperature drop (2 shoulder and 1 hip study), and shivering (5 shoulder and 1 hip study). Warming of irrigation fluids for shoulder or hip arthroscopy significantly decreased the risk of hypothermia (odds ratio, 0.15; 95% confidence interval [CI], 0.06-0.40; P = .0001), increased the lowest mean temperature (mean difference, 0.46°C; 95% CI, 0.11°C-0.81°C; P = .01), decreased the maximum temperature drop (mean difference, -0.64°C; 95% CI, -0.94°C to -0.35°C; P < .0001), and decreased the risk of shivering (odds ratio, 0.25; 95% CI, 0.07-0.86; P = .03).

CONCLUSIONS

When irrigation fluids are warmed for shoulder and hip arthroscopy, the risk of hypothermia is less, the drop in intraoperative temperature is less, the lowest body temperature is higher, and the risk of postoperative shivering is reduced.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Do Arthroscopic Fluid Pumps Display True Surgical Site Pressure During Hip Arthroscopy?

PURPOSE

To report on the accuracy of 5 commercially available arthroscopic fluid pumps to measure fluid pressure at the surgical site during hip arthroscopy.

METHODS

Patients undergoing hip arthroscopy for femoroacetabular impingement were block randomized to the use of 1 of 5 arthroscopic fluid pumps. A spinal needle inserted into the operative field was used to measure surgical site pressure. Displayed pump pressures and surgical site pressures were recorded at 30-second intervals for the duration of the case. Mean differences between displayed pump pressures and surgical site pressures were obtained for each pump group.

RESULTS

Of the 5 pumps studied, 3 (Crossflow, 24K, and Continuous Wave III) reflected the operative field fluid pressure within 11 mm Hg of the pressure readout. In contrast, 2 of the 5 pumps (Double Pump RF and FMS/DUO+) showed a difference of greater than 59 mm Hg between the operative field fluid pressure and the pressure readout.

CONCLUSIONS

Joint-calibrated pumps more closely reflect true surgical site pressure than gravity-equivalent pumps. With a basic understanding of pump design, either type of pump can be used safely and efficiently. The risk of unfamiliarity with these differences is, on one end, the possibility of pump underperformance and, on the other, potentially dangerously high operating pressures.

LEVEL OF EVIDENCE

Level II, prospective block-randomized study.

Editorial Commentary: Fluid Extravasation in Hip Arthroscopy-A Tough Case Just Got Much Worse

Hip arthroscopy has its complications like any other surgery, but abdominal compartment syndrome is unique to the hip and is a complication with devastating consequences. Avoidance is the rule.