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Laungani D, Porto JR, Haase L, Smith K, Chen R, Gillespie R. Tranexamic Acid in Total Shoulder Arthroplasty: A Scoping Review of Current Practices and Future Directions. JBJS Rev 2024; 12:01874474-202406000-00006. [PMID: 38889236 DOI: 10.2106/jbjs.rvw.24.00035] [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: 06/20/2024]
Abstract
BACKGROUND The effectiveness of tranexamic acid (TXA) as an antifibrinolytic agent in total shoulder arthroplasty (TSA) is well documented; however, there remains considerable practice variability concerning the optimal route of administration and dosing protocols concerning the medication's use. Our aim was to conduct a scoping review of the literature regarding the efficacy of various methods of TXA administration in TSA and to identify knowledge gaps that may be addressed. METHODS A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The PubMed and MEDLINE electronic databases were searched to identify all articles published before March 2023 investigating the administration of TXA in TSA. Randomized controlled trials and cohort studies were included, and data were extracted to capture information regarding intervention details and related outcomes such as blood loss, transfusion needs, and complication rates. RESULTS A total of 15 studies were included in this review. All selected studies used either intravenous (IV) or topical TXA, with 1 study also including a combined approach of both topical and IV TXA. Of the studies that used an IV approach, the most commonly reported favorable outcomes were a reduction in blood volume loss, reduction in hemoglobin or hematocrit change, and decreased drain output. Dosing varied significantly between all identified studies because some used a standard dosing amount in grams or milligrams for all treatment group participants, whereas others used weight-based dosing amounts. All studies that used a weight-based dosing regimen as well as studies using a standard dosing amount between 1,000 and 5,000 mg reported favorable outcomes for postoperative blood loss. CONCLUSION Both IV and topical TXA clearly demonstrate favorable perioperative hematologic profiles in TSA. Although both approaches have demonstrated a successful association with decreased blood loss and transfusion requirements, there is no definitive benefit to choosing one over the other. Furthermore, the use of oral TXA either in combination or isolation warrants further study in TSA because of its comparable efficacy profiles and significantly lower associated costs of application.
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Affiliation(s)
- Dev Laungani
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- University Hospitals Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Joshua R Porto
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- University Hospitals Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Lucas Haase
- University Hospitals Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Kira Smith
- University Hospitals Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Raymond Chen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- University Hospitals Department of Orthopaedic Surgery, Cleveland, Ohio
| | - Robert Gillespie
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- University Hospitals Department of Orthopaedic Surgery, Cleveland, Ohio
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de Geofroy B, Micicoi G, Olmos M, Boileau P, Bronsard N, Gonzalez JF, Gauci MO. Early morbidity and mortality after one-stage bilateral shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:505-511. [PMID: 37853140 DOI: 10.1007/s00264-023-06003-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. METHODS A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. RESULTS There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. CONCLUSIONS One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.
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Affiliation(s)
- Bernard de Geofroy
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Grégoire Micicoi
- Department of Orthopaedic Surgery and Sport Surgery, University Institute of Locomotion and Sport, University Hospital of Nice, 30 Av Voie Romaine, 06000 Cedex 1, Nice, CS, France
| | - Manuel Olmos
- Department of Orthopaedic Surgery and Sport Surgery, University Institute of Locomotion and Sport, University Hospital of Nice, 30 Av Voie Romaine, 06000 Cedex 1, Nice, CS, France
| | - Pascal Boileau
- Institut de Chirurgie Réparatrice, Groupe Kantys, Locomoteur & Sport, Clinique St Antoine7 Av Durante, 06000, Nice, France
| | - Nicolas Bronsard
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Jean-François Gonzalez
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Marc Olivier Gauci
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France.
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Garcia-Maya B, Morais S, Diez-Sebastian J, Antuña S, Barco R. The efficacy of topical tranexamic acid in reverse shoulder arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:387-393. [PMID: 37054841 DOI: 10.1016/j.recot.2023.04.003] [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: 01/16/2023] [Revised: 03/24/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Topical tranexamic acid (TXA) has been shown to decrease blood loss in knee and hip arthroplasty. Despite there is evidence about its effectiveness when administered intravenous, its effectiveness and optimal dose when used topically has not been established. We hypothesized that the use of 1.5g (30mL) of topical TXA could decrease the amount of blood loss in patients after reverse total shoulder arthroplasty (RTSA). MATERIAL AND METHODS One hundred and seventy-seven patients receiving a RSTA for arthropathy or fracture were retrospectively reviewed. Preoperative-to-postoperative change in hemoglobin (ΔHb) and hematocrit (ΔHct) level drain volume output, length of stay and complications were evaluated for each patient. RESULTS Patients receiving TXA has significant less drain output in both for arthropathy (ARSA) (104 vs. 195mL, p=0.004) and fracture (FRSA) (47 vs. 79mL, p=0.01). Systemic blood loss was slightly lower in TXA group, but this was not statistically significant (ARSA, ΔHb 1.67 vs. 1.90mg/dL, FRSA 2.61 vs. 2.7mg/dL, p=0.79). This was also observed in hospital length of stay (ARSA 2.0 vs. 2.3 days, p=0.34; 2.3 vs. 2.5, p=0.56) and need of transfusion (0% AIHE; AIHF 5% vs. 7%, p=0.66). Patients operated for a fracture had a higher rate of complications (7% vs. 15.6%, p=0.04). There were no adverse events related to TXA administration. CONCLUSION Topical use of 1.5g of TXA decreases blood loss, especially on the surgical site without associated complications. Thus, hematoma decrease could avoid the systematic use of postoperative drains after reverse shoulder arthroplasty.
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Affiliation(s)
- B Garcia-Maya
- Hospital Universitario Infanta Elena, Madrid, España.
| | - S Morais
- Araba University Hospital Txagorritxu Campus, Araba, España
| | | | - S Antuña
- La Paz University Hospital, Madrid, España
| | - R Barco
- La Paz University Hospital, Madrid, España
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Garcia-Maya B, Morais S, Diez-Sebastian J, Antuña S, Barco R. [Translated article] The efficacy of topical tranexamic acid in reverse shoulder arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T387-T393. [PMID: 37311478 DOI: 10.1016/j.recot.2023.06.010] [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: 01/16/2023] [Accepted: 04/05/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Topical tranexamic acid (TXA) has been shown to decrease blood loss in knee and hip arthroplasty. Despite there is evidence about its effectiveness when administered intravenous, its effectiveness and optimal dose when used topically have not been established. We hypothesised that the use of 1.5g (30mL) of topical TXA could decrease the amount of blood loss in patients after reverse total shoulder arthroplasty (RTSA). MATERIAL AND METHODS One hundred and seventy-seven patients receiving a RSTA for arthropathy or fracture were retrospectively reviewed. Preoperative-to-postoperative change in haemoglobin (ΔHb) and hematocrit (ΔHct) level drain volume output, length of stay and complications were evaluated for each patient. RESULTS Patients receiving TXA has significant less drain output in both for arthropathy (ARSA) (104 vs. 195mL, p=0.004) and fracture (FRSA) (47 vs. 79mL, p=0.01). Systemic blood loss was slightly lower in TXA group, but this was not statistically significant (ARSA, ΔHb 1.67 vs. 1.90mg/dL, FRSA 2.61 vs. 2.7mg/dL, p=0.79). This was also observed in hospital length of stay (ARSA 2.0 vs. 2.3 days, p=0.34; 2.3 vs. 2.5, p=0.56) and need of transfusion (0% AIHE; AIHF 5% vs. 7%, p=0.66). Patients operated for a fracture had a higher rate of complications (7% vs. 15.6%, p=0.04). There were no adverse events related to TXA administration. CONCLUSION Topical use of 1.5g of TXA decreases blood loss, especially on the surgical site without associated complications. Thus, haematoma decrease could avoid the systematic use of postoperative drains after reverse shoulder arthroplasty.
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Affiliation(s)
- B Garcia-Maya
- Hospital Universitario Infanta Elena, Madrid, Spain.
| | - S Morais
- Araba University Hospital Txagorritxu Campus, Araba, Spain
| | | | - S Antuña
- La Paz University Hospital, Madrid, Spain
| | - R Barco
- La Paz University Hospital, Madrid, Spain
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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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Beyth S, Fraind-Maya G, Safran O. Tranexamic Acid Treatment Reduces Blood Loss After Elective and Semi-Urgent Reverse Total Shoulder Arthroplasty. Geriatr Orthop Surg Rehabil 2023; 14:21514593231181992. [PMID: 37325700 PMCID: PMC10262644 DOI: 10.1177/21514593231181992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Post operative blood loss after reverse shoulder arthroplasty (RSA) is associated with the need for blood transfusion and prolonged hospital stay, among other complications. Tranexamic acid (TXA) reduces perioperative blood loss and is effective when delivered systemically or locally. We compared the effects of TXA on perioperative blood loss between elective and semi-urgent RSA. Methods We retrospectively reviewed patients who underwent either elective or semi-urgent RSA for fracture repair, with and without TXA treatment. Demographics, clinical records, and laboratory results were collected and analyzed to compare peripheral blood hemoglobin concentrations before and after surgery, the need for blood transfusion, and length of hospital stay between the 2 groups. Results In a cohort of 158 patients, 91 (58%) underwent elective RSA. TXA was administered in 91 (58%) patients from the entire group. TXA administration was associated with a significant decrease in post operative hemoglobin concentration reduction in both the elective and fracture groups (P = .026 and P = .018, respectively), a significant decrease in post operative blood transfusion rates (P = .004 and P = .003, respectively), and a decrease in the need for prolonged hospitalization (P = .038 and P = .009, respectively). Discussion The local application of TXA during RSA yielded a significant reduction in perioperative blood loss. We showed a significant positive effect of local TXA administration during RSA that is comparable for both elective and semi-urgent patients. Due to the baseline characteristics of fracture patients, their clinical benefits may be more notable. Conclusions The positive outcomes for surgical patients with the use of TXA during RSA can possibly cause future consideration in clinical practice.
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Affiliation(s)
- Shaul Beyth
- Orthopedic Department, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Fraind-Maya
- Orthopedic Department, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ori Safran
- Orthopedic Department, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Deng HM. Efficacy and safety of intravenous tranexamic acid in total shoulder arthroplasty: A meta-analysis. World J Clin Cases 2023; 11:2992-3001. [PMID: 37215404 PMCID: PMC10198082 DOI: 10.12998/wjcc.v11.i13.2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Total shoulder arthroplasty (TSA) results in a large amount of perioperative blood loss due to severe trauma.
AIM To investigate the safety and efficacy of intravenous tranexamic acid (TXA) in TSA.
METHODS We searched the PubMed, Cochrane Library, Embase and Web of Science databases for randomized controlled trials (RCTs) on the use of TXA in TSA. And all the results were checked and assessed by Reference Citation Analysis (https://www.referencecitationanalysis.com/). A meta-analysis was performed with Review Manager 5.3 to calculate the odds ratio (OR) or weighted mean difference (WMD) of related outcome indicators.
RESULTS A total of 5 RCTs with level 1 evidence were included. There were 369 cases, with 186 in the TXA group and 183 in the placebo group. The meta-analysis showed that TXA can significantly reduce total blood loss during the perioperative period [WMD = -249.56, 95% confidence interval (CI): -347.6 to -151.52, P < 0.0001], and the incidence of adverse reactions was low (OR = 0.36, 95%CI: 0.16-0.83, P = 0.02). Compared with the placebo group, the TXA group had significantly less total haemoglobin loss (WMD = -34.39, 95%CI: -50.56 to -18.22), less haemoglobin fluctuation before and after the operation (WMD = -0.6, 95%CI: -0.93 to -0.27) and less 24-h drain output (WMD = -136.87, 95%CI: -165.87 to -106.49). There were no significant differences in the operation time (P = 0.11) or hospital length of stay (P = 0.30) between the two groups.
CONCLUSION The application of intravenous TXA in the perioperative period of TSA can significantly reduce the total volume of perioperative blood loss and reduce the incidence of adverse reactions, so TXA is worthy of widespread clinical use.
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Affiliation(s)
- Hua-Mei Deng
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510120, Guangdong Province, China
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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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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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Hawkes D, Brookes-Fazakerley S, Robinson S, Bhalaik V. Intraoperative and early postoperative complications of reverse shoulder arthroplasty: A current concepts review. J Orthop 2023; 35:120-125. [PMID: 36471697 PMCID: PMC9718996 DOI: 10.1016/j.jor.2022.11.012] [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: 08/03/2022] [Revised: 10/19/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Reverse shoulder arthroplasty is a common procedure performed for a variety of shoulder pathologies. Aims and objectives This current concept review evaluates the intraoperative and early postoperative complications, with a specific focus given to neurological and vascular injury, fracture, dislocation and venous thromboembolism. Conclusion A detailed knowledge of potential complications will allow surgeons to mitigate risk and maximise outcomes.
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Affiliation(s)
- David Hawkes
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Steven Brookes-Fazakerley
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Simon Robinson
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Vijay Bhalaik
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
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Kelly M, Turcotte J, Fowler MB, West M, Lashgari C, Gelfand J. Impact of tranexamic acid on clinical and hematologic outcomes following total shoulder arthroplasty. Shoulder Elbow 2022; 14:544-550. [PMID: 36199511 PMCID: PMC9527491 DOI: 10.1177/17585732211023053] [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: 02/01/2021] [Revised: 03/23/2021] [Accepted: 05/17/2021] [Indexed: 01/17/2023]
Abstract
Background The purpose of this study is to evaluate the impact of intravenous tranexamic acid on clinical and hematologic outcomes after total shoulder arthroplasty. Methods Retrospective review was conducted for 282 consecutive patients undergoing either anatomic shoulder arthroplasty or reverse total shoulder arthroplasty. Univariate analysis and multivariate linear regression were used to compare outcomes for patients receiving intravenous tranexamic acid with those who did not. Results Of the 282 patients included in this study, 78 patients received intravenous tranexamic acid and 204 did not. Patients who received intravenous tranexamic acid had significantly lower pre- to postoperative change in hemoglobin and hematocrit, and decreased postoperative drain output. In addition, patients receiving intravenous tranexamic acid were significantly less likely to have a postoperative hematocrit <30. There were no significant differences in length of stay, rate of 30 day hematoma, surgical site infection, deep vein thrombosis, or readmission between groups. Conclusion Intravenous tranexamic acid is associated with a significant reduction in change in hematocrit and hemoglobin and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, tranexamic acid appears to have little impact on clinical outcomes such as length of stay and 30-day complication rates.
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Ek ET, Wang KK, Bohan CM, Goulding NJ, Jamieson RP. Role of Tranexamic Acid in Arthroscopic Osteocapsular Release of the Elbow for Degenerative Arthritis. Orthop J Sports Med 2022; 10:23259671221089608. [PMID: 35464902 PMCID: PMC9019345 DOI: 10.1177/23259671221089608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Minimizing intra-articular bleeding and swelling is crucial in preventing the development of stiffness around the elbow. Tranexamic acid (TXA) has been shown to be an effective adjunct in reducing perioperative bleeding after surgery. Purpose: To determine the effect of intravenous (IV) TXA on postoperative drain tube output in arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of 83 consecutive patients with primary degenerative elbow arthritis who underwent an arthroscopic osteocapsular release between 2015 and 2018. They organized patients into a no-TXA group (control) and a group that was given 1.0 g of IV TXA before tourniquet release. The primary outcome measure was drain tube output, and secondary outcome measures included postoperative day 1 pain levels on a visual analog scale and early range of motion at 8 weeks. Differences between groups were analyzed using 1-way analysis of variance, the Mann-Whitney U test, or the Fisher exact test. Results: There were 43 patients in the no-TXA group and 40 patients in the TXA group. Administration of IV TXA resulted in a 51% decrease in mean intra-articular bleeding for the TXA group, as measured via drain tube output (88.8 ± 80.5 mL [no-TXA] vs 43.4 ± 52.4 mL [TXA]; P = .0016). In both groups, there were significant increases in elbow arc of motion when compared with preoperative measurements. There were no between-group differences in early range of motion (129.7° ± 12.4° [no-TXA] vs 131.7° ± 9.2° [TXA]; P = .549) or postoperative pain (1.9 ± 2.2 [no-TXA] vs 1.5 ± 1.7 [TXA]; P = .89). Conclusion: In this study, IV TXA significantly reduced postoperative intra-articular bleeding in patients who underwent arthroscopic osteocapsular release of the elbow for primary degenerative arthritis. However, there were no differences in postoperative range of motion or pain between patients who received TXA and controls.
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Affiliation(s)
- Eugene T. Ek
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
| | - Kemble K. Wang
- Melbourne Orthopaedic Group, Melbourne, Victoria, Australia
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Goyal N, Wilson DJ, Wysocki RW, Fernandez JJ, Cohen MS. The use of tranexamic acid in open elbow release surgery. Shoulder Elbow 2022; 14:189-193. [PMID: 35265185 PMCID: PMC8899323 DOI: 10.1177/1758573220976055] [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: 08/17/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) has been effective in reducing perioperative blood loss in hip, knee, and shoulder arthroplasty. Our purpose was to assess the effect of TXA on perioperative blood loss for open elbow release. METHODS Consecutive open elbow releases performed between October 2016 and March 2020 were identified. Patients were included if both anterior and posterior joint releases with a single medial approach was performed. From November 2018 onward, intravenous TXA and topical TXA infused through a deep hemovac drain were administered as part of the perioperative protocol. Drain output, intraoperative blood loss, postoperative aspiration rate, and postoperative transfusion frequency were assessed. RESULTS Fifty patients (25 TXA, 25 non-TXA) were included. Drain output was significantly lower in the TXA-treated group compared to the non-treated group (121 mL vs. 221 mL; p = 0.003). There was no significant difference in intraoperative blood loss and the incidence of postoperative aspiration between groups. None of the patients received a blood transfusion or had a documented thromboembolic event. DISCUSSION The use of tranexamic acid with open elbow release surgeries resulted in decreased drain output, with no thromboembolic events. Perioperative tranexamic acid can be a safe and effective modality in reducing perioperative blood loss for open elbow release surgery.
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Affiliation(s)
- Nitin Goyal
- Nitin Goyal, 1611 W Harrison St, Chicago, IL 60612, USA.
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14
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15
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Garcia T, Fragão-Marques M, Pimentão P, Pinto M, Pedro I, Martins C. Tranexamic acid in total shoulder arthroplasty under regional anesthesia: a randomized, single blinded, controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:220-227. [PMID: 35144837 PMCID: PMC9373691 DOI: 10.1016/j.bjane.2021.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 10/26/2020] [Indexed: 04/25/2023]
Abstract
PURPOSE The purpose of this study was to determine whether Tranexamic Acid (TXA) can significantly reduce perioperative blood loss in Total Shoulder Arthroplasty (TSA) performed under regional anesthesia. METHODS We performed a randomized, single blinded, controlled study. Forty-five patients were submitted to TSA under regional anesthesia to treat cuff tear arthropathy, proximal humeral fractures, chronic instability, primary osteoarthrosis, and failures of previous prosthesis. Patients were randomized to either group TXA therapy (TXA), with 1 g intravenous (IV), or no Intervention (NTXA). Postoperative total drain output, hemoglobin variation, total blood loss, hemoglobin loss, and need for transfusion were measured. Pain-related variables were also assessed: postoperative pain assessment by visual analog scale, inpatient pain breakthrough, quality of recovery, length of stay, and coagulation function testing. RESULTS Participants presented a mean age of 76 years, 15.6% were male, 82.2% were American Society of Anesthesiologists (ASA) physical status I or II. There were no differences between groups concerning transfusions, operative time, Post-Anesthesia Care Unit (PACU) length of stay and in-hospital stay, and QoR-15 or postoperative pain. Bleeding measured by drain output at 2, 24 and 48 hours was significantly less in the TXA group at each timepoint. There was a difference in Hb variation - TXA: median (IQR) -1.4 (1.3) g.dL-1 vs. NTXA: -2.2 (1.3) g.dL-1; median difference: 0.80 (0.00-1.20); p = 0.047. aPTT was lower in TXA administered patients - TXA: median (IQR) 29.6 (14.0)s vs. NTXA: 33 (5.8)s; difference in medians: -4.00 (-6.50--1.00); p = 0.012. CONCLUSION TXA use significantly decreased blood loss measured by drain output and Hb drop in TSA under regional anesthesia.
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Affiliation(s)
- Teresa Garcia
- Hospital Lusíadas, Department of Anesthesiology, Lisboa, Portugal
| | - Mariana Fragão-Marques
- Centro Hospitalar Universitário de São João, Department of Clinical Pathology, Porto, Portugal.
| | - Pedro Pimentão
- Hospital Lusíadas, Department of Anesthesiology, Lisboa, Portugal; Hospital Lusíadas, Lisboa, Portugal
| | - Martim Pinto
- Hospital Lusíadas, Department of Anesthesiology, Lisboa, Portugal; Hospital Lusíadas, Lisboa, Portugal
| | - Inês Pedro
- Hospital Lusíadas, Department of Anesthesiology, Lisboa, Portugal; Hospital Lusíadas, Lisboa, Portugal
| | - Carlos Martins
- Hospital Lusíadas, Department of Anesthesiology, Lisboa, Portugal
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16
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Rogers TH, Labott JR, Austin DC, Barlow JD, Morrey ME, Sanchez-Sotelo J, Sperling JW. Perioperative Clopidogrel (Plavix®) Continuation in Shoulder Arthroplasty: Approach Cautiously. JSES Int 2022; 6:406-412. [PMID: 35572450 PMCID: PMC9091745 DOI: 10.1016/j.jseint.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
| | | | | | | | | | | | - John W. Sperling
- Corresponding author: John W. Sperling, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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17
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Pecold J, Al-Jeabory M, Krupowies M, Manka E, Smereka A, Ladny JR, Szarpak L. Tranexamic Acid for Shoulder Arthroplasty: A Systematic Review and Meta-Analysis. J Clin Med 2021; 11:48. [PMID: 35011788 PMCID: PMC8745038 DOI: 10.3390/jcm11010048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/19/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to decrease blood loss and transfusion rates after knee and hip arthroplasty, however with only limited evidence to support its use in shoulder arthroplasty. Therefore, we performed a systematic review and meta-analysis to evaluate the clinical usefulness of tranexamic acid for shoulder arthroplasty. A thorough literature search was conducted across four electronic databases (PubMed, Cochrane Library, Web of Science, Scopus) from inception through to 1 December 2021. The mean difference (MD), odds ratio (OR) or relative risk (RR) and 95% confidence interval (CI) were used to estimate pooled results from studies. Total of 10 studies comprising of 993 patients met the inclusion criteria and were included in the analysis. Blood volume loss in the TXA and non-TXA group was 0.66 ± 0.52 vs. 0.834 ± 0.592 L (MD= -0.15; 95%CI: -0.23 to -0.07; p < 0.001). Change of hemoglobin levels were 2.2 ± 1.0 for TXA group compared to 2.7 ± 1.1 for non-TXA group (MD= -0.51; 95%CI: -0.57 to -0.44; p < 0.001) and hematocrit change was 6.1 ± 2.7% vs. 7.9 ± 3.1%, respectively; (MD= -1.43; 95%CI: -2.27 to -0.59; p < 0.001). Tranexamic acid use for shoulder arthroplasty reduces blood volume loss during and after surgery and reduces drain output and hematocrit change.
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Affiliation(s)
- Jaroslaw Pecold
- Department of Trauma and Orthopedic Surgery, Ruda Slaska City Hospital, 41-703 Ruda Slaska, Poland; (J.P.); (M.A.-J.)
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.K.); (J.R.L.)
| | - Mahdi Al-Jeabory
- Department of Trauma and Orthopedic Surgery, Ruda Slaska City Hospital, 41-703 Ruda Slaska, Poland; (J.P.); (M.A.-J.)
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.K.); (J.R.L.)
| | - Maciej Krupowies
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.K.); (J.R.L.)
| | - Ewa Manka
- Department of Internal Medicine, Angiology and Physical Medicine in Bytom, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, 41-800 Zabrze, Poland;
| | - Adam Smereka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Wroclaw Medical University, 53-126 Wroclaw, Poland;
| | - Jerzy Robert Ladny
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.K.); (J.R.L.)
- Department of Emergency Medicine, Bialystok Medical University, 15-026 Bialystok, Poland
| | - Lukasz Szarpak
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.K.); (J.R.L.)
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy, 03-411 Warsaw, Poland
- Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland
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18
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Xiang X. [Interpretation of 2020 American Academy of Orthopaedic Surgeons (AAOS) on the Management of Glenohumeral Joint Osteoarthritis Evidence-Based Clinical Practice Guideline]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1403-1410. [PMID: 34779165 DOI: 10.7507/1002-1892.202105085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Based on peer-reviewed systematic reviews and randomized controlled trials published between January 2000 and June 2019 with regards to the management of glenohumeral joint osteoarthritis (GJO), the American Academy of Orthopaedic Surgeons (AAOS) established the clinical practice guidelines for the treatment of GJO. The guidelines provided practice recommendations including risk factors, non-surgical treatment, surgical treatment, prosthesis selection, and perioperative management for GJO. The recommendations were graded according to different evidence strength. This paper interprets the guidline in order to provide reference for domestic medical workers.
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Affiliation(s)
- Xianxiang Xiang
- Department of Sports Medicine, Affiliated Zhongshan Hospital of Dalian University, Dalian Liaoning, 116001, P.R.China
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19
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Fan D, Ma J, Zhang L. Tranexamic acid achieves less blood loss volume of in primary shoulder arthroplasty: a systematic review and meta-analysis of level I randomized controlled trials. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:344-352. [PMID: 37588711 PMCID: PMC10426620 DOI: 10.1016/j.xrrt.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Tranexamic acid (TXA) reduces blood loss in knee and hip arthroplasty, but the effectiveness in shoulder arthroplasty is unknown. This study aimed to evaluate current level I randomized controlled trials examining the efficacy of TXA in primary shoulder arthroplasty. Methods A protocol for the study was designed and registered with PROSPERO (CRD42021230398). The PubMed, Embase, and Cochrane Library databases were searched using the following search strategy: "shoulder replacement" OR "shoulder arthroplasty" OR "reverse shoulder arthroplasty" AND "tranexamic acid." All randomized controlled trials were included in this study. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was followed. Outcomes include blood loss, drain output, hemoglobin, thromboembolic complications, and blood transfusion. Results Five randomized controlled trials of 435 patients (219 patients in the TXA group and 216 patients in the non-TXA group) were included in the systematic review. The results indicated that the group using TXA had less total blood loss (MD, -249.56 mL; 95% confidence interval [CI] -347.60 to -151.52), less drainage output (MD, -113.72 mL; -155.92 to -71.52 95% CI), and less of a change in hemoglobin (MD, -0.68 g/dl; -0.94 to -0.42 g/dl 95% CI). No significant differences in blood transfusion (risk ratio 0.40; -0.11 to 1.45 95% CI) or thromboembolic events (risk ratio 0.13, 0.02 to 1.12 95% CI) were observed. Subgroup analyses showed that there was no significant difference in total blood loss, drainage output, or change in hemoglobin between single dose and multiple doses. Conclusions TXA in primary shoulder arthroplasty can reduce blood loss, drain output, and hemoglobin changes. Subgroup analysis showed that multiple TXA doses have similar results compared with single dose in primary shoulder arthroplasty. More randomized controlled trials comparing different administration routes of TXA in primary and revision shoulder arthroplasty are required.
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Affiliation(s)
- DingYuan Fan
- Beijing University of Chinese Medicine, Beijing, China
- Department of Joint Surgery and Sports Medicine, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jia Ma
- Department of Joint Surgery and Sports Medicine, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lei Zhang
- Department of Joint Surgery and Sports Medicine, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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20
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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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21
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Thangarajah T. Day case shoulder arthroplasty: needed now more than ever. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 34431350 DOI: 10.12968/hmed.2021.0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The demand for total shoulder arthroplasty has grown over the years and is set to continue in a similar trend because of the ageing population. Following a global reduction in elective orthopaedic treatment and an exponential rise in surgical waiting times, innovative strategies are desperately needed to mitigate against the harmful effects of delaying vital operations on both patients and the wider society. Day case shoulder arthroplasty is a safe alternative to a traditional inpatient approach, with evidence supporting substantial cost savings, improved outcomes and fewer complications. Rigorous patient selection and a multidisciplinary team approach are paramount when adopting a day case service to deliver joint replacement surgery. This review outlines the principles of day case total shoulder arthroplasty and highlights key considerations when transitioning to this approach.
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Affiliation(s)
- Tanujan Thangarajah
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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22
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Godlewski M, Knudsen ML, Braman JP, Harrison AK. Perioperative Management in Reverse Total Shoulder Arthroplasty. Curr Rev Musculoskelet Med 2021; 14:282-290. [PMID: 34414560 PMCID: PMC8390714 DOI: 10.1007/s12178-021-09709-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW A successful reverse total shoulder arthroplasty requires careful preoperative planning and perioperative management. Preoperative comorbidity risks, perioperative pain management, and postoperative rehabilitation are all critical components of this arthroplasty. The current review examines available literature to guide the perioperative care of the reverse total shoulder arthroplasty patient. RECENT FINDINGS One of the most important advances for shoulder arthroplasty in recent years has been heightened awareness of various modalities for perioperative pain management. A number of recent studies have focused on the options for regional blockade as a critical tool for postoperative pain relief and the use of either continuous interscalene blocks or single shot blocks are supported. Additional studies are necessary to define the best local anesthetic agent and delivery mechanism to provide appropriate pain relief with a low side effect profile. Management of the patient throughout the perioperative course is a critical component in achieving better patient outcomes delivering high quality patient care. An orthopedic surgery team focused on perioperative management is better positioned to decrease adverse events and improve patient outcomes after reverse total shoulder arthroplasty.
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Affiliation(s)
- Matthew Godlewski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
| | - Michael L Knudsen
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
| | - Jonathan P Braman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
| | - Alicia K Harrison
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MIN USA
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23
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Cunningham G, Hughes J, Borner B, Mattern O, Taha ME, Smith MM, Young AA, Cass B. A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg 2021; 30:1553-1560. [PMID: 33421559 DOI: 10.1016/j.jse.2020.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty. MATERIALS AND METHODS We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications. RESULTS Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion. CONCLUSION A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.
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Affiliation(s)
- Gregory Cunningham
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland; Shoulder Center, Hirslanden Clinique la Colline, Geneva, Switzerland
| | - Jeffery Hughes
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Benoit Borner
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland.
| | - Owen Mattern
- The Orthopaedic Group, Melbourne, VIC, Australia
| | - Mohy E Taha
- Division of Orthopaedics and Trauma Surgery, Basel University Hospital, Basel, Switzerland
| | - Margaret M Smith
- Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Allan A Young
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Benjamin Cass
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
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24
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Iijima Y, Sasanuma H, Saito T, Nakama S, Takeshita K. A case of simultaneous bilateral reverse shoulder arthroplasty for bilateral comminuted proximal humerus fractures in an elderly patient. JSES Int 2021; 5:688-691. [PMID: 34223416 PMCID: PMC8245984 DOI: 10.1016/j.jseint.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yuki Iijima
- Jichi Medical University, Department of Orthopaedic Surgery, Shimotsuke, Tochigi, Japan
| | - Hideyuki Sasanuma
- Tochigi Medical Center Shimotsuga, Department of Orthopaedic Surgery, Ohira, Tochigi, Japan
| | - Tomohiro Saito
- Jichi Medical University, Department of Orthopaedic Surgery, Shimotsuke, Tochigi, Japan
| | - Sueo Nakama
- Tochigi Medical Center Shimotsuga, Department of Orthopaedic Surgery, Ohira, Tochigi, Japan
| | - Katsushi Takeshita
- Jichi Medical University, Department of Orthopaedic Surgery, Shimotsuke, Tochigi, Japan
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25
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Donovan RL, Varma JR, Whitehouse MR, Blom AW, Kunutsor SK. Tranexamic acid use to decrease blood loss in primary shoulder and elbow replacement: A systematic review and meta-analysis. J Orthop 2021; 24:239-247. [PMID: 33854291 PMCID: PMC8022108 DOI: 10.1016/j.jor.2021.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/07/2021] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Tranexamic acid (TXA) is an inexpensive antifibrinolytic agent that significantly reduces peri-operative blood loss and transfusion requirements after total hip and knee replacement. This meta-analysis demonstrates the effects of TXA on blood loss in total shoulder replacement (TSR) and total elbow replacement (TER). METHODS We systematically searched MEDLINE, EMBASE and CENTRAL from inception to September 03, 2020 for randomised controlled trial (RCTs) and observational studies. Our primary outcome was blood loss. Secondary outcomes included the need for blood transfusion, and post-operative venous thromboembolic (VTE) complications. Mean differences (MD) and relative risks with 95% confidence intervals (CIs) were reported. RESULTS Four RCTs and five retrospective cohort studies (RCS) met eligibility criteria for TSRs, but none for TERs. RCT data determined that TXA administration significantly decreased estimated total blood loss (MD -358mL), post-operative blood loss (MD -113mL), change in haemoglobin (Hb) (MD -0.71 g/dL) and total Hb loss (MD -35.3g) when compared to placebo. RCS data demonstrated significant association between TXA administration and decreased in post-operative blood loss, change in Hb, change in Hct and length of stay. There was no significant difference in transfusion requirements or VTE complications. CONCLUSION TXA administration in safe and effective in patients undergoing primary TSR: it significantly decreases blood loss compared with placebo and is associated with shorter length of stay compared with no treatment. No significant increase in VTE complications was found. TXA administration should be routinely considered for patients undergoing TSR. Further research is needed to demonstrate the treatment effect in patients undergoing TER.
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Affiliation(s)
- Richard L. Donovan
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Jonny R. Varma
- North Bristol NHS Trust, Brunel Building, Southmead Road, Bristol, BS10 5NB, UK
| | - Michael R. Whitehouse
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Ashley W. Blom
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Setor K. Kunutsor
- Musculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
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26
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Belay ES, O'Donnell J, Flamant E, Hinton Z, Klifto CS, Anakwenze O. Intravenous tranexamic acid vs. topical thrombin in total shoulder arthroplasty: a comparative study. J Shoulder Elbow Surg 2021; 30:312-316. [PMID: 32592848 DOI: 10.1016/j.jse.2020.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Blood loss and transfusions have been highlighted as a significant predictor of postoperative morbidity. Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion in shoulder arthroplasty. However, the utility of topical thrombin in total shoulder arthroplasty (TSA) is unknown. The purpose of this study was to assess the utility of topical thrombin in TSA and compare the effectiveness of topical thrombin to intravenous (IV) TXA. METHODS An institutional database was used to query shoulder arthroplasty patients from January 2017 to July 2019. Patients undergoing TSA were identified with CPT (Current Procedural Terminology) code (23742). After excluding reverse shoulder arthroplasty, arthroplasty for fracture or revision, the study groups were stratified based on intervention with IV TXA, topical thrombin, or neither. Patient demographics, American Society of Anesthesiologists (ASA) class, baseline coagulopathy, preoperative and postoperative hemoglobin levels, operative time, transfusion, length of stay, and 90-day readmission for each treatment group was obtained. RESULTS A total of 283 TSA cases were included for final analysis. There was no statistically significant difference in the baseline characteristics with age, body mass index, or ASA class. The postoperative hemoglobin level (mg/dL) was higher in the group that received either IV TXA or thrombin compared with no hemostatic agents (P = .001). Calculated blood loss in TSA was significantly higher in the group without hemostatic agents, 369.8 mL (standard deviation [SD] 59.5), compared with IV TXA or topical thrombin, 344.3 mL (SD 67.1) and 342.9 mL (SD 65.6) (P = .03). Operative time was highest in the group that received no hemostatic agents, 2.3 hours (SD 0.6) (P = .01). The transfusion rate for TSA treated with IV TXA or topical thrombin was equivalent (2.2%) but significantly lower than the no intervention group (12%) (P = .01). The odds ratio for transfusion with IV TXA was 0.16 (95% confidence interval [CI] 0.07-0.40, P = .001) and for topical thrombin, 0.1 (95% CI 0.02-0.42, P = .02). CONCLUSION Topical thrombin is an effective adjunct to reduce blood loss and transfusion risk after TSA and a reasonable intraoperative alternative for TXA for patients with contraindication to IV TXA.
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Affiliation(s)
- Elshaday S Belay
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Jeffrey O'Donnell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Zoe Hinton
- Duke University School of Medicine, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Rojas J, Srikumaran U, McFarland EG. Inconclusive evidence for the efficacy of tranexamic acid in reducing transfusions, postoperative infection or hematoma formation after primary shoulder arthroplasty: A meta-analysis with trial sequential analysis. Shoulder Elbow 2021; 13:38-50. [PMID: 33717217 PMCID: PMC7905512 DOI: 10.1177/1758573219896794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/05/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Tranexamic acid efficacy on clinically relevant adverse outcomes in patients undergoing shoulder arthroplasty has been contradictory. The aim of this review was to analyze whether tranexamic acid administration could decrease transfusions, infection and hematoma formation in patients undergoing shoulder arthroplasty. METHODS PubMed, EMBASE, and the Cochrane Library were searched up to May 2019 for randomized controlled trials comparing tranexamic acid to placebo in shoulder arthroplasty. Random-effect models were performed to meta-analyze the evidence. Trial sequential analysis was used to calculate and to establish the conclusiveness of the evidence derived from the meta-analysis. RESULTS Four randomized controlled trials comprising 375 patients were included. Meta-analysis showed no effect of tranexamic acid on transfusion rate (RR = 0.48 (adjusted 95% CI 0.05 to 3.85)). The possible effect of tranexamic acid on hematoma formation or infection rates after shoulder arthroplasty is non-estimable with the current evidence. The sample size necessary to reliably determine if tranexamic acid decreases transfusions, infection rates and hematoma formation is not available from the current literature as determined by the trial sequential analysis. DISCUSSION While tranexamic acid has proven its efficacy in decreasing blood loss in shoulder arthroplasty, this meta-analysis of randomized controlled trials clarifies that there is currently no conclusive evidence for a positive effect of tranexamic acid upon transfusion rate, infection rates or hematoma formation in patients undergoing primary shoulder arthroplasty.
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Affiliation(s)
- Jorge Rojas
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA,Division of Shoulder and Elbow Surgery, Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Uma Srikumaran
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA,Edward G McFarland, Division of Shoulder and Elbow Surgery, The Johns Hopkins University, 10753 Falls Road, Pavilion II, Suite 215, Lutherville, MD 21093, USA.
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Clay TB, Lawal AS, Wright TW, Patrick M, Struk AM, Farmer KW, King JJ. Tranexamic acid use is associated with lower transfusion rates in shoulder arthroplasty patients with preoperative anaemia. Shoulder Elbow 2020; 12:61-69. [PMID: 33343717 PMCID: PMC7726184 DOI: 10.1177/1758573219841058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 03/06/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND We evaluate tranexamic acid use in high-risk shoulder arthroplasty patients, hypothesizing that tranexamic acid will decrease transfusion rates in patients with low preoperative haematocrit. METHODS A retrospective review of shoulder arthroplasty patients with preoperative anaemia compared those treated with and without perioperative tranexamic acid. Inclusion criterion was any shoulder arthroplasty with a preoperative haematocrit (Hct) <38%. Tranexamic acid was given generally as 1 g intravenously before incision and 1 g during wound closure; topical tranexamic acid was used in cases of contraindication to IV tranexamic acid. Preoperative Hct, postoperative Hct, estimated blood loss, preoperative anticoagulation use, American Society of Anesthesiologist score, transfusion rate and demographic data were compared between groups with and without tranexamic acid. RESULTS Of the 435 arthroplasties performed, 109 patients had preoperative Hct < 38% (haemoglobin of 12.7 g/dL); 69 had tranexamic acid perioperatively and 40 did not. Demographics, anticoagulation use, diagnosis, arthroplasty types, estimated blood loss and preoperative Hct were similar between groups. The tranexamic acid group had a higher postoperative Hct, significantly lower transfusion rate and significantly smaller drop in Hct. Hct levels, Hct change and transfusion rate for topical versus intravenous tranexamic acid were not significantly different. DISCUSSION Perioperative tranexamic acid in high-risk shoulder arthroplasty patients with preoperative Hct <38% is associated with higher postoperative Hct and lower transfusion rates.
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Affiliation(s)
| | | | | | | | | | | | - Joseph J King
- Joseph J King, Orthopaedics and Sports Medicine Institute, University of Florida, 3450 Hull Road, Gainesville, FL 32611, USA.
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Effect of tranexamic acid on blood loss after reverse total shoulder arthroplasty according to the administration method: a prospective, multicenter, randomized, controlled study. J Shoulder Elbow Surg 2020; 29:1087-1095. [PMID: 32423576 DOI: 10.1016/j.jse.2020.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ideal method of administering tranexamic acid (TXA) for reverse total shoulder arthroplasty (RTSA) remains unknown. We aimed to evaluate TXA efficacy according to 3 administration methods after RTSA. METHODS Overall, 102 patients who underwent RTSA using a single implant between September 2016 and November 2018 were randomized to the following groups according to the TXA administration method: intravenous (n = 34; 1 g + 0.9% normal saline 100 mL), topical (n = 33; 2 g + 0.9% normal saline 50 mL), and combined groups (n = 34). Patients were enrolled in 4 tertial referral hospitals for prospective multicenter studies. The primary outcome was a hemoglobin decrease in 24 hours postoperatively; secondary outcomes were total drain volume, transfusion rate, and calculated total blood loss. RESULTS Demographic data, including preoperative hemoglobin levels, were not different among the 3 groups, but the average age was higher in the combined group (P = .038). Hemoglobin decrease (1.8 ± 1.1 vs. 1.8 ± 1.0 vs. 2.0 ± 1.1 g/dL, P = .769), total drain volume (209.2 ± 147.6 vs. 167.2 ± 102.0 vs. 166.0 ± 118.7, P = .270), and total blood loss (701.1 ± 352.3 vs. 656.5 ± 285.6 vs. 699.0 ± 248.7 mL, P = .810) were not significantly different among the 3 groups (all P > .05). The transfusion rate was higher in the intravenous group (n = 4), whereas only 1 patient had transfusion in the topical group and none in the combined group, although the difference was not statistically significant (P = .084). CONCLUSION Blood loss did not differ among TXA administration methods after RTSA. However, considering the risk of complication in intravenous TXA, topical TXA after RTSA may be safer, even for patients with normal risk for venous thromboembolic complication.
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Utilization and Real-world Effectiveness of Tranexamic Use in Shoulder Arthroplasty: A Population-based Study. J Am Acad Orthop Surg 2019; 27:736-742. [PMID: 30964754 DOI: 10.5435/jaaos-d-18-00206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty, but limited data exist for its effectiveness in patients undergoing shoulder arthroplasty. We aimed to use national data to assess the frequency of use and effectiveness of TXA in patients undergoing shoulder arthroplasty. METHODS Using national claims data from patients undergoing shoulder arthroplasty (Premier Healthcare; 2010 to 2016; n = 82,512; 429 hospitals), we categorized patients according to whether they received perioperative TXA. Multilevel multivariable regression models measured associations between TXA and blood transfusion risk, combined complications (including thromboembolic events, acute renal failure, cerebral infarction, and acute myocardial infarction), and length and cost of hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS Overall, TXA was used in 12.8% (n = 10,582) of patients with a strong increasing trend. After adjustment for relevant covariates, TXA use (compared with no TXA use) was associated with a 36% decrease in transfusion risk (OR, 0.64; 95% CI, 0.52 to 0.77; P < 0.05) and a 35% decreased risk for combined complications (OR, 0.65; 95% CI, 0.50 to 0.83; P < 0.05). Moreover, TXA use was associated with 6.2% shorter hospital stay (95% CI, -8.0% to -4.4%; P < 0.05), whereas no difference was observed with the cost of hospitalization. CONCLUSION In this first large-scale study assessing TXA use and effectiveness in patients undergoing shoulder arthroplasty, we found that although TXA utilization is still low, it is associated with a marked decrease in transfusion risk with no increases in complication risk. Effects on the length and cost of hospitalization appeared minor. Future studies should assess whether higher volumes of TXA utilization would translate into more gains on the length and cost of hospitalization. LEVEL OF EVIDENCE Level III.
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Hematologic profile in reverse total shoulder arthroplasty: perioperative and postoperative blood loss. J Shoulder Elbow Surg 2019; 28:1737-1742. [PMID: 30981547 DOI: 10.1016/j.jse.2019.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/22/2018] [Accepted: 01/04/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies have investigated the amount of blood loss during reverse total shoulder arthroplasty (RTSA). The purpose of this study was to investigate blood loss in patients who underwent RTSA for massive irreparable rotator cuff tear (MIRCT) using the hemoglobin (Hb) balance method and total Hemovac amount and to identify predictors of blood transfusion in these patients. METHODS We retrospectively reviewed 121 patients who underwent RTSA for MIRCT. The mean age was 71.2 ± 6.9 years, and 75 were women. Age, sex, body mass index, use of anticoagulants, American Society of Anesthesiologists physical status score, comorbidities (eg, hypertension, diabetes mellitus, cerebrovascular accident), preoperative Hb level, preoperative hematocrit level, preoperative prothrombin time/international normalized ratio, use of cement, and operative time were evaluated as values predicting blood transfusion. RESULTS The overall blood loss was 846.6 ± 527.6 mL, which included 346 ± 231.2 mL of intraoperative blood loss and 500.3 ± 196.4 mL of postoperative blood loss. Values predicting blood transfusion were a lower preoperative Hb level (P < .001), hematocrit level (P < .001), hypertension (P = .018), and cerebrovascular accident (P = .008). Receiver operating characteristic analysis identified the following cutoff values for predicting transfusion: preoperative Hb level of 13.5 g/dL (90.3% sensitivity) and hematocrit of 40% (90.3% sensitivity). CONCLUSIONS RTSA for MIRCT is associated with blood loss during and after surgery. The amount of blood loss should be noted, and blood transfusion could be predicted by calculating the blood loss and predictive values. Lower preoperative Hb level, hematocrit, hypertension, and cerebrovascular accident are predictors of blood transfusion. Blood transfusion should be considered if a patient with preoperative Hb level <13.5 g/dL and hematocrit <40% has a history of hypertension or cerebrovascular accident.
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Budge M. Topical and Intravenous Tranexamic Acid Are Equivalent in Decreasing Blood Loss in Total Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2019; 3:2471549218821181. [PMID: 34497940 PMCID: PMC8282158 DOI: 10.1177/2471549218821181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 12/03/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) has been shown to be an effective modality to decrease blood loss in total shoulder arthroplasty (TSA). However, the most effective method of TXA administration remains controversial. The purpose of this study was to directly compare the use intravenous and topical TXA to determine which regimen was more effective in improving postoperative hemoglobin (Hb), transfusion rates, and patient outcomes after primary TSA. METHODS We conducted a retrospective review of 3 sequential cohorts of patients undergoing primary TSA with no TXA, intravenous TXA, or topical TXA. Postoperative data collection included daily Hb levels (g/dL), transfusions, thromboembolic events, length of stay, and discharge disposition. One-way analysis of variance was used to compare data between the 3 groups with post hoc Tukey honestly significant difference test for differences between pairs. RESULTS Average change in Hb was 2.36 g/dL in the IV TXA group and 2.27 g/dL in the Topical TXA group which was not statistically significant (P = .69). Average change in Hb in the control group was 3.27 g/dL which was significant when compared to both TXA groups (P < .01). There were no transfusions or thromboembolic events in either TXA group. In the control group, there were 2 transfusions which was not statistically significant (P = .09). There was no significant difference in the discharge disposition or days in hospital between the 2 groups receiving TXA (P = .33). CONCLUSION Intravenous and topical TXA are equivalent in improving postoperative Hb in TSA.
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Kuo LT, Hsu WH, Chi CC, Yoo JC. Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord 2018; 19:60. [PMID: 29454385 PMCID: PMC5816518 DOI: 10.1186/s12891-018-1972-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/08/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The effects of tranexamic acid (TXA) in the setting of shoulder arthroplasty are unclear. The objective of this study was to examine the effects of TXA in reducing the need for blood transfusions and blood loss in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective cohort studies (RCS) that compared outcomes of patients who did and did not receive TXA during TSA or RTSA. We searched Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was transfusion rate, and secondary outcomes were changes in hemoglobin, estimated total blood loss (ETBL), blood loss via drainage, operative time, hospital stay, overall complications, and thromboembolic events. RESULTS We identified 3 RCTs and 3 RCS including 677 patients with 680 shoulders (343 TXA and 337 non-TXA). The random-effects model meta-analysis showed that TXA group had a lower transfusion rate (risk ratio (RR) 0.34, 95% CI 0.14 to 0.79), less change in hemoglobin (mean difference (MD) -0.64 g/dl, 95% CI -0.81 to - 0.46), and reduced ETBL (MD -249.24 ml, 95% CI -338.74 to - 159.74). In patients with RTSA, the TXA group had a lower transfusion rate (RR 0.28, 95% CI 0.14 to 0.79), less ETBL (MD -249.15 ml, 95% CI -426.60 to - 71.70), less change in hemoglobin (MD - 0.64 g/dl, 95% CI -0.86 to - 0.42), and less blood loss via drainage (MD - 84.56 ml, 95% CI -145.72.14 to - 23.39) than non-TXA group. CONCLUSIONS The use of TXA in primary shoulder arthroplasty appears safe, and can reduce transfusion rate, changes in hemoglobin, and perioperative total blood loss, especially in patients with RTSA. LEVEL OF EVIDENCE Systematic Review and meta-analysis, III.
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Affiliation(s)
- Liang-Tseng Kuo
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Wei-Hsiu Hsu
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chi Chi
- Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Department of Dermatology, Chang Gung Memorial Hospital, Linkou, 5, Fuxing St, Guishan Dist, Taoyuan, 33305, Taiwan.
| | - Jae Chul Yoo
- Department of Orthopedic Surgery, College of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea.
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Box HN, Tisano BS, Khazzam M. Tranexamic acid administration for anatomic and reverse total shoulder arthroplasty: a systematic review and meta-analysis. JSES OPEN ACCESS 2018; 2:28-33. [PMID: 30675564 PMCID: PMC6334886 DOI: 10.1016/j.jses.2017.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Tranexamic acid (TXA) has been shown to reduce perioperative blood loss and risk of blood transfusion. Evidence establishing its efficacy in total shoulder arthroplasty (TSA) is limited. The current study evaluated the effect of TXA on perioperative blood loss and transfusion risk after TSA. Methods A systematic review and meta-analysis of TXA administration for TSA was performed, and 6 studies with a total of 680 patients were found. Data on change in hemoglobin, drain output, total blood loss, and transfusion were extracted. Meta-analysis was performed with stratification into reverse and anatomic TSA subgroups. Results TXA administration was associated with decreased change in hemoglobin (−0.63 g/dL; 95% CI, −0.87 to −0.39 g/dL; P < .00001), drain output (−112.05 mL; 95% CI, −182.29 to −41.81 mL; P < .0001), and total blood loss (−231.87 mL; 95% CI, −334.23 to −129.48 mL; P < .00001) after reverse TSA. There was a trend toward reduction in transfusion rate after reverse TSA (−4%; 95% CI, −8% to 0%; P = .06). TXA administration was associated with reduced drain output after anatomic TSA (−123.07 mL; 95% CI, −163.93 to −82.20 mL; P < 0.00001). TXA administration was not associated with decreased transfusion rate after anatomic TSA. Data to evaluate the effect of TXA on change in hemoglobin and total blood loss after anatomic TSA were insufficient. Conclusions Routine administration of TXA reduces perioperative blood loss and may reduce the risk of transfusion after reverse TSA. Future studies are needed to further characterize its effect on the risk of transfusion after reverse TSA and efficacy in anatomic TSA.
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Affiliation(s)
- Hayden N Box
- Shoulder Service, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Breann S Tisano
- Shoulder Service, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael Khazzam
- Shoulder Service, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Cvetanovich GL, Fillingham YA, O'Brien M, Forsythe B, Cole BJ, Verma NN, Romeo AA, Nicholson GP. Tranexamic acid reduces blood loss after primary shoulder arthroplasty: a double-blind, placebo-controlled, prospective, randomized controlled trial. JSES OPEN ACCESS 2018; 2:23-27. [PMID: 30675563 PMCID: PMC6334853 DOI: 10.1016/j.jses.2018.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease blood loss and transfusion rates after hip and knee arthroplasty, with only limited evidence to support its use in shoulder arthroplasty. This study was conducted to determine whether intravenous (IV) TXA is more effective than placebo in reducing blood loss after primary total shoulder arthroplasty (TSA). Methods In this prospective, double-blind, placebo-controlled, randomized clinical trial, patients undergoing primary anatomic and reverse TSA were randomized to receive 1 g of intravenous TXA or a placebo of an equivalent volume of intravenous normal saline administered 10 minutes before the incision. The primary outcome measurement was calculated postoperative blood loss. Secondary outcomes included transfusion rates, weight of hemoglobin loss, hospital length of stay, and thromboembolic events. Results The study enrolled 110 patients, 2 of whom were excluded because they did not have a postoperative hemoglobin measurement, and the remaining 108 patients (52 for TXA, 56 for placebo) were analyzed. There were no significant differences between TXA and placebo groups in preoperative characteristics. For the primary outcome, the TXA group had significantly lower postoperative blood loss of 1100.9 ± 367.4 mL compared with 1274.5 ± 460.0 mL for the placebo group (P = .03). For secondary outcomes, TXA had lower weight of hemoglobin loss compared with placebo (152.2 ± 57.3 g vs. 178.0 ± 65.8 g; P = .03). No patients in the TXA or placebo groups required a transfusion. Conclusions Intravenous TXA reduced blood loss after primary TSA compared with placebo.
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Affiliation(s)
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael O'Brien
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian Forsythe
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Abstract
Health care policy makers have placed increased attention on the cost of health care making outpatient joint arthroplasty an attractive alternative to routine hospital admission. Recent studies have shown outpatient shoulder arthroplasty is a safe and cost-effective alternative to inpatient shoulder arthroplasty. Proper patient selection, patient education, effective pain management strategies, and attention to intraoperative blood loss are keys in the success of outpatient shoulder arthroplasty.
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Affiliation(s)
- Tyler J Brolin
- Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Thomas W Throckmorton
- Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Kirsch JM, Bedi A, Horner N, Wiater JM, Pauzenberger L, Koueiter DM, Miller BS, Bhandari M, Khan M. Tranexamic Acid in Shoulder Arthroplasty. JBJS Rev 2017; 5:e3. [DOI: 10.2106/jbjs.rvw.17.00021] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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He J, Wang XE, Yuan GH, Zhang LH. The efficacy of tranexamic acid in reducing blood loss in total shoulder arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96:e7880. [PMID: 28906369 PMCID: PMC5604638 DOI: 10.1097/md.0000000000007880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this meta-analysis is to compare the efficacy of tranexamic acid (TXA) versus placebo after a total shoulder arthroplasty (TSA). METHODS In April 2017, a systematic computer-based search was conducted in the databases of PubMed, Embase, Web of Science, Cochrane Library, and Google. Studies comparing TXA versus placebo in reducing blood loss after TSA were included. The endpoints were the need for transfusion, blood loss in drainage, hemoglobin drop, and total blood loss. Stata 12.0 software was used for the meta-analysis. RESULTS Six studies involving a total of 637 patients met the inclusion criteria. The meta-analysis revealed that, compared with control groups, treatment with TXA could decrease the need for transfusion (P < .00001), blood loss in drainage (P = .000), hemoglobin drop (P = .001), and total blood loss (P = .000). CONCLUSION TXA can decrease the need for transfusion as well as total blood loss in TSA patients. There was a negative correlation between the TXA dose and the need for transfusion and blood loss in drainage. Because the administration route and the dose of TXA were different, more studies are needed in order to identify the optimal dose and route.
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Affiliation(s)
- Jing He
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Xi-e Wang
- Surgical Department, Jinan Infectious Diseases Hospital, Jinan
| | - Guo-Hong Yuan
- Department of Anesthesiology, Shouguang City People's Hospital, Shouguang City, Shandong
| | - Lian-Hai Zhang
- Emergency Department, Zaozhuang Municipal Hospital, Zaozhuang, China
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Pauzenberger L, Domej MA, Heuberer PR, Hexel M, Grieb A, Laky B, Blasl J, Anderl W. The effect of intravenous tranexamic acid on blood loss and early post-operative pain in total shoulder arthroplasty. Bone Joint J 2017; 99-B:1073-1079. [DOI: 10.1302/0301-620x.99b8.bjj-2016-1205.r1] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/28/2017] [Indexed: 11/05/2022]
Abstract
Aims The purpose of the present study was to evaluate the impact of intravenous tranexamic acid on the reduction of blood loss, transfusion rate, and early post-operative clinical outcome in total shoulder arthroplasty. Patients and Methods A randomised, placebo-controlled trial which included 54 patients undergoing unilateral primary stemless anatomical or stemmed reverse total shoulder arthroplasty was undertaken. Patients received either 100 ml saline (placebo, n = 27), or 100 ml saline together with 1000 mg of tranexamic acid (TXA, n = 27) intravenously prior to skin incision and during wound closure. Peri-operative blood loss via an intra-articular drain was recorded and total blood loss was calculated. The post-operative transfusion rate was documented. Assessment of early clinical parameters included the visual analogue scale for pain (VAS), documentation of haematoma formation and adverse events. Results Mean peri-operative blood drainage (placebo: 170 ml versus TXA: 50 ml, p = 0.001) and calculated mean total blood loss (placebo: 1248.2 ml versus TXA: 871.0 ml, p = 0.009) were significantly lower in the TXA group. No transfusions were necessary during the study period in either group. Mean VAS for pain significantly decreased from pre-operative (VAS 7) to the early post-operative period (VAS 1.7, p < 0.001). Significant differences regarding mean post-operative pain between placebo (VAS 2.0) and TXA (VAS 1.3) were detected (p = 0.05). The occurrence of haematomas was significantly more frequent in the placebo (59.3%, n = 16) than in the TXA group (25.9%, n = 6, p = 0.027). Whereas only mild haematomas developed in the TXA group, in the placebo group a total of 22.2% (n = 6) developed either moderate or severe haematomas. No adverse events associated with administration of TXA occurred. Conclusion Intravenous administration of TXA successfully reduced mean peri-operative blood drainage, total estimated blood loss, pain during the first post-operative days, and haematoma formation in total shoulder arthroplasty. Cite this article: Bone Joint J 2017;99-B:1073–9.
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Affiliation(s)
- L. Pauzenberger
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
| | - M. A. Domej
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
| | - P. R. Heuberer
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
| | - M. Hexel
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
| | - A. Grieb
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
| | - B. Laky
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
| | - J. Blasl
- St. Vincent Hospital Vienna, Austria, Stumpergasse
13, 1060 Vienna, Austria
| | - W. Anderl
- St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
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Abstract
BACKGROUND The objective of this meta-analysis was to evaluate the efficacy and safety of tranexamic acid (TXA) in shoulder arthroplasty (SA). METHODS Academic articles were identified from the Cochrane Library, Medline (1966-2017.2), PubMed (1966-2017.2), Embase (1980-2017.2), and ScienceDirect (1966-2017.2). Randomized controlled trials (RCTs) and non-RCTs studying TXA in SA were included. Two independent reviewers conducted independent data abstraction. The I statistic was used to assess heterogeneity. Fixed- or random-effects models were used for meta-analysis. RESULTS Two RCTs and 2 non-RCTs met the inclusion criteria. This meta-analysis found significant differences in postoperative hemoglobin reduction (MD = -0.71 g/dL), drainage volume (MD = -133.21 mL), and total blood loss (MD = -226.82 mL) between TXA groups and controls. There were no significant differences in blood transfusion requirements, operation time, or length of hospital stay. CONCLUSIONS The use of TXA in SA decreases postoperative hemoglobin reduction, drainage volume, and total blood loss and does not increase the risk of complications. Because of the limited high-quality evidence currently available, additional randomized controlled trials are required.
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Effect of Tranexamic Acid on Hematologic Values and Blood Loss in Reverse Total Shoulder Arthroplasty. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9590803. [PMID: 28819631 PMCID: PMC5551469 DOI: 10.1155/2017/9590803] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 06/22/2017] [Accepted: 07/02/2017] [Indexed: 02/02/2023]
Abstract
Purpose Use of tranexamic acid (TXA) in the setting of arthroplasty of the lower extremity has been previously described. The aim of this study was to evaluate the benefit of a single dose of TXA (500 mg vial) administered intravenously just prior to RTSA in an Asian population. Methods The records of 48 patients (no TXA, n = 24, versus TXA, n = 24) that underwent RTSA for cuff tear arthropathy were retrospectively reviewed. All patients had a Hemovac drain positioned for 2 days after surgery. Hemoglobin (Hb) and hematocrit (Hct) were checked on postoperative day 2 and compared with preoperative levels. Results Hematologic change on postoperative day 2 as determined by Hb level after surgery was statistically lower in the TXA group (2.8 ± 0.8 versus 2.1 ± 0.8 (mg/dL), P = 0.006). Mean fall in Hct level was also significantly less in the TXA group (8.0 ± 2.5 versus 6.1 ± 2.6 (L/L), P = 0.012). Total Hemovac drainage tended to be lower in the TXA group (263.4 ± 129.3 versus 203.5 ± 84.2 (ml), P = 0.064). TXA was found to have no noticeable side effects. Conclusion The use of a single intravenous dose of TXA immediately prior to RTSA reduces hematologic deterioration postoperatively and the amount of Hemovac drainage. TXA could avoid unnecessary transfusion and its associated medical side effects and cost.
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Sun CX, Zhang L, Mi LD, Du GY, Sun XG, He SW. Efficiency and safety of tranexamic acid in reducing blood loss in total shoulder arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e7015. [PMID: 28562553 PMCID: PMC5459718 DOI: 10.1097/md.0000000000007015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE This meta-analysis aimed to evaluate the efficiency and safety of tranexamic acid for reducing blood loss and transfusion requirements in patients undergoing total shoulder arthroplasty. METHODS A systematic search was performed in Embase (1980-2017.04, embase.com), Medline (1966-2017.04, medline.com), PubMed (1966-2017.04, pubmed.com), ScienceDirect (1985-2017.04, sciencedirect.com), and Web of Science (1950-2017.04, webofknowledge.com). Study which assessed the efficiency and safety of tranexamic acid in total shoulder arthroplasty was selected. Meta-analysis was performed using Stata 11.0 software. RESULTS In all, 484 patients from 2 randomized controlled trials (RCTs) and 2 non-RCTs were subjected to meta-analysis. The present meta-analysis demonstrated that there was less total blood loss (mean difference [MD] -172.16, 95% confidence interval [CI] -35.46 to -308.87, P = .01, d = 0.33) and transfusion rate (odds ratio 0.34, 95% CI 0.13 to 0.91, P = .03, d = 0.29) in tranexamic acid groups compared with the control groups. There were no significant differences in duration of surgery (MD 0.02, 95% CI -0.12 to 0.22, P = .89, d = 0.19), length of stay (MD -0.06, 95% CI -0.26 to 0.14, P = .56, d = 0.20), or incidence of adverse effects such as deep venous thrombosis (odds ratio 1.15, 95% CI 0.33 to 4.00, P = .83, d = 0.53). CONCLUSION Clinical application of tranexamic acid seemed to result in significant reductions in total blood loss, hemoglobin decline and transfusion requirements following total shoulder arthroplasty. Moreover, no increased risk of the thrombotic events was identified. Due to the limited quality of the evidence currently available, higher quality RCTs are required.
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