Search

Introduction: Visual clarity in arthroscopic rotator cuff repair is essential to reduce the operative time and for efficiency of repair. Tranexamic acid (TXA) in open shoulder surgery has been shown to reduce blood loss but its use in shoulder arthroscopy for rotator cuff repair for improved clarity is not understood. The purpose of this SR is to determine the effect of TXA and epinephrine on visual clarity in shoulder arthroscopy for rotator cuff repair., Hypothesis: We hypothesise that visual clarity should improve in those that have TXA compared to those who do not receive TXA., Methods: A review of the online databases MEDLINE and Embase was conducted on 8th October 2022 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Randomised clinical trials reporting visual clarity and/or, operative time, volume of irrigation fluid used and mean arterial pressure were included. The studies were appraised using the CONSORT tool., Results: Seven studies met eligible criteria, all of which were double-blinded RCTs. Five studies reported no difference in visual clarity between TXA vs. saline, while two reported a significant improvement with TXA. Pooling of data showed that visual clarity was significantly better in the TXA group vs. saline, on a standardised 10-point Likert scale (mean difference 0.73 points, p=0.03). However, the use of epinephrine was reported in two studies and its administration offered significantly better visual clarity than TXA (mean difference 0.9 points, p=0.02). There was no significant difference with TXA use in MAP (mean difference 1.2mmHg, p=0.14), operative time (mean difference 6.8minutes, p=0.11), irrigation volume used (mean difference 0.2L, p=0.88), or postoperative pain (mean difference 3.89 on a 0-100 VAS, p=0.34)., Conclusion: The use of TXA in shoulder arthroscopy has shown to have significantly improved visual clarity in comparison to saline irrigation alone. This may not necessarily result in a significant clinical difference and may not translate to significantly less operative time or postoperative pain score. Furthermore, epinephrine use alone offers significantly better clarity than TXA. There may not be an added benefit to give both, but this area requires further research., Level of Evidence: II; systematic review., (Crown Copyright © 2024. Published by Elsevier Masson SAS. All rights reserved.)

Background: The autograft of choice for anterior cruciate ligament reconstruction (ACLR) remains debateable. Recently there has been increased popularity of soft tissue quadriceps tendon (s-QT) autograft due to less donor site morbidity, reduced anterior knee pain and comparable re-operation and complication rates. The aim of this review was to analyse functional outcomes of primary ACLR using s-QT in adult population without the bone plug and to report its complication profile against other autografts., Patient and Methods: This systematic review was performed in accordance with PRISMA guidelines and a review of literature was conducted on four online databases (Medline, EMBASE, Cochrane and Google Scholar). Clinical studies reporting on patients undergoing primary ACLR with s-QT autograft or in comparison to BPTB or HS autografts with a minimum of 6 months follow-up were included. The studies were inclusive of only all soft tissue QT autograft regardless of the implants or fixation method used. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool., Results: Fourteen studies were eligible. There were three randomised control studies (RCT) and 11 non-randomised comparative studies with 1543 patients who underwent ACLR. 682 underwent s-QT, 498 had hamstring tendon (HT) and 174 had bone-patellar tendon-bone (BPTB). 60% (n = 930) were males and mean follow up was 23.6 months (6-65). Eight studies reported post-operative patient reported outcome measures (PROMs). The mean International Knee Documentation Committee (IKDC) score was 91.5 ± 15.1 whereas mean Lysholm score was 90 ± 3.9. Five studies reported on laxity with mean anterior tibial translation (ATT) of 1.28 ± 1.09 mm. Overall complication rate of s-QT ACLR was 6% with 3% graft failure, 0.52% arthrofibrosis, 0.2% infection, 0.75% revision ACLR. There was no significant difference in functional outcome scores, knee stability and range of motion (ROM) between s-QT, HT and BPTB., Conclusion: s-QT for ACLR has a comparable functional outcome, laxity, failure and with overall graft failure rate of 3%., Level of Evidence: III; Systematic review and meta-analysis., (Crown Copyright © 2024. Published by Elsevier Masson SAS. All rights reserved.)

Background: A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored., Purpose: To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed., Results: A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios., Conclusion: For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage., Registration: NCT01324531 (ClinicalTrials.gov identifier)., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The Pan Am Clinic Foundation is supported by Conmed, Arthrex, Ossur, Smith & Nephew, Stryker, and Zimmer Biomet. J.M.W. has received consulting fees from Smither & Nephew and Stryker. P.B.M. has received consulting fees from Conmed and Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: The addition of epinephrine in irrigation fluid and the intravenous or local administration of tranexamic acid have independently been reported to decrease bleeding, thereby improving surgeons' visualization during arthroscopic shoulder procedures. No study has compared the effect of intravenous tranexamic acid, epinephrine in the irrigation fluid, or the combination of both tranexamic acid and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. We hypothesized that intravenous tranexamic acid is more effective than epinephrine mixed in the irrigation fluid in improving visualization during shoulder arthroscopy, with no additive effect when both are used., Methods: Patients aged ≥18 years undergoing shoulder arthroscopy were randomized into one of 4 study arms: (1) saline irrigation fluid (placebo); (2) epinephrine (0.33 mL of 1:1000 per liter) mixed in irrigation fluid (EPI); (3) 1 g intravenous tranexamic acid (TXA); and (4) epinephrine and tranexamic acid combined (TXA + EPI). Visualization was rated intraoperatively on a scale from 0, indicating poor clarity, to 3, indicating excellent clarity, every 15 minutes and overall. The primary outcome measure was the overall rating of visualization. A stepwise linear regression was performed using visualization as the dependent variable and independent variables including presence or absence of epinephrine and tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid., Results: One hundred twenty-eight patients (mean age 56 years) were randomized. Mean visual clarity for the placebo, TXA, EPI, and TXA + EPI groups were 2.0 (±0.6), 2.0 (±0.6), 2.6 (±0.5), and 2.7 (±0.5), respectively (P < .001). The presence or absence of epinephrine was the most significant predictor of visual clarity (P < .001). Tranexamic acid presence or absence had no effect. No adverse events were recorded in any of the groups., Conclusion: Intravenous tranexamic acid is not an effective alternative to epinephrine in irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries, and there is no additive effect when both are used., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Shoulder arthroplasty is a treatment option of the sequelae of native shoulder joint infections. However, the functional outcomes and re-infection rates are unknown. The aim of this review was to analyse the outcome of shoulder arthroplasty in patients with native shoulder infections., Methods: A review of the online databases MEDLINE and Embase was conducted according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Studies reporting either primary or secondary infections of native shoulder joints treated with any form of arthroplasty were included and appraised using the methodological index for non-randomised studies (MINORS) tool., Results: Fourteen studies were eligible for inclusion. Mean age ranged from 56 to 72 years and the mean follow-up from 20.5 months to 8.2 years. Primary shoulder infections were present in 50 patients and secondary infections in 86. 76 patients underwent a two stage: 46 patients a single-stage procedure whilst 14 refused second-stage surgery. Mean post-operative Constant score ranged from 38 to 56.2. The overall reported re-infection rate was 2.3% and complication rate was 26%., Conclusion: Shoulder arthroplasty in the management of either primary or secondary native shoulder infections has a high complication rate and low functional outcome but low re-infection rates at short-term follow-up., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Purpose: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports., Methods: This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively., Results: We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001)., Conclusions: At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates., Level of Evidence: Level I, randomized controlled trial., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)