Epinephrine in irrigation fluid for visual clarity in arthroscopic shoulder surgery: a systematic review and meta-analysis.

PURPOSE: To investigate whether epinephrine in irrigation fluid improves visual clarity in arthroscopic shoulder surgery. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the surgical outcomes of patients who did and did not receive epinephrine during arthroscopic shoulder surgery. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for relevant RCTs. We used the Cochrane Collaboration's tool to assess the risk of bias and adopted random-effects model meta-analysis to combine data. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to evaluate the overall quality of the body of the retrieved evidence. The primary outcome was visual clarity. The secondary outcomes were operative time, amount of irrigation fluid, the need for increased pump pressure, and adverse cardiovascular events. RESULTS: This study included three RCTs with a total of 238 participants (124 in the epinephrine group and 114 in the non-epinephrine group). The use of epinephrine in irrigation fluid for shoulder arthroscopy achieved better visual clarity (standardized mean difference, 1.01; 95% confidence interval [CI] 0.63 to 1.39; p < 0.0001) and less need for increased pump pressure (risk ratio, 0.40; 95% CI 0.25 to 0.64; p = 0.0001) compared to the non-epinephrine group. No significant differences were noted in operative time (mean difference - 5.08; 95% CI - 14.46 to 4.31; p = 0.29) and amount of irrigation fluid (mean difference - 1.04; 95% CI - 2.38 to 0.39; p = 0.12) between the two groups. No adverse events were recorded in any of the included trials. CONCLUSIONS: The current evidence shows that the use of epinephrine in arthroscopic shoulder surgery may improve visualization and does not appear to have any major disadvantages. LEVEL OF EVIDENCE: Level I.

The "bridging sign": a MR finding for combined full-thickness tears of the subscapularis tendon and the supraspinatus tendon.

BACKGROUND: In daily practice, we discovered one of the secondary magnetic resonance (MR) findings of the subscapularis (SSC) tendon tear, the "bridging sign", which has not been previously described. PURPOSE: To describe the "bridging sign" on shoulder MR imaging and its radiological and clinical significance in patients with SSC tendon tear. MATERIAL AND METHODS: Twenty-nine patients who had undergone shoulder arthroscopy and had full-thickness tear of the subscapularis tendon were enrolled. The medical records of the 29 patients were retrospectively reviewed for the duration of shoulder pain, rotator cuff tears, and associated arthroscopic findings: biceps tendon abnormality and superior glenoid labral tear. Then, preoperative shoulder MR images were retrospectively reviewed for the presence or absence of the "bridging sign" and associated MR findings: periarticular fluid and fatty atrophy of the supraspinatus and subscapularis muscles. The type of rotator cuff tear associated with the "bridging sign" was assessed and the sensitivity, specificity, and accuracy of the "bridging sign" for the diagnosis of a certain type of rotator cuff tear were calculated. Associated arthroscopic and MR findings and mean duration of the shoulder pain between the patients with and without the "bridging sign" were compared. RESULTS: The "bridging sign" was seen in 17 of 29 patients and corresponded to a complex of the torn and superomedially retracted subscapularis tendon, coracohumeral ligament, and superior glenohumeral ligament, adhered to the anterior margin of the torn supraspinatus (SSP) tendon on arthroscopy. All patients with the "bridging sign" had combined full-thickness tear (FTT) of the cranial 1/2 portion of the subscapularis tendon and anterior 1/2 portion of the SSP tendon. The sensitivity, specificity, and accuracy of the "bridging sign" for the diagnosis of combined FTTs of the SSC tendon and anterior portion of the SSP tendon were 81.0%, 100%, and 86.2%, respectively. The patients with the "bridging sign" had longer duration of shoulder pain and more frequent associated arthroscopic and MR findings than the patients without the "bridging sign". CONCLUSION: The "bridging sign" is a highly specific finding for combined full-thickness tears of the subscapularis tendon and anterior portion of the supraspinatus tendon, associated with more chronic shoulder pain and more sever rotator cuff tear.

Three-dimensional isotropic shoulder MR arthrography: comparison with two-dimensional MR arthrography for the diagnosis of labral lesions at 3.0 T.

PURPOSE: To compare the diagnostic accuracy of three-dimensional (3D) isotropic magnetic resonance (MR) arthrography with two-dimensional (2D) MR arthrography for the diagnosis of labral lesions of the shoulder performed by using a 3.0-T imager. MATERIALS AND METHODS: Institutional review board approval was given for this retrospective study and informed consent was waived. From March 2006 to January 2007, 100 patients underwent 3D isotropic and 2D MR shoulder arthrographic imaging by using a 3.0-T imager and subsequent arthroscopic surgery. The 3D isotropic sequences were performed by using fast gradient-echo imaging with fat suppression (voxel size, 0.6 x 0.6 x 0.6 mm; imaging time, 5 minutes 32 seconds) and were evaluated for the presence of superior, anterior, and posterior labral lesions by using 3D isotropic and 2D MR arthrography. The statistical differences between the sensitivity and specificity for both methods were analyzed by using the McNemar test, with arthroscopic findings regarded as reference standard. RESULTS: Surgical findings confirmed 53 superior labral anterior posterior (SLAP) lesions, 17 anterior labral lesions, and five posterior labral lesions. Respective sensitivity and specificity were 85% and 96% for SLAP lesions, 100% and 98% for anterior labral lesions, and 80% and 99% for posterior labral lesions by using 2D MR arthrography and 83% and 96% for SLAP lesions, 100% and 96% for anterior labral lesions, and 80% and 99% for posterior labral lesions by using 3D isotropic MR arthrography. There was no significant difference in sensitivities and specificities of both methods; however, the power of this study was limited and larger comparison is needed. CONCLUSION: Isotropic 3D shoulder MR arthrography combined with a multiplanar reconstruction technique can help in the diagnosis of shoulder labral lesions as does 2D MR arthrography, but with shorter imaging times.

Comparison of indirect isotropic MR arthrography and conventional MR arthrography of labral lesions and rotator cuff tears: a prospective study.

OBJECTIVE: The purpose of our study was to prospectively compare the diagnostic accuracy of 3D isotropic indirect MR arthrography with conventional sequences of indirect MR arthrography for the diagnosis of labral and rotator cuff lesions on a 3-T MR unit. SUBJECTS AND METHODS: Thirty-six consecutive patients who were scheduled for shoulder arthroscopic surgery at our institution underwent indirect MR arthrography. Both conventional sequences and an additional 3D isotropic sequence were obtained 1 day before arthroscopic surgery. Two musculoskeletal radiologists prospectively evaluated the images in consensus for the presence of superior and anterior labral lesions and subscapularis and supraspinatus-infraspinatus tendon tears using the conventional sequences and the 3D isotropic sequence. We analyzed the statistical difference between the sensitivities and specificities of both methods using arthroscopic findings as the reference standard. RESULTS: Surgical findings confirmed the presence of 23 superior labral lesions, eight anterior labral lesions, 21 subscapularis tears, and 24 supraspinatus-infraspinatus tears. The sensitivity and specificity of the conventional sequences were 74% and 54% for superior labral lesions, 88% and 96% for anterior labral lesions, 67% and 85% for subscapularis tendon tears, and 96% and 75% for supraspinatus-infraspinatus tendon tears. The sensitivity and specificity of the 3D isotropic sequence were 70% and 85% for superior labral lesions, 100% and 100% for anterior labral lesions, 67% and 85% for subscapularis tendon tears, and 96% and 67% for supraspinatus-infraspinatus tendon tears. No statistically significant difference was seen in sensitivities and specificities for both methods. CONCLUSION: Three-dimensional isotropic MR arthrography sequences with multiplanar reconstruction can provide a similar capability for the diagnosis of labral and rotator cuff lesions as conventional MR arthrography sequences but in a shorter imaging time.

Comparison study of indirect MR arthrography and direct MR arthrography of the shoulder.

OBJECTIVE: To compare the diagnostic value of indirect magnetic resonance arthrography (I-MRA) with that of direct MR arthrography (D-MRA) for labral tears, rotator cuff tears, and long head of biceps tendon (LHBT) tears using a 3-T MR unit. MATERIALS AND METHODS: Institutional review board approval was given; written informed consent was obtained from all patients. From November 2005 to June 2006, 19 patients (eight men and 11 women; mean age, 51 years) who had undergone both I-MRA and D-MRA underwent arthroscopic surgery. Both methods were performed in fat-saturated axial, coronal oblique, and sagittal oblique T1-weighted sequences, as well as axial and coronal oblique T2-weighted sequences. Two radiologists independently and retrospectively evaluated two sets of MRA for the diagnosis of superior and anterior labral tears, subscapularis tendon (SSC), and supraspinatus-infraspinatus tendon (SSP-ISP) tears, and LHBT tears. With the arthroscopic finding as a gold standard, we analyzed statistical differences of sensitivities and specificities between two sets of MRA and inter-observer agreement was evaluated using the kappa value. RESULTS: The sensitivity and specificity of I-MRA and D-MRA for reader 1 were 79/80% and 71/80%, respectively, for superior labral tears; 100/100% and 100/100%, respectively, for anterior labral tears; 64/75% and 64/100%, respectively, for SSC tears; 100/86% and 100/100%, respectively, for SSP-ISP tears; and 67/100% and 78/100%, respectively, for LHBT tears. Those of I-MRA and D-MRA for reader 2 were 86/80% and 71/100%, respectively, for superior labral tears; 100/83% and 100/100%, respectively, for anterior labral tears; 64/88% and 82/100%, respectively, for SSC tears; 92/86% and 100/100%, respectively, for SSP-ISP tears; and 78/90% and 89/100%, respectively, for LHBT tears. No significant differences were found between the methods. Inter-observer agreements were higher than moderate (kappa > 0.41) with both methods. CONCLUSIONS: Based on a relatively small number of patients, no significant difference was detected between I-MRI and D-MRI with regard rotator cuff, labral, and LHBT tears.

Effectiveness of Fiber Reinforcement on the Mechanical Properties and Shrinkage Cracking of Recycled Fine Aggregate Concrete.

This paper presents an experimental study conducted to investigate the effect of fiber reinforcement on the mechanical properties and shrinkage cracking of recycled fine aggregate concrete (RFAC) with two types of fiber-polyvinyl alcohol (PVA) and nylon. A small fiber volume fraction, such as 0.05% or 0.1%, in RFAC with polyvinyl alcohol or nylon fibers was used for optimum efficiency in minimum quantity. Additionally, to make a comparative evaluation of the mechanical properties and shrinkage cracking, we examined natural fine aggregate concrete as well. The test results revealed that the addition of fibers and fine aggregates plays an important role in improving the mechanical performance of the investigated concrete specimens as well as controlling their cracking behavior. The mechanical properties such as compressive strength, splitting tensile strength, and flexural strength of fiber-reinforced RFAC were slightly better than those of non-fiber-reinforced RFAC. The shrinkage cracking behavior was examined using plat-ring-type and slab-type tests. The fiber-reinforced RFAC showed a greater reduction in the surface cracks than non-fiber-reinforced concrete. The addition of fibers at a small volume fraction in RFAC is more effective for drying shrinkage cracks than for improving mechanical performance.

Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder.

BACKGROUND: The purpose of this study was to evaluate the results of arthroscopic treatment of traumatic unidirectional recurrent posterior subluxation of the shoulder. METHODS: We treated twenty-seven patients who had traumatic unidirectional recurrent posterior subluxation of the shoulder with arthroscopic labral repair and posterior capsular shift, and we evaluated them at a mean of thirty-nine months postoperatively. Patients who had posteroinferior instability, multidirectional instability, or an atraumatic onset or who were undergoing revision were excluded. There were twenty-five male and two female patients with a mean age of twenty-one years (range, fourteen to thirty-three years). All patients were involved in sports activity, and all had had a substantial injury prior to the onset of the instability. Results were assessed on the basis of stability, motion, and UCLA (University of California at Los Angeles), ASES (American Shoulder and Elbow Surgeons), and Rowe scores. Pain and function were also evaluated with visual analog scales. RESULTS: All patients had one or more lesions in the posteroinferior aspect of the labrum and capsule. The most common finding was incomplete stripping of the posteroinferior aspect of the labrum (eighteen patients). At the arthroscopy, the posteroinferior aspect of the capsule appeared to be stretched in twenty-two patients. At the time of follow-up, all patients had improved shoulder function and scores (p < 0.01). All patients also had a stable shoulder according to subjective and objective measurements, except for one patient who had recurrent subluxation. Except for that patient, all patients were able to return to their prior sports activity with little or no limitation. Shoulder function was graded as >90% of the preinjury level in twenty-four patients. There were twenty-one excellent UCLA scores, five good scores, and one fair score. The average pain score improved from 4.5 points preoperatively to 0.2 point at the time of follow-up (p < 0.0001). The mean loss of internal rotation was one vertebral level. There were no operative complications. CONCLUSIONS: Arthroscopic posterior labral repair and capsular shift to treat traumatic unidirectional recurrent posterior subluxation is a reliable procedure with respect to providing stability, pain relief, and functional restoration.

Kim's lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder.

PURPOSE: The purpose of this article is to report a new clinical entity of posterior instability of the shoulder and the results of its treatment. TYPE OF STUDY: Case series. METHODS: The Kim's lesion, which is an incomplete and concealed avulsion of the posteroinferior labrum, was arthroscopically identified in 15 patients who presented with posterior or multidirectional posteroinferior instability. Patients were treated by arthroscopic labroplasty and capsular shift. At a minimum follow-up of 2 years, the outcome was evaluated using subjective (pain and function visual analogue scale) and objective (UCLA, ASES, and Rowe scores) measurements. RESULTS: When visualized under an arthroscope, Kim's lesion apparently had an intact labral attachment and appeared to have a superficial crack at the junction between the articular cartilage of the glenoid and the posteroinferior labrum. However, probing of the lesion revealed detachment of the deep portion of the posteroinferior labrum. The posteroinferior labrum was flat with loss of normal height, which resulted in the retroversion of the chondrolabral glenoid. Incision of the superficial portion of the lesion exposed a loose deep portion of the labrum. Labroplasty was performed to restore the labral height, as well as capsular shift with or without rotator interval closure. The surgical outcome was satisfactory in 14 patients and unsatisfactory in 1 patient. Shoulders were stable in all patients with unidirectional posterior instability. There was 1 recurrence of multidirectional posteroinferior instability. CONCLUSIONS: Kim's lesion is an incomplete avulsion of the posteroinferior labrum, which is concealed by apparently intact superficial portion. The clinical significance of this lesion is the need for surgeons to convert this concealed incomplete lesion to a complete tear and repair it with the posterior band of the inferior glenohumeral ligament. A failure to address this lesion may result in persistent posterior instability. LEVEL OF EVIDENCE: Level IV, therapeutic, Case Series.

Clinical results of single-tunnel coracoclavicular ligament reconstruction using autogenous semitendinosus tendon.

BACKGROUND: Over 60 repair/reconstruction techniques have been described for the treatment of coracoclavicular (CC) ligament injuries. PURPOSE: To report the functional and radiological outcomes of single-tunnel CC ligament reconstruction using autogenous semitendinosus tendon. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between August 2005 and January 2008, a total of 21 patients, 16 patients (14 men, 2 women) with a Rockwood type IV, type V, or a chronic type III acromioclavicular (AC) dislocation and 5 patients (4 men, 1 woman) with a painful nonunited distal clavicle fracture with CC separation, underwent CC reconstructive surgery using a semitendinosus autograft. All 21 patients were followed up clinically and radiographically. The mean follow-up was 33 months (range, 18-47), and the mean patient age was 39.8 years (range, 18-70). Chronic type III AC dislocations and nonunited distal clavicle fractures with CC separation were scored using preoperative AC scoring (AC Joint Separation Questionnaire). Constant, University of California-Los Angeles (UCLA), and AC scores were evaluated for all patients at final follow-up. RESULTS: At the final follow-up, 10 patients achieved an "excellent" result and 11 a "good" result according to the AC scoring scheme. Mean final Constant and UCLA scores were 84.7 (range, 67-94) and 30.0 (range, 23-35), respectively. In the antero-posterior (AP) plane, 17 (81%) of the 21 patients maintained complete reduction, and 1 of the remaining 4, a manual laborer, had complete reduction loss. Of the 17 patients with an axillary view at final follow-up, 1 patient (5.9%) showed partial subluxation, although no subluxation was observed in the AP radiograph. The other 16 patients (94.1%) had a complete reduction state in axillary view. CONCLUSION: Single-tunnel CC reconstruction with an autogenous hamstring tendon graft after a mean follow-up of 33 months (range, 18-47) appears to be a satisfactory means of treating acute Rockwood type IV, V, chronic type III, and painful nonunited distal clavicle fractures with CC separation.

An osteolytic meningioma en plaque of the sphenoid ridge.

Meningioma en plaque (MEP) is a rare tumor characterized more by its clinical and biological behavior than its histological appearance. Hyperostosis of the skull is one of the characteristic signs of MEP. This bony change can produce clinical symptoms and signs in MEP by pressing against adjacent structures. The authors report a rare case of an osteolytic MEP extending from the sphenoid wing into the orbital wall, middle fossa, and temporalis muscle.