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Correspondence should be addressed to: Brett
rthroscopic procedures are as- potentially faster recovery.1 With any sur- D. Owens, MD, Brown University Alpert Medi-
sociated with smaller incisions, gery, exposure is critical. In arthroscopy, cal School, 100 Butler Dr, Providence, RI 02906
(owensbrett@gmail.com).
less structural damage, improved maintaining adequate exposure through-
Received: August 27, 2015; Accepted: Octo-
intra-articular visualization, less pain in out the procedure requires an optical sys- ber 19, 2015.
the immediate postoperative period, and tem and good joint distension by a system doi: 10.3928/01477447-20160427-01
Over the years, the use of arthroscopy has Basic Science pump system believe they generate better
progressed to include the knee, shoulder, Pressure visualization and clearing of joint debris
hip, wrist, elbow, and ankle. Orthopedic Forty years ago, little was known re- during arthroscopy.10,11,14
surgeons commonly perform arthroscopy garding intra-articular pressure during
procedures, and it is important to under- arthroscopy. Questions regarding minimal Flow
stand the equipment that is used. pressure required for good visualization, Flow through a tube follows Poi-
pressure necessary to rupture the synovi- seuille’s law:
History um, pressure changes caused by position- Flow=(Pressure gradient)/(Resistance
The earliest reference for exploration ing, and even average pressures attained to flow).
of body cavities using arthroscopy was by the gravity flow method remained un- A gravity-fed system is related to the
found in the ancient Hebrew literature. answered. height difference between the fluid res-
More recently, in the 19th century, the In 1977, Gillquist et al9 first reported ervoir and the joint (ie, raising the inflow
development of endoscopic devices was that a threshold pressure of 28 mm Hg bag and not the amount of fluid in the
spurred by the desire to explore the blad- was necessary for good visualization bag). Also, with a gravity system in which
der.3 The first use in orthopedic surgery during arthroscopy of the knee. Ewing outflow is closed, flow will occur until
occurred in 1918 when Dr Kenji Takagi et al10 corroborated this finding in 1986 the joint is distended to an intra-articular
described endoscopy of a cadaver knee and reported that 30 mm Hg was the aver- pressure equal to the inflow pressure gra-
joint using a Charrier number 22 cysto- age threshold pressure required to cause dient, at which time, flow will cease.
scope.4 He later modified his instrumenta- tamponade of small intra-articular ves- Regardless of whether inflow comes
tion to develop the first joint arthroscope. sels. They also stated that a pressure of 70 from a gravity or pump system, intra-
Arthroscopy of the knee gained worldwide mm Hg was necessary for consistent and articular flow requires that fluid must come
attention in 1958 when it was introduced sustained capsular distention. into and out of the joint at 2 separate points
at the Internal Society of Orthopaedic Sur- In 1986, Bergstrom and Gillquist11 (inflow-outflow system). The primary
gery and Traumatology conference. With performed a study on 45 knee arthrosco- need for fluid flow is to clear the joint of
the advancement of arthroscopy, it quick- pies using a mechanical pump with open cloudy fluid caused by blood or debris to
ly became apparent synovial fluid was not outflow and flow rates of 45 cc per minute. allow improved visualization. When good
the preferred medium for visualization. They reported good visualization for all of visualization is achieved, there is no need
Saline rapidly became the standard to re- the procedures with intra-articular pres- for continuous flow. If flow rates become
place synovial fluid to enhance visualiza- sures ranging between 40 and 60 mm Hg exceedingly high, turbulence is created,
tion of key structures and pathology.5-7 and noted that pressure never rose above which can interfere with visualization.
Pump systems used for arthroscopic 60 mm Hg. In 1992, Arangio and Kostel- Conversely, there are times when flow may
surgery have evolved over the years to nik12 investigated the minimum adequate be a hindrance, such as during loose body
provide improved visualization.8 Gravity pressure required for arthroscopic proce- removal or when performing microfracture
flow systems were used first and are still dures of the knee. Their results showed and checking for backbleeding.
commonly used, followed by automated that with an average pressure of 55 If the rate of fluid outflow exceeds the
pump systems. Gravity flow systems mm Hg, arthroscopy could be performed capacity of the inflow system, a negative
simply use gravity to control inflow by in all knee positions studied and that pres- fluid balance exists, which leads to loss
positioning a bag of fluid higher than the sure required for adequate joint distention of joint distention and loss of visibility.
joint to provide enough pressure for insuf- ranged from 30 to 60 mm Hg.13 This situation commonly occurs with
flation. The development and use of an As technology advances, the pressure outflow through a motorized suction
automated pump for arthroscopy began in gradient of an inflow system produced by shaver where outflow occurs by a nega-
Sweden in the 1970s. Currently, there are an automated pump is totally controlled tive pressure suction line attached to the
2 basic types of automated pump systems. by the pump and is not dependent on the shaver. Use of a mechanical pump in this
The first type is a pressure-control pump, fluid reservoir height, volume, or gravity. setting can increase flow rates propor-
which controls pressure via inflow only. Automated pumps have the capability of tional to the outflow to a point where a
More recent automated pump systems producing predictable continuous flow fluid balance exists, thus avoiding loss of
maintain pressure by controlling inflow rates with an open system. In addition, joint distention. With a gravity-fed sys-
and outflow independently, thus termed they are able to generate intra-articular tem, this problem may be circumvented
pressure and flow control pumps or dual pressures that exceed those possible with by intermittently clamping the suction
systems. gravity inflow systems. Advocates of the line to the shaver, thus giving inflow time
afforded to the surgeon during the proce- procedures. Visualization and technical ing an 8-month period. During the first
dure while maintaining patient safety. Vi- ease were assessed subjectively via obser- 4 months, a pressure-driven pump was
sualization stems from a combination of vations of the video monitor and given a used, and during the second 4 months, a
camera image quality and maintaining a score based on the amount of impairment pressure and flow control pump was used.
clear fluid medium. The irrigation system of visualization. They concluded that the Fifty-eight ACL reconstructions were per-
controls the fluid medium environment by adequacy of visualization and technical formed; 21 procedures were performed
regulating fluid volume used via inflow ease significantly improved with the pres- using the pressure-control system, and
and outflow and the intra-articular vs set sure and flow control system compared 23 procedures were performed using the
pressure. Patient safety relies on maintain- with the pressure system alone. They also dual system. Average operative time using
ing low intra-articular pressures and low compared surgical times for the 2 pumps the pressure-control pump was 126 min-
levels of fluid extravasation.17 based on the duration of the surgery. They utes vs 111 minutes for the dual system.
The advantages to using a gravity flow reported an increased number of surger- There was an average 15-minute decrease
system are the ease of setup and main- ies less than 1 hour using the pressure and in surgical time (P=.04) in favor of the
tenance as well as a low complication flow control units and concluded that the dual system. The authors concluded this
profile since the pressure rarely reaches increased number of shorter duration sur- was likely due to the improved visualiza-
dangerous levels. Gravity flow systems geries was due to improved visualization. tion provided by the independent control
have been used in Sweden for approxi- Ampat et al19 prospectively compared of pressure and flow.
mately 14 years without significant com- these 2 types of pump systems (Aquaflo2
plications.9,11 The drawback associated pump vs Fluid Management System [FMS; Complications
with using a gravity-fed system is that it DePuy, Mitek, Raynham, Massachusetts]) Automated pressure-sensitive pumps
requires manual adjustments throughout for shoulder arthroscopic surgery based on monitor intra-articular pressure and au-
the case to change the amount of inflow visual clarity, presence of bleeding vessels, tomatically shut down if preset pressure
and outflow necessary for good visualiza- and total red blood cell loss for subacromial levels are not maintained. In normal op-
tion. This can be troublesome for long decompressions of 20 shoulders. The sur- eration, they automatically maintain flow
cases, especially if the tourniquet cannot geon assessed the visual clarity and pres- and pressure independent of one another
be used. ence of bleeding vessels subjectively. Total to maintain joint distention and improve
Ewing et al10 stated that an ideal au- red blood cell loss was determined by mul- irrigation.13 However, if the pressure sen-
tomated pump should deliver necessary tiplying the volume of fluid that was used sor fails, automated pumps may not shut
flow rates, keep the intra-articular pres- and the cell count in the effluent. There down, and intra-articular pressures can
sure at adequate levels for visualization, were no significant differences in relation rise to dangerous levels.
and include safety features such as pres- to visual clarity, presence of bleeding, or High intra-articular pressures may
sure monitors that sound a warning when red blood cell loss, and they concluded that pose a risk to fluid extravasation, com-
the pressure is too high. Use of these there was no difference between the pumps partment syndrome, and synovial pouch
pumps set to deliver a constant intra- in straightforward shoulder procedures. rupture. Studies have reported synovial
articular pressure slightly above end cap- The studies by Ogilvie-Harris and pouch rupture when intra-articular pres-
illary diastolic filling pressure should al- Weisleder18 and Ampat et al19 compared sure rises in the range of 120 to 150
low one to perform arthroscopic surgery visualization based on subjective mea- mm Hg.21,22 Despite known possible com-
in a clear field of view without the use of sures, and neither study set out to mea- plications related to high pressure, many
a tourniquet. When an automated pump sure the amount of operative time saving. commercial devices allow pressure values
meets all of these criteria, then this prod- Tuijthof et al17 compared a gravity pump far above 100 mm Hg.8
uct would offer many advantages over the with a pressure and flow control pump us- Complications rate of 1% have been
gravity-flow methods.10 ing objective data and demonstrated time described in the literature, with complica-
More recently, evidence suggests that saving for the latter system. tions including fluid extravasation (intra-
dual systems provide better visualiza- Sieg et al20 sought to perform a direct peritoneal and extraperitoneal accumula-
tion than pressure-control systems, which comparison in terms of operative times tion), synovial pouch rupture (distension
may lead to decreased operative times. in anterior cruciate ligament (ACL) re- of compartments of the leg and thigh),
Ogilvie-Harris and Weisleder18 prospec- constructive surgery using these 2 auto- and compartment syndrome.13 There are
tively compared pressure-controlled mated pumps. This retrospective study reported cases for termination of knee ar-
pumps vs pressure and flow control evaluated all ACL reconstructive sur- throscopy due to distention of the anterior
pumps for multiple types of arthroscopic geries performed by 3 surgeons dur- and posterior compartment of the leg and
thigh, and compartment syndrome with no cons. Instr Course Lect. 2003; 52:81-92. 15. DeHaven KE. Principles of triangulation for
arthroscopic surgery. Orthop Clin North Am.
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1982; 13(2):329-336.
plications in arthroscopic surgery. In: Grana
salis pedis arteries requiring fasciotomies. WA, ed. Update in Arthroscopic Techniques 16. Crane L. Arthroscopic surgery under local
Noyes and Spievack23 reported excessive (Techniques in Orthopaedics). Baltimore, anesthesia. Orthopedics. 1984; 7(4):748-749.
fluid extravasation in 4 of 300 cases dur- MD: University Park Press; 1984:87-97. 17. Tuijthof GJ, Sierevelt IN, van Dijk CN. Dis-
ing a 9-month period. Other complica- 3. Jackson RW. History of arthroscopy. In: turbances in the arthroscopic view defined
McGinty JB, Caspari RB, Jackson RW, with video analysis. Knee Surg Sports Trau-
tions that have been reported include mas- Pochling GG, eds. Operative Arthroscopy. matol Arthrosc. 2007; 15(9):1101-1106.
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1996:263-297.
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5. Casscells SW. The place of arthroscopy in the 19. Ampat G, Bruguera J, Copeland SA. Aqua-
a tibia plateau fracture.24,25 diagnosis and treatment of internal derange- flo pump vs FMS 4 pump for shoulder ar-
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Conclusion
6. Metcalf RW. Operative arthroscopy of the 20. Sieg R, Bear R, Machen MS, Owen BD.
Advantages of mechanical fluid ir-
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rigation system over gravity irrigation sure and flow-control pump versus pressure-
7. Eriksson E, Sebik A. Arthroscopy and ar-
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throscopic surgery in a gas versus a fluid
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8. Muellner T, Menth-Chiari W, Reihsner R,
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Disadvantages include the need for ad- pressures in the knee joint during arthrosco-
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