And I'll introduce our first speaker. Instead of Jason Old, we're going to have Alan Getgood, who's giving his first shoulder talking about 10 years. Thank you. All right, so yeah, I've been drafted in off the bench to help out my Canadian colleagues who unfortunately, due to unforeseen circumstances, could not be here. Thank you very much. I will take a photograph. Thank you, Ivan. So yeah, so the authors do not have any relevant disclosures. My main disclosure is that, as Alison said, this is the first time I've given a shoulder talking over 10 years, so I hope it's less painful for you as it probably will be for me. So, okay, visual clarity. It's important when performing arthroscopic surgery. Epinephrine in an irrigation fluid has been well utilized in shoulder arthroscopy. Of course, there's been a lot of studies looking at tranexamic acid in orthopedic surgery in terms of reducing blood loss. The question is whether or not that can decrease bleeding and improve visualization. No study has ever been performed comparing TXA as well as epinephrine, comparing the two products but also in their combination versus a placebo and looking at visual clarity during shoulder arthroscopy. So the study purpose was to determine if TXA is a safe alternative to epinephrine to try and improve visualization during arthroscopic shoulder surgery and whether or not the combination of both products could have an additive effect on improving visualization. This is a double-blind randomized clinical trial. It's based in a single institution of five fellowship trained upper extremity surgeons. There are 128 participants all over the age of 18 years of age. There are standard inclusion in terms of arthroscopic shoulder procedures and then there are a number of exclusions. The interventions were saline placebo, epinephrine in the irrigation fluid, IV tranexamic acid or a combination of both. This is a standardized computer-based randomization with surgeons blinded to group allocation. In terms of the protocol, they used a four-point Likert scale every 15 minutes during the surgery to judge visual clarity and they also measured mean arterial pressure and irrigation pump pressure again every 15 minutes. This is the Likert scale that was utilized. You can see that picture zero. That was my experience of shoulder arthroscopic surgery and that's why I gave it up. In terms of the data analysis, they used linear regression using the dependent variable being the visualization with independent variables of either TXA or epinephrine and then a number of predictors to see what was associated in terms of correlations. The complexity of the surgery was one of those and if we break those down, simple reconstruction, so looking at small rotator cuff repairs with biceps tenodesis or chromioplasty, the more complex larger cuff tears associated with distal clavicle excision or biceps tenodesis. In terms of the results, just a concert flow diagram really showing the breakdown of the different groups and the exclusions. The demographics just really shows that the randomization worked perfectly. There was no difference across the board in terms of those patients that were entered in the study. Then looking at the primary outcome of the visual clarity, you really don't see a significant difference between the four treatment groups. When they do their linear regression, it's a bit of a typo on this slide, but the green is essentially the significant predictors that were associated with improved visual clarity. Essentially epinephrine, surgery duration, mean arterial pressure were all significant predictors of visual clarity. Tranexamic acid, pump pressure increase, surgery complexity were not predictive of visual clarity. So the main findings essentially is that IV TXA does not improve visual clarity and that epinephrine mixed in the irrigation fluid significantly improves visual clarity during orthoscopic shoulder surgery and there is certainly no benefit of adding TXA to IV TXA to already utilization of epinephrine in the irrigation fluid. And also surgical procedure, so increased duration of surgery, increased mean arterial pressure were both negative predictors of visual clarity. So I think it all stands to reason. Primary outcome, of course, the limitations. Like any RCT, we can always pick holes in some of the limitations, but I think that the authors should be commended in doing this great work. Primary outcome is subjective rating with five different surgeons. Visualization was only every 15 minutes and patient positioning and anesthetic type were not standardized. So in conclusion, IV TXA is not effective as an alternative to epinephrine in irrigation fluid to improve visual clarity during orthoscopic shoulder surgery and there's no additional improvement in visual clarity when TXA is used in combination with epinephrine beyond the effect of epinephrine alone. With that, I'd like to thank you very much for your attention. I'm hoping it's going to be at least another 10 years we'll have to give another shoulder talk. Thank you very much.

Alan Getgood

tranexamic acid

epinephrine

arthroscopic shoulder surgery

double-blind randomized clinical trial