Tranexamic acid administration for arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial

The effect of tranexamic acid and epinephrine on visual clarity during arthroscopic shoulder surgery: A meta-analysis of RCTs

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.

Tranexamic acid use in arthroscopic rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials

Background

Rotator cuff disease, a prevalent cause of shoulder disability and pain among middle-aged and older adults, has seen an uptick in arthroscopic repairs in the last 2 decades. These repairs necessitate optimal visualization and controlled hemostasis to prevent complications. This study aimed to assess the efficacy of tranexamic acid (TXA) in arthroscopic rotator cuff repairs by evaluating all available randomized controlled trials (RCTs) in the literature.

Methods

A systematic search was conducted in PubMed, Cochrane Library, Embase, Science Direct, Web of Science, Google Scholar, and CINAHL databases from inception through November 2022 for RCTs investigating the use of TXA in arthroscopic rotator cuff repair. The studies selected reported on the primary outcomes, which include visual clarity during surgery, postoperative pain, and operative time. The quality of the studies was evaluated using the RoB 2 (Risk of Bias) tool.

Results

A total of 7 studies, with level I and II of evidence, comprising 510 randomized patients (253 females, 257 males) were included, with mean ages of 59 and 58 years for the TXA and control groups, respectively. Bias was graded "Low" in 2 RCTs and "Some concerns" in 5 RCTs. Visual analog scale for pain was significantly different with TXA use at postoperative day 1 (weighted mean difference (WMD) = -0.55; 95% confidence interval (CI): -1.07 to -0.04, P = .04). Operative time was significantly higher for the control group with a mean difference of 7.97 minutes (WMD = -7.97; 95% CI: -15.19 to -0.74, P = .04). The impact of TXA on visual clarity during shoulder arthroscopy remains uncertain. However, postoperative shoulder swelling results were comparable in both groups (WMD = -1.71; 95% CI: -3.72 to 0.29, I2 = 99% (where I2 = heterogeneity statistic), P = .69). Considerable heterogeneity was seen in some results.

Conclusion

Pooled data suggest that the use of TXA in shoulder arthroscopy does reduce postoperative shoulder pain and has a positive effect on decreasing operative time. However, the reduction in pain may not be clinically significant, and there is no effect on reducing shoulder swelling. The impact of TXA on visual clarity remains inconclusive, and further research is needed using methodologically rigorous articles that incorporate objective measures and controlled factors to eliminate subjective bias.

Intravenous Tranexamic Acid Improves Visual Clarity During Synovectomy in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Double-Blind, Randomized Controlled Study

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.

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

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.

Effect of tranexamic acid on shoulder surgery: an updated meta-analysis of randomized studies

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.

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

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.

Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis

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.

Efficacy and Safety of Tranexamic Acid in Shoulder Arthroscopic Surgery: A Systematic Review and Meta-Analysis

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.