Post Arthroscopic Pain Management:

Should concerns over the topical use of local anaesthetics 
following joint surgery be prompting a move toward alternatives?

We review some expert comment.

(Published in Orthopaedic Product News Issue February 2018).

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. Orthopaedic surgeons with differing specialities perform arthroscopies routinely, and the topical use of intra or peri articular local anaesthetic has constituted a “Standardised” post-operative analgesic regime for many years.
Recent research has demonstrated that “Bupivacaine, lidocaine, ropivacaine and levobupivacaine are all toxic to cartilage”. 1  In addition, “Intra-articular use of local anaesthetics may have lasting detrimental effects on human articular cartilage and chondrocytes”, and even “Single-dose intra-articular administration of local anaesthetics impede chondrocyte metabolism” 2,3. Given the concerns around the use of LA, is there a viable alternative?

VISCOSEAL® (TRB Chemedica) is a physiologic 0.5% concentration, isotonic solution of Hyaluronan of fermentative origin, designed and licensed as a synovial fluid substitute for use following arthroscopic surgery. Presented in a 10ml pre-filled and terminally sterilised syringe, it is 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. It displaces any irrigating solution left in the joint space, minimising impairment of cartilage metabolism, and re-establishes the protective coating of hyaluronan over the surface of the articular cartilage and synovial membrane, preventing innervation of pain receptors4,5.  

    

Eminent Orthopaedic and Sports Injury Shoulder surgeon, Prof. Lennard Funk comments:
”I was always concerned about bursal adhesions following arthroscopic subacromial decompressions, and aware of the literature on the damage local anaesthetics and large amounts of irrigation fluids caused to cartilage. Therefore, both the theoretical and research benefits of Viscoseal appealed to me. My subsequent study6 demonstrated there were significant differences in pain and analgesia requirements favouring the patients who received Viscoseal over those that did not. I was pleasantly surprised when I presented our data at the OARSI Conference in 2004 that almost identical data were presented for the knee.  The improved pain relief with Viscoseal has led to my continuing use of the product in everyday practice.”  

    

Mr Sanjeev Anand, Consultant Orthopaedic Knee, Sports Injury and Hip Arthroscopy Surgeon, conducted seminal research into VISCOSEAL® following knee arthroscopy:
“We were aware that some patients seemed to do less well following fairly simple knee arthroscopy, and also aware of emerging published data regarding the deleterious effects of local anaesthetic on articular cartilage, so when we were introduced to the concept of synovial fluid replacement following arthroscopy, we set up a study to determine if there was any measurable merit to the idea. The results demonstrated statistically significant differences between the Viscoseal group compared with the Bupivacaine controls, the SF-12 values, the WOMAC scores, analgesic consumption, and pain and swelling evaluations all favoured the study group. We were very satisfied that our results supported the study intervention under investigation” 7.


    

Mr Praveen Sarda, Consultant Orthopaedic Shoulder Surgeon, has been engaged in recent research into pain management and recovery following shoulder arthroscopy, and is currently finalising data sets from a study which compared VISCOSEAL® with saline control following Arthroscopic Subacromial Decompression in patients who had all received pre-operative interscalene block. “We wanted to determine if there were any measurable benefits to using synovial fluid replacement following ASAD in patients who had also received brachial plexus block. Without pre-empting the results, it was noticeable that on occasion the block procedure could take almost as long as the arthroscopy itself. Even with use of US guidance, there is a small risk that IS block can be misplaced. Additionally it may have a disruptive intra-operative effect on diaphragm function, and leads to temporary loss of sensory and motor function in the affected limb that can last 24 to 48 hours8. The infiltration of the study product was very quick and easy. It will be interesting to see our analysed data to determine if a topical post-operative synovial fluid replacement improves outcomes or rehabilitation in our cohort.”

    

Leading Sports Medicine and Orthopaedic Knee surgeon Prof. Sanjiv Jari is a long-standing advocate of the cartilage-preserving properties of Sodium Hyaluronate: “I’d been aware of the reported benefits associated with Hyaluronic Acid injections for degenerative and traumatic changes in knees for many years, when the concept of a physiologic Hyaluronate-based synovial fluid replacement was introduced to me, I was interested to see if it offered an effective alternative to local anaesthetic. It’s very quick and easy to use. I instil it following evacuation of irrigation fluid via a syringe attached to the outflow cannula. I liked the concept of restoring a more physiologic environment to joints following arthroscopy, and my clinical experience has certainly borne out research that demonstrates improved pain and function scores following debridement and meniscectomy in patients receiving Viscoseal.”




References.
1 Gulihar A, Robati S, Twaij H, Salih A, Taylor GJS. Articular cartilage and local anaesthetic: A systematic review of the current literature. Journal of Orthopaedics. 2015;12(Suppl 2)
2   Piper SL1, Kramer JD, Kim HT, Feeley BT. Effects of local anesthetics on articular cartilage. Am J Sports Med. 2011 Oct;39(10):2245-53.
3 Kreuz PC1, Steinwachs M2, Angele P3. Single-dose local anesthetics exhibit a type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and cartilage: a systematic review of the current literature. Knee Surg Sports Traumatol Arthrosc. 2017 Mar 13. doi: 10.1007/s00167-017-4470-5.
4 Mathies B. Knee Surg Sports Traumatol Arthrosc. 2006;14(1):32-9
5 Waddell DD, Bert JM. Arthroscopy. 2010;26(1):105-11
6 Funk L, Wykes PR. Osteoarthritis Cartilage. 2004;12 (Suppl B):S126
7 Anand S et al. “Effect of Sodium Hyaluronate on Recovery after Arthroscopic Knee Surgery”; J Knee Surg 2016; 29(06): 502-509 DOI: 10.1055/s-0035-156673
8 Sites BD, Taenzer AH, Herrick MD, et al. Incidence of local anaesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks: an analysis from a prospective clinical registry, Reg Anesth Pain Med, 2012, vol.37 (pg.478-82)