International Orthopaedics

, Volume 42, Issue 12, pp 2881–2889 | Cite as

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

  • Liang-Tseng Kuo
  • Chi-Lung Chen
  • Pei-An Yu
  • Wei-Hsiu HsuEmail author
  • Ching-Chi ChiEmail author
  • Jae-Chul Yoo
Original Paper



To investigate whether epinephrine in irrigation fluid improves visual clarity in arthroscopic shoulder surgery.


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.


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.


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


Arthroscopy Epinephrine Shoulder Visualization Systematic review Meta-analysis 



The authors thank Ms. Yu-Shiun Tsai for her help in searching the databases and obtaining the full text of the trials.

Authors’ contributions

Author A was responsible for the study concept and design and drafting of the manuscript. Author A and Author B were responsible for the trial selection and appraisal of methodological quality. Author A and Author C participated in acquisition, analysis, and interpretation of data. Author E provided consultation of statistics and methodology. Author F provided consultation of clinical and reviewed the manuscript. Author D and Author E were in charge of the study concept and design, supervised the study, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

Compliance with ethical standards

Conflict of interest

Liang-Tseng Kuo, Chi-Lung Chen, Pei-An Yu, Wei-Hsiu Hsu, Ching-Chi Chi, and Jae-Chul Yoo declare that they have no conflict of interest.

Ethical approval

No ethical approval is needed for our systematic review and meta-analysis.

Informed consent

No identifying information about individual participants was shown in this systematic reivew, and thus inform consent was not needed.

Supplementary material

264_2018_4021_MOESM1_ESM.docx (16 kb)
Table S1 GRADE Recommendation of Outcomes (DOCX 16 kb)
264_2018_4021_MOESM2_ESM.docx (66 kb)
ESM 1 (DOCX 66 kb)


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Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Division of Sports Medicine, Department of Orthopaedic SurgeryChang Gung Memorial HospitalChiayiTaiwan
  2. 2.Center for Evidence-Based MedicineChang Gung Memorial HospitalChiayiTaiwan
  3. 3.College of MedicineChang Gung UniversityTaoyuanTaiwan
  4. 4.Department of DermatologyChang Gung Memorial HospitalTaoyuanTaiwan
  5. 5.Department of Orthopaedic Surgery, College of Medicine, Samsung Medical CenterSungkyunkwan UniversitySeoulRepublic of Korea

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