Effect of a Preoperative Subacromial Epinephrine Injection on Visualization During Shoulder Arthroscopic Surgery: A Randomized Controlled Trial.

Background: The addition of epinephrine to arthroscopic irrigation fluid has been shown to improve surgeon-rated visual clarity during shoulder arthroscopic surgery. Subacromial injections of epinephrine are also used for this purpose. Purpose/Hypothesis: To assess the influence of a preoperative subacromial epinephrine injection on surgeon visualization during subacromial shoulder arthroscopic surgery. It was hypothesized that the epinephrine injection would improve surgeon-rated visual clarity. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A double-blind randomized controlled trial including adult patients undergoing shoulder arthroscopic surgery in the beach-chair position requiring visualization of the subacromial space was performed. Patients in the epinephrine group (n = 30) received a preoperative subacromial injection of bupivacaine and epinephrine, and those in the control group (n = 30) received a preoperative subacromial injection of bupivacaine. Epinephrine was added to the first 10 L of arthroscopic irrigation fluid in all patients. The primary outcome was surgeon-rated visual clarity throughout the procedure that was recorded at the end of the procedure using a visual analog scale (VAS) scored from 0 (worst) to 10 (best). Secondary outcomes included an increase in pump pressure during the procedure, total operative time, and the intraoperative use of blood pressure-modulating medications. Results: Rotator cuff repair was performed in 88.3% of patients (25/30 epinephrine; 28/30 control), with multiple procedures performed in 85.0% of patients (23/30 epinephrine; 27/30 control). The VAS score for visual clarity was slightly better in the epinephrine group compared with the control group, although the difference was neither statistically nor clinically significant (8.3 ± 1.4 vs 7.5 ± 1.8, respectively; P = .09). There was no difference between the epinephrine and control groups in the need for an increase in pump pressure to improve visualization (8/30 [26.7%] vs 7/30 [23.3%], respectively; P > .99), total operative time (62.0 ± 19.4 vs 64.0 ± 30.1 minutes, respectively; P = .90), or the intraoperative use of blood pressure-modulating medications (20/30 [66.7%] vs 17/30 [56.7%], respectively; P = .60). There were no perioperative adverse events in either group. Conclusion: The addition of a subacromial epinephrine injection before shoulder arthroscopic surgery resulted in a small improvement in visual clarity that was neither statistically nor clinically significant, with no adverse effects reported in this study. Registration: NCT05244525 (ClinicalTrials.gov).

Occupational Radiation Exposure During Intraoperative 3-Dimensional Fluoroscopy in Pelvis and Acetabular Surgery.

OBJECTIVES: To quantify the occupational radiation exposure with a 3-dimensional (3D) fluoroscopic machine during routine use in pelvic and acetabular surgery and to determine whether the additional radiation exposure encountered with the 3D fluoroscopic spin is within previously accepted limits. DESIGN: Prospective cohort study. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: All patients undergoing 3D fluoroscopy intraoperatively during pelvis (OTA/AO 61B,C) or acetabular (OTA/AO 62A-C) surgery between April 2021 and July 2021. OUTCOME MEASURES AND COMPARISONS: Radiation dose at standardized locations around the operating room during the spin portion of the 3D fluoroscopy. RESULTS: Seventy-six 3D spins were performed on 69 patients during the study period. The average emitted radiation dose from the machine for the routine fluoroscopy portion of the case was 74.5 mGy. The average displayed radiation dose in the air for the spin portion of the case was 39.9 mGy, an average of 53.6% less radiation than the routine fluoroscopy portion. For the spin portion, the average radiation exposure seen by the patient was 3.42 mGy (centered on the patient) and the average maximal exposure in the room was 0.062 mGy. Minimal radiation was detected outside the operating room doors. CONCLUSIONS: The radiation exposure encountered by operating room personnel with 3D fluoroscopy appears to be within safe occupational limits. The marginal increase in radiation exposure during pelvic and acetabular surgery should not discourage the use of 3D imaging intraoperatively. LEVEL OF EVIDENCE: Level IV, Case Series.

Tunnel-free acromioclavicular joint reconstruction is associated with improved initial reduction and higher patient satisfaction.

Background: Many surgical techniques have been described for acromioclavicular (AC) joint reconstruction. Creation of bone tunnels through the clavicle or coracoid has been shown to be a risk factor for fracture. Use of an AC reconstruction technique that does not create bone tunnels may obviate this risk. This study aims to evaluate clinical outcomes of AC joint reconstruction using a tunnel-free technique compared to reconstruction using a cortical button and clavicular drill holes. Methods: Consecutive patients who underwent AC joint reconstruction by a single surgeon in a subspecialty referral practice were included. One group of patients received cortical button fixation (button group), in which sutures were passed around the coracoid, brought up through a drill hole in the clavicle, and tied over a cortical button. The other group of patients received tunnel-free fixation, in which a self-locking tape suture was passed in a cerclage fashion around the base of the coracoid and the clavicle and tensioned with a tensioning device (cerclage group). Both groups underwent reconstruction of the coracoclavicular (CC) ligament and AC joint capsule using tibialis anterior allograft. Patient-reported outcome scores and satisfaction were collected and compared between groups. Radiographs were reviewed to evaluate CC ligament distance and loss of reduction. Results: Twenty-two patients were included in the study (button n = 10, cerclage n = 12). Preoperative demographics and injury characteristics were not different between groups. Average radiographic follow-up was not different between groups (button: 231 days, cerclage: 105 days). Postoperative American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores were similar between groups. Two postoperative clavicle fractures were sustained in the button group. These occurred through clavicular drill holes and were preceded by tunnel widening. No fractures occurred in the cerclage group. CC distance at initial follow-up was significantly less in the cerclage group (button: 11.2 ± 4.5 mm, cerclage: 7.0 ± 2.9 mm, P =.023). Loss of reduction was similar throughout the postoperative period (button: 4.3 ± 2.6 mm, cerclage: 4.8 ± 4.1 mm, P >.05. Forty percent of patients were unsatisfied with their clavicle after button fixation (n = 4/10), compared with zero after cerclage fixation (n = 0/12, P =.03). Reasons for dissatisfaction were fracture (n = 2) and persistent cosmetic deformity (n = 2). Conclusion: Tunnel-free AC joint reconstruction is associated with improved initial radiographic appearance and patient satisfaction compared to single cortical button fixation. Postoperative clavicle fracture and persistent cosmetic deformity drive patient dissatisfaction, which may be minimized by avoiding clavicular drill holes and using a tensioned self-locking cerclage suture to improve initial reduction.

A Retrospective Study of the Adjunctive Use of Gabapentin With Benzodiazepines for the Treatment of Benzodiazepine Withdrawal.

Benzodiazepine withdrawal is a widespread problem with potentially severe and deadly consequences. Currently, the only medications available for treating benzodiazepine withdrawal are short-acting and long-acting benzodiazepines. Identifying other drugs to help in treating benzodiazepine withdrawal is necessary. Gabapentin, an anxiolytic drug that is also used off-label to treat alcohol withdrawal, is a potential candidate for modulating benzodiazepine withdrawal. Using electronic records from a large inpatient psychiatric facility, a retrospective study of 172 patients presenting with benzodiazepine withdrawal was conducted to determine if the coincidental use of gabapentin for other medical conditions was associated with better outcomes of benzodiazepine withdrawal (N=57 gabapentin, N=115 no gabapentin). The primary outcomes were hospital length of stay and total amount of benzodiazepines given (lorazepam milligram equivalent). In this retrospective analysis of electronic medical record data, the patients experiencing benzodiazepine withdrawal who received gabapentin as an adjunct to the use of benzodiazepines were administered a smaller amount of benzodiazepines and had a shorter length of hospital stay relative to the comparison group who did not receive adjunctive gabapentin. These results suggest the potential use of gabapentin as an adjunct to the use of benzodiazepines for treating benzodiazepine withdrawal. The limitations of this study included a small sample size and variability in medication management strategies across the sample.

Control of Collagen Triple Helix Stability by Phosphorylation.

The phosphorylation of the collagen triple helix plays an important role in collagen synthesis, assembly, signaling, and immune response, although no reports detailing the effect this modification has on the structure and stability of the triple helix exist. Here we investigate the changes in stability and structure resulting from the phosphorylation of collagen. Additionally, the formation of pairwise interactions between phosphorylated residues and lysine is examined. In all tested cases, phosphorylation increases helix stability. When charged-pair interactions are possible, stabilization via phosphorylation can play a very large role, resulting inasmuch as a 13.0 °C increase in triple helix stability. Two-dimensional NMR and molecular modeling are used to study the local structure of the triple helix. Our results suggest a mechanism of action for phosphorylation in the regulation of collagen and also expand upon our understanding of pairwise amino acid stabilization of the collagen triple helix.