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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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Kent LM, Hurley ET, Davey MS, Klifto CS, Mullett H. Low complication rate following reverse total shoulder arthroplasty at 90-days follow-up - A systematic review. J ISAKOS 2024; 9:205-210. [PMID: 37979691 DOI: 10.1016/j.jisako.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/20/2023]
Abstract
IMPORTANCE As reverse total shoulder arthroplasty (RTSA) has become an increasingly common procedure, rates of post-operative complications leading to potential hospital readmission are of greater importance. No previous systematic reviews have focused exclusively on post-operative complications and mortality rates at 90 days post RTSA. OBJECTIVES The purpose of this study was to review complication, readmission, and mortality rates within 90 days post RTSA. EVIDENCE REVIEW Two independent reviewers performed a literature search using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RTSA at 90-days follow-up specifically were considered for inclusion. FINDINGS Our search included 79,037 shoulders (62.1 % female) from a total of 15 studies with an average age of 72.4 ± 5.8 years. The overall 90-day re-admission rates were reported in nine studies as 6.1 % (4205/69,127) following RTSA. Additionally, a total of five studies reported the overall 90-day mortality rate as 1.1 % (19/1733). The overall pooled rate of medical complications was 3.9 % (2998/77,826) as reported in 13 studies, at 90-days post-RTSA, with the occurrence of anaemia being the most commonly reported outcomes as 2.9 % (1013/34,385) in six studies. The overall rate of surgical complications was 1.1 % reported in 13 studies (1327/77,826), with the pooled rate of surgical revisions of 1.5 % (607/40,563) at 90-days follow-up. A total of 8, 5, and 3 studies reported rates of dislocation, requirement for closed reduction and glenoid loosening as 0.9 % (344/37,995), 0.6 % (7/1180), and 0.3 % (30/9115) respectively at 90-days following RTSA. CONCLUSIONS AND RELEVANCE This study established that the overall rates of mortality and medical and surgical complications are low in the short-term following RTSA, with only 6 % of patients requiring re-admission in the first 90 days. LEVEL OF EVIDENCE IV - Systematic Review of all levels of evidence.
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Affiliation(s)
- Louise M Kent
- Sports Surgery Clinic, Dublin D09 C523, Ireland; Duke University Hospital, Durham, NC 27710, USA
| | - Eoghan T Hurley
- Sports Surgery Clinic, Dublin D09 C523, Ireland; Duke University Hospital, Durham, NC 27710, USA.
| | - Martin S Davey
- Sports Surgery Clinic, Dublin D09 C523, Ireland; Duke University Hospital, Durham, NC 27710, USA
| | - Christopher S Klifto
- Sports Surgery Clinic, Dublin D09 C523, Ireland; Duke University Hospital, Durham, NC 27710, USA
| | - Hannan Mullett
- Sports Surgery Clinic, Dublin D09 C523, Ireland; Duke University Hospital, Durham, NC 27710, USA
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Malik SS, Tahir M, Jordan RW, Kwapisz A, D'Alessandro P, MacDonald PB, Woodmass JM. The effect of tranexamic acid and epinephrine on visual clarity during arthroscopic shoulder surgery: A meta-analysis of RCTs. Orthop Traumatol Surg Res 2024:103844. [PMID: 38395349 DOI: 10.1016/j.otsr.2024.103844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/31/2023] [Accepted: 02/19/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Visual clarity in arthroscopic rotator cuff repair is essential to reduce the operative time and for efficiency of repair. Tranexamic acid (TXA) in open shoulder surgery has been shown to reduce blood loss but its use in shoulder arthroscopy for rotator cuff repair for improved clarity is not understood. The purpose of this SR is to determine the effect of TXA and epinephrine on visual clarity in shoulder arthroscopy for rotator cuff repair. HYPOTHESIS We hypothesise that visual clarity should improve in those that have TXA compared to those who do not receive TXA. METHODS A review of the online databases MEDLINE and Embase was conducted on 8th October 2022 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Randomised clinical trials reporting visual clarity and/or, operative time, volume of irrigation fluid used and mean arterial pressure were included. The studies were appraised using the CONSORT tool. RESULTS Seven studies met eligible criteria, all of which were double-blinded RCTs. Five studies reported no difference in visual clarity between TXA vs. saline, while two reported a significant improvement with TXA. Pooling of data showed that visual clarity was significantly better in the TXA group vs. saline, on a standardised 10-point Likert scale (mean difference 0.73 points, p=0.03). However, the use of epinephrine was reported in two studies and its administration offered significantly better visual clarity than TXA (mean difference 0.9 points, p=0.02). There was no significant difference with TXA use in MAP (mean difference 1.2mmHg, p=0.14), operative time (mean difference 6.8minutes, p=0.11), irrigation volume used (mean difference 0.2L, p=0.88), or postoperative pain (mean difference 3.89 on a 0-100 VAS, p=0.34). CONCLUSION The use of TXA in shoulder arthroscopy has shown to have significantly improved visual clarity in comparison to saline irrigation alone. This may not necessarily result in a significant clinical difference and may not translate to significantly less operative time or postoperative pain score. Furthermore, epinephrine use alone offers significantly better clarity than TXA. There may not be an added benefit to give both, but this area requires further research. LEVEL OF EVIDENCE II; systematic review.
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Affiliation(s)
- Shahbaz S Malik
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD, United Kingdom
| | - Muaaz Tahir
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Robert W Jordan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Adam Kwapisz
- Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Łódź, Łódź, Poland
| | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia. Medical School, Discipline of Surgery, University of Western Australia, Western Australia, Australia
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Tan TK, Tan P, Wang K, Hau R. Effect of tranexamic acid on shoulder surgery: an updated meta-analysis of randomized studies. J Shoulder Elbow Surg 2024; 33:e97-e108. [PMID: 37890768 DOI: 10.1016/j.jse.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/05/2023] [Accepted: 09/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The effect of tranexamic acid (TXA) has been proven to be effective in reducing blood loss in lower limb arthroplasty. The aim of this study is to investigate the effect of TXA in shoulder surgery with the updated studies. MATERIALS AND METHODS A systematic review and meta-analysis of all the randomized controlled trials were conducted. We compared the outcomes of patients with and without TXA. The PubMed, MEDLINE, EMBASE, and CENTRAL databases were systematically searched for relevant studies. RESULTS A total of 14 studies, enrolling 1131 patients, were included for qualitative and quantitative analysis. Our results revealed that TXA was associated with a significant reduction in total volume blood loss (mean difference [MD]: -112.97, P = .0006), drain output (MD: -81.90, P < .00001), hemoglobin changes (MD: -0.55, P = .02), shorter operative time (MD: -6.19, P = .01), and lower risk of hematoma formation (odds ratio: -0.20, P = .01). The postoperative visual analog scale pain score was also significantly better in the TXA group (MD: -0.78, P < .00001). No significant difference was detected in length of hospital stay and incidence of thromboembolization. CONCLUSION The usage of TXA in shoulder surgery appeared to be safe and effective in reducing blood loss without any significant complication.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Monash Health Dandenong Hospital, Dandenong, VIC, Australia.
| | - Pham Tan
- Radiology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kemble Wang
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia; Department of Surgery, University of Melbourne, Carlton, VIC, Australia
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Cui H, Luo G, Wang Y, Luan M, He K, Ruan J, Li J, Lou T, Sun Z, Chen S, Yu S, Wang W, Fan C. Tranexamic acid in patients with post-traumatic elbow stiffness: protocol for a randomised, double-blind, placebo-controlled trial investigating the effectiveness of tranexamic acid at reducing the recurrence of heterotopic ossification after open elbow arthrolysis. BMJ Open 2023; 13:e075502. [PMID: 38110382 DOI: 10.1136/bmjopen-2023-075502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Exaggerated inflammatory response is one of the main mechanisms underlying heterotopic ossification (HO). It has been suggested that the antifibrinolytic drug tranexamic acid (TXA) can exert a significant anti-inflammatory effect during orthopaedic surgery. However, no prospective studies have yet investigated the effects of TXA on HO recurrence in patients following open elbow arthrolysis (OEA). METHODS AND ANALYSIS Here, we present a protocol for a single-centre, randomised, double-blind, placebo-controlled trial to investigate the effectiveness of TXA on HO recurrence after OEA in a single hospital. A minimum sample size of 138 eligible and consenting participants randomised into treatment and control groups in a 1:1 manner will be included. Patients will receive 2 g of intravenous TXA (experimental group) or placebo (normal saline, control group) administered before skin incision. The primary outcome is HO recurrence rate within 12 months after surgery. The secondary outcomes are the serum immune-inflammatory cytokines including erythrocyte sedimentation rate, C reactive protein, interleukin (IL)-6, IL-1β, IL-13 at the first and third day postoperatively, and elbow range of motion and functional score at 1.5, 6, 9 and 12 months after surgery. After completion of the trial, the results will be reported in accordance with the extensions of the Consolidated Standards of Reporting Trials Statement for trials. The results of this study should determine whether TXA can reduce the rates of HO occurrence after OEA. ETHICS AND DISSEMINATION Ethical approval has been granted by the Medical Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (reference number 2022-123-(1)). The results of this study will be disseminated through presentations at academic conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2300068106.
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Affiliation(s)
- Haomin Cui
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Gang Luo
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Yin Wang
- Nursing Department, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Luan
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kuangyu He
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Jihao Ruan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Juehong Li
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Tengfei Lou
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Ziyang Sun
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Shuai Chen
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Shiyang Yu
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
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Pai B H P, Patel S, Lai YH. Updated Clinical Review: Perioperative Use of Tranexamic Acid in Orthopedics and Other Surgeries. Adv Anesth 2023; 41:1-15. [PMID: 38251612 DOI: 10.1016/j.aan.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Tranexamic acid is a well-known antifibrinolytic that has numerous clinical indications, and it is efficacious and safe in many perioperative scenarios including patients with some thrombotic risks. However, further studies that characterize clinical outcomes concerning dosing, timing, and routes in combination are needed in ultra high-risk populations.
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Affiliation(s)
- Poonam Pai B H
- Department of Anesthesiology and Perioperative Pain Medicine, Mount Sinai West-Morningside Hospitals, 1000 Tenth Avenue, Suite 1G, New York, NY 10019, USA.
| | - Shivani Patel
- Department of Anesthesiology and Perioperative Pain Medicine, Mount Sinai West-Morningside Hospitals, 1000 Tenth Avenue, Suite 1G, New York, NY 10019, USA
| | - Yan H Lai
- Department of Anesthesiology and Perioperative Pain Medicine, Mount Sinai West-Morningside Hospitals, 1000 Tenth Avenue, Suite 1G, New York, NY 10019, USA
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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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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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Shen L, Jiang Z, Wang Q, Xu W. Topical use of tranexamic acid can reduce opioid consumption compared with intravenous use for patients undergoing primary total hip arthroplasty: a prospective randomized controlled trial. BMC Musculoskelet Disord 2023; 24:455. [PMID: 37270493 DOI: 10.1186/s12891-023-06576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/26/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND The problem of opioid addiction after total hip arthroplasty (THA) has been widely concerned. Tranexamic acid (TXA) has been shown to be effective in reducing blood loss for patients undergoing THA, but few studies focus on its alleviation of postoperative local pain symptoms. The purpose of this study was to investigate whether topical TXA could reduce early postoperative hip pain for primary THA patients, thereby reducing the use of opioids, and whether local pain is related to inflammatory response. METHODS In this prospective randomized controlled study, we randomly divided 161 patients into a topical group (n = 79) and an intravenous group (n = 82). Hip pain was assessed using the visual analogue scale (VAS) score within three days after surgery and tramadol was used for pain relief when necessary. Inflammatory markers such as high-sensitivity C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), total blood loss and hemoglobin drop were assessed by hematologic tests. The primary outcomes included the VAS score and dose of tramadol from the first to the third day after surgery. The secondary outcomes included the inflammatory markers level, total blood loss and complications. RESULTS The pain score and inflammation markers level on the first day in the topical TXA group were significantly lower than those in the intravenous TXA group (P < 0.05). The correlation analysis showed that the VAS score on the first day after surgery was positively correlated with the inflammation markers level (P < 0.05). The tramadol dose for topical group was lower than intravenous group on the first and second day after surgery. There were no differences in total blood loss between the two groups (640.60 ± 188.12 ml vs. 634.20 ± 187.85 ml, P = 0.06). There was no difference in the incidence of complications. CONCLUSION Topical use of TXA could relieve the local pain symptoms and reduce opioid consumption compared with intravenous use for patients undergoing primary THA by reduce the early postoperative inflammatory response. TRIAL REGISTRATION The trial was registered at the China Clinical Trial Registry (ChiCTR2100052396) on 10/24/2021.
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Affiliation(s)
- Lei Shen
- Department of Orthopaedics, the Second Affiliated Hospital of Soochow University, 1055 Road Sanxiang, Suzhou, Jiangsu, 215004, China
- Department of Orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, 214200, China
| | - Zhenhuan Jiang
- Department of Orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, 214200, China
| | - Qiang Wang
- Department of Orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, 214200, China
| | - Wei Xu
- Department of Orthopaedics, the Second Affiliated Hospital of Soochow University, 1055 Road Sanxiang, Suzhou, Jiangsu, 215004, China.
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Allen J, Abdelmonem M, Fieraru G, Guyver P. Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It. Shoulder Elbow 2023; 15:311-320. [PMID: 37325384 PMCID: PMC10268136 DOI: 10.1177/17585732221079582] [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: 11/28/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 09/20/2023]
Abstract
Background As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT). Methods A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery. Results The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty. Discussion This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.
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Affiliation(s)
- James Allen
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
- Huddersfield Royal Infirmary, Huddersfield, UK
| | - Mohamed Abdelmonem
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
| | - Gabriel Fieraru
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
| | - Paul Guyver
- Derriford Hospital, University Hospitals Plymouth NHS Trust, Huddersfield, UK
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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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13
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Iseki T, Iseki T, Kanto R, Onishi S, Yoshiya S, Tachibana T, Nakayama H. Efficacy of intravenous tranexamic acid administration in medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO) for varus knee osteoarthritis: a randomized control trial. J Orthop Surg Res 2023; 18:178. [PMID: 36890541 PMCID: PMC9996975 DOI: 10.1186/s13018-023-03666-z] [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: 09/13/2022] [Accepted: 03/01/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND This randomized controlled study was undertaken to investigate the efficacy of intravenous tranexamic acid (TXA) administration in reducing perioperative blood loss in patients undergoing medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO). It was hypothesized that TXA would reduce perioperative blood loss in MOWDTO. METHODS A total of 61 knees in 59 patients who underwent MOWDTO during the study period were randomly assigned to either of the groups with intravenous TXA administration (TXA group) or without TXA administration (control group). In the TXA group, patients received 1000 mg of TXA intravenously before skin incision and 6 h after the first dose. The primary outcomes was the volume of perioperative total blood loss which calculated using the blood volume and hemoglobin (Hb) drop. The Hb drop was calculated as the difference between preoperative Hb and postoperative Hb at days 1, 3, and 7. RESULTS The perioperative total blood loss was significantly lower in the TXA group (543 ± 219 ml vs. 880 ± 268 ml, P < 0.001). The Hb drop was significantly lower at postoperative days 1, 3 and 7 in the TXA group than in the control group (day 1: 1.28 ± 0.68 g/dl vs. 1.91 ± 0.69 g/dl, P = 0.001; day 3: 1.54 ± 0.66 g/dl vs. 2.69 ± 1.00 g/dl, P < 0.001; day 7: 1.74 ± 0.66 g/dl vs. 2.83 ± 0.91 g/dl, P < 0.001). CONCLUSION Intravenous TXA administration in MOWDTO could reduce the perioperative blood loss. Trial registration The study was approved by the institutional review board. (Registered on 26/02/2019 Registration Number 3136). Level of Evidence Level I, randomized controlled trial.
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Affiliation(s)
- Takuya Iseki
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan.
| | - Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Ryo Kanto
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Shintaro Onishi
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, 1-4 Ohama-Cho, Nishinomiya City, Hyogo, 662-0957, Japan
| | - Shinichi Yoshiya
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, 1-4 Ohama-Cho, Nishinomiya City, Hyogo, 662-0957, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Hiroshi Nakayama
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
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Kim MG, Im CJ, Jung WC, Yoon TR, Park KS. Comparison between simultaneous bilateral total hip arthroplasty with and without drainage: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e31134. [PMID: 36316828 PMCID: PMC9622565 DOI: 10.1097/md.0000000000031134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Simultaneous bilateral total hip arthroplasty (SBTHA) is an effective procedure for patients with disease bilaterally. But there is concern about increased blood loss and complications of SBTHA than staged total hip arthroplasty (THA). This study aimed to evaluate the differences in the clinical outcomes and complication rate of SBTHA with drainage and without drainage for reducing the concerns. Between October 2015 and April 2019, a retrospective cohort study was conducted with modified minimally invasive 2-incision method and a consecutive series of 41 SBTHA performed with drainage (Group I) were compared to 37 SBTHA performed without drainage (Group II). It was assessed clinically and radiographically for a mean of 2.1 ± 0.8 years (range, 1.0-4.8 years). Postoperative hematologic values (Hgb loss, total blood loss, transfusion rate), pain susceptibility, functional outcome (Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score) and complication were compared in the drained group and the non-drained group. Postoperative Hgb loss (I: 2163.2 ± 698.7 g, II: 1730.4 ± 572.5 g; P = .002), total blood loss (I: 1528.8 ± 421.7 mL, II: 1237.6 ± 325.9 mL; P = .001) and mean transfusion unit (I: 0.7 ± 1.0 IU, II: 0.1 ± 0.3 IU; P < .001) were significantly lower in the without drainage group than in the with drainage group. But the morphine equivalent (I: 132.7 ± 314.1 mg, II: 732.2 ± 591.5 mg; P < .001) was significantly larger in the without drainage group. No significant difference was found between the drainage group and without drainage group in Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index score at final follow-up. SBTHA without drainage can reduce postoperative blood loss and the requirement for transfusion without increasing other complication. But SBTHA without drainage is more painful method than SBTHA with drainage. Therefore, SBTHA without drainage will be a good option to reduce the burden on the patient by reducing postoperative bleeding if it can control pain well after surgery. III, Retrospective case-control study.
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Affiliation(s)
- Min-Gwang Kim
- Center for Joint Disease, Department of Orthopedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Chae-Jin Im
- Center for Joint Disease, Department of Orthopedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Woo-Chul Jung
- Center for Joint Disease, Department of Orthopedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Taek-Rim Yoon
- Center for Joint Disease, Department of Orthopedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Kyung-Soon Park
- Center for Joint Disease, Department of Orthopedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
- *Correspondence: Kyung-Soon Park, Center for Joint Disease, Department of Orthopedic Surgery, Chonnam National University Medical School and Hwasun Hospital, 322 Seo Yang-Ro, Hwasun-Eup, Hwasun-Gun, Jeonnam 519-809, Republic of Korea (e-mail: )
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15
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de Brito RM, de Oliveira CMB, Moura ECR, Campelo GP, Lima RC, Fe CSDM, Sousa TM, de Oliveira EJSG, Dibai AV, Leal PDC. Tranexamic acid effects in postoperative bleeding outcomes in laparoscopic sleeve gastrectomy: a controlled study. Acta Cir Bras 2022; 37:e370702. [PMID: 36228297 PMCID: PMC9553071 DOI: 10.1590/acb370702] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/18/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To demonstrate through a controlled study whether the use of tranexamic acid in bariatric surgeries is effective for bleeding control. METHODS Prospective, comparative, and double-blind study performed with patients from 18 to 65 years old submitted to bariatric surgery. The selected patients received venous tranexamic acid (TXA) during the induction of anesthesia or not (CG). The anesthesia and thromboprophylaxis protocols were similar among the groups. For statistical analysis, the χ2 and analysis of variance tests were performed at a significance level of p < 0.05, using the statistical program SPSS 21.0®. RESULTS Sixty-one patients were included in the study, 31 in the control group and 30 in the TXA group (GTXA). In the intraoperative period, the bleeding volume was greater in the CG than in the GTXA. In the postoperative period, the tranexamic acid group had a higher value hematocrit, absence of surgical reoperations due to bleeding complications, and shorter hospitalization time than the control group. CONCLUSIONS The use of tranexamic acid was effective in reducing bleeding rates and of hospital stay length, in addition to demonstrating the clinical safety of its use, for not having been associated with any thromboembolic events.
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Affiliation(s)
- Roger Moura de Brito
- Ms. Hospital São Domingos – Center for Bariatric and Metabolic Surgery – Sao Luis (MA), Brazil
| | | | - Ed Carlos Rey Moura
- PhD. Universidade Federal do Maranhão – Postgraduate Program in Adult Health – Sao Luis (MA), Brazil
| | | | - Roclides Castro Lima
- Ms. Hospital São Domingos – Center for Bariatric and Metabolic Surgery – Sao Luis (MA), Brazil
| | - Ciro Sousa de Moura Fe
- Graduate student. Universidade Federal do Maranhão – Department of Medicine – Sao Luis (MA), Brazil
| | - Tércio Maia Sousa
- Graduate student. Universidade Federal do Maranhão – Department of Medicine – Sao Luis (MA), Brazil
| | | | - Almir Vieira Dibai
- PhD. Universidade Federal do Maranhão – Postgraduate Program in Adult Health – Sao Luis (MA), Brazil
| | - Plínio da Cunha Leal
- PhD. Universidade Federal do Maranhão – Postgraduate Program in Adult Health – Sao Luis (MA), Brazil.,Corresponding author:
- (55 98) 98852-2021
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16
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Mackenzie SP, Spasojevic M, Smith M, Mattern O, Piggott RP, Patel SS, Bedaiwy N, Cass B, Young A. The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial. J Shoulder Elbow Surg 2022; 31:1399-1408. [PMID: 35346849 DOI: 10.1016/j.jse.2022.02.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores. METHODS A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks. RESULTS There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis. CONCLUSION TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis.
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Affiliation(s)
| | - Miloš Spasojevic
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia.
| | - Margaret Smith
- Institute of Bone and Joint Research (University of Sydney) at Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Owen Mattern
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | | | - Shaan S Patel
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | - Najla Bedaiwy
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | - Benjamin Cass
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
| | - Allan Young
- Sydney Shoulder Research Institute, St Leonards, NSW, Australia
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17
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Kopechek KJ, Frantz TL, Everhart JS, Samade R, Bishop JY, Neviaser AS, Cvetanovich GL. Risk factors for postoperative blood transfusion after shoulder arthroplasty. Shoulder Elbow 2022; 14:254-262. [PMID: 35599709 PMCID: PMC9121285 DOI: 10.1177/1758573220982253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/29/2020] [Indexed: 11/17/2022]
Abstract
Purpose To identify the effect of surgical indication, patient factors, and perioperative characteristics on transfusion after shoulder arthroplasty (SA). Methods Shoulder arthroplasties for osteoarthritis (OA) (N = 47), rotator cuff arthropathy (RCA) (N = 50), fracture (N = 76), revision (N = 66), and periprosthetic joint infection (PJI) (N = 35) performed at a single institution during a 6-year period were included. All other indications were excluded. Patient-based and surgical risk factors, including surgical indication, for postoperative allogeneic red blood cell transfusion were assessed with multivariate logistic regression analysis. Results A total of 274 SAs were included; transfusions were performed in 2% (2/97) of primary SAs for OA or RCA. Increased transfusion rates occurred in PJI (23%, p = 0.0006) and fracture (18%, p = 0.0018) cases. The mean preoperative hemoglobin (Hgb) was 12.2 ± 2.2 with PJI, 12.0 ± 2.1 with fracture, and 13.3 ± 1.6 g/dL for all other SAs. Independent risk factors for transfusion included lower preoperative hemoglobin (p < 0.001), PJI indication (p = 0.008), and fracture indication (p = 0.02), with no difference for fracture greater or less than 4 weeks old (p = 0.53). Conclusion Risk factors for allogeneic red blood cell transfusion after SA were low preoperative hemoglobin and procedures for PJI or fracture.Level of Evidence: Level III, retrospective case-control study.
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Affiliation(s)
- Kyle J Kopechek
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Travis L Frantz
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Joshua S Everhart
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Richard Samade
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Julie Y Bishop
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Andrew S Neviaser
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedics, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
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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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19
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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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20
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Wang Y, Liu Y, Liu J, Wang M, Wang Y. Coadministration of Curcumin and Hydromorphone Hydrochloride Alleviates Postoperative Pain in Rats. Biol Pharm Bull 2022; 45:27-33. [PMID: 34980778 DOI: 10.1248/bpb.b21-00434] [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: 11/22/2022]
Abstract
This study aimed to explore the effect of curcumin and hydromorphone hydrochloride (HH) cotreatment on postoperative pain in rats. An incision + formaldehyde-induced pain rat model was established. Rats were treated with vehicle, curcumin, HH, or curcumin + HH. Paw mechanical withdrawal threshold and thermal withdrawal latency were measured at 1 d before surgery as well as 1 , 2 h, 1 , 3 , and 7 d after surgery to assess pain sensitivity. The L4-6 region of the spinal cord was collected from each rat at 2 h, 1 , 3 , and 7 d after surgery. Western blot analysis and immunohistochemical staining were carried out to detect the protein expression of pain-related genes. Quantitative real-time PCR and enzyme-linked immunosorbent assay were conducted to measure the expression and production of proinflammatory mediators. Compared with other groups, Curcumin + HH significantly reduced pain sensitivity in the model rats. Mechanistically, curcumin + HH suppressed protein expression of stromal cell-derived factor-1 (SDF-1), CXC chemokine receptor 4 (CXCR4), p-Akt, and c-fos while enhancing protein expression of nerve growth factor (NGF) in the dorsal root ganglia (DRG) of model rats. Curcumin + HH inhibited the expression and production of interleukin 1β (IL-1β), cyclooxygenase-2 (COX-2), tumor necrosis factor α (TNF-α), and p65 nuclear factor kappa B (NF-κB) in the DRG. Coadministration of curcumin and HH alleviates incision + formaldehyde-induced pain in rats, possibly by suppressing the SDF-1/CXCR4 pathway and the production of proinflammatory mediators. Our results provide curcumin and HH cotreatment as a promising therapeutic strategy in the management of postoperative pain.
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Affiliation(s)
- Yihan Wang
- Department of anesthesiology, Lanzhou University Second Hospital
| | - Yang Liu
- Department of anesthesiology, Lanzhou University Second Hospital
| | - Jieting Liu
- Department of anesthesiology, Lanzhou University Second Hospital
| | - Min Wang
- Department of anesthesiology, Lanzhou University Second Hospital
| | - Yingbin Wang
- Department of anesthesiology, Lanzhou University Second Hospital
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21
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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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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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23
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Xiao M, Cohen SA, Cheung EV, Freehill MT, Abrams GD. Pain management in shoulder arthroplasty: a systematic review and network meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2021; 30:2638-2647. [PMID: 34284094 DOI: 10.1016/j.jse.2021.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/29/2021] [Accepted: 06/07/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use. METHODS A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for Level I-II randomized controlled trials that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, and other modalities. The 2 primary outcome measures were pain level measured on a 0-10 visual analog scale and opioid use. The risk of study bias and methodologic quality were analyzed using The Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for visual analog scale pain scores at postsurgical time points and opioid use using a frequentist approach and random-effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P score, and statistical significance was set at P < .05. RESULTS The initial search yielded 2391 articles (695 duplicates, 1696 screened, 53 undergoing full-text review). Eighteen articles (1358 shoulders; 51% female patients; mean age range, 65-73.7 years; 4 studies with low risk of bias, 12 with some risk, and 2 with high risk) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) injection (P < .001 for 4 and 8 hours) or local ropivacaine injection (P < .001 for 4 hours and P = .019 for 8 hours) had significantly more pain compared with patients who received either a continuous interscalene block (cISB) or single-shot interscalene block (ssISB). No differences in opioid use (at P < .05) were detected between modalities. The P scores of treatments demonstrated that ssISBs were most favorable at time points < 24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of an ssISB with a local LB injection. CONCLUSION Interscalene blocks are superior to local injections alone at managing pain after TSA. Single-shot interscalene blocks are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24-48 hours after surgery may be best managed with cISBs or a combination of an ssISB with a local LB injection.
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Affiliation(s)
- Michelle Xiao
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Samuel A Cohen
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Emilie V Cheung
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael T Freehill
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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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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Hartland AW, Teoh KH, Rashid MS. Clinical Effectiveness of Intraoperative Tranexamic Acid Use in Shoulder Surgery: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:3145-3154. [PMID: 33475421 PMCID: PMC8411466 DOI: 10.1177/0363546520981679] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery. PURPOSE To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate. RESULTS Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures. CONCLUSION This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required. CLINICAL RELEVANCE TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.
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Affiliation(s)
| | - Kar H. Teoh
- Princess Alexandra Hospital, Harlow,
Essex, UK
| | - Mustafa S. Rashid
- Nuffield Department of Orthopaedics,
Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK,Mustafa S. Rashid, MB ChB,
MSc, PhD, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal
Sciences, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK (
)
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26
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Tranexamic acid is beneficial for blood management of high tibial osteotomy: a randomized controlled study. Arch Orthop Trauma Surg 2021; 141:1463-1472. [PMID: 32715401 DOI: 10.1007/s00402-020-03558-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate whether TXA can effectively reduce blood loss after HTO and related complications and to evaluate its safety. MATERIALS AND METHODS From March 2016 to March 2018, 100 patients who underwent medial opening wedge HTO in the Department of Orthopedics, the second affiliated hospital of xi'an jiaotong university, with an average age of 52.8 ± 3.2 years, were randomly divided into the TXA group (using intravenous TXA) and the control group (using the same amount of normal saline), with 50 patients in each group. The postoperative wound drainage volume, decrease in hemoglobin and hematocrit value, total blood loss, wound healing, blood transfusion, deep venous thrombosis (DVT) and pulmonary embolism (PE) were compared between the two groups. RESULTS The drainage volume on the first postoperative day and the total drainage volume of the TXA group were significantly lower compared with those of the control group (145.7 vs 264.5 ml, 282.3 vs 413.2 ml, P < 0.05). The decreases in the hemoglobin and hematocrit values on the postoperative first, second and fifth days were lower in the TXA group than those in the control group (1.4 VS 3.5, 2.6 vs 3.3, 1.9 vs 2.9 g, P < 0.05; 3.3 vs 5.5, 5.0 vs 9.1, 3.8 vs 7.2%, P < 0.05), and the mean total blood loss was also lower in the TXA group than that in the control group (477.9 vs 834.6 ml, P < 0.05). In the control group, 1 patient had wound hematoma requiring additional paracentesis and pressure dressing, 1 patient had superficial wound infection requiring additional debridement, and 1 patient had postoperative blood transfusion compared to none in the TXA group (P > 0.05). There was no symptomatic DVT or PE in either of the groups. CONCLUSION Intravenous TXA can effectively and safely reduce blood loss and bleeding-related complications after HTO and was beneficial for the blood management of HTO.
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Cui H, Yu S, Ruan J, Sun Z, Li J, Chen S, Fan C. Intravenous tranexamic acid reduce postoperative drainage and pain after open elbow arthrolysis: a randomized controlled trial. J Shoulder Elbow Surg 2021; 30:1725-1732. [PMID: 33964430 DOI: 10.1016/j.jse.2021.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/05/2021] [Accepted: 04/18/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open elbow arthrolysis (OEA), which has become an established treatment for post-traumatic elbow stiffness (PTES), requires complete release of contracture tissue and wide excision of ectopic bone, which results in extensive bleeding. The aim of the present study is to evaluate the efficacy of intravenous tranexamic acid (TXA) on postoperative drainage, calculated blood loss, and early clinical outcomes in patients undergoing OEA. METHODS A double-blind, randomized, placebo-controlled trial including 96 patients undergoing OEA was undertaken. Patients received intravenously either 100 mL saline (placebo group, n = 48), or 100 mL saline plus 1 g TXA (TXA group, n = 48) before skin incision. The primary outcome was the drainage volume on postoperative days (PODs) 1-3. Secondary outcomes included the calculated blood loss, elbow pain score measured by visual analog scale (VAS), elbow function valued by Mayo Elbow Performance Score (MEPS), and rate of complications after OEA. RESULTS Mean total postoperative drainage volume (TXA group: 182 mL vs. placebo group: 214 mL, P = .003) and mean calculated total blood loss (TXA group: 582 mL vs. placebo group: 657 mL, P = .004) were significantly lower in the TXA group. No transfusions were necessary in either group. Mean VAS pain scores in elbow motion showed marked differences between both groups on POD 1 (TXA: 5 vs. placebo: 6, P = .003) and POD 2 (TXA: 4 vs. placebo: 5, P = .023) but not in other postoperative time points. No differences were detected in complications, such as pin-related infection, hematoma, new or exacerbation of ulnar nerve symptoms, and recurrent heterotopic ossification. At the 6-month follow-up, no statistical differences were found between the 2 groups with respect to the elbow functions including range of motion, VAS score, and MEPS. CONCLUSION Intravenous administration of TXA significantly decreased the postoperative drainage volume and the total estimated blood loss and alleviated the elbow pain with motion during early postoperative days in patients undergoing OEA.
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Affiliation(s)
- Haomin Cui
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Shiyang Yu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Jihao Ruan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Ziyang Sun
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Juehong Li
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Shuai Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China.
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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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B H PP, Diskina D, Lin HM, Vulcano E, Lai YH. Use of tranexamic acid does not influence perioperative outcomes in ambulatory foot and ankle surgery-a prospective triple blinded randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2021; 45:2277-2284. [PMID: 34324042 DOI: 10.1007/s00264-021-05131-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE TXA is an antifibrinolytic medication widely used to reduce perioperative blood loss, but it has been seldom used during foot and ankle surgery. Our study evaluates the impact of TXA use on blood loss, post-operative pain, peri-operative opioid consumption, and wound healing in ambulatory outpatient foot and ankle procedures. DESIGN Prospective, triple-blinded, randomized controlled trial. SETTING Peri-operative environment of a major academic health centre in New York City. PATIENTS A total of 100 participants who were scheduled for ambulatory foot and ankle surgery with a single surgeon. INTERVENTIONS Patients receive either 10 mg/kg TXA (TXA group) or 10 ml/kg of normal saline (placebo group) intravenously prior to skin incision. MEASUREMENTS Primary outcome was intra-operative blood loss. Secondary outcomes were peri-operative opioid consumption and wound complications between post-operative days 14 and 21. MAIN RESULTS We found no difference between TXA and placebo groups in terms of intra-operative blood loss, p value 0.71, 95% CI (63.13-19.80). There was no difference between the two groups in terms of post-operative morphine milliequivalents (MME). The incidence of wound complications was 16.3% in the TXA group compared to 15.7% in the placebo group with OR 1.04, p value 0.93, 95% CI (0.32-2.77). No adverse events associated with TXA were reported. CONCLUSIONS The use of TXA during foot and ankle surgery was not associated with any benefits in perioperative outcomes in our outpatient ambulatory surgical population. Considering potential risks, we do not support the routine use of TXA in this surgical model.
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Affiliation(s)
| | | | - Hung Mo Lin
- Mount Sinai Health System, New York, NY, USA
| | - Ettore Vulcano
- Mount Sinai Medical Center, Columbia University, Miami, FL, USA
| | - Yan H Lai
- Department of Anesthesiology, Mount Sinai Health System, 1000 Tenth Avenue, New York, NY, 10019, USA.
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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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Hurley ET, Maye AB, Thompson K, Anil U, Resad S, Virk M, Strauss EJ, Alaia MJ, Campbell KA. Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis. Am J Sports Med 2021; 49:2262-2271. [PMID: 33321046 DOI: 10.1177/0363546520971757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. PURPOSE To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. RESULTS Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions. CONCLUSION Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.
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Affiliation(s)
| | - Andrew B Maye
- New York University Langone Health, New York, New York, USA
| | | | - Utkarsh Anil
- New York University Langone Health, New York, New York, USA
| | - Sehar Resad
- New York University Langone Health, New York, New York, USA
| | - Mandeep Virk
- New York University Langone Health, New York, New York, USA
| | - Eric J Strauss
- New York University Langone Health, New York, New York, USA
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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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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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Liu EY, Kord D, Horner NS, Leroux T, Alolabi B, Khan M. Stemless anatomic total shoulder arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg 2020; 29:1928-1937. [PMID: 32220527 DOI: 10.1016/j.jse.2019.12.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 12/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) is used in the treatment of osteoarthritis of the shoulder joint and other degenerative shoulder diseases. It has several proposed advantages over stemmed TSA including increased bone preservation, decreased operative time, and easier removal at revision. METHODS A systematic search was conducted using MEDLINE, Embase, PubMed, and CENTRAL (Cochrane Central Register of Controlled Trials) to retrieve all relevant studies. RESULTS The literature search yielded 1417 studies, of which 22 were included in this review, with 962 patients undergoing stemless TSA. Stemless TSA led to significant improvements in range of motion and functional scores in all included studies. Meta-analysis of comparative studies between stemless and stemmed TSA identified no significant differences in postoperative Constant scores (mean difference [MD], 1.26; 95% confidence interval [CI], -3.29 to 5.81 points; P = .59) or complication rates (odds ratio, 1.79; 95% CI, 0.71-4.54; P = .22). Stemless TSA resulted in a significantly shorter operative time compared with stemmed TSA (MD, -15.03 minutes; 95% CI, -23.79 to -6.26 minutes; P = .0008). Stemless TSA also resulted in significantly decreased intraoperative blood loss compared with stemmed TSA (MD, -96.95 mL; 95% CI, -148.53 to -45.36 mL; P = .0002). CONCLUSION Stemless anatomic TSA resulted in similar functional outcomes and complication rates to stemmed TSA with decreased operative time and lower blood loss. Further research is required to investigate the long-term durability of the stemless implant.
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Affiliation(s)
- Eva Y Liu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dorsa Kord
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nolan S Horner
- Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada
| | | | - Bashar Alolabi
- Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Moin Khan
- Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
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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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Hurley ET, Lim Fat D, Pauzenberger L, Mullett H. Tranexamic acid for the Latarjet procedure: a randomized controlled trial. J Shoulder Elbow Surg 2020; 29:882-885. [PMID: 32305106 DOI: 10.1016/j.jse.2020.01.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 12/26/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce perioperative bleeding and the need for transfusion. The purpose of the study was to assess whether TXA could reduce the incidence of postoperative swelling and hematoma formation and pain and opioid use in the early postoperative period following the Latarjet procedure. METHODS A randomized controlled trial was conducted in 100 patients undergoing open Latarjet surgery for anterior shoulder instability by a single surgeon. Patients were randomized to receive either 1 g TXA or a placebo intravenously preoperatively. Outcomes measured during the perioperative period were (1) intraoperative blood loss, (2) postoperative blood loss (via drain output), (3) postoperative swelling/hematoma formation, (4) visual analog scale (VAS) score, and (5) postoperative opioid use (in morphine milligram equivalents). RESULTS There was no significant difference in intraoperative blood loss (60.9 vs. 68.9 mL, P = .18). However, there was significantly lower postoperative blood loss with TXA (29.6 vs. 64.9 mL, P < .01). There was a significantly lower rate of painful postoperative swelling (4% vs. 32%, P < .01). Additionally, we found a significantly lower VAS score for pain (1.7 vs. 3.0, P < .01) and significantly less postoperative opioid use (9.4 vs. 22 mg, P < .01) in the TXA group. Postoperative swelling was shown to correlate with increased pain and opioid use (P < .01). CONCLUSION Our study found that TXA significantly reduced postoperative blood loss, painful postoperative swelling, and hematoma formation and subsequently reduced postoperative pain and opioid use following the Latarjet procedure.
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Affiliation(s)
- Eoghan T Hurley
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Department of Trauma & Orthopaedic Surgery, Dublin, Ireland; National University of Ireland Galway, Galway, Ireland.
| | | | | | - Hannan Mullett
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Department of Trauma & Orthopaedic Surgery, Dublin, Ireland
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Liu YF, Hong CK, Hsu KL, Kuan FC, Chen Y, Yeh ML, Su WR. Intravenous Administration of Tranexamic Acid Significantly Improved Clarity of the Visual Field in Arthroscopic Shoulder Surgery. A Prospective, Double-Blind, and Randomized Controlled Trial. Arthroscopy 2020; 36:640-647. [PMID: 31870749 DOI: 10.1016/j.arthro.2019.10.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/31/2019] [Accepted: 10/16/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine whether intravenous administration of tranexamic acid (TXA) before shoulder arthroscopic rotator cuff repair surgery can improve arthroscopy visual clarity. METHODS This was a prospective, double-blind, randomized, and placebo-controlled study. From May 2016 to April 2018, patients requiring arthroscopic rotator cuff repair were enrolled and randomly assigned to either the TXA group. receiving 1000 mg of TXA intravenously 10 minutes before surgery. or the placebo group. receiving the same volume of plain saline. Patients with pre-existing liver/renal disease, coagulopathy, or concurrent use of anticoagulation medications were excluded. Visual clarity was rated using a Numeric Rating Scale from grade 1 (poor) to grade 3 (clear) every 15 minutes throughout the surgery. Secondary outcomes included estimated perioperative blood loss, operative time, degree of shoulder swelling, postoperative subjective pain score, inpatient duration, and associated comorbidities were recorded. Both parametric and nonparametric methods were used for the statistical analysis. RESULTS In total, 72 patients were enrolled, 37 in the TXA group and 35 in the placebo group. The demographic data were similar between the 2 groups. Visual clarity was found to be significantly better in the TXA group, with a greater percentage of grade 3 vision clarity (53.7 ± 18.9 % vs 40.5 ± 22.1%, P = .036). The average visual score in the TXA group (2.5 ± 0.2) also was better than that of the control group (2.3 ± 0.3) (P = .048). The postoperative subjective pain score was significantly lower in the TXA group (3.0 ± 1.5) than in the control group (4.3 ± 2.0) (P = .009). In addition, postoperative analgesic usage was significant lower in the TXA groups (9.6 ± 9.7 morphine milligram equivalent) than in the control group (14.7 ± 13.4 morphine milligram equivalent) (P = .037). Other parameters, such as operative time, estimated perioperative blood loss, degree of shoulder swelling, and duration of inpatient stay were similar between the 2 groups. None of the patients developed complications after surgery. CONCLUSIONS Intravenous administration of TXA is an alternative way to improve visual clarity in arthroscopic shoulder surgery. It also reduces subjective pain and analgesic consumption in the early postoperative period without significant side effects. LEVEL OF EVIDENCE Therapeutic studies level II.
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Affiliation(s)
- Yuan-Fu Liu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Yueh Chen
- Department of Orthopaedic Surgery, Sin Lau Christian Hospital, Tainan, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Leeman M, Huisbrink J, Wijnand JMA, Biter LU, Verbrugge SJC, Dunkelgrun M, Apers JA. Trial protocol: preoperative administration of tranexamic acid in sleeve gastrectomy (PATAS) to reduce haemorrhage rates. A randomised controlled trial. BMJ Open 2020; 10:e034572. [PMID: 32029498 PMCID: PMC7044819 DOI: 10.1136/bmjopen-2019-034572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Fast-track protocols often include short-term thromboprophylaxis and short length of hospital stay. These treatment strategies may negatively affect the occurrence and diagnosis of postoperative haemorrhage. Over the years, the rates of venous thromboembolic events (VTEs) have decreased, while there seems to be an increase in the occurrence of postoperative haemorrhage. Tranexamic acid (TXA) can potentially lower the incidence of postoperative haemorrhage. This trial aims to investigate whether preoperative administration of TXA reduces the preoperative and postoperative haemorrhage rates in laparoscopic sleeve gastrectomy (LSG). METHODS AND ANALYSIS This is a single centre double-blind randomised placebo-controlled trial. Patients undergoing an LSG are included after obtaining informed consent. Patients are randomised between two groups: (1) administration of placebo infusion and (2) administration of 1500 mg TXA. In both groups, the infusions will be administered during the induction phase of the procedure. Primary outcome measures are preoperative use of haemostatic clips, postoperative haemoglobin decrease and postoperative haemorrhage. Secondary outcome measure is the rates of VTE. ETHICS AND DISSEMINATION The protocol version 3 was approved by the medical ethical committee Medical Research Ethics Committees United (MEC-U), Nieuwegein, on 29 July 2019. The trial results will be submitted for publication in a peer-reviewed journal and at conference presentations. TRIAL REGISTRATION NUMBER The Netherlands Trial Registry (NL8029); Pre-results.
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Affiliation(s)
- Marjolijn Leeman
- Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Jeannine Huisbrink
- Pharmacology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Julie M A Wijnand
- Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - L Ulas Biter
- Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Serge J C Verbrugge
- Anaesthesiology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Martin Dunkelgrun
- Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Jan A Apers
- Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
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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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Richards JE, Samet RE, Koerner AK, Grissom TE. Tranexamic Acid in the Perioperative Period: Yes, No, Maybe? Adv Anesth 2019; 37:87-110. [PMID: 31677661 DOI: 10.1016/j.aan.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - A Kennedy Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Center for the Sustainment of Trauma and Readiness Skills (CSTARS)-Baltimore, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S13-S31. [PMID: 31196506 DOI: 10.1016/j.jse.2019.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/20/2019] [Indexed: 02/01/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.
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Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Yates J, Perelman I, Khair S, Taylor J, Lampron J, Tinmouth A, Saidenberg E. Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis. Transfusion 2018; 59:806-824. [PMID: 30516835 DOI: 10.1111/trf.15030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.
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Affiliation(s)
- Jeffrey Yates
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simonne Khair
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
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Abstract
BACKGROUND Medial opening wedge high tibial osteotomy (HTO) entails extensive soft tissue release that may lead to substantial perioperative bleeding. Although tranexamic acid (TXA) is a well-established blood-conserving agent in total joint arthroplasty, its potential to reduce blood loss in patients undergoing HTO has not been studied extensively. QUESTIONS/PURPOSES (1) Does TXA reduce total estimated blood loss in HTO? (2) Does TXA use in HTO affect in-hospital endpoints as measured by visual analog scale (VAS) pain scores at rest the day after surgery, wound complications in the immediate postoperative period, blood transfusions, or symptomatic deep vein thrombosis? METHODS Between January 2015 and May 2017, a single surgeon performed 156 HTOs, all of which were done using the medial opening wedge technique. We began using intravenous TXA for all HTOs in June 2016. This left us with 89 patients who were treated during a time when no TXA was used and 67 patients who were treated when all patients received TXA. Two patients in the control group had simultaneous TKA in the contralateral leg and one patient in each group had missing data so these patients were excluded, leaving 86 (97%) patients in the control group and 66 (98.5%) in the TXA group available for analysis in this retrospective study. There were no demographic differences between the groups in terms of age, sex, body mass index, and baseline hemoglobin values. Total estimated blood loss was the primary outcome variable, which was calculated using total blood volume and decrease in hemoglobin values. Secondary outcome variables included pain VAS at rest the day after surgery, wound complications in the immediate postoperative period, allogeneic blood transfusions, and occurrence of symptomatic thromboembolic manifestations. The decision on when to transfuse was based on predetermined criteria. An orthopaedic surgeon not involved in patient care collected the patient data from electronic medical records and did chart review. RESULTS The TXA group had less total blood loss (372 ± 36 mL versus 635 ± 53 mL, mean difference 263 mL [95% confidence interval, 248-278]; p < 0.001). Between groups, differences in VAS pain scores at rest the day after surgery favored the TXA group but were small and unlikely to be clinically important. There were two wound complications in the control group (one hematoma and one superficial wound infection) and none in the TXA group. No patients in either group received a blood transfusion, and no symptomatic thromboembolic events were detected in either group. CONCLUSIONS This study demonstrates that the systemic administration of TXA reduces postoperative blood loss in medial opening wedge HTO; however, insofar as no transfusions were administered to patients even before the routine use of TXA in this series, and no clinically important differences in pain scores were identified, the clinical benefit of routine use of TXA in patients undergoing HTO is uncertain. Our study was too small to make safety-related claims on rare endpoints such as wound complications or thromboembolic events. Larger, and preferably randomized, trials are needed to help define whether it is important to use TXA in this setting. Our data can help inform sample size calculations for such studies. LEVEL OF EVIDENCE Level III, therapeutic study.
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Tranexamic acid is effective for blood management in open-wedge high tibial osteotomy. Orthop Traumatol Surg Res 2018; 104:1003-1007. [PMID: 30245067 DOI: 10.1016/j.otsr.2018.07.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/08/2018] [Accepted: 07/30/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There has been paucity in literature regarding the blood-sparing effect of TXA after high tibial osteotomy (HTO). The purpose of this study is to determine the efficacy of tranexamic acid (TXA) with regard to its blood-sparing effects in open-wedge HTO, and to assess thromboembolic complications in patients undergoing open-wedge HTO with or without the use of TXA. HYPOTHESIS The intravenous TXA would reduce postoperative blood loss and transfusion requirements without increasing thromboembolic complications in open-wedge HTO. MATERIALS AND METHODS From March 2011 to December 2016, medial open-wedge HTO was performed in 150 consecutive knees with varus gonarthrosis. The mean age at the time of surgery was 55.3±5.0 years. TXA was intravenously used in the latter 75 knees (TXA group), and the group was retrospectively compared with the former 75 knees without use of TXA (control group). Outcome measures were postoperative hemoglobin drop, drain amount, total estimated blood loss, transfusion requirements, and incidence of thromboembolic complications. RESULTS The use of TXA led to a significant decrease in hemoglobin drop (p<0.001) and drain amount (p=0.025). Total estimated blood loss was lower in the TXA group than in the control group (p<0.001). Two knees in the control group had postoperative blood transfusion, compared to none in the TXA group (p>0.05). There were no thromboembolic complications such as symptomatic deep vein thrombosis and pulmonary embolism in both groups. CONCLUSION The use of TXA reduced perioperative hemoglobin drop, drain amount, and total estimated blood loss without thromboembolic complications in patients undergoing open-wedge HTO. Therefore, the use of TXA is a safe and viable option for perioperative blood management in open-wedge HTO. LEVEL OF EVIDENCE III, Case control study.
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Wang D, Wang HY, Luo ZY, Meng WK, Pei FX, Li Q, Zhou ZK, Zeng WN. Blood-conserving efficacy of multiple doses of oral tranexamic acid associated with an enhanced-recovery programme in primary total knee arthroplasty: a randomized controlled trial. Bone Joint J 2018; 100-B:1025-1032. [PMID: 30062946 DOI: 10.1302/0301-620x.100b8.bjj-2017-1598.r1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aims The aim of this study was to identify the most effective regimen of multiple doses of oral tranexamic acid (TXA) in achieving maximum reduction of blood loss in total knee arthroplasty (TKA). Patients and Methods In this randomized controlled trial, 200 patients were randomized to receive a single dose of 2.0 g of TXA orally two hours preoperatively (group A), a single dose of TXA followed by 1.0 g orally three hours postoperatively (group B), a single dose of TXA followed by 1.0 g three and nine hours postoperatively (group C), or a single dose of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively (group D). All patients followed a routine enhanced-recovery protocol. The primary outcome measure was the total blood loss. Secondary outcome measures were hidden blood loss (HBL), reduction in the level of haemoglobin, the rate of transfusion and adverse events. Results Groups C (661.1 ml, sd 262.4) and D (597.7 ml, sd 219.6) had significantly lower mean total blood loss compared with groups A and B. The mean HBL was significantly lower in groups B (699.2 ml), C (533.1 ml) and D (469.9 ml) than in group A (p = 0.006, p < 0.001, and p < 0.001, respectively). Groups C (2.22 ml, sd 0.91) and D (2.04 ml, sd 0.95) had a lower reduction in the level of haemoglobin than groups A and B. However, there were no differences between groups C and D in relation to the three parameters. Conclusion The addition of two or three postoperative doses of TXA to one preoperative dose produced a significant reduction in blood loss. The two-dose postoperative regimen is the least necessary regimen for clinical efficacy in primary unilateral TKA. The three-dose regimen produced maximum reduction of blood loss. Cite this article: Bone Joint J 2018;100-B:1025–32.
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Affiliation(s)
- D. Wang
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - H-Y. Wang
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Z-Y. Luo
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - W-K. Meng
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - F-X. Pei
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Q. Li
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Z-K. Zhou
- Department of Orthopedics, West China
Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - W-N. Zeng
- Center for Joint Surgery, Southwest Hospital,
Third Military Medical University, Chongqing, China
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Parker JD, Lim KS, Kieser DC, Woodfield TBF, Hooper GJ. Is tranexamic acid toxic to articular cartilage when administered topically? Bone Joint J 2018; 100-B:404-412. [DOI: 10.1302/0301-620x.100b3.bjj-2017-1135.r1] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Aims The intra-articular administration of tranexamic acid (TXA) has been shown to be effective in reducing blood loss in unicompartmental knee arthroplasty and anterior cruciate reconstruction. The effects on human articular cartilage, however, remains unknown. Our aim, in this study, was to investigate any detrimental effect of TXA on chondrocytes, and to establish if there was a safe dose for its use in clinical practice. The hypothesis was that TXA would cause a dose-dependent damage to human articular cartilage. Materials and Methods The cellular morphology, adhesion, metabolic activity, and viability of human chondrocytes when increasing the concentration (0 mg/ml to 40 mg/ml) and length of exposure to TXA (0 to 12 hours) were analyzed in a 2D model. This was then repeated, excluding cellular adhesion, in a 3D model and confirmed in viable samples of articular cartilage. Results Increasing concentrations above 20 mg/ml resulted in atypical morphology, reduced cellular adhesion and metabolic activity associated with increased chondrocyte death. However, the cell matrix was not affected by the concentration of TXA or the length of exposure, and offered cellular protection for concentrations below 20 mg/ml. Conclusion These results show that when in vitro chondrocytes are exposed to higher concentrations of TXA, such as that expected following recommended intra-articular administration, cytotoxicity is observed. This effect is dose-dependent, such that a tissue concentration of 10 mg/ml to 20 mg/ml could be expected to be safe. Cite this article: Bone Joint J 2018;100-B:404–12.
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Affiliation(s)
- J. D. Parker
- University of Otago Christchurch, 2
Riccarton Avenue, Christchurch, New
Zealand
| | - K. S. Lim
- University of Otago Christchurch, 2
Riccarton Avenue, Christchurch, New
Zealand
| | - D. C. Kieser
- University of Otago Christchurch, 2
Riccarton Avenue, Christchurch, New
Zealand
| | - T. B. F. Woodfield
- University of Otago Christchurch, 2
Riccarton Avenue, Christchurch, New
Zealand
| | - G. J. Hooper
- Department of Orthopaedic Surgery and
Musculoskeletal Medicine, University of Otago Christchurch, Christchurch, New
Zealand
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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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