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Hoffman RA, Green A, Paxton ES. Optimizing Visualization in Shoulder Arthroscopy: An Evidence-Based Guide. J Am Acad Orthop Surg 2024:00124635-990000000-01033. [PMID: 38996206 DOI: 10.5435/jaaos-d-23-01025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Indexed: 07/14/2024] Open
Abstract
Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.
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Affiliation(s)
- Ryan A Hoffman
- From the Division of Shoulder and Elbow Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Samborski SA, Morris SC, Leary S, Geiger K, Hlas A, Westermann R, Banffy M. Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy. Arthroscopy 2024:S0749-8063(24)00300-1. [PMID: 38703922 DOI: 10.1016/j.arthro.2024.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. METHODS This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. RESULTS A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n = 45; primary, n = 404) than in the group that did not receive TXA (n = 25; primary, n = 388) (P = .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P = .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P = .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5 minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n = 27) than in the group that did (n = 10) (P = .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P = .24). CONCLUSIONS There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. LEVEL OF EVIDENCE Level III, retrospective multicenter consecutive series.
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Affiliation(s)
| | - S Craig Morris
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, U.S.A
| | | | | | - Armen Hlas
- University of Iowa, Iowa City, Iowa, U.S.A
| | | | - Michael Banffy
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, U.S.A
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Shin HJ, You HS, Lee K, Je LG, Kim SG, Yang KS, Jeong WK. Intravenous Tranexamic Acid Improves Visual Clarity During Synovectomy in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Double-Blind, Randomized Controlled Study. Arthroscopy 2024; 40:1409-1419. [PMID: 37890542 DOI: 10.1016/j.arthro.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE To assess the effects of intravenous tranexamic acid (TXA) on visual clarity at various surgical stages and the correlation between the severity of synovitis and bursitis and the grade of visual clarity in patients undergoing arthroscopic shoulder surgery under an interscalene brachial plexus block. METHODS This double-blind, randomized controlled study included patients undergoing arthroscopic rotator cuff repair. The TXA group underwent injection of a 100-mL mixture of 1,000 mg of TXA and normal saline solution intravenously whereas the control group was administered the same volume of normal saline solution at 10 minutes preoperatively. Visual clarity was rated according to a 3-grade visual clarity scoring system from grade 1 (clear) to grade 3 (poor) at 4 surgical stages (I, intra-articular soft-tissue procedures including synovectomy; II, acromioplasty; III, bursectomy; and IV, greater tuberoplasty). The primary outcome was arthroscopic visual clarity. The secondary outcomes were medications administered for hemodynamic stability, length of hospital stay, and thromboembolic events. RESULTS Altogether, 63 patients were included in the study; they were divided into the TXA group, comprising 32 patients, and the control group, comprising 31 patients. The TXA group showed significantly better visual clarity than the control group (median [interquartile range], 1 [1-2] vs 2 [1-2]; P = .027) during stage I but not during stages II through IV. Spearman correlation analysis revealed a significant correlation between synovitis and visual clarity grade during synovectomy (correlation coefficient, 0.393; P = .001) but not between bursitis and visual clarity grade during bursectomy. Deep vein thrombosis and pulmonary embolism did not occur in either group. CONCLUSIONS Intravenous TXA can improve visual clarity during intra-articular soft-tissue procedures, including synovectomy. However, it does not have a significant effect during acromioplasty, bursectomy, and greater tuberoplasty. TXA can be used to improve visual clarity in patients with suspected severe synovitis. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Kaehong Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Lee Gyeong Je
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Anam Hospital, Seoul, Republic of Korea
| | - Seul Gi Kim
- Department of Orthopedic Surgery, Seoul Barunsesang Hospital, Seoul, Republic of Korea
| | - Kyung-Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Woong Kyo Jeong
- Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Republic of Korea.
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Suter T, McRae S, Zhang Y, MacDonald PB, Woodmass JM, Mutter TC, Wolfe S, Marsh J, Dubberley J, Old J. The effect of intravenous tranexamic acid on visual clarity in arthroscopic shoulder surgery compared to epinephrine and a placebo: a double-blinded, randomized controlled trial. J Shoulder Elbow Surg 2024; 33:628-639. [PMID: 37981002 DOI: 10.1016/j.jse.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 09/22/2023] [Accepted: 10/08/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The addition of epinephrine in irrigation fluid and the intravenous or local administration of tranexamic acid have independently been reported to decrease bleeding, thereby improving surgeons' visualization during arthroscopic shoulder procedures. No study has compared the effect of intravenous tranexamic acid, epinephrine in the irrigation fluid, or the combination of both tranexamic acid and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. We hypothesized that intravenous tranexamic acid is more effective than epinephrine mixed in the irrigation fluid in improving visualization during shoulder arthroscopy, with no additive effect when both are used. METHODS Patients aged ≥18 years undergoing shoulder arthroscopy were randomized into one of 4 study arms: (1) saline irrigation fluid (placebo); (2) epinephrine (0.33 mL of 1:1000 per liter) mixed in irrigation fluid (EPI); (3) 1 g intravenous tranexamic acid (TXA); and (4) epinephrine and tranexamic acid combined (TXA + EPI). Visualization was rated intraoperatively on a scale from 0, indicating poor clarity, to 3, indicating excellent clarity, every 15 minutes and overall. The primary outcome measure was the overall rating of visualization. A stepwise linear regression was performed using visualization as the dependent variable and independent variables including presence or absence of epinephrine and tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid. RESULTS One hundred twenty-eight patients (mean age 56 years) were randomized. Mean visual clarity for the placebo, TXA, EPI, and TXA + EPI groups were 2.0 (±0.6), 2.0 (±0.6), 2.6 (±0.5), and 2.7 (±0.5), respectively (P < .001). The presence or absence of epinephrine was the most significant predictor of visual clarity (P < .001). Tranexamic acid presence or absence had no effect. No adverse events were recorded in any of the groups. CONCLUSION Intravenous tranexamic acid is not an effective alternative to epinephrine in irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries, and there is no additive effect when both are used.
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Affiliation(s)
- Thomas Suter
- Department of Orthopaedic Surgery, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Sheila McRae
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Section of Orthopaedics, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Yiyang Zhang
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada
| | - Peter B MacDonald
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada
| | - Jarret M Woodmass
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada
| | - Thomas C Mutter
- Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada; Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Scott Wolfe
- Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada; Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathan Marsh
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada
| | - Jamie Dubberley
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada
| | - Jason Old
- Pan Am Clinic Foundation, Research, Winnipeg, MB, Canada; Pan Am Clinic, Orthopaedic Surgery, Winnipeg, MB, Canada.
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Malik SS, Tahir M, Jordan RW, Kwapisz A, D'Alessandro P, MacDonald PB, Woodmass JM. The effect of tranexamic acid and epinephrine on visual clarity during arthroscopic shoulder surgery: A meta-analysis of RCTs. Orthop Traumatol Surg Res 2024:103844. [PMID: 38395349 DOI: 10.1016/j.otsr.2024.103844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/31/2023] [Accepted: 02/19/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Visual clarity in arthroscopic rotator cuff repair is essential to reduce the operative time and for efficiency of repair. Tranexamic acid (TXA) in open shoulder surgery has been shown to reduce blood loss but its use in shoulder arthroscopy for rotator cuff repair for improved clarity is not understood. The purpose of this SR is to determine the effect of TXA and epinephrine on visual clarity in shoulder arthroscopy for rotator cuff repair. HYPOTHESIS We hypothesise that visual clarity should improve in those that have TXA compared to those who do not receive TXA. METHODS A review of the online databases MEDLINE and Embase was conducted on 8th October 2022 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Randomised clinical trials reporting visual clarity and/or, operative time, volume of irrigation fluid used and mean arterial pressure were included. The studies were appraised using the CONSORT tool. RESULTS Seven studies met eligible criteria, all of which were double-blinded RCTs. Five studies reported no difference in visual clarity between TXA vs. saline, while two reported a significant improvement with TXA. Pooling of data showed that visual clarity was significantly better in the TXA group vs. saline, on a standardised 10-point Likert scale (mean difference 0.73 points, p=0.03). However, the use of epinephrine was reported in two studies and its administration offered significantly better visual clarity than TXA (mean difference 0.9 points, p=0.02). There was no significant difference with TXA use in MAP (mean difference 1.2mmHg, p=0.14), operative time (mean difference 6.8minutes, p=0.11), irrigation volume used (mean difference 0.2L, p=0.88), or postoperative pain (mean difference 3.89 on a 0-100 VAS, p=0.34). CONCLUSION The use of TXA in shoulder arthroscopy has shown to have significantly improved visual clarity in comparison to saline irrigation alone. This may not necessarily result in a significant clinical difference and may not translate to significantly less operative time or postoperative pain score. Furthermore, epinephrine use alone offers significantly better clarity than TXA. There may not be an added benefit to give both, but this area requires further research. LEVEL OF EVIDENCE II; systematic review.
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Affiliation(s)
- Shahbaz S Malik
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD, United Kingdom
| | - Muaaz Tahir
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Robert W Jordan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Adam Kwapisz
- Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Łódź, Łódź, Poland
| | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia. Medical School, Discipline of Surgery, University of Western Australia, Western Australia, Australia
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Yoon JP, Park SJ, Kim DH, Lee HJ, Park EJJ, Shim BJ, Chung SH, Kim JS, Chung SW. Tranexamic Acid Can Reduce Early Tendon Adhesions After Rotator Cuff Repair and Is Not Detrimental to Tendon-Bone Healing: A Comparative Animal Model Study. Arthroscopy 2024:S0749-8063(24)00071-9. [PMID: 38311267 DOI: 10.1016/j.arthro.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To determine the effects of topical tranexamic acid (TXA) administration on tendon adhesions, shoulder range of motion (ROM), and tendon healing in an acute rotator cuff repair rat model. METHODS A total of 20 Sprague Dawley rats were used. Tendon adhesion, ROM, and biomechanical and histological analysis of tendon-bone healing was conducted at 3 and 6 weeks after surgery. The rats underwent rotator cuff repair surgery on both shoulders and were administered TXA via subacromial injections. The tendon adhesion was evaluated macroscopically and histologically. Biomechanical tendon healing was measured using a universal testing machine, and histological analysis was quantified by H&E, Masson's trichrome, and picrosirius red staining. RESULTS At 3 weeks after surgery, the adhesion score was significantly lower in the TXA group (2.10 ± 0.32) than in the control group (2.70 ± 0.48) (P = .005), but there was no significant difference between the 2 groups at 6 weeks. Regarding ROM, compared with the control group, the TXA group showed significantly higher external rotation (36.35° ± 4.52° vs 28.42° ± 4.66°, P < .001) and internal rotation (45.35° ± 9.36° vs 38.94° ± 5.23°, P = .013) 3 weeks after surgery. However, at 6 weeks, there were no significant differences in external and internal rotation between the 2 groups. In the biomechanical analysis, no significant differences in gross examination (3 weeks, P = .175, 6 weeks, P = .295), load to failure (3 weeks, P = .117, 6 weeks, P = .295), or ultimate stress (3 weeks, P = .602, 6 weeks, P = .917) were noted between the 2 groups 3 and 6 weeks after surgery. In the histological analysis of tendon healing, no significant differences in the total score (3 weeks, P = .323, 6 weeks, P = .572) were found between the 2 groups 3 and 6 weeks after surgery. CONCLUSIONS Topical TXA administration showed a beneficial effect in reducing tendon adhesions and improving ROM 3 weeks postoperatively and had no effect at 6 weeks. This suggests that additional intervention with TXA may be useful in achieving long-term improvement in shoulder stiffness. Additionally, TXA may increase tissue ground substance accumulation in the late postoperative period but does not adversely affect tendon-bone interface healing. CLINICAL RELEVANCE The use of TXA after rotator cuff repair has no effect on tendon-bone interface healing in clinical practice and can improve shoulder stiffness in the early postoperative period. Additional research on the long-term effects is needed.
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Affiliation(s)
- Jong Pil Yoon
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Sung-Jin Park
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea.
| | - Dong-Hyun Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Hyun Joo Lee
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Eugene Jae Jin Park
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Bum-Jin Shim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seung Ho Chung
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jun Sung Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seok Won Chung
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Seoul, Republic of Korea
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Tan TK, Tan P, Wang K, Hau R. Effect of tranexamic acid on shoulder surgery: an updated meta-analysis of randomized studies. J Shoulder Elbow Surg 2024; 33:e97-e108. [PMID: 37890768 DOI: 10.1016/j.jse.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The effect of tranexamic acid (TXA) has been proven to be effective in reducing blood loss in lower limb arthroplasty. The aim of this study is to investigate the effect of TXA in shoulder surgery with the updated studies. MATERIALS AND METHODS A systematic review and meta-analysis of all the randomized controlled trials were conducted. We compared the outcomes of patients with and without TXA. The PubMed, MEDLINE, EMBASE, and CENTRAL databases were systematically searched for relevant studies. RESULTS A total of 14 studies, enrolling 1131 patients, were included for qualitative and quantitative analysis. Our results revealed that TXA was associated with a significant reduction in total volume blood loss (mean difference [MD]: -112.97, P = .0006), drain output (MD: -81.90, P < .00001), hemoglobin changes (MD: -0.55, P = .02), shorter operative time (MD: -6.19, P = .01), and lower risk of hematoma formation (odds ratio: -0.20, P = .01). The postoperative visual analog scale pain score was also significantly better in the TXA group (MD: -0.78, P < .00001). No significant difference was detected in length of hospital stay and incidence of thromboembolization. CONCLUSION The usage of TXA in shoulder surgery appeared to be safe and effective in reducing blood loss without any significant complication.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Monash Health Dandenong Hospital, Dandenong, VIC, Australia.
| | - Pham Tan
- Radiology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kemble Wang
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Department of Surgery, University of Melbourne, Carlton, VIC, Australia
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Zhao J, Liang G, Huang H, Hong K, Pan J, Yang W, Liu J, Zeng L. Intravenous Tranexamic Acid Significantly Improved Visualization and Shortened the Operation Time in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis of Level I and II Studies. Arthroscopy 2024; 40:592-601. [PMID: 37423470 DOI: 10.1016/j.arthro.2023.06.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE To further clarify the role of tranexamic acid (TXA) in arthroscopic rotator cuff repair (ARCR), especially visual field clarity and operation time. METHODS We searched the PubMed, Cochrane Library, and Embase databases to find prospective randomized controlled clinical trials (RCTs) examining the use of TXA in ARCR. All included RCTs were evaluated for methodological quality using the Cochrane Collaboration's risk of bias tool. We used Review Manager 5.3 for meta-analysis and calculated the weighted mean difference (WMD) and 95% confidence interval (CI) of the related outcome indicators. The GRADE system was used to evaluate the strength of the clinical evidence provided by the included studies. RESULTS Six RCTs (3 Level I, 3 Level II) from four countries or regions were included in this study: 2 studies used intra-articular (IA) TXA, and 4 studies used intravenous TXA. A total of 451 patients underwent ARCR, including 227 patients in the TXA group and 224 patients in the non-TXA group. In 2 RCTs evaluating good visualization, intravenous TXA achieved a better surgical field of view in ARCR compared to the control group (P =.036; P = .045). Meta-analysis showed that compared with non-TXA, intravenous TXA shortened the operation time (WMD = -12.87 min, 95% CI: -18.81 to -6.93). These two RCTs did not reveal a statistically significant difference in the impact of intravenous TXA and non-TXA on mean arterial pressure (MAP) (P = .306; P = .549). Compared with epinephrine (EPN), IA TXA had no significant effects on improving the visual field clarity under arthroscopy, shortening the operation time or reducing the total amount of irrigation fluid (P > .05). Compared with saline irrigation, IA TXA improved the surgical field of vision and shortened the operation time (P < .001). No adverse events were reported for either intravenous TXA or IA TXA. CONCLUSIONS Intravenous TXA can shorten the operation time of ARCR, and the conclusions of existing RCTs suggest that intravenous TXA can improve visual field clarity during ARCR, thus supporting the application of intravenous TXA in ARCR. Compared with EPN, IA TXA was not better at improving the visual field clarity under arthroscopy and shortening the operation time, but it was better than saline irrigation. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of Level I and II studies.
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Affiliation(s)
- Jinlong Zhao
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China; The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China; The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Guihong Liang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China; The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China; The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Hetao Huang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Kunhao Hong
- The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China; Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
| | - Jianke Pan
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Weiyi Yang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jun Liu
- The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China; The Fifth Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China; Guangdong Second Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
| | - Lingfeng Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China; The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China; The Research Team on Bone and Joint Degeneration and Injury of Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.
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McDermott ER, Tennent DJ, Song DJ. Improving visualization in shoulder arthroscopy. Clin Shoulder Elb 2023; 26:455-461. [PMID: 37088880 DOI: 10.5397/cise.2022.01291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/27/2022] [Indexed: 02/24/2023] Open
Abstract
Arthroscopic shoulder procedures are one of the most common procedures used to restore function through minimally invasive techniques. With the demand for shoulder arthroscopic procedures comes the need for safe, effective, and efficient surgery that maximizes patient outcomes while minimizing complications. Many variables contribute to visualization in shoulder arthroscopy including vascular anatomy, blood pressure control, arthroscopic pump systems, turbulence control, epinephrine, and tranexamic acid. Furthermore, patient positioning can have a dramatic effect on visualization with both the beach chair position and lateral decubitus positioning having various strengths and weaknesses depending on the intended procedure being performed. The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy.
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Affiliation(s)
- Emily R McDermott
- Department of Orthopedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - David J Tennent
- Department of Orthopedic Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
| | - Daniel J Song
- Department of Orthopedic Surgery, Evans Army Community Hospital, Fort Carson, CO, USA
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Han C, Liu M, Lian X, Sun T, Yan S, Bai X, Gan D, Leng B, Qiu Y, Ren Y. Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis. J Shoulder Elbow Surg 2023; 32:2389-2399. [PMID: 37468032 DOI: 10.1016/j.jse.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE Although tranexamic acid (TXA) is being increasingly used in orthopedic arthroplasty and lower-extremity arthroscopic procedures, its use in arthroscopic rotator cuff repair (ARCR) is less widely reported. The aim of this study was to evaluate the clinical effectiveness and safety of TXA administration in ARCR. METHODS A systematic review and meta-analysis of randomized controlled trials was performed to compare clinical outcomes in patients who underwent ARCR with or without TXA. Literature was retrieved using the Cochrane Library, MEDLINE, PubMed, and Embase electronic databases. The primary outcome of this study was visual clarity. Secondary outcomes contained total operative time, postoperative pain score, amount of blood loss, shoulder swelling (change in shoulder circumference), volume of irrigation fluid, number of adjustments of the pump pressure for irrigation, and adverse cardiovascular events. RESULTS Seven studies (3 and 4 with level I and II evidence, respectively), which included 272 and 265 patients who underwent arthroscopy with and without TXA, respectively, met the eligibility criteria. Pooled analysis showed significant improvements in visual clarity (mean difference, 9.10%; 95% CI, 4.05-14.15; P = .0004) and total operative time (mean difference, -11.24 minute; 95% CI, -19.90 to -2.57) associated with perioperative TXA application. None of the trials reported adverse events and complications associated with TXA. CONCLUSION The best available evidence indicates that TXA administration could significantly improve arthroscopic visual clarity and effectively save operative time in ARCR without increasing the incidence of adverse events. Furthermore, the optimal dose, route, and timing of TXA application in ARCR surgery remains to be validated by future high-level evidence studies.
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Affiliation(s)
- Changxu Han
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Ming Liu
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xin Lian
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Tao Sun
- Emergency Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Shengjuan Yan
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xianming Bai
- Spine Surgery Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Dige Gan
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Bing Leng
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Yi Qiu
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
| | - Yizhong Ren
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
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11
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Farhan-Alanie MM, Boutefnouchet T. Tourniquet-less arthroscopic anterior cruciate ligament reconstruction: a technical guide & narrative review of the evidence. Acta Orthop Belg 2023; 89:449-453. [PMID: 37935228 DOI: 10.52628/89.3.11747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Arthroscopic anterior cruciate ligament reconstruction (ACLR) is often performed with the use of a thigh tourniquet. Surgeons believe this helps improve visualisation and reduce operative time. However, tourniquet use has been associated with many complications including increased pain, neurovascular injury, venous thromboembolism, haematoma formation, and others. In this article, we describe a method allowing comparable arthroscopic visualisation to be achieved without the aid of a tourniquet for ACLR procedures. The literature evidence relating to this technique as well as tourniquet use for ACLR is also reviewed. Tourniquet-less ACLR can be achieved through the combined application of hypotensive anaesthesia, intravenous tranexamic acid, and use of adrenaline-supplemented irrigation fluid and local anaesthetic. Performing ACLR without a tourniquet avoids the risks associated with its use and reduces the severity of post-operative haemarthrosis which may contribute to the patient's pain and limit their ability to perform their rehabilitation exercises.
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12
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Takahashi R, Kajita Y, Iwahori Y, Harada Y. Tranexamic acid has no effect on postoperative pain control after arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial. Asia Pac J Sports Med Arthrosc Rehabil Technol 2023; 33:32-35. [PMID: 37693817 PMCID: PMC10491640 DOI: 10.1016/j.asmart.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 04/11/2023] [Accepted: 08/05/2023] [Indexed: 09/12/2023] Open
Abstract
Background The purpose of this study was to compare the efficacies of tranexamic acid (TXA) versus placebo after arthroscopic rotator cuff repair (ARCR). Methods This prospective, double-blind, and randomized study was conducted in 70 patients who underwent ARCR from 2021 to 2022 at our hospital. Thirty-four shoulders were randomly assigned to the TXA group, and 36 to the control group; TXA (10 mL) and normal saline (10 mL) were administered locally after surgery and in the control group, respectively. We evaluated visual analog scale pain scores at rest, during activity, and at night and the circumference and diameter of the shoulder joint in both groups preoperatively and at 1, 2, and 3 days, and 1 week after the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. Results There was no significant difference in the visual analog scale scores at rest, during activity, and at night between the groups (p > 0.05). The circumference and diameter of the shoulder joint were not also significantly different between both groups (p > 0.05). Conclusion Local TXA administration in patients who undergo ARCR does not significantly impact postoperative pain levels and the circumference and diameter of the shoulder joint.
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Affiliation(s)
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Japan
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13
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Tranexamic acid is not associated with decreased infection risk after primary shoulder arthroplasty: a cohort study of 9276 patients. J Shoulder Elbow Surg 2023; 32:581-588. [PMID: 36208673 DOI: 10.1016/j.jse.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of tranexamic acid (TXA) is associated with less blood loss and reduced transfusion risk after shoulder arthroplasty surgery. Recent studies have shown lower odds of postoperative infection after hip or knee arthroplasty with its use. The purpose of this study was to determine whether TXA use reduces the risk of infection after primary elective shoulder arthroplasty. METHODS A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged 18 years who underwent primary elective anatomic total shoulder arthroplasty for osteoarthritis or primary reverse shoulder arthroplasty for rotator cuff arthropathy were included (2013-2020). We compared patients who received preoperative intravenous TXA to those who did not receive TXA by assessing the risk for revision due to deep infection within 5 years' follow-up using multivariable Cox proportional hazard regression. Interaction between TXA and diabetes status was analyzed separately. RESULTS The study sample included 9276 shoulder arthroplasties performed by 153 surgeons at 43 hospitals. The mean age was 70.0 years and 48% were male. The 5-year probability of revision for deep infection was 0.8% and 0.7% for patients with and without TXA, respectively. We failed to observe a difference in infection risk after adjustment for confounders and surgeon differences (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.80, P = .998). Further, no differences were observed in patients with (HR 1.64, 95% CI 0.42-6.44, P = .481) or without diabetes (HR 0.79, 95% CI 0.40-1.55, P = .488). CONCLUSION In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection.
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14
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Takahashi R, Kajita Y, Iwahori Y, Harada Y. Tranexamic acid administration for arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial. J Orthop Sci 2023; 28:328-332. [PMID: 34949506 DOI: 10.1016/j.jos.2021.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to compare the efficacy of tranexamic acid versus placebo after arthroscopic rotator cuff repair. METHODS This prospective, double-blind, and randomized study involved 66 patients who consecutively underwent arthroscopic rotator cuff repair from 2020 to 2021 at our hospital. Thirty-three shoulders each were randomly assigned to the tranexamic acid and control groups. In the former group, 1000 mg of tranexamic acid (20 mL) was administered intravenously 10 min before surgery and the same volume of normal saline (20 mL) was administered intravenously in the control group. We evaluated visual clarity; visual analog scale pain scores at rest, during activity, and at night; the circumference and diameter of the shoulder joint in the groups before and after the surgery at 1, 2, and 3 days, and 1 week; estimated perioperative blood loss; and operative time. Visual clarity was rated using a numeric rating scale from grade 1 (poor) to grade 3 (clear) every 15 min throughout the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. RESULTS Visual clarity was found to be significantly better in the tranexamic acid group, with a greater percentage of grade 3 visual clarity (75.6 ± 11.2% vs 68.1 ± 13.4%, p = 0.045). The visual analog scale scores at rest and at night in the control group were significantly lower than those in the tranexamic acid group for 1 week postoperatively (13.8 ± 14.8 vs 5 ± 9.3, p = 0.008, 36.1 ± 23.3 vs 19.3 ± 24, p = 0.012). The circumference and diameter of the shoulder joint, estimated perioperative blood loss, and operative time were not significantly different between the two groups. CONCLUSION Intravenous administration of tranexamic acid is an alternative way to improve visual clarity in arthroscopic rotator cuff repair; however, there are no other significant differences compared to the administration of placebo.
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Affiliation(s)
- Ryosuke Takahashi
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan.
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan; Department of Orthopaedic Surgery, Aichi Medical University, Japan.
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan.
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Japan.
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15
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Reduction of perioperative blood loss and operating time for arthroscopic rotator cuff repair by intravenous administration of tranexamic acid. Asia Pac J Sports Med Arthrosc Rehabil Technol 2023; 31:6-10. [PMID: 36820053 PMCID: PMC9937805 DOI: 10.1016/j.asmart.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 02/10/2023] Open
Abstract
Background Tranexamic acid (TXA) is widely used in hip and knee arthroplasty to reduce perioperative bleeding. Recently, its use has been expanded to arthroscopic surgery. The purpose of this study was to evaluate the efficacy of preoperative use of TXA in arthroscopic rotator cuff repair (RCR). Methods A cohort comprising 129 consecutive patients who underwent arthroscopic primary RCR at our institution was retrospectively investigated according to whether they received TXA (April 2018 to December 2020, TXA group, n = 64) or did not receive TXA (April 2016 to March 2018, non-TXA group, n = 65). TXA was administered at a dose of 1 g intravenously. Rotator cuff tears were repaired by the suture bridge technique. Videos of the arthroscopic procedures were reviewed and rated for visual clarity using a 10-point numeric rating scale. Arthroscopic procedures were divided into glenohumeral, resection of bursal tissue and acromioplasty, and RCR steps. Each step was rated separately. Age, sex, body mass index, hemoglobin level before and on days 1 and 7 after surgery, operating time, mean arterial pressure, tear size, and number of anchors used for cuff repair were compared between the two groups. Results There were no statistically significant differences in the patient demographic data. The operating time was significantly shorter in the TXA group than in non-TXA group (97.8 ± 21.8 min vs 116.2 ± 26.0 min). The clarity of the visual field was similar between the two groups during the glenohumeral phase but was significantly higher in the TXA group during the resection of bursal tissue and acromioplasty and RCR phases. Hemoglobin level was not significantly different between the groups on postoperative day 1 but was significantly higher in the TXA group on day 7. Conclusion Administration of a single intravenous dose of TXA improved visual clarity in arthroscopic RCR, decreased the total operating time, and reduced hemoglobin loss on postoperative day 7.
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16
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Bildik C, Pehlivanoglu T. Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients. J Shoulder Elbow Surg 2023; 32:223-231. [PMID: 36403924 DOI: 10.1016/j.jse.2022.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used in orthopedic surgery with the aim of reducing intraoperative and postoperative bleeding, as well as bleeding-related complications. The purpose of this study was to assess whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve visual clarity, shorten the duration of the operation, and provide superior pain management as compared with placebo. METHODS We conducted a prospective, randomized, double-blind, placebo-controlled study. Patients aged ≥18 years with a magnetic resonance imaging-confirmed RCT and a history of failed conservative treatment for ≥6 months were included. Patients with a history of coagulopathy; a history of cardiac, renal, or hepatic disease; a history of conservative treatment for <6 months; and/or acute RCTs were excluded. Visual clarity as the primary outcome was assessed using an arthroscopic visual scale comprising 5 grades-ranging from grade 1, best visual clarity, to grade 5, worst visual clarity (requiring conversion to open surgery)-after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were operative duration and postoperative pain scores. RESULTS A total of 63 patients with similar demographic data (age and sex) and intraoperative mean arterial pressure were enrolled and randomized into 2 groups: The TXA group comprised 32 patients with a mean age of 56.46 years, and the placebo group comprised 31 patients with a mean age of 57.83 years. The TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual scale score, 1.5 ± 0.5 vs. 2.86 ± 1.7; P < .001), with a significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, P < .001) and a significantly lower percentage of grade 4 visual clarity (0% vs. 3.2%, P = .003). Grade 5 visual clarity was not recorded in any patient in either group. The TXA group showed a significantly shorter operative duration (55.73 minutes vs. 67.26 minutes, P = .001) and superior pain scores at 8 hours (2.3 vs. 3.6, P = .002) and 24 hours (1.6 vs. 2.4, P < .001) postoperatively. No complications were recorded in either group. CONCLUSIONS This study showed that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity while shortening the total operative duration significantly and providing significantly superior pain management in the first 8 and 24 hours postoperatively as compared with placebo. This study underlines the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.
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Affiliation(s)
- Celaleddin Bildik
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey
| | - Tuna Pehlivanoglu
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey; Department of Orthopaedic Surgery, Liv Hospital Ulus, Istanbul, Turkey.
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17
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Zhu R, Jiang H, Xu W, Shen L, Jin G. Impact of intra-articular injection with tranexamic acid on total blood loss and postoperative pain after arthroscopic rotator cuff repair surgery. Front Surg 2023; 10:1052039. [PMID: 36911608 PMCID: PMC9995381 DOI: 10.3389/fsurg.2023.1052039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives To evaluate the impact of intra-articular injection with tranexamic acid (TXA) on total blood loss (TBL) and postoperative pain after arthroscopic rotator cuff repair (ARCR). Methods This study retrospectively included patients with full-thickness rotator cuff tears who underwent shoulder ARCR surgery in Taizhou hospital, China, between January 2018 and December 2020. Patients received 10 ml (100 mg/ml) of intra-articular TXA injection (TXA group) or 10 ml of normal saline (non-TXA group) after the incision was sutured. The primary variable was the type of drug injected into the shoulder joint at the end of the operation. The primary outcome were perioperative TBL and postoperative pain [measured by visual analog scale (VAS)]. The secondary outcomes were differences in red blood cell count, hemoglobin count, hematocrit, platelet count. Results A total of 162 patients were included, 83 patients in TXA group and 79 patients in non-TXA group. Notably, patients in TXA group were more likely to have lower TBL volume [261.21 (175.13-506.67) ml vs. 382.41 (236.11-593.31), P = 0.025], and postoperative VAS score ≤ 2 within 24 h (P = 0.031) compared with those in non-TXA group. In addition, the median hemoglobin count difference was significantly lower in TXA group than that of in non-TXA group (P = 0.045), while, the differences in median counts of red blood cell, hematocrit, and platelet between the two groups were comparable (all P > 0.05). Conclusion Intra-articular injection of TXA might reduce the TBL and degree of postoperative pain within 24 h after shoulder arthroscopy.
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Affiliation(s)
- Rangteng Zhu
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Hantao Jiang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Wei Xu
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Liping Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Gang Jin
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
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18
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Sun Y, Xiao D, Fu W, Cai W, Huang X, Li Q, Li J. Efficacy and Safety of Tranexamic Acid in Shoulder Arthroscopic Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11236886. [PMID: 36498460 PMCID: PMC9738808 DOI: 10.3390/jcm11236886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Visual clarity during shoulder arthroscopy can ensure an efficient and effective performance of the procedure, and it is highly related to bleeding without a tourniquet. Tranexamic acid (TXA) is widely used in adult reconstruction procedures; however, its use in shoulder arthroscopic operations is a relatively novel topic. PURPOSE To analyze the available literature on visual clarity, blood loss, pain control, functional outcomes, and complications after the administration of tranexamic acid in shoulder arthroscopic surgery. METHODS A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of shoulder arthroscopic surgery. The literature search included the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The primary outcomes included visual clarity, blood loss, and visual analog scale scores for pain. Secondary outcomes were operative time, irrigation amount used, postoperative shoulder swelling, the need for pressure increase, mean arterial pressure (MAP), functional outcomes, postoperative adverse effects such as deep venous thrombosis, and pulmonary embolism. The outcomes were pooled to perform a meta-analysis. RESULTS Seven prospective randomized controlled trials met the inclusion criteria for analysis. All of the included studies performed arthroscopic rotator cuff repair. No significant difference in visual clarity was observed (SMD (standardized mean difference), 0.45 [95% CI(confidence interval), -0.68, 1.59]; p = 0.44) nor in pain score (MD (mean difference), -0.46 [95% CI, -0.97, 0.05]; p = 0.08) between the TXA group and the control group. Two studies found no significant difference in blood loss between the TXA group and the control group. The meta-analysis from five studies demonstrated no significant difference between the TXA and control groups in operative time (MD, -3.51 [95% CI, -15.82, 8.80]; p = 0.58) or irrigation amount used (MD, -2.53 [95% CI, -5.93, 0.87]; p = 0.14). Two trials reported different statistical results in postoperative shoulder swelling. No significant differences regarding the need for pressure increase and MAP were reported between groups. No wound complications or infections or cardiac, thrombotic, or thromboembolic complications were recorded in either group. CONCLUSION The use of intravenous or local TXA in shoulder arthroscopic surgery did not increase complications or thromboembolic events, but TXA had no obviously effect of reducing bleeding to obtain a clear visual field or pain release in patients undergoing shoulder arthroscopic surgery.
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Affiliation(s)
- Yiyuan Sun
- Day Surgery Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Dan Xiao
- Yong Chuan Hospital of ChongQing Medical University, Chongqing 402160, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
- Correspondence:
| | - Wufeng Cai
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Xihao Huang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Qi Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
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Nicholson TA, Kirsch JM, Churchill R, Lazarus MD, Abboud JA, Namdari S. The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial. J Shoulder Elbow Surg 2022; 31:2211-2216. [PMID: 35970278 DOI: 10.1016/j.jse.2022.06.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/19/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair. METHODS This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance. RESULTS There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery. CONCLUSION The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.
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Affiliation(s)
- Thema A Nicholson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jacob M Kirsch
- Boston Sports and Shoulder Center at New England Baptist Hospital, Boston, MA, USA
| | | | - Mark D Lazarus
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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20
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Soft-Tissue Considerations in Shoulder Surgery in the Patient With Lymphedema. J Am Acad Orthop Surg 2022; 30:925-932. [PMID: 35486892 DOI: 10.5435/jaaos-d-21-01136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/20/2022] [Indexed: 02/01/2023] Open
Abstract
Lymphedema is a chronic, progressive, and often debilitating condition that results in swelling of the affected tissue. Secondary lymphedema is most commonly recognized by unilateral swelling of the ipsilateral extremity after the treatment of cancer. It is estimated that nearly 1.45 million women suffer from breast cancer-related lymphedema in the United States. The number of patients suffering from upper extremity lymphedema is expected to increase because multimodal treatment of breast cancer increases the long-term survival after diagnosis. Because this population ages, the likelihood of encountering a patient with concurrent lymphedema and shoulder pathology requiring orthopaedic intervention is likely to rise. A patient with an already edematous arm and/or impaired drainage of that arm is likely to have different and more complex intraoperative and postoperative courses than patients with normal lymphatic drainage. Although a lymphedematous arm should not preclude surgical intervention, there are considerations when approaching shoulder surgery in the setting of upper extremity lymphedema that may help mitigate complications and aid the patient in their orthopaedic recovery.
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21
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Tranexamic Acid Associated With Less Wound Complications in Ankle and Hindfoot Surgery: Level III, Retrospective Cohort Study. J Am Acad Orthop Surg 2022; 30:789-797. [PMID: 35858253 DOI: 10.5435/jaaos-d-21-01064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 05/21/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The purpose of this study was to determine whether total ankle arthroplasty (TAA) and ankle/hindfoot fusion patients receiving tranexamic acid (TXA) exhibit fewer wound complications. METHODS A retrospective review was conducted of 212 patients (217 feet) undergoing TAA (n = 72), ankle (n = 36), tibiotalocalcaneal (n = 20), pantalar (n = 1), or hindfoot fusion (ie, subtalar = 47, double = 33, and triple = 8) between 2015 and 2020 by a fellowship-trained foot and ankle surgeon at an academic medical center. Demographics, medical history, complications, and union status were compared between TXA (n = 101) and non-TXA (n = 116) cohorts. The mean follow-up was 1.24 years (range, 0.25 to 4.68). RESULTS The TXA group had significantly less postoperative infections (5.9% versus 15.5%, P = 0.025). Within a subgroup analysis of ankle/hindfoot fusions, the TXA group exhibited significantly more Charcot neuroarthropathy (20.7% versus 5.7%, P = 0.006) and shorter follow-up duration (0.96 versus 1.30 years, P = 0.030); however, TXA was associated with shorter time to fusion (146 versus 202 days, P = 0.049) and fewer revision surgeries (8.6% versus 21.8%, P = 0.036). Subgroup analysis excluding feet with Charcot also demonstrated less postoperative infections (4.5% versus 14.4%, P = 0.020). Subgroup analysis of TAAs showed fewer cases of superficial infections (2.3% versus 27.6%, P = 0.002) and delayed wound healing (25.6% versus 48.3%, P = 0.047) in the TXA cohort. DISCUSSION TXA use in ankle/hindfoot surgery was correlated with a reduction in superficial infections and radiographic time to union. The use of TXA in TAA correlated with fewer superficial infections and cases of delayed wound healing. Thus, in addition to other areas of orthopaedics, TXA seems to be beneficial in hindfoot and ankle surgery. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS All data were obtained from our institution's medical records. This study is not associated with a clinical trial.
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Johns WL, Walley KC, Jackson B, Gonzalez TA. Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis. Foot Ankle Spec 2022; 15:377-383. [PMID: 33401927 DOI: 10.1177/1938640020983639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Benjamin Jackson
- School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina
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Mackenzie SP, Spasojevic M, Smith M, Mattern O, Piggott RP, Patel SS, Bedaiwy N, Cass B, Young A. The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial. J Shoulder Elbow Surg 2022; 31:1399-1408. [PMID: 35346849 DOI: 10.1016/j.jse.2022.02.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores. METHODS A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks. RESULTS There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis. CONCLUSION TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis.
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Affiliation(s)
| | - Miloš Spasojevic
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia.
| | - Margaret Smith
- Institute of Bone and Joint Research (University of Sydney) at Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Owen Mattern
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | | | - Shaan S Patel
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | - Najla Bedaiwy
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | - Benjamin Cass
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | - Allan Young
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
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Goldstein K, Jones C, Kay J, Shin J, de Sa D. Tranexamic Acid Administration in Arthroscopic Surgery Is a Safe Adjunct to Decrease Postoperative Pain and Swelling: A Systematic Review and Meta-analysis. Arthroscopy 2022; 38:1366-1377.e9. [PMID: 34655767 DOI: 10.1016/j.arthro.2021.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 10/03/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model. RESULTS There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: -1.65, 95% confidence interval [CI] -3.41 to 0.10, P = .06, I2 = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I2 = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: -61.14 mL, 95% CI -104.43 to -17.85, I2 = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: -0.76, 95% CI -0.97 to -0.54, I2 = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI -3.43 to 4.50, I2 = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups. CONCLUSIONS This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kyle Goldstein
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Conor Jones
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario
| | - Jason Shin
- Department of Orthopaedic Surgery. University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario.
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The utilization of tranexamic acid in orthopaedic procedures and gap in research for its benefits conferred in hip arthroscopy. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hohmann E. Editorial Commentary: The Current Evidence in Support of Tranexamic Acid in Arthroscopic Surgery Is Poor. Arthroscopy 2022; 38:519-521. [PMID: 35123721 DOI: 10.1016/j.arthro.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 02/02/2023]
Abstract
Tranexamic acid (TXA) has been used to treat severe bleeding events for nearly 60 years and is on the list of World Health Organization essential medicines. Initially, it was described to treat heavy menstrual bleeding, but it is now used for a variety of applications. In orthopedic surgery, TXA is commonly used to reduce bleeding after total joint arthroplasty and spine surgery. The use of TXA for joint arthroplasty has been principally endorsed by various orthopedic societies, but they have also criticized a lack of evidence for high-risk patients with a history of pulmonary embolus, vascular stents, stroke, transient ischemic attack, and other cardiac, respiratory, or vascular conditions. TXA may also reduce bleeding complications in arthroscopic surgery, and the findings of recent meta-analyses suggest that intravenous application reduced drainage output and the need for knee joint aspiration and reduced knee swelling. It also had a positive short-term effect on clinical and functional outcomes. However, high risk of bias, low-study quality, and heterogeneity substantially reduced the quality of evidence and the validity of the study conclusions. In my opinion, on the basis of the current evidence, the routine use of TXA in arthroscopic surgery is not recommended.
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Viberg B. Tranexamic Acid: When is It Indicated in Orthopaedic Surgery? ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021. [PMID: 34902870 DOI: 10.1055/a-1666-9382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Tranexamic acid (TXA) has been studied extensively during the last 5-8 years. It inhibits clot dissolution during surgery and can therefore reduce blood loss. However, there has been concern that this could result in more frequent complications, specifically in terms of thromboembolic events. The indications for TXA are widespread, and this review covers the literature on orthopaedic indications such as joint replacement, fracture surgery, and arthroscopic procedures. In general, TXA is safe and can be used in a wide variety of orthopaedic procedures, lowering blood loss without increasing the risk of complications.
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Affiliation(s)
- Bjarke Viberg
- Orthopaedic Surgery and Traumatology, Hospital Lillebaelt - University Hospital of Southern Denmark, Kolding, Denmark.,Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
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Johns WL, Walley KC, Hammoud S, Gonzalez TA, Ciccotti MG, Patel NK. Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:4030-4041. [PMID: 33630652 DOI: 10.1177/0363546521988943] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study. PURPOSE To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures. STUDY DESIGN Meta-analysis. METHODS A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis. RESULTS Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, -95.51 to -27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (-1.96 points; 95% CI, -2.19 to -1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups. CONCLUSION The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Sommer Hammoud
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Medical College of Virginia at Virginia Commonwealth University, Richmond, Virginia, USA
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Haratian A, Shelby T, Hasan LK, Bolia IK, Weber AE, Petrigliano FA. Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations. Orthop Res Rev 2021; 13:187-199. [PMID: 34703327 PMCID: PMC8541761 DOI: 10.2147/orr.s321881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023] Open
Abstract
Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.
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Affiliation(s)
- Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Tara Shelby
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Hartland AW, Teoh KH, Rashid MS. Clinical Effectiveness of Intraoperative Tranexamic Acid Use in Shoulder Surgery: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:3145-3154. [PMID: 33475421 PMCID: PMC8411466 DOI: 10.1177/0363546520981679] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery. PURPOSE To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate. RESULTS Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures. CONCLUSION This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required. CLINICAL RELEVANCE TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.
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Affiliation(s)
| | - Kar H. Teoh
- Princess Alexandra Hospital, Harlow,
Essex, UK
| | - Mustafa S. Rashid
- Nuffield Department of Orthopaedics,
Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK,Mustafa S. Rashid, MB ChB,
MSc, PhD, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal
Sciences, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK (
)
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B H PP, Diskina D, Lin HM, Vulcano E, Lai YH. Use of tranexamic acid does not influence perioperative outcomes in ambulatory foot and ankle surgery-a prospective triple blinded randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2021; 45:2277-2284. [PMID: 34324042 DOI: 10.1007/s00264-021-05131-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE TXA is an antifibrinolytic medication widely used to reduce perioperative blood loss, but it has been seldom used during foot and ankle surgery. Our study evaluates the impact of TXA use on blood loss, post-operative pain, peri-operative opioid consumption, and wound healing in ambulatory outpatient foot and ankle procedures. DESIGN Prospective, triple-blinded, randomized controlled trial. SETTING Peri-operative environment of a major academic health centre in New York City. PATIENTS A total of 100 participants who were scheduled for ambulatory foot and ankle surgery with a single surgeon. INTERVENTIONS Patients receive either 10 mg/kg TXA (TXA group) or 10 ml/kg of normal saline (placebo group) intravenously prior to skin incision. MEASUREMENTS Primary outcome was intra-operative blood loss. Secondary outcomes were peri-operative opioid consumption and wound complications between post-operative days 14 and 21. MAIN RESULTS We found no difference between TXA and placebo groups in terms of intra-operative blood loss, p value 0.71, 95% CI (63.13-19.80). There was no difference between the two groups in terms of post-operative morphine milliequivalents (MME). The incidence of wound complications was 16.3% in the TXA group compared to 15.7% in the placebo group with OR 1.04, p value 0.93, 95% CI (0.32-2.77). No adverse events associated with TXA were reported. CONCLUSIONS The use of TXA during foot and ankle surgery was not associated with any benefits in perioperative outcomes in our outpatient ambulatory surgical population. Considering potential risks, we do not support the routine use of TXA in this surgical model.
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Affiliation(s)
| | | | - Hung Mo Lin
- Mount Sinai Health System, New York, NY, USA
| | - Ettore Vulcano
- Mount Sinai Medical Center, Columbia University, Miami, FL, USA
| | - Yan H Lai
- Department of Anesthesiology, Mount Sinai Health System, 1000 Tenth Avenue, New York, NY, 10019, USA.
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Hurley ET, Maye AB, Thompson K, Anil U, Resad S, Virk M, Strauss EJ, Alaia MJ, Campbell KA. Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis. Am J Sports Med 2021; 49:2262-2271. [PMID: 33321046 DOI: 10.1177/0363546520971757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. PURPOSE To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. RESULTS Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions. CONCLUSION Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.
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Affiliation(s)
| | - Andrew B Maye
- New York University Langone Health, New York, New York, USA
| | | | - Utkarsh Anil
- New York University Langone Health, New York, New York, USA
| | - Sehar Resad
- New York University Langone Health, New York, New York, USA
| | - Mandeep Virk
- New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- New York University Langone Health, New York, New York, USA
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Taeuber I, Weibel S, Herrmann E, Neef V, Schlesinger T, Kranke P, Messroghli L, Zacharowski K, Choorapoikayil S, Meybohm P. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surg 2021; 156:e210884. [PMID: 33851983 PMCID: PMC8047805 DOI: 10.1001/jamasurg.2021.0884] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use. OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines. DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020. STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded. DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality. RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53). CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.
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Affiliation(s)
- Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Leila Messroghli
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Belk JW, McCarty EC, Houck DA, Dragoo JL, Savoie FH, Thon SG. Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies. Arthroscopy 2021; 37:1323-1333. [PMID: 33278534 DOI: 10.1016/j.arthro.2020.11.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder. METHODS A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores). RESULTS Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05). CONCLUSION Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients. LEVEL OF EVIDENCE II, systematic review of level I and II studies.
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Affiliation(s)
- John W Belk
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A..
| | - Eric C McCarty
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Darby A Houck
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Jason L Dragoo
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Felix H Savoie
- Department of Orthopaedics, Tulane University, New Orleans, Louisiana, U.S.A
| | - Stephen G Thon
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
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Thangarajah T, Lo IK, Sabo MT. Rotator cuff repair techniques: Current concepts. J Clin Orthop Trauma 2021; 17:149-156. [PMID: 33854942 PMCID: PMC8022250 DOI: 10.1016/j.jcot.2021.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 01/04/2023] Open
Abstract
Arthroscopic rotator cuff repair is being performed by an ever-increasing number of surgeons. With an ageing population and growing patient expectations it is crucial that clinical outcomes are optimised. Anatomical reduction of the tendon back to its footprint with minimal tension contributes to this, but this can only be achieved if key biomechanical factors are taken into consideration. In this review of the technical aspects of a rotator cuff repair, we focus on: (1) patient positioning, (2) biomechanical principles, (3) optimal visualisation, and (4) repair techniques for both anterior and postero-superior tears.
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Affiliation(s)
- Tanujan Thangarajah
- University of Calgary, Department of Trauma and Orthopaedic Surgery, 2500 University Drive NW, Calgary, Alberta, 2N 1N4, Canada
| | - Ian K. Lo
- University of Calgary, Department of Trauma and Orthopaedic Surgery, 2500 University Drive NW, Calgary, Alberta, 2N 1N4, Canada
| | - Marlis T. Sabo
- SCRUBS Research Unit, Cumming School of Medicine, University of Calgary, Canada
- Corresponding author. 4448 Front St SE, Calgary, AB, T3M 1M4, Canada.
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van Eck CF, van Meel TA, van den Bekerom MP, Zijl JA, Kooistra B. Heat-Related Complications from Radiofrequency and Electrocautery Devices Used in Arthroscopic Surgery: A Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e605-e613. [PMID: 34027473 PMCID: PMC8129439 DOI: 10.1016/j.asmr.2020.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/20/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To investigate the occurrence of heat-related complications from radiofrequency and electrocautery devices in patients undergoing arthroscopic surgery. Methods A systematic review was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting complications after arthroscopy using electrosurgery devices were included. Only English- and Dutch-language articles were included. Basic science/nonclinical studies/human cadaveric studies and animal studies were excluded. Article selection was performed by 2 separate reviewers. Interobserver agreement of the selection procedure was determined by Cohen’s kappa. All included articles were critically appraised using an adapted version of the ROBINS-I tool. Results Twenty-five studies were included in this systematic review. A total of 309 cases of heat-related complications were identified. Chondrolysis was present in 45 cases and dermal burns in 15 cases. Axillary nerve injuries were reported in 197 cases of arthroscopic adhesive capsulitis release. However, it was unclear whether these injuries were directly related to the overheating of the arthroscopic fluid. No one specific risk factor for thermal complications was identified, but related factors included the leakage of the arthroscopy fluid, use of a thermal device continuously for a long period of time, proximity of the thermal device to the tissue, intra-articular local anesthetic injection or the use of intra-articular pain pumps, and certain surgical procedures, such as thermal capsulorrhaphy, capsular release, and synovectomy. Conclusions The most common heat-related complications in arthroscopy are dermal burns and chondrolysis. Risk factors include leakage of arthroscopy fluid, use of a thermal device, intra-articular anesthetics/pain pumps, and performing specific surgical procedures. Level of Evidence Systematic review of level III-IV studies.
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Affiliation(s)
- Carola F. van Eck
- Department of Orthopaedic Surgery/Orthopaedic Engineering & Sports Medicine Laboratory, University of Pittsburgh, Pittsburgh, PA
- Address correspondence to Carola F. van Eck, M.D., Ph.D., F.A.A.O.S., UPMC Lemieux Sports Complex, 8000 Cranberry Springs Dr., Cranberry Township, PA 16066.
| | - Tim A.C. van Meel
- Department of General Surgery, Amphia Ziekenhuis, Breda, the Netherlands
| | | | - Jacco A.C. Zijl
- Department of Orthopaedic Surgery, St. Antonius Ziekenhuis, Utrecht, the Netherlands
| | - Bauke Kooistra
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis Amsterdam, the Netherlands
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Comparison of the efficacy of irrigation with epinephrine or tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A double-blind, randomized-controlled study. Jt Dis Relat Surg 2021; 32:115-121. [PMID: 33463426 PMCID: PMC8073435 DOI: 10.5606/ehc.2021.78393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/18/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES This study aims to investigate whether there was a difference between epinephrine (EPN) and tranexamic acid (TXA) in providing visual clarity during arthroscopic rotator cuff tear repair. PATIENTS AND METHODS This double-blind, prospective, randomized-controlled clinical study included a total of 90 patients (42 males, 48 females; mean age: 55.6±8.3 years; range, 18 to 69 years) in whom either EPN (EPN group, n=47) or TXA-diluted irrigation solutions (TXA group, n=43) were used during rotator cuff tear arthroscopy between December 2017 and November 2019. Arthroscopy was performed using irrigation fluid containing 0.33 mg of EPN per 1 L of saline in the EPN group and 0.42 mg of TXA per 1 L of saline in the TXA group. All procedures were performed by two specialized shoulder surgeons. Visual clarity (primary endpoint) was rated by the operating surgeon using the Visual Analog Scale (VAS) in the immediate postoperative period. Secondary endpoints included total operating time (TOT), potential thrombotic or thromboembolic side effects, mean arterial pressure (MAP), and total amount of irrigation fluid used. RESULTS There was no significant difference in the surgeon rated- VAS scores between the groups. The mean VAS score was 7.6±1.62 (range, 4 to 10) in the EPN group and 7.1±1.74 (range, 3 to 10) in the TXA group (p=0.59). No cardiac, thrombotic, or thromboembolic complications were observed in any of the groups. CONCLUSION Adding TXA to the irrigation fluid during the arthroscopic rotator cuff repair may provide similar visual quality to the EPN, as measured by VAS.
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Abstract
With sincere thanks to the Arthroscopy Association of North America Education Foundation for their support, we are pleased to announce the Annual Awards for our best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2020, as well as the Most Downloaded and Most Cited papers published 5 years ago. We proudly introduce new members of our editorial team, and your editors update their disclosures of potential conflicts of interest.
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Johns WL, Walley KC, Seedat R, Jackson B, Boukhemis K, Gonzalez T. Tranexamic Acid Use in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420975419. [PMID: 35097417 PMCID: PMC8564923 DOI: 10.1177/2473011420975419] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery. Methods: A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months. Results: Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05). Conclusions: The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised. Level of Evidence: Level IV, case series.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Raees Seedat
- Virginia Commonwealth University, School of Medicine, Richmond, VA, USA
| | - Benjamin Jackson
- University of South Carolina, School of Medicine, Columbia, SC, USA
| | | | - Tyler Gonzalez
- University of South Carolina, School of Medicine, Columbia, SC, USA
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