Safety and efficacy of hyperosmolar irrigation solution in shoulder arthroscopy

Optimizing Visualization in Shoulder Arthroscopy: An Evidence-Based Guide

Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.

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.

Response of Articular Cartilage to Hyperosmolar Stress: Report of an Ex Vivo Injury Model

BACKGROUND

Physiological 0.9% saline is commonly used as an irrigation fluid in modern arthroscopy. There is a growing body of evidence that a hyperosmolar saline solution has chondroprotective effects, especially if iatrogenic injury occurs.

PURPOSE

To (1) corroborate the superiority of a hyperosmolar saline solution regarding chondrocyte survival after mechanical injury and (2) observe the modulatory response of articular cartilage to osmotic stress and injury.

STUDY DESIGN

Controlled laboratory study.

METHODS

Osteochondral explants were isolated from bovine stifle joints and exposed to either 0.9% saline (308 mOsm) or hyperosmolar saline (600 mOsm) and then damaged with a sharp dermatome blade to attain a confined full-thickness cartilage injury site, incubated in the same fluids for another 3 hours, and transferred to chondropermissive medium for further culture for 1 week. Chondrocyte survival was assessed by confocal imaging, while the cellular response was evaluated over 1 week by relative gene expression for apoptotic and inflammatory markers and mediator release into the medium.

RESULTS

The full-thickness cartilage cut resulted in a confined zone of cell death that mainly affected superficial zone chondrocytes. Injured samples that were exposed to hyperosmolar saline showed less expansion of cell death in both the axial (P < .007) and the coronal (P < .004) plane. There was no progression of cell death during the following week of culture. Histological assessment revealed an intact cartilage matrix and normal chondrocyte morphology. Inflammatory and proapoptotic genes were upregulated on the first days postexposure with a notable downregulation toward day 7. Mediator release into the medium was concentrated on day 3.

CONCLUSION

This in vitro cartilage injury model provides further evidence for the chondroprotective effect of a hyperosmolar saline irrigation fluid, as well as novel data on the capability of articular cartilage to quickly regain joint homeostasis after osmotic stress and injury.

CLINICAL RELEVANCE

Raising the osmolarity of an irrigating solution may be a simple and safe strategy to protect articular cartilage during arthroscopic surgery.

Osmolarity-Induced Altered Intracellular Molecular Crowding Drives Osteoarthritis Pathology

Osteoarthritis (OA) is a multifactorial degenerative joint disease of which the underlying mechanisms are yet to be fully understood. At the molecular level, multiple factors including altered signaling pathways, epigenetics, metabolic imbalance, extracellular matrix degradation, production of matrix metalloproteinases, and inflammatory cytokines, are known to play a detrimental role in OA. However, these factors do not initiate OA, but are mediators or consequences of the disease, while many other factors causing the etiology of OA are still unknown. Here, it is revealed that microenvironmental osmolarity can induce and reverse osteoarthritis-related behavior of chondrocytes via altered intracellular molecular crowding, which represents a previously unknown mechanism underlying OA pathophysiology. Decreased intracellular crowding is associated with increased sensitivity to proinflammatory triggers and decreased responsiveness to anabolic stimuli. OA-induced lowered intracellular molecular crowding could be renormalized via exposure to higher extracellular osmolarity such as those found in healthy joints, which reverse OA chondrocyte's sensitivity to catabolic stimuli as well as its glycolytic metabolism.

A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery

» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.

Prospective Randomized Controlled Clinical Trial Comparing Hyperosmolar Saline to Standard Isotonic Irrigation Fluid for Arthroscopic Knee Surgery: Initial Clinical Outcomes

Numerous in vitro studies suggest higher osmolarity irrigation fluids potentiate a chondroprotective environment, and a recent clinical study using hyperosmolar saline for shoulder arthroscopy reported potential clinical advantages. This prospective randomized double-blind controlled clinical trial was designed to assess initial clinical outcomes associated with use of a hyperosmolar irrigation solution in patients undergoing arthroscopic knee surgery. With institutional review board approval and informed consent, patients scheduled for arthroscopic knee surgery were randomized to surgery with either isotonic lactated Ringer's (273 mOsm/L) or hyperosmolar saline (593 mOsm/L) irrigation solution. Outcomes included perioperative blood pressure, knee girth, visual analogue scale (VAS) pain scores, and narcotic pain medication consumption. Forty-six patients underwent arthroscopic knee surgery with isotonic (n = 23) or hyperosmolar (n = 23) irrigation fluids. There were 11 males and 12 females (mean age = 44.0 years) in the isotonic cohort and 8 males and 15 females (mean age = 40.2 years) in the hyperosmolar cohort. There were no significant differences with respect to surgical duration (pump time) or amount of irrigation fluid used between the two cohorts. There were no significant differences with respect to change in knee girth, blood pressure, or VAS pain scores. However, patients treated with hyperosmolar saline consumed less narcotic medication on postoperative day 3 (4.0 ± 7.6 vs. 15.5 ± 17.4 mg, p = 0.01). The results of this randomized clinical trial suggest that a hyperosmolar irrigation solution is safe and relatively inexpensive for use in patients undergoing arthroscopic knee surgery and contributes to a reduction in initial postoperative narcotic pain medication consumption. A hyperosmolar saline irrigation fluid was not associated with any detrimental effects on the execution of the surgical procedure, postoperative pain, or periarticular fluid extravasation. Taken together with previous basic science, translational, and clinical studies, hyperosmolar saline irrigation fluid is promising alternative to traditional isotonic irrigation fluids for knee arthroscopy. This study is a prospective trial and reflects level of evidence I.

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

OBJECTIVE

To evaluate differences in pro-inflammatory and degradative mediator production from osteoarthritic knee articular cartilage explants treated with a hyperosmolar saline solution supplemented with anti-inflammatory components (l-glutamine, ascorbic acid, sodium pyruvate, epigallocatechin gallate [EGCG], and dexamethasone) or normal saline using an in vitro model for knee arthroscopy.

DESIGN

Full-thickness 6 mm articular cartilage explants (n = 12/patient) were created from femoral condyle and tibial plateau samples collected from patients who received knee arthroplasty. One explant half was treated for 3 hours with hyperosmolar saline (600 mOsm/L) supplemented with anti-inflammatory components and the corresponding half with normal saline (308 mOsm/L). Explants were cultured for 3 days and then collected for biomarker analyses. Media biomarker concentrations were normalized to the wet weight of the tissue (mg) and were analyzed by a paired t test with significance set at P < 0.05.

RESULTS

Cartilage was collected from 9 females and 2 males (mean age = 68 years). Concentrations of MCP-1 (P < 0.001), IL-8 (P = 0.03), GRO-α (P = 0.02), MMP-1 (P < 0.001), MMP-2 (P < 0.001), and MMP-3 (P < 0.001) were significantly lower in explant halves treated with the enhanced hyperosmolar solution. When considering only those cartilage explants in the top tercile of tissue metabolism, IL-6 (P = 0.005), IL-8 (P = 0.0001), MCP-1 (P < 0.001), GRO-α (P = 0.0003), MMP-1 (P < 0.001), MMP-2 (P < 0.001), MMP-3 (P < 0.001), and GAG expression (P = 0.0001) was significantly lower in cartilage explant halves treated with the enhanced hyperosmolar solution.

CONCLUSIONS

Treatment of cartilage explants with a hyperosmolar saline arthroscopic irrigation solution supplemented with anti-inflammatory components was associated with significant decreases in inflammatory and degradative mediator production and mitigation of proteoglycan loss.

Ex vivo study: is it possible to overcome the blurriness caused by holmium laser fragmentation of kidney stones?

Better endoscopic vision is mandatory for successful ureteroscopic stone operations to achieve shorter operating time. However, an important impairing factor for a good endoscopic view is the cloudiness of vision which was formed during laser fragmentation. Holmium laser fragmentation of calcium oxalate stones produces calcium carbonate solubility of which is dependent on pH, citrate, and phosphate. In this ex vivo research, the solubility of calcium carbonate has been investigated in solutions composed of various concentrations of citrate and phosphate buffered at different pH levels after laser fragmentation of calcium oxalate stones. Calcium oxalate stones were placed into the laboratory tubes filled with various concentrations of citrate-phosphate buffers with different pH values. Laser energy in dusting mode was applied to the stones and spectrophotometric measurement for optical density (OD) was calculated for each buffered solution for clarity comparison. In the first phase, solutions composed of four different molar concentrations of citrate-phosphate buffer (0.2, 0.3, 0.4 and 0.5 molars) at various pH levels were used. Then, the next phase of the study was designed to compare solutions demonstrating the lowest OD values with an isotonic saline solution. The results were most convenient at 0.5 molarity (pH = 6) followed by 0.4 molarity (pH = 7) in the first phase (OD values of 0.054 and 0.065, respectively). In the next phase, OD values of both buffered solutions were significantly lower than those of isotonic saline solution (p = 0). Two specific buffers have provided better optic visibility values after laser fragmentation supporting their use as an irrigation solution for the favor of less cloudiness.

The Safety and Efficacy of Using Drainage in Arthroscopic Rotator Cuff Repair

PURPOSE

This study aimed to evaluate the effects of not using a drain or placing a drain in the glenohumeral (GH) or subacromial (SA) joint spaces on fluid retention and pain in the early postoperative period and late clinical outcomes.

METHODS

Patients who underwent arthroscopic rotator cuff repair between 2018 and 2020 were included in the study. Before the operation, demographic data, range of motion (ROM), visual analog scale (VAS) scores, Constant-Murley scores has documented. Deltoid muscle diameter (DMD) were measured. The total amount of irrigation used during the surgery and the operation duration were recorded, and the active amount of fluid coming from the drain in patients with a drain was recorded. The first postoperative DMD measure was made in the operating room and accepted as day 0. DMD measurements repeated postoperative first and second day. VAS assessments were performed on the postoperative first and second days. At the outpatient clinic, these measurements were repeated on the first and second weeks after discharge. Functional evaluations were made with ROM and Constant-Murley scores at the final follow-up examination.

RESULTS

There was no difference in the amount of drainage between the two groups in which a drain was used. When the three groups were compared among themselves regarding preoperative and postoperative VAS scores, Constant-Murley scores, and DMD, no significant difference was found.

CONCLUSIONS

We do not recommend the routine use of drains after arthroscopic rotator cuff surgery in terms of cost-effectiveness.

LEVEL OF EVIDENCE

Level II: Prospective Cohort Study.

Editorial Commentary: Raising the Osmolarity of Arthroscopic Irrigating Solutions May Be Chondroprotective: We Must Be Kind to Joints During Arthroscopy!

The irrigation of joints during arthroscopic procedures typically uses a non-physiological solution. This replaces the natural synovial fluid and rapidly subjects the connective tissues to an alien hypo-osmotic environment in which cartilage cells are far more sensitive to iatrogenic injury. Raising the osmolarity of the irrigating solution may be a simple, safe, and effective chondroprotective strategy.

Use of a Hyperosmolar Saline Solution to Mitigate Proinflammatory and Degradative Responses of Articular Cartilage and Meniscus for Application to Arthroscopic Surgery

PURPOSE

This study was designed to evaluate differences in proinflammatory and degradative mediator production and extracellular matrix degradation from osteoarthritic knee articular cartilage and meniscus explants treated with either hyperosmolar saline or isotonic saline.

METHODS

6 mm-diameter full-thickness explants were created from articular cartilage and menisci recovered after patients underwent knee surgery. One explant half was treated for 3 hours with hyperosmolar saline (600 mOsm/L) and the corresponding half with isotonic saline (300 mOsm/L). Explants were subsequently cultured for 3 days in tissue culture media. On day 3, media were collected for biomarker analyses. Results were normalized to tissue wet weight and analyzed statistically.

RESULTS

Articular cartilage was collected from 10 patients (5 male, 5 female; mean age = 66.9 years) and menisci were collected from 8 patients (2 male, 6 female; mean age = 66 years). Articular cartilage media concentrations of monocyte chemoattractant protein-1 (P = .001) and interleukin (IL)-6 (P = .049) were significantly lower in explants treated with hyperosmolar saline. Meniscus media concentrations of prostaglandin E₂ (P = .008), monocyte chemoattractant protein-1 (P = .011), IL-6 (P = .029), IL-8 (P = .012), matrix metalloproteinase-2 (P = .011), and glycosaminoglycan (P = .008) were significantly lower in explants treated with hyperosmolar saline.

CONCLUSIONS

Treatment of cartilage and meniscus explants with hyperosmolar saline effectively mitigated key proinflammatory mediator production, as well as degradative mediator production and glycosaminoglycan loss from meniscus, with no detrimental effects noted compared to isotonic saline.

CLINICAL RELEVANCE

These results suggest that hyperosmolar saline irrigation fluid may provide a safe alternative to standard isotonic saline irrigation fluid, and could mitigate untoward effects associated with inflammatory responses after standard-of-care knee arthroscopy.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Damage control articular surgery: Maintaining chondrocyte health and minimising iatrogenic injury

Articular cartilage has limited intrinsic regenerative potential. The maintenance of healthy articular cartilage is essential to prevent joint degeneration and the morbidity associated with arthritis. In this review, we outline the structure and function of healthy articular cartilage. We summarise some of the recent literature outlining the influence of surgical factors on chondrocyte health. These factors include mechanical injury from instrumentation and drilling, drying, and the influence of irrigation fluids, antimicrobial solutions and local anaesthetics. We demonstrate that there is scope for improving cartilage viability at the time of surgery if simple chondroprotective measures are routinely adopted.

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.

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase-2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre-operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α-2-adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra-articular injection, and for surgical technique-linked interventions, such as platelet-rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Hyperosmolar Potassium (K+) Treatment Suppresses Osteoarthritic Chondrocyte Catabolic and Inflammatory Protein Production in a 3-Dimensional In Vitro Model

OBJECTIVE

The main goal of this study was to provide a proof-of-concept demonstrating that hyperosmolar K⁺ solutions can limit production of catabolic and inflammatory mediators in human osteoarthritic chondrocytes (OACs).

METHODS

A 3-dimensional in vitro model with poly(ethylene glycol) diacrylate (PEGDA) hydrogels was used. Catabolic and pro-inflammatory protein production from encapsulated OACs was assessed following culture for 1 or 7 days in the presence or absence of 80 mM K⁺ gluconate, 80 mM sodium (Na⁺) gluconate, or 160 mM sucrose, each added to culture media (final osmolarity ~490 mOsm).

RESULTS

Relative to untreated controls, OACs treated with hyperosmolar (80 mM Na⁺ gluconate or 160 mM sucrose) solutions produced lower levels of catabolic and inflammatory mediators in a marker- and time-dependent manner (i.e., MMP-9 after 1 day; MCP-1 after 7 days ( P ≤ 0.015)). In contrast, OAC treatment with 80 mM K⁺ gluconate reduced catabolic and inflammatory mediators to a greater extent (both the number of markers and degree of suppression) relative to untreated, Na⁺ gluconate, or sucrose controls (i.e., MMP-3, -9, -13, TIMP-1, MCP-1, and IL-8 after 1 day; MMP-1, -3, -9, -13, TIMP-1, MCP-1, and IL-8 after 7 days ( P ≤ 0.029).

CONCLUSIONS

Hyperosmolar K⁺ solutions are capable of attenuating protein production of catabolic and inflammatory OA markers, providing the proof-of-concept needed for further development of a K⁺-based intra-articular injection for OA treatment. Moreover, K⁺ performed significantly better than Na⁺- or sucrose-based solutions, supporting the application of K⁺ toward improving irrigation solutions for joint surgery.

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

Purpose

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.

Level of evidence

Level IV, Systematic review of Level IV studies.