Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization.

The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week.

One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups.

Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone.

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization.

The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week.

One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups.

Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone.

Previously, we conducted a multi-center, double-blinded randomized controlled trial comparing arthroscopic Bankart repair with and without remplissage. The end point for the randomized controlled trial was two years post-operative, providing support for the benefits of remplissage in the short term in reducing recurrent instability. The aim of this study was to compare the medium term (3 to 9 years) outcomes of patients previously randomized to have undergone isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) for the management of recurrent anterior glenohumeral instability. The rate of recurrent instability and instances of re-operation were examined.

The original study was a double-blinded, randomized clinical trial with two 1:1 parallel groups with recruitment undertaken between 2011 and 2017. For this medium-term study, participants were reached for a telephone follow-up in 2020 and asked a series of standardized questions regarding ensuing instances of subluxation, dislocation or reoperation that had occurred on their shoulder for which they were randomized. Descriptive statistics were generated for all variables. “Failure” was defined as occurrence of a dislocation. “Recurrent instability” was defined as the participant reporting a dislocation or two or more occurences of subluxation greater than one year post-operative. All analyses were undertaken based on intention-to-treat whereby their data was analyzed based on the group to which they were originally allocated.

One-hundred and eight participants were randomized of which 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 final follow-up was 49.3 for the NO REMP group and 53.8 for the REMP group. The rates of re-dislocation or failure were 8% (4/52) in the REMP group at an average of 23.8 months post-operative versus 22% (11/50) in the NO REMP at an average of 16.5 months post-operative. The rates of recurrent instability were 10% (5/52) in the REMP group at an average of 24 months post-operative versus 30% (15/50) in the NO REMP group at an average of 19.5 months post-operative. Survival curves were significantly different favouring REMP in both scenarios.

Arthroscopic Bankart repair combined with remplissage is an effective procedure in the treatment of patients with an engaging Hill-Sachs lesion and minimal glenoid bone loss (<15%). Patients can expect favourable rates of recurrent instability when compared with isolated Bankart repair at medium term follw-up.

Our primary objective was to compare healing rates in patients undergoing arthroscopic rotator cuff repair for degenerative tears, with and without bone channeling. Our secondary objectives were to compare disease-specific quality of life and patient reported outcomes as measured by the Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score and Constant score between groups.

Patients undergoing arthroscopic rotator cuff repair at three sites were randomized to receive either bone channeling augmentation or standard repair. Healing rates were determined by ultrasound at 6 and 24 months post operatively. WORC, ASES, and Constant scores were compared between groups at baseline and at 3, 6, 12 and 24 months post operatively.

One hundred sixty-eight patients were recruited and randomized between 2013 to 2018. Statistically significant improvements occurred in both groups from pre-operative to all time points in all clinical outcome scores (p < 0 .0001). Intention to treat analysis revealed no statistical differences in healing rates between the two interventions at 24 months post-operative. No differences were observed in WORC, ASES or Constant scores at any time-point.

This trial did not demonstrate superiority of intra-operative bone channeling in rotator cuff repair surgery at 24 months post-operative. Healing rates and patient-reported function and quality of life measures were similar between groups.

When compared to magnetic resonance imaging (MRI), ultrasound (US) performed by experienced users is an inexpensive tool that has good sensitivity and specificity for diagnosing rotator cuff (RC) tears. However, many practitioners are now utilizing in-office US with little to no formal training as an adjunct to clinical evaluation in the management of RC pathology. The purpose of our study was to determine if US without formal training is effective in managing patients with a suspected RC tear.

This was a single centre prospective observational study. Five fellowship-trained surgeons each examined 50 participants referred for a suspected RC tear (n= 250). Patients were screened prior to the consultation and were included if ≥ 40 years old, had an MRI of their affected shoulder, had failed conservative treatment of at least 6 months, and had ongoing pain and disability. Patients were excluded if they had glenohumeral instability, evidence of major joint trauma, or osteonecrosis. After routine clinical exam, surgeons recorded their treatment plan (“No Surgery”, “Uncertain”, or “Surgery”). Surgeons then performed an in-office diagnostic US followed by an MRI and documented their treatment plan after each imaging study. Interrater reliability was analyzed using a kappa statistic to compare clinical to ultrasound findings and ultrasound findings to MRI, normal and abnormal categorization of biceps, supraspinatus, and subscapularis.

Following clinical assessment, the treatment plan was recorded as “No Surgery” in 90 (36%), “Uncertain” in 96 (39%) of cases, “Surgery” in 61 (25%) cases, and incomplete in 3 (2%). In-office US allowed resolution of 68 (71%) of uncertain cases with 227 (88%) of patients having a definitive treatment plan. No patients in the “No Surgery” group had a change in treatment plan. After MRI, 16 (6%) patients in the “No Surgery” crossed-over to the “Surgery” group after identification of full-thickness tears, larger than expected tears or alternate pathology (e.g., labral tear).

The combination of clinical examination and in-office US may be an effective method in the initial management of patients with suspected rotator cuff pathology. Using this method, a definitive diagnosis and treatment plan was established in 88% of patients with the remaining 12% requiring an MRI. A small percentage (6%) of patients with larger than expected full-thickness rotator cuff tears and/or alternate glenohumeral pathology (e.g., labral tear) would be missed at initial evaluation.

Recent literature has demonstrated that conventional arthroscopic techniques do not adequately visualise areas of predilection of pathology of the long head of biceps (LHB) tendon and are associated with a 30–50% rate of missed diagnoses. The aim of this study was to evaluate the safety, effectiveness and ease of performing biceps tenoscopy as a novel strategy for reducing the rate of missed diagnoses.

Five forequarter amputation cadaver specimens were studied. The pressure in the anterior compartment was measured before and after surgical evaluation. Diagnostic glenohumeral arthroscopy was performed and the biceps tendon was tagged to mark the maximum length visualised by pulling the tendon into the joint. Biceps tenoscopy was performed using 3 different techniques (1. Flexible video-endoscopy, 2. Standard arthroscopy via Neviaser portal. 3. Standard arthroscope via antero-superior portal with retrograde instrumentation). Each was assessed for safety, ease of the procedure and whether the full length of the extra-articular part of the LHB tendon could be visualised. The t-test was used to compare the length of the LHB tendon visualised at standard glenohumeral arthroscopy vs that visualised at biceps tenoscopy. An open dissection was performed after the arthroscopic procedures to evaluate for an iatrogenic injury to local structures.

Biceps tenoscopy allowed visualisation to the musculotendinous junction in all cases. The mean length of the tendon visualised was therefore significantly greater at biceps tenoscopy (104 mm) than at standard glenohumeral arthroscopy (33 mm) (mean difference 71 mm, p<0.0001). Biceps tenoscopy was safe with regards to compartment syndrome and there was no difference between pre- and post-operative pressure measurements (mean difference 0 mmHg, p=1). No iatrogenic injuries were identified at open dissection.

Biceps tenoscopy allows excellent visualisation of the entire length of the LHB tendon and therefore has the potential to reduce the rate of missed diagnoses. This study did not demonstrate any risk of iatrogenic injury to important local structures or any risk of compartment syndrome. Clinical evaluation is required to further validate this technique.

The majority of studies reporting sensitivity and specificity data for imaging modalities and physical examination tests for long head of biceps (LHB) tendon pathology use arthroscopy as the gold standard. However, there is little published data to validate this as an appropriate benchmark. The aim of this study was to determine the maximum length of the LHB tendon that can be seen at glenohumeral arthroscopy and whether it allows adequate visualisation of common sites of pathology.

Seven female cadaveric specimens were studied. Mean age was 74 years (range 44–96 years). Each specimen underwent arthroscopy in lateral decubitus (LD) and beach chair (BC) positions. The LBH-tendon was tagged with a suture placed with a spinal needle marking the intra-articular length and the maximum excursions achieved using a hook and a grasper in both LD and BC positions. T-tests were used to compare data.

The mean intra-articular and extra-articular lengths of the tendon were 23.9 mm and 82.3 mm respectively. The mean length of tendon that could be visualised by pulling it into the joint with a hook was significantly less than with a grasper (LD: hook 29.9 mm, grasper 33.9 mm, mean difference 4 mm, p=0.0032. BC: hook 32.7 mm, grasper 37.6 mm, mean difference 4.9 mm, p=0.0001). Using the BC position allowed visualisation of a significantly greater length than the LD position when using either a hook (mean difference 2.86 mm, p=0.0327) or a grasper (mean difference 3.7 mm, p=0.0077). The mean length of the extra-articular part of the tendon visualised using a hook was 6 mm in LD and 8.9 mm in BC. The maximum length of the extra-articular portion visualised using this technique was 14 mm (17%).

Pulling the tendon into the joint with a hook does not allow adequate visualisation of common distal sites of pathology in either LD or BC. Although the BC position allows a significantly greater proportion of the tendon to be visualised this represents a numerically small value and is not likely to be clinically significant. The use of a grasper also allowed greater excursion but results in iatrogenic tendon injury which precludes its use. The reported incidence of pathology in Denard zone C (distal to subscapularis) is 80% and in our study it was not possible to evaluate this zone even by using a grasper or maximum manual force to increase excursion. This is consistent with the extremely high rate of missed diagnoses reported in the literature. Surgeons should be aware that the technique of pulling the LHB-tendon into the joint is inadequate for visualising distal pathology and results in a high rate of missed diagnoses. Furthermore, efforts to achieve greater excursion by “optimum” limb positioning intra-operatively do not confer an important clinical advantage and are probably unnecessary.

Purpose: The hypothesis of this randomized controlled trial is patients undergoing ACL reconstruction using contralateral hamstring harvest will have better quality of life and strength than using ipsilateral graft.

Method: One hundred participants were assigned to the ipsilateral (IG) or contralateral (CG) group. Primary and secondary outcomes were ACL Quality of Life (ACL-QOL) and concentric isovelocity knee flexion/extension strength measured on a dynamometer at five speeds. Data was gathered pre-surgery, and at 3, 6, 12, and 24 months post-surgery. Findings to 12 months are presented.

Results: ACL-QOL scores and knee flexion/extension strength were not significantly different between groups across time. Comparing side-to-side strength within each group, knee extension strength was consistently higher on the non-reconstructed side. In the IG, there were no side-to-side differences in knee flexion strength. In the CG, flexion on the reconstructed side was stronger than the grafted side early post surgery (3, 6 months) at 60 degrees/s, but this pattern was reversed at 90, 150, and 210 degrees/s. Post-hoc comparisons revealed hamstring/ quadriceps (H/Q) ratios were not different between limbs in the CG or for the uninvolved limb for the IG. However, at most time points and speeds, the H/Q ratio for the involved limb in the IG was higher than the uninvolved limb in the IG and either limb in the CG.

Conclusion: This study reveals that ipsilateral graft harvest may alter the H/Q ratio. It was also demonstrated that contralateral graft harvest may normalize this effect. This may have some bearing on function and re-injury risk that should be further investigated.

Purpose of the study: Posterior fracture-impaction of the humeral head (Hill-Sachs defect or Malgainge notch) is a well-known factor of failure for arthroscopic shoulder stabilisation procedures. Recently, Wolf proposed arthroscopic posterior capsulodesis and tenodesis of the infraspinatus, or what we call in French Hill-Sachs Remplissage (filling). We hypothesised that capsule and tendon healing within the bony defect could explain the efficacy of this arthroscopic technique.

Material and methods: Prospective clinical study of a continuous series. Inclusion criteria:

recurrent anterior instability (dislocation or subluxation);

Exclusion criteria:

associated bone loss in the glenoid;

Twenty shoulders (20 patients) met the inclusion and exclusion criteria and underwent Hill-Sachs remplissage. Four orthopaedic surgeons evaluated independently the soft tissue healing in the humeral defect. Mann-Whitney analysis was used to search for a link between rate of healing and clinical outcome.

Results: Filling of the humeral defect reached 75 to 100% in 16 patients (80%°; it was 50–75% in 4 patients. Healing was never noted less than 50%. The short-term clinical outcome (mean follow-up 11.4 months, range 6–32) showed an excellent results as assessed by the Constant score (mean 92±8.9 points) and the Walch-Duplay score (91 points). The subjective shoulder value (SSV) was 50% preoperatively and 89% at last follow-up. There were no cases of recurrent instability. This study was unable to establish a relationship between minor healing and less favourable clinical outcome.

Discussion: This study confirmed our hypothesis that arthroscopic Hill-Sachs remplissage provides a high rate of significant healing in a majority of patients. Capsule and tendon healing in the humeral defect yields significant shoulder stability via at least two mechanisms:

prevention of defect engagement on the anterior border of the glenoid and

Further mid- and long-term results will be needed to establish a confirmed correlation between healing and clinical outcome.

Purpose of the study: The purpose of this study was to determine the feasibility and reproducibility of a new arthroscopic procedure combining a Bristow-Latarjet lock with Bankart reinsertion of the lambrum.

Material and methods: Forty-seven consecutive patients with significant bone defects in the glenoid and a deficient capsule were treated arthroscopically: arthroscopic Bankart had failed in six. The procedure was performed exclusively arthroscopically using a special instrumentation: after its osteotomy and identification of the axiallary nerve, the coracoids was passed through the subcapular muscle with its tendon; the block was fixed on the scapular neck after 90° lateral rotation so as to prolong the natural concavity of the glenoid. Anchors and sutures were then used to refix the capsule and the labrum onto the glenoid border, leaving the block in an extra-articular position. Follow-up included a physical examination and standard x-rays at 45, 90 and 180 days; 31 patients had a postoperative scan. Three independent operators read the images.

Results: The procedure was completed arthroscopically in 41 of 47 patients (8%); conversion to a deltopectoral approach was required for six patients (12%). The axillary nerve was successfully identified in all shoulders. The block had a subequatorial position in 98% (46/47 shoulders) and equatorial in one. The block was tangent to the surface of the glenoid in 92% (43/47), lateral in one (2%) and too medial (> 5mm) in three (6%). One patient presented an early fracture of the block and five patients exhibited block migration; there was a partial lysis of the block in two patients. The final rate of nonunion of the block was 13% (6/47). Fractures, migrations and non-unions were related to technical errors: screws too short (unicortical) and/or poorly centred in the block.

Conclusion: Our results show that arthroscopic transfer of the coracoids to the scapular neck is a safe and successful operation. The rate of correctly positioned healed blocks was equivalent or superior to conventional techniques. The complications observed show that the arthroscopic block technique is difficult with a long learning curve.

Purpose: The “Hill-Sachs Remplissage” (HSR) is a procedure used in the treatment of anterior shoulder instability associated with an engaging Hill-Sachs (HS) defect. It consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon within the defect. There is currently no evidence that the capsule and tendon heal in the humeral bone defect. Our hypotheses were

that the capsulotenodesis heals in the HS defect and fills at least 50% of its area; and,

Method: Prospective clinical study. Inclusion criteria:

recurrent anterior shoulder instability;

Exclusion criteria:

glenoid bone loss;

Twenty-nine patients underwent an arthroscopic Bankart repair plus HSR. Clinical assessment at a mean follow up of 13.1 months (range 6 to 32 months) consisted of a structured interview and detailed physical examination including range of motion compare to the contralateral shoulder and instability signs. Range of motion was analyzed in two groups according to length of follow-up, Group 1 with less than 12 months follow-up (14 patients); and Group 2 with greater than 12 months follow-up (15 patients). Either a CT arthrogram (25 patients) or an Arthro-MRI (2 patient) was performed at a minimum of six months postoperatively. Four orthopaedic surgeons analyzed the images independently to determine the percentage of healing of the capsulotenodesis.

Results: There was no recurrence of instability at the latest follow-up. There was no statistically significant deficit in forward elevation in either group. Group 1 patients had statistically significant mean deficits as compared to the contralateral side of 15 degrees of external rotation in adduction (ER1), 15 degrees of external rotation at 90 degrees of abduction (ER2), and 1.1 points of internal rotation in adduction according to the Constant score system (ER1). Group 2 patients had statistically significant mean deficits of 4 degrees of ER1 and 11 degrees of ER2, with no significant difference in IR1. There was healing of the capsulotenodesis within the bone defect in all twenty-seven patients. The bone defect was filled more than 75% of its surface in 22 of 29 patients (76%). The remaining seven had between 50 and 75% filling (24%). There was no defect filling of less than 50% in this study.

Conclusion: We demonstrated greater than 50% HS defect filling in all patients in our series after an arthroscopic “Hill-Sachs Remplissage” and filling > 75% in 22 of 29 (76%). Modest deficits of external rotation were demonstrated at greater than 12 months follow-up. While these results suggest that the technical goal of HS defect filling is achievable, longer term studies are necessary to establish whether there is an association between the rate of healing, the functional impairment of external rotation and clinical outcomes.

Introduction: The aim of this study was to assess the outcomes of patients with recurrent antero-inferior gle-nohumeral instability with associated antero-inferior glenoid bone loss treated with a specific open stabilisation technique, using intra-substance coracoid bone grafting. It is hypothesised that this method of reconstruction produces low recurrence of instability as well potential for patients to return to high-risk sport.

Methods: 30 shoulders with recurrent anterior dislocation and glenoid bone loss were stabilised with open capsular and labral repair and intra-substance coracoid bone grafting. Motion and stability were assessed by Rowe Stability Score (RSS) with follow-up over 2 years in all cases. American Shoulder and Elbow Score (ASES) and Oxford Stability Scoring (OSS) were also recorded at follow-up. Intention to and actual return to sporting level was assessed. Union of the graft was confirmed by CT scan.

Results: For all 30 shoulders at a mean follow-up time of 2 years 11 months (range 2–5 years) the RSS improved from a mean of 32 to 78.5 post-op. 1 redislocation occurred whilst continuing high-risk sport after 2 years. ASES index at 2 years had a mean of 91.8 whilst the OSS was 18.5. Pre-operatively, 24 patients participated in high-risk sport. 20 intended to return to high-risk sport post operatively. 18 achieved this return without restriction. CT scans were available on 25 shoulders at a mean of 4.5 months after surgery. 1 showed slight resorption of the graft, union was confirmed in 23.

Conclusion: This small sample shows an overall acceptable clinical and radiological outcome at a minimum of 2-year follow-up. These results support the current literature advocating open stabilisation and bone grafting of the glenoid where loss is evident, particularly in the young contact athlete with recurrent instability and high expectations of success.