Purpose
To determine arthroscopic fluid volume use patterns across common elective orthopaedic procedures, evaluate intersurgeon consistency in fluid use, and assess whether blood loss reduction adjuncts affect fluid consumption to generate actionable insights to guide surgeons in optimizing resource use, reducing waste, and improving efficiency during times of resource constraint.
Methods
A cross-sectional analysis at a single outpatient surgery center of adult arthroscopic procedures was conducted. A representative sample of 500 arthroscopic cases of the shoulder, elbow, knee, and ankle performed by multiple surgeons were reviewed. A total of 449 cases met inclusion criteria. Analysis of fluid use relative to body area, Current Procedural Terminology codes, surgeon, and blood loss reduction adjuncts (tranexamic acid [TXA] and epinephrine) was performed using analysis of variance tests.
Results
Mean fluid volume was greatest in shoulder arthroscopy (16,582 ± 7,026 mL), followed by knee (8,677 ± 7,027 mL), elbow (6,489 ± 2,540 mL), and ankle procedures (3,534 ± 1,500 mL). Significant intersurgeon variation was observed (F = 19.61, P =.0001). Epinephrine was used in 58.8% of cases, with mean fluid volume of 11,571 ± 6,896 mL for local injection and 15,401 ± 8,610 mL for arthroscopic fluid administration. Cases without epinephrine averaged 7,676 ± 6,570 mL of fluid use. TXA was used in only 0.7% of cases. Neither epinephrine nor TXA showed significant reduction in fluid consumption ( P >.05).
Conclusions
Arthroscopic fluid use across anatomic regions was highly varied, with shoulder procedures requiring the greatest volumes. Surgeon-specific use patterns also varied considerably. The use of neither TXA nor epinephrine reduced fluid consumption, although this finding may reflect the small sample size and lack of standardized protocols rather than true ineffectiveness.
Level of Evidence
Level III, cross-sectional study.
The national shortage of intravenous fluids in the United States that began in 2024 has emerged as a critical issue and has impacted patient care at hospitals and ambulatory surgery centers. The fluid shortage has resulted in fluid rationing, procedure cancellations, and delays in care. , Attempts to optimize pump pressure and portal placement to facilitate efficient irrigation have previously been published. , However, data on expected fluid use for standard arthroscopic orthopaedic procedures are less well known, leaving decision makers without a reliable benchmark of the fluid “cost” for each procedure. As supply chain issues and supply shortages have become more commonplace, , it is important for hospital systems and ambulatory surgery centers alike to have more evidence-based approaches to resource acquisition and planning.
Furthermore, multiple techniques have been described to limit blood loss and improve visualization during arthroscopy—such as the use of tranexamic acid (TXA) and epinephrine. ,,, Although these methods have been shown to reduce total operative time in certain procedures, ,, it is less clear to what extent these interventions influence the total volume of arthroscopy fluid used. Bermudo Gamboa et al. found no significant reduction in the volume of fluid used during shoulder arthroscopy with the use of preoperative local epinephrine infiltration but did note improved visualization. Similarly, Jensen et al. found improved visualization but no difference the amount of irrigation fluid when diluting epinephrine in saline via a pressure-controlled pump used intraoperatively.
Anecdotally, it is common practice to use 3-L bags of fluid during arthroscopy. However, there is very little information regarding the amount of fluid used in arthroscopic cases other than isolated studies such as one by Smith and Shah in 2008, which showed the mean fluid use of 3.2 ± 2.2 L for shoulder arthroscopy. However, this may not be the most efficient size to use during a national shortage of fluid. In addition, although data exist regarding the overall cost of arthroscopic procedures across different joints, these studies often focus on broader comparisons, such as cost differences between surgery centers and hospital-based practices or variations by Current Procedural Terminology (CPT) codes or implant choices, seldom diving into fluid use and its costs. ,,,,, The purpose of this study is to determine arthroscopic fluid volume use patterns across common elective orthopaedic procedures, evaluate intersurgeon consistency in fluid use, and assess whether blood loss reduction adjuncts affect fluid consumption to generate actionable insights to guide surgeons in optimizing resource use, reducing waste, and improving efficiency during times of resource constraint. We hypothesized that (1) arthroscopic fluid use would vary significantly by anatomic region for common elective orthopaedic procedures, (2) different surgeons would have consistent fluid use patterns when performing similar procedures, and (3) the use of blood loss reduction adjuncts (TXA and epinephrine) would be associated with reduced arthroscopic fluid consumption.
Methods
Study Design and Setting
This retrospective cross-sectional study was conducted at a single outpatient surgery center that is owned and used by a large multispecialty private practice orthopaedic surgery group. The group of surgeons includes a mix of general orthopaedic surgeons and fellowship-trained subspecialists typical of a community orthopaedic practice. Elective arthroscopic surgeries performed between 2014 and 2024 were compiled for screening. Data were collected retrospectively from a review of the electronic medical record. Data were entered securely in an institution-specific REDCap database. This study received approval from local institutional review board (IRB00121568 approved on November 7, 2024, by Wake Forest University Institutional Review Board) and is compliant with US Health Insurance Portability and Accountability Act (HIPAA).
Participants
The study included adult patients (≥18 years) undergoing arthroscopic orthopaedic surgeries between 2014 and 2024. Patients were excluded if there was no documentation of total volume of arthroscopy fluid use. All records included for initial review were sorted into random sequence before being uploaded to the REDCap database, the first 500 were then selected as a representative random sample—with subsets allocated by body area (200 shoulders, 200 knees, 50 elbows, and 50 ankles) ( Fig 1 ). The number of cases for each body area was predetermined on the basis of the distribution of surgical volume of the surgical center by body area, the inherent variability of CPT codes used in each body area (greater for shoulder and knee than ankle and elbow), and what could be pragmatically completed in a timely manner while the national fluid shortage was still a current issue.
CONSORT diagram of patient selection for arthroscopic fluid use analysis. From 3,937 total surgeries assessed for eligibility, 3,434 were randomly excluded to create a representative sample of 501 surgeries (40% knee, 40% shoulder, 10% elbow, 10% ankle). After excluding 1 nonarthroscopic surgery and 51 cases with missing data (21 without documented arthroscopy fluid use, 27 patients younger than 18 years, 3 with multiple exclusion criteria), 449 eligible surgeries were included in the final analysis (200 shoulder, 159 knee, 46 elbow, 44 ankle). This systematic selection process ensured representative sampling across all major arthroscopic joint procedures while maintaining adequate statistical power for intersurgeon and interjoint comparisons. (CONSORT, Consolidated Standards of Reporting Trials.)
Description of Experiment
After screening for inclusion, data pertinent to the arthroscopic fluid volume were collected via retrospective review of the electronic medical record, including surgeon, CPT codes, use of epinephrine and TXA, volume of arthroscopic fluid used, and arthroscopic pump fluid pressure when available.
Variables, Outcome Measures, Data Sources, and Bias
The primary outcome was the volume of arthroscopic fluid used per procedure. Independent variables included surgeon, CPT codes, patient positioning, and the use of TXA or epinephrine. Epinephrine was reported as administered via local intra-articular injection and/or diluted in arthroscopic fluid and administered intraoperatively via pressure-controlled pump. TXA was given only intravenously. Potential biases, such as inconsistencies in data recording, were minimized through standardized data-abstraction protocols.
Statistical Analysis
Descriptive statistics of means standard deviations, minimums and maximums, and frequencies were used to summarize the data. F ratio statistics from analysis of variance tests were used to determine significant differences between the means. Study data were collected and managed using Research Electronic Data Capture tools hosted locally. , All statistical analyses were conducted using SAS/STAT software, Version 9.4, of the SAS System for Windows (SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC). A power calculation was not performed because of the retrospective and cross-sectional nature of the study.
Accounting for All Patients/Study Subjects
All eligible patients during the study period were included, with bilateral cases analyzed separately when applicable to ensure comprehensive data representation.
Results
A total of 449 surgeries in 444 patients met final inclusion criteria. Reasons for exclusion included no arthroscopy used (n = 1), no documented use of fluid (n = 21), patients younger than 18 years old (n = 27), or more than 1 of the aforementioned causes (n = 3). Of the final study population, the mean age at the time of surgery was 51 ± 15 years, and most patients were male (n = 271, 61%). The most common operative site was the shoulder (n = 200, 44.5%) followed by the knee (n = 159, 35.4%) ( Table 1 ).
Table 1
Demographics
| Characteristics | N = 444 (%) |
|---|---|
| Sex | |
| Female | 173 (38.9) |
| Male | 271 (61.1) |
| Race | |
| White | 318 (71.6) |
| Black | 67 (15.1) |
| Unknown or declined | 52 (11.7) |
| Hispanic | 6 (1.4) |
| Asian or Native American | 1 (0.2) |
| Age at surgery, yr, mean (SD) | 51 (14.9) |
| BMI, mean (SD) | 29.8 (5.9) |
BMI, body mass index; SD, standard deviation.
Arthroscopic Fluid Use by Anatomic Region and CPT Code
The mean volume of arthroscopic fluid used for all included surgeries was 11,442 mL. The mean volume of arthroscopic fluid used was greatest for shoulder surgeries (16,582 mL) and lowest for ankle surgeries (3,534 mL) ( Table 2 ). The difference in mean arthroscopic fluid use by anatomic region was statistically significant ( P <.001), with varying effect sizes of individual CPT codes on overall fluid use ( Table 3 ). There was insufficient variety of CPT codes used in ankle arthroscopy to calculate an effect size with only a single CPT code being used (29898).
Table 2
Fluid Used by Anatomic Region
| Anatomic Region | N = 449 | Mean (SD) | Range |
|---|---|---|---|
| Shoulder | 200 | 16,582 (7,026) | 3,000-51,000 |
| Elbow | 46 | 6,489 (2,540) | 3,000-12,000 |
| Knee | 159 | 8,677 (7,027) | 3,000-39,000 |
| Ankle | 44 | 3,534 (1,500) | 2,000-9,000 |
| Total | 449 | 11,442 (8,538) | 2,000-51,000 |
SD, standard deviation.
Table 3
Effect on Total Fluid Volume of Individual CPT Codes
| CPT Code | CPT Description | N | Effect on Mean | P Value |
|---|---|---|---|---|
| Shoulder arthroscopy (mean volume: 16,582 mL) | ||||
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | 2 | + 4,977 mL | .47 |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | 3 | − 4,646 mL | .34 |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial (ie, arch) release, when performed | 141 | − 533 mL | .73 |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | 195 | + 3,490 mL | .61 |
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | 130 | + 3,411 mL | .02 |
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | 2 | + 4,977 mL | .47 |
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | 3 | − 4,646 mL | .34 |
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial (ie, arch) release, when performed | 141 | − 533 mL | .73 |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | 195 | + 3,490 mL | .61 |
| Elbow arthroscopy (mean volume: 6,489 mL) | ||||
| 29834 | Arthroscopy, elbow, surgical; with removal of loose body or foreign body | 16 | + 1.301 mL | .13 |
| 29835 | Arthroscopy, elbow, surgical; synovectomy, partial | 1 | + 4,858 mL | .04 |
| 29836 | Arthroscopy, elbow, surgical; synovectomy, complete | 3 | + 3,292 mL | .02 |
| 29837 | Arthroscopy, elbow, surgical; debridement, limited | 1 | − 3,751 mL | .14 |
| 29838 | Arthroscopy, elbow, surgical; debridement, extensive | 41 | + 391 mL | .77 |
| Knee arthroscopy (mean volume: 8,677 mL) | ||||
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) | 5 | − 1,067 mL | <.01 |
| 29877 | Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) | 4 | + 635 mL | .73 |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | 13 | + 4,876 mL | .86 |
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) | 58 | + 1,384 mL | .24 |
| 29883 | Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) | 3 | + 9,001 mL | .03 |
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