Suprascapular nerve release does not provide additional benefits in arthroscopic rotator cuff repair surgery: a systematic review and meta-analysis.

PURPOSE: To investigate the effect of suprascapular nerve release in arthroscopic rotator cuff repair surgery. METHODS: This systematic review was performed to include randomized controlled trials (RCTs) and non-RCTs that compared the outcomes of patients who did and did not receive suprascapular nerve release (SSNR) during arthroscopic rotator cuff repair surgery. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant studies. Methodological Index for Non-randomized Studies (MINORS) was used for cohort study assessment. The Cochrane risk of bias assessment tool (version 1.0) was used to assess the risk of bias in randomized trials. The primary outcomes were pain and shoulder function. The secondary outcome was the re-tear rate. RESULTS: Two RCTs and three non-RCTs with a total of 187 patients (90 patients received SSNR and 97 patients did not receive SSNR) were included in this systematic review. The meta-analysis revealed that the SSNR group did not had a more pain reduction, assessed by visual analogue scale, compared to the non-SSNR group. Also, the SSNR group did not have a significantly more improvement in the UCLA score, compared to the non-SSNR group. In addition, there was no significant difference between the two groups in terms of Constant score and re-tear rate. CONCLUSIONS: The result of this study showed that additional suprascapular nerve release did not provide additional benefit in arthroscopic rotator cuff repair surgery. Routine arthroscopic SSNR is not recommended when treating patients with rotator cuff tear. LEVEL OF EVIDENCE: Level III.

Pneumothorax, an Uncommon but Devastating Complication following Shoulder Arthroscopy: Case Reports.

Shoulder arthroscopy is a mature and widely used treatment to deal with various shoulder disorders. It enables faster recovery and decreases postoperative complications. However, some complications related to shoulder arthroscopy cannot be neglected because they could be life threatening. We presented three cases of various clinical manifestations of pneumothorax after shoulder arthroscopy. The first case was a 65-year-old female who underwent arthroscopic rotator cuff repair under general anesthesia and interscalene nerve block in the beach-chair position. The second case was a 58-year-old male undergoing arthroscopic rotator cuff repair and reduction in glenoid fracture under general anesthesia in the lateral decubitus position. The third case was a 62-year-old man receiving arthroscopic rotator cuff repair under general anesthesia in the lateral decubitus position. Each case's operation time was 90, 240, and 270 min. The pressure of the irrigation pumping system was 30, 50, and 70 mmHg, respectively. The second and third cases did not undergo interscalene nerve block. Although the incidence of pneumothorax following shoulder surgery and interscalene nerve block was only 0.2%, it is one of the most life-threatening complications following shoulder arthroscopy. In these cases, multifactorial factors, including patient positioning, interscalene nerve block, long surgical time, size of rotator cuff tears, and the pressure of the irrigation and suction system, can be attributed to the occurrence of pneumothorax. It is crucial to fully comprehend the diagnosis and management of pneumothorax to reduce the risk for patients receiving shoulder arthroscopy.

Correction: Liao et al. Twelve-Week Lower Trapezius-Centred Muscular Training Regimen in University Archers. Healthcare 2022, 10, 171.

The authors would like to make the following corrections to the published paper [...].

Twelve-Week Lower Trapezius-Centred Muscular Training Regimen in University Archers.

Archery is a fine-motor-skill sport, in which success results from multiple factors including a fine neuromuscular tuning. The present study hypothesised that lower trapezius specific training can improve archers' performance with concomitant changes in muscle activity and shoulder kinematics. We conducted a prospective study in a university archery team. Athletes were classified into exercise and control groups. A supervised lower trapezius muscle training program was performed for 12 weeks in the exercise group. The exercise program focused on a lower trapezius-centred muscular training. Performance in a simulated game was recorded as the primary outcome, and shoulder muscle strength, kinematics, and surface electromyography were measured and analysed. In the exercise group, the average score of the simulation game increased from 628 to 639 after the training regimens (maximum score was 720), while there were no such increases in the control group. The lower trapezius muscle strength increased from 8 to 9 kgf after training regimens and shoulder horizontal abductor also increased from 81 to 93 body weight% for the exercise group. The upper/lower trapezius ratio decreased from 2.2 to 1.1 after training. The lower trapezius exercise training regimen could effectively improve the performance of an archer with a simultaneous increase in shoulder horizontal abductor and lower trapezius muscle strength.

12-week curcumin supplementation may relieve postexercise muscle fatigue in adolescent athletes.

Introduction: High-intensity exercise causes oxidative stress, muscle soreness, and muscle fatigue, leading to reduced exercise performance. Curcumin possesses antioxidative and anti-inflammatory properties and thus alleviates postexercise damage. Therefore, this study evaluated the effect of curcumin on athletes' postexercise recovery. Methods: A non-randomized prospective cohort investigation was done. We recruited middle and high school athletes engaged in wrestling, soccer, and soft tennis. During the 12-week daily exercise training, the participants were assigned to receive curcumin supplementation (curcumin group) or not (control group). Body composition, exercise performance, inflammatory factors, muscle fatigue, and muscle soreness were recorded at the baseline and end of the study. We used the Mann-Whitney U test to compare the participants' demographics, such as age, height, weight, and training years. The Wilcoxon test was used to compare the differences between the groups before and after curcumin supplementation. Results: Of 28 participants (21 men and 7 women, with a mean age of 17 years), 13 were in the curcumin group and 15 in the control group. A significant decrease in muscle fatigue and muscle soreness scores was observed in the curcumin group after 12 weeks. Moreover, a significant decrease in the 8-hydroxy-2 deoxyguanosine level and a significant increase in basic metabolic rate and fat-free mass were observed in the curcumin group. Conclusion: Curcumin can reduce muscle fatigue and soreness after exercise, indicating its potential to alleviate postexercise damage. It could be considered to cooperate with nutritional supplements in regular training in adolescent athletes.

A Role of CXCL1 Drives Osteosarcoma Lung Metastasis via VCAM-1 Production.

Osteosarcoma, a common aggressive and malignant cancer, appears in the musculoskeletal system among young adults. The major cause of mortality in osteosarcoma was the recurrence of lung metastases. However, the molecular mechanisms of metastasis involved in osteosarcomas remain unclear. Recently, CXCL1 and CXCR2 have been crucial indicators for lung metastasis in osteosarcoma by paracrine releases, suggesting the involvement of directing neutrophils into tumor microenvironment. In this study, overexpression of CXCL1 has a positive correlation with the migratory and invasive activities in osteosarcoma cell lines. Furthermore, the signaling pathway, CXCR2/FAK/PI3K/Akt, is activated through CXCL1 by promoting vascular cell adhesion molecule 1 (VCAM-1) via upregulation of nuclear factor-kappa B (NF-κB) expression and nuclear translocation. The in vivo animal model further demonstrated that CXCL1 serves as a critical promoter in osteosarcoma metastasis to the lung. The correlated expression of CXCL1 and VCAM-1 was observed in the immunohistochemistry staining from human osteosarcoma specimens. Our findings demonstrate the cascade mechanism regulating the network in lung metastasis osteosarcoma, therefore indicating that the CXCL1/CXCR2 pathway is a worthwhile candidate to further develop treatment schemas.

Effect of chronic kidney disease on outcomes following proximal humerus fragility fracture surgery in diabetic patients: A nationwide population-based cohort study.

BACKGROUND: The proximal humerus fracture (PHF) is the third most common fragility fracture. Diabetes mellitus (DM) and chronic kidney disease (CKD) are both risks for fragility fractures; however, the interplay of DM and CKD makes treatment outcomes unpredictable. This study aimed to investigate and compare early and late outcomes following proximal humerus fracture fixation surgery in diabetic patients with different renal function conditions. METHODS: DM patients receiving PHF fixation surgery during 1998-2013 were recruited from Taiwan's National Health Insurance Research Database. According to their renal function, patients were divided into three study groups: non-chronic kidney disease (CKD), non-dialysis CKD, and dialysis. Outcomes of interest were early and late perioperative outcomes. Early outcomes included in-hospital newly-onset morbidities. Late outcomes included infection, revision, readmission, and all-cause mortality. RESULTS: This study included a total of 10,850 diabetic patients: 2152 had CKD (non-dialysis CKD group), 196 underwent permanent dialysis (dialysis group), and the remaining 8502 did not have CKD (non-CKD group). During a mean follow-up of 5.56 years, the dialysis group showed the highest risk of overall infection, all-cause revision, readmission, and mortality compared to the non-dialysis CKD group and non-CKD group. Furthermore, subgroup analysis showed that CKD patients had a higher risk of surgical infection following PHF surgery than non-CKD patients in cases with a traffic accident or fewer comorbidities (Charlson Comorbidity Index, CCI <3) (P for interaction: 0.086 and 0.096, respectively). Also, CKD patients had an even higher mortality risk after PHF surgery than non-CKD patients, in females, those living in higher urbanization areas, or with more comorbidities (CCI ≥3) (P for interaction: 0.011, 0.057, and 0.069, respectively). CONCLUSION: CKD was associated with elevated risks for infection, revision, readmission, and mortality after PHF fixation surgery in diabetic patients. These findings should be taken into consideration when caring for diabetic patients.

GMI, an Immunomodulatory Peptide from Ganoderma microsporum, Restrains Periprosthetic Joint Infections via Modulating the Functions of Myeloid-Derived Suppressor Cells and Effector T Cells.

Periprosthetic joint infections (PJIs) caused by Staphylococcus aureus infection are difficult to treat due to antibiotic resistance. It is known that the biofilms from methicillin-resistant S. aureus (MRSA) promote expansion of myeloid-derived suppressor cells (MDSCs) to suppress T-cell proliferation and benefit bacterial infections. This study finds that GMI, a fungal immunomodulatory peptide isolated from Ganoderma microsporum, suppresses MDSC expansion to promote the proliferation of cytotoxic T cells. The enhancement is likely attributed to increased expression of IL-6 and TNF-α and reduction in ROS expression. Similar beneficial effects of GMI on the suppression of MDSC expansion and IL-6 expression are also observed in the whole blood and reduces the accumulation of MDSCs in the infected bone region in a mouse PJI infection model. This study shows that GMI is potentially useful for treating S. aureus-induced PJIs.

Chronic Kidney Disease Is Associated with High Mortality Risk in Patients with Diabetes after Primary Shoulder Arthroplasty: A Nationwide Population-Based Cohort Study.

The number of diabetic patients with chronic kidney disease (CKD) undergoing shoulder arthroplasty is growing. This study aims to compare perioperative outcomes of shoulder arthroplasty in diabetic patients at different renal function stages. Between 1998 and 2013, a total of 4443 diabetic patients with shoulder arthroplasty were enrolled: 1174 (26%) had CKD without dialysis (CKD group), 427 (9%) underwent dialysis (dialysis group), and 3042 (68%) had no CKD (non-CKD group). Compared with the non-CKD group, the CKD (odds ratio [OR], 4.69; 95% confidence interval [CI], 2.02-10.89) and dialysis (OR, 6.71; 95% CI, 1.63-27.73) groups had a high risk of in-hospital death. The dialysis group had a high risk of infection after shoulder arthroplasty compared with the CKD (subdistribution hazard ratio [SHR], 1.69; 95% CI, 1.07-2.69) and non-CKD (SHR, 1.76; 95% CI, 1.14-2.73) groups. The dialysis group showed higher risks of all-cause readmission and mortality than the CKD and non-CKD groups after a 3-month follow-up. In conclusion, CKD was associated with worse outcomes after shoulder arthroplasty. Compared with those without CKD, CKD patients had significantly increased readmission and mortality risks but did not have an increased risk of surgical complications, including superficial infection or implant removal.

Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years: A Systematic Review and Meta-analysis.

BACKGROUND: There is no consensus regarding the best treatment approach for middle-aged patients with anterior cruciate ligament (ACL) injuries. Chronic ACL-deficient knees are often associated with instability as well as secondary meniscal and cartilage lesions. ACL reconstruction (ACLR) has achieved satisfactory outcomes in younger patients; however, the effectiveness and safety of ACLR in middle-aged patients remain uncertain. PURPOSE: To compare the patient-reported functional scores, arthrometric outcomes, and complications of primary ACLR between older (≥50 years) and younger (<50 years) patients. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: We conducted a systematic review of cohort studies that compared the clinical outcomes of ACLR between patients aged ≥50 years and those aged <50 years. The Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases were searched for relevant studies. The Methodological Index for Non-randomized Studies (MINORS) criteria was used to assess the risk of bias and conducted a random-effects meta-analysis to combine the data, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the overall quality of the body of retrieved evidence. The primary outcome was knee functional outcomes, and secondary outcomes were arthrometric outcomes of ACLR and complications. RESULTS: This study included 4 retrospective cohort studies with a total of 287 participants (129 in the older group and 158 in the younger group). All included studies reported significant improvements in clinical outcomes in both groups after ACLR. No significant differences were noted in the improvement of International Knee Documentation Committee (IKDC) scores (mean difference [MD], 0.20 [95% CI, -2.65 to 3.05]; P = .89) and Lysholm scores (MD, -1.98 [95% CI, -6.93 to 2.98]; P = .43) between the 2 groups. No significant differences were observed in anteroposterior stability or risk of complications between the groups. CONCLUSION: ACLR may be performed in middle-aged patients (≥50 years) without concern for inferior clinical and arthrometric results compared with younger patients (<50 years).

Effects of Chronic Kidney Disease on Hemiarthroplasty Outcomes for Fragility Hip Fracture in Diabetic Patients: A Nationwide Population-Based Observational Study.

BACKGROUND: The aim of this study is to compare perioperative outcomes, readmission, and mortality after hemiarthroplasty for hip fractures in diabetic patients with different renal function statuses. METHODS: In this retrospective population-based cohort study, diabetic patients who received primary hemiarthroplasty for hip fracture between January 1997 and December 2013 were identified from the Taiwan National Health Insurance Research Database. Primary outcomes were perioperative outcomes including infection and revision. Secondary outcomes were all-cause readmission and mortality. RESULTS: A total of 29,535 diabetic patients were included: 8270 patients had chronic kidney disease (CKD group), 1311 patients underwent permanent dialysis (dialysis group), and 19,954 patients did not have CKD (non-CKD group). During a mean follow-up of 4.5 years, these 3 groups had comparable risks of any infection, including superficial and deep infection. Dialysis patients had a significantly higher risk of revision than did CKD and non-CKD patients (subdistribution hazard ratio 1.65, 95% confidence interval 1.16-2.36; subdistribution hazard ratio 1.57, 95% confidence interval 1.10-2.24, respectively). Compared with the non-CKD group, the dialysis group had significantly higher risks of readmission and mortality at all time points, namely 3 months after surgery, 1 year after surgery, and the final follow-up. The CKD group also had higher risks of readmission and mortality than did the non-CKD group at all time points. CONCLUSION: CKD is associated with poor outcomes following hemiarthroplasty for fragility hip fracture. CKD patients may have higher risks of surgical complications including revision than non-CKD patients, and they have significantly elevated risks of readmission and mortality.

Depression increases the risk of rotator cuff tear and rotator cuff repair surgery: A nationwide population-based study.

BACKGROUND: Chronic inflammation is known to be associated with both rotator cuff tears (RCTs) and depression. However, no epidemiological studies with a longitudinal follow-up have been performed to prove this association. We aimed to investigate whether depressed patients had an elevated risk of RCT and subsequent repair surgery compared with those without depression. METHODS: This retrospective cohort study comprised of patients diagnosed with depression between 2000 and 2010 (depression cohort) and patients without depression (non-depression cohort, 1:2 age and sex matched). The risk of RCT and rotator cuff repair surgery were determined during a 13-year follow-up (2000-2013) between these two cohorts. RESULTS: This study included 26,868 patients with depression and 53,736 patients without depression. The incidence of RCT was 648 and 438 per 100,000 person-years in the depression and non-depression cohorts, respectively. The adjusted hazard ratio (HR) was 1.46 (95% confidence interval [CI], 1.36-1.57) for depressed patients. The incidence of rotator cuff repair surgery was 28 and 18 per 100,000 person-years in the depression and non-depression cohorts, respectively. Depressed patients also had a significantly increased risk of subsequent rotator cuff repair surgery (adjusted HR = 1.46; 95% CI, 1.04-2.06). CONCLUSION: The present study showed that depression was associated with an increased risk of rotator cuff tear and rotator cuff repair surgery.

The effects of high impact exercise intervention on bone mineral density, physical fitness, and quality of life in postmenopausal women with osteopenia: A retrospective cohort study.

Osteoporosis and osteopenia prevailed in postmenopausal women and predisposed to osteoporotic fractures that increase mortality, morbidity, and the cost of social care. Here, we investigated the effect of 24 weeks of aerobic dancing on the bone miner density, physical fitness and health-related quality of life (HRQoL) in postmenopausal women with osteopenia. Total 80 participants (control [CON]: 40; exercise [EX]: 40) were included in the final analysis. The EX group underwent a 24-week aerobic dance intervention. Bone mineral density (BMD), physical fitness, and SF-36 questionnaire were assessed at baseline and 24-weeks. The BMD change in the femoral neck at the 24-weeks were significantly different between the 2 groups (CON: -1.3 ±â€Š2.7%, EX: 3.1 ±â€Š4.6%, P = .001). Grip strength, sidestep and physical functional domain of HRQoL in the EX group were significantly improved compared to the CON. The results were suggested 24-week aerobic dance intervention could result in the lower the incidence of bone fracture through increasing BMD and decreasing fall risk for postmenopausal women.

Chronic Kidney Disease Worsens Health Outcomes in Diabetic Patients After Hip Fracture Surgery: An Asian Nationwide Population-Based Cohort Study.

There is an increased tendency for hip fractures in patients with chronic kidney disease (CKD). Although surgery is the mainstay of treatment for hip fractures, there is scant information on outcomes after hip fracture surgery in diabetic patients at different stages of CKD. In this population-based cohort study, we compared the surgical outcome, readmission, and mortality rates after osteosynthesis of hip fractures in diabetic patients with different stages of renal function. Diabetic patients who received primary osteosynthesis for hip fracture between January 1997 and December 2013 were enrolled. The primary outcomes were surgical outcomes, including infection and revision surgery. The secondary outcomes were all-cause readmission and mortality. This study included 44,065 patients; 11,954 had CKD (diabetic CKD group), 1662 patients were receiving dialysis (diabetic dialysis group), and 30,449 patients had no CKD (diabetic non-CKD group). We found that the diabetic dialysis group had a significantly higher risk of infection and revision surgery compared with diabetic non-CKD patients (HR = 1.52, 95% CI, 1.24 to 1.87; HR = 1.62, 95% CI, 1.33 to 1.97, respectively, both P < 0.001) and diabetic CKD patients (HR = 1.62, 95% CI, 1.32 to 1.99; HR = 1.48, 95% CI, 1.22 to 1.80, respectively, both P < 0.001). Diabetic CKD patients had a comparable risk of surgical complications including infection and revision as diabetic non-CKD patients. For readmission and mortality, the diabetic dialysis group had the highest risk among the three groups at all time-points (3 months after surgery, 1 year, and the last follow-up, all P < 0.001). Compared with the diabetic non-CKD group, the diabetic CKD group had an elevated risk of readmission and mortality at all time-points (all P < 0.001). In conclusion, CKD was associated with worse outcomes after hip fracture fixation surgery. Although at significantly higher risk of readmission and mortality, CKD patients still had a comparable risk of infection and revision to non-CKD patients. © 2019 American Society for Bone and Mineral Research.

A multiplex PCR assay for detection of Vibrio vulnificus, Aeromonas hydrophila, methicillin-resistant Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus agalactiae from the isolates of patients with necrotizing fasciitis.

BACKGROUND: Vibrio vulnificus, Aeromonas hydrophila, methicillin-resistant Staphylococcus aureus (MRSA), group A Streptococcus, and group B Streptococcus are commonly detected causative agents of necrotizing fasciitis (NF) in Chia-Yi Chang Gung Memorial Hospital. The aim of this study was to develop and evaluate a multiplex PCR method for the simultaneous detection of five of the most important human pathogens involved in NF by using a novel combination of species-specific genes. METHODS: The samples used were collected from 99 patients with surgically confirmed NF of the extremities who were hospitalized consecutively between June 2015 and November 2017. Two sets of blood and tissue samples were collected from all patients; one set was sent to a microbiology laboratory for bacterial identification and the other set was sent to an immunohistochemistry laboratory for PCR amplification. RESULTS: The multiplex PCR results for the blood samples showed negative findings. The multiplex PCR results for the tissue specimens showed 28 positive findings. Fourteen (87.5%) of the 16 V. vulnificus culture-positive tissue specimens, six (75%) of the eight A. hydrophila culture-positive tissue specimens, and four (100%) of the four MRSA culture-positive tissue specimens were positive by PCR. Similarly, two (100%) of the group A Streptococcus and two (100%) of the group B Streptococcus were PCR-positive. CONCLUSIONS: The accuracy rate of the multiplex PCR presenting positive results in these culture-positive tissue samples was 87.5% (28/32). This suggests that multiplex PCR of tissue specimens may be a useful and rapid diagnostic tool for the detection of these lethal microorganisms in patients with NF.

Effect of high body mass index on knee muscle strength and function after anterior cruciate ligament reconstruction using hamstring tendon autografts.

BACKGROUND: Increased body mass index (BMI) has been associated with poorer function in patients who have undergone anterior cruciate ligament (ACL) reconstruction. However, the effect of high BMI on muscle strength in these patients remained unclear. The current study aimed to compare knee muscle strength and Knee injury and Osteoarthritis Outcome Score (KOOS) in ACL-reconstructed patients with a variety of different BMIs. METHODS: From November 2013 to March 2016, we prospectively enrolled 30 patients who underwent ACL reconstruction (18-60 years of age). Anthropometric parameters, body compositions, isokinetic muscle strength and KOOS were assessed preoperatively, and at post-operative 16th week and 28th week. The patients were stratified into two groups by BMI, i.e. normal BMI (18.5-24.9 kg/m2) and high BMI (≥25.0 kg/m2). RESULTS: Twelve patients in the normal BMI group completed the follow-up, while sixteen patients did so in the high BMI group. In comparison of muscle strength between baseline and 28th week follow-up, the normal BMI group had significant increases in overall knee muscle strength, while the high BMI group only had increases in extensors of uninjured knee and flexors of the injured knee. However, there were significant increases in all KOOS subscales for the high BMI group. The high BMI patients reported increased KOOS, which may reflect the contribution of ligament stability in the presence of inadequate muscle strength. CONCLUSIONS: The normal BMI patients had improvement in all knee muscle strength following ACL reconstruction, while high BMI patients only had increases in certain knee muscles. High BMI patients had a decreased quadriceps muscle symmetry index, as compared to their normal BMI counterparts. Increases in quadriceps muscle strength of the uninjured knee and ACL reconstruction were associated with improvements in KOOS in high BMI patients.

Bone marrow-stimulating techniques in arthroscopic rotator cuff repair: a systematic review protocol.

INTRODUCTION: Bone marrow-stimulating (BMS) techniques during arthroscopic rotator cuff repair surgery theoretically enhance the biological component for healing and hence improve tendon healing, but their efficacy remains unproven. The purpose of this review is to determine the effects and associated harms of BMS in arthroscopic rotator cuff repair surgery. METHODS AND ANALYSIS: We will perform a systematic review and meta-analysis of randomised-controlled trials (RCTs) and retrospective cohort studies (RCS) that compare outcomes following BMS use against no use of BMS during arthroscopic rotator cuff repair surgery. We will search the databases including the Cochrane Central Register of Controlled Trials, Medline and Embase, and clinical trial registries for relevant studies. We will include studies published from start of indexing until 23 August 2018. Two reviewers will independently assess the eligibility for studies. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will use the Cochrane Collaboration tool to assess the risk of bias of included RCTs, while we will use the Risk Of Bias In Non-randomised Studies - of Interventions tool to evaluate the risk of bias of RCS. We will perform a random-effects meta-analysis in calculating the pooled risk estimates when appropriate. We will assess the overall quality of the data for each individual outcome using the Grading of Recommendations, Assessments, Development and Evaluation approach. The primary outcomes are tendon healing rate, overall pain and shoulder functions. The secondary outcomes are the proportion of participants with adverse events related to interventions, the range of motion and the proportion of participants with return to previous activities. ETHICS AND DISSEMINATION: We will report this review according to the guidance of the PRISMA statement. The results of this review will be disseminated through conference presentations and publications in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42018087161.

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.

Effect of Extracorporeal Shockwave Therapy on Passive Ankle Stiffness in Patients With Plantar Fasciopathy.

Plantar fasciopathy (PF) is the most common cause of heel pain. Extracorporeal shockwave therapy (ESWT) improves the gait pattern in patients with PF. However, the effects of ESWT on the biomechanics of the ankle in these patients remains unclear. Sixteen participants were included in the present study. Of the 16 participants, 8 patients with PF were assigned to receive extracorporeal shockwave therapy, and 8 healthy participants served as an external control group. ESWT was applied to the PF group for 1500 pulses at an energy flux of 0.26 mJ/mm2 every 3 weeks for 3 sessions. The biomechanics of the ankle joints were then assessed using an isokinetic dynamometer, and a health-related quality of life questionnaire was administered at baseline and at the final follow-up session 12 weeks after the initial treatment. Passive stiffness was calculated and compared between the foot affected with PF, the opposite foot, and both feet of those in the healthy control group. The Kruskal-Wallis 1-way analysis of variance with repeated measures was performed, and statistical significance was considered present at the 5% (p ≤ .05) level. Ankle dorsiflexion in the affected limb increased from 14° ± 3° to 17° ± 2° after ESWT (p < .05). No statistically significant differences were noted in the strength of dorsiflexion or plantarflexion at baseline and after ESWT. However, a statistically significant increase in the ratio of strength in ankle dorsiflexion versus plantarflexion was found after ESWT (p < .05). No differences in the passive stiffness of the ankle joint were demonstrated. Patients reported an improved physical function score after ESWT (p < .05). An increased dorsiflexion/plantarflexion torque ratio and maximal dorsiflexion associated with decreased pain might contribute to the improved physical function after ESWT for PF.

Chronic kidney disease is associated with a risk of higher mortality following total knee arthroplasty in diabetic patients: a nationwide population-based study.

Diabetes and chronic kidney disease (CKD) are associated with a higher rate of complications in patients undergoing total knee arthroplasty (TKA). The purpose of this study was to determine the effects of CKD and diabetes in patients after TKA. Diabetic patients who received unilateral primary TKA between January 2008 and December 2011 were enrolled. The follow-up period was more than 6 months. The primary outcome was a TKA-related infection and the secondary outcome was all-cause mortality. The study cohort included 13844 patients who were followed for a mean period of 2 years, of whom 1459 (10.5%) had CKD. The patients with CKD were older than those without CKD (71.6 versus 70.3 years, P<0.0001) and had higher rates of hypertension, gouty arthritis, ischemic heart disease, chronic pulmonary obstructive disease, pulmonary embolism and deep vein thrombosis (all P<0.0001). After adjustment of comorbidities, the CKD group had a higher incidence of urinary tract infections (OR: 1.61, 95% CI: 1.19-2.17). There were no significant differences in wound infections, pneumonia, pulmonary embolism or in-hospital death between the two groups. After adjustment of confounders, the CKD group had higher rates of myocardial infarction (HR: 2.06, 95% CI: 1.26-3.39) and mortality (HR: 1.99, 95% CI: 1.59-2.48). The risk of TKA-related infection during follow-up was comparable between the two groups (HR: 1.31, 95% CI: 0.94-1.82). In conclusion, CKD is associated with increased risks of urinary tract infections, myocardial infarction and all-cause mortality after TKA. Surgeons should be aware of this when evaluating TKA patients with renal disease.