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Viscoseal

Viscoseal Synovial Fluid Replacement
following Arthroscopic Surgery

Arthroscopic Surgery confers significant benefits on thousands of patients every year. The technique offers less insult to the joint, decreases the risk of complication and infection, and reduces pain, hospitalisation time, and recovery time.

As with any surgical intervention there can be side effects associated with arthroscopy, primarily these are pain, swelling and loss of joint mobility. A contribution to these effects is made by the irrigation solutions used during arthroscopies to flush debris from the joint, and maintain a clear visual aspect for the surgeon.
Because the irrigation solution washes out the synovial fluid (SF) that resides in all synovial joints, the protective and lubricating functions of the SF are temporarily absent, and several days may elapse before the joint begins to replace the fluid that has been lost (Fig. 1) (1-3;17-21). 
Additional problems arise due to the fact that irrigation solutions may have a negative effect on the metabolism of articular cartilage (1-3;17-21), and reduced mobility due to arthroscopy may lead to decreased production of Hyaluronan, a vital constituent of both cartilage and synovial fluid (4-6).


Fig. 1: Irrigation fluid washes out synovial fluid (blue) during arthroscopy.

Viscoseal (TRB Chemedica) is a 0.5% concentration, isotonic solution of Hyaluronan of fermentative origin designed as a synovial fluid substitute for use following arthroscopic surgery or joint lavage.
Instilled into the joint immediately after surgery, Viscoseal acts as a temporary substitute for the synovial fluid (SF) that has been lost during arthroscopy, performing the lubricating, shock absorbing and filtering functions of this fluid. In addition, it displaces any irrigating solution left in the joint space, preventing impairment of cartilage metabolism.
The introduction of Viscoseal into the joint space re-establishes the protective coating of Hyaluronan over the surface of the articular cartilage and synovial membrane. By replacing the superficial layer of viscous Hyaluronan on the intima of the synovium, potential innervation of pain receptors is reduced. This reduction in pain helps to enhance joint mobility, which in turn promotes the production of endogenous Hyaluronan.


Fig. 2: Viscoseal installation at the end of the arthroscopic procedure

Clinical studies have shown that instilling exogenous Hyaluronan:

  • Is effective, in combination with arthroscopic surgery, in reducing pain and improving joint mobility in patients with chronic joint derangement (7).
  • Reduces pain, improves joint function and decreases levels of prostaglandins and cytokines in the synovial fluid in patients with chronic joint derangement (8,9).
In addition, research has demonstrated that exogenous Hyaluronan:
Stimulates collagen remodelling and inhibits swelling of the meniscus during healing of meniscal tears (10).
  • Restores cartilage metabolism that has been disturbed by irrigation with saline solution (11).
  • Reduces joint pain caused by pain mediators (12-14).

Viscoseal & Shoulder Arthroscopy:
A study by L Funk & P Wykes (15) demonstrated a significant reduction in post-operative pain when Viscoseal is used after shoulder arthroscopy. 
Patients also needed less pain-killers and were able to go home earlier from hospital after the operation. There were no adverse effects. 
For more details click here .



 

Presentation by Len Funk at the Swiss Orthopaedic and Traumatology Conference, 2009

Questions:

 


REFERENCES.

  1. Irrigating solutions for arthroscopy - a metabolic study. Reagan BF et al. JBJS (Am)1983; 65(a): p629-631
  2. The effect of arthroscopic irrigating solutions on cartilage & synovium. Straehly D et al. Trans Orthop Res. Soc 1985;10: p260
  3. The effect in vitro of irrigating solutions on intact rat articular cartilage. SK Bulstra, R Kuijer, P Eerdmans, AJ van der … - J Bone Joint Surg Br, 1994
  4. Akeson, WH et al. Clin. Orthop. 1987; 219: 28-37
  5. Saamanen, AM et al. J. Orthop. Res. 1990; 8: 863-73
  6. Joint immobilization reduces synovial fluid hyaluronan concentration and is accompanied by changes in the synovial intimal cell population. Pitsillides AA et al. Rheumatology 1999; 38: p1108-1112
  7. Miyamoto, H et al. Aust. Dent. J. 1998; 43; 301-4
  8. Hirota, W. Br. J. Oral Maxillofac. Surg. 1998; 36: 35-8
  9. Sato, S et al. Oral Surg Oral Med Pathol Oral Radiol Endod. 1997; 84:241-4
  10. Sonoda, M et al. Am. J. Sports Med. 2000; 28: 90-7
  11. NaCl irrigation of the rat knee inhibits cartilage metabolism: hyaluronan restores this disturbed metabolism to normal. Bulstra SK et al. presentation at ORS, Anaheim, CA 1999.
  12. Gotoh, S et al Nippon Yakurigaku Zasshi 1988; 92: 17-27
  13. Gotoh, S et al Ann. Rheum. Dis. 1993; 52: 817-22
  14. Yamashita, I et al. Nippon Seikeigaka Gakkai Zasshi 1995; 69: 735-43
  15. Funk L, Wykes P. Osteoarthritis & Cartilage 2004; 12(Suppl B):126-7
  16. Villamor et al. Viscoseal aids recovery after arthroscopy - a single blind, randomised multicentre study. Osteoarthritis & Cartilage 2004; 12(Suppl B)
  17. Articular irrigation in arthroscopy. JL Martinez Moreno, VM FJ - Int Orthop, 1986
  18. Effect of various irrigating fluids on the ultrastructure of articular cartilage. JM Bert, Z Posalaky, S Snyder, D McGinley, C Chock Effects of immobilization on joints. Akeson WH et al. Clin. Orthop. 1987; 219: p28-37
  19. Proteoglycan alterations following immobilization and remobilization in the articular cartilage of young canine knee (stifle) joints. Saaman A-M et al.  J. orthop. Res. 1990; 8:863-873
  20. Effects of irrigation fluid on human menisci: an experimental comparison of water, normal saline, and glycine. Mah ET, Lee WK, Southwood RT, Carbone A, Leppard PJ. Arthroscopy. 1991;7(1):24-32.
  21. Influence of various irrigation fluids on articular cartilage. Gradinger R, Trager J, Klauser RJ. Arthroscopy. 1995 Jun;11(3):263-9.

Related Articles:

- Shoulder Arthroscopy
- Hyaluronan Background
- Hyaluronans in the Shoulder



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