Comparison of the efficacy of irrigation with epinephrine or tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A double-blind, randomized-controlled study

Does epinephrine use reduce perioperative blood loss during pelvic and femoral osteotomy with open reduction of the patients with developmental dysplasia of the hip?

OBJECTIVES

In this study, we aimed to investigate whether the use of epinephrine solution-impregnated gauzes and irrigation fluid with epinephrine could reduce perioperative blood loss during the combined surgical treatment of developmental dysplasia of the hip (DDH) patients.

PATIENTS AND METHODS

Between January 2018 and June 2023, a total of 68 pediatric patients (8 males, 60 females; mean age: 32.4±13.2 months; range, 18 to 98 months) who underwent combined surgery for DDH were retrospectively analyzed. The patients were divided into two groups as those who used topical epinephrine in the surgical sites during combined surgical treatment (n=34) and those who did not (n=34). Demographic and clinical characteristics and pre-, intra-, and postoperative data were recorded. To avoid transfusion complications, blood transfusion was performed in only symptomatic patients in the postoperative period.

RESULTS

Age, sex, weight, and surgical duration were similar between the two groups (p>0.05). No statistically significant difference was found between the groups in terms of preoperative hemoglobin and hematocrit levels (p>0.05) There were statistically significantly differences between the groups in terms of postoperative hemoglobin and hematocrit levels, perioperative amount of blood loss, and postoperative length of hospital stay (p<0.001). No significant difference was found between the groups in terms of intraoperative hemodynamic parameters (p>0.05). The differences in perioperative and estimated intraoperative blood loss amounts and length of hospital stay were statistically significant between the groups (p<0.001). There was a significant relationship between the groups in terms of perioperative and estimated intraoperative blood loss, and transfusion of blood products (p<0.01). Blood transfusion was administered to five patients in the no epinephrine group. No local complications were observed in any group; however, one patient had transfusion-related fever and one patient had allergic skin lesions in the no epinephrine group.

CONCLUSION

The intraoperative topical use of epinephrine irrigation solution and epinephrine solution-impregnated gauze dressings is effective and safe in reducing blood loss in DDH patients.

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

BACKGROUND

Visual clarity during shoulder arthroscopy can ensure an efficient and effective performance of the procedure, and it is highly related to bleeding without a tourniquet. Tranexamic acid (TXA) is widely used in adult reconstruction procedures; however, its use in shoulder arthroscopic operations is a relatively novel topic.

PURPOSE

To analyze the available literature on visual clarity, blood loss, pain control, functional outcomes, and complications after the administration of tranexamic acid in shoulder arthroscopic surgery.

METHODS

A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of shoulder arthroscopic surgery. The literature search included the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The primary outcomes included visual clarity, blood loss, and visual analog scale scores for pain. Secondary outcomes were operative time, irrigation amount used, postoperative shoulder swelling, the need for pressure increase, mean arterial pressure (MAP), functional outcomes, postoperative adverse effects such as deep venous thrombosis, and pulmonary embolism. The outcomes were pooled to perform a meta-analysis.

RESULTS

Seven prospective randomized controlled trials met the inclusion criteria for analysis. All of the included studies performed arthroscopic rotator cuff repair. No significant difference in visual clarity was observed (SMD (standardized mean difference), 0.45 [95% CI(confidence interval), -0.68, 1.59]; p = 0.44) nor in pain score (MD (mean difference), -0.46 [95% CI, -0.97, 0.05]; p = 0.08) between the TXA group and the control group. Two studies found no significant difference in blood loss between the TXA group and the control group. The meta-analysis from five studies demonstrated no significant difference between the TXA and control groups in operative time (MD, -3.51 [95% CI, -15.82, 8.80]; p = 0.58) or irrigation amount used (MD, -2.53 [95% CI, -5.93, 0.87]; p = 0.14). Two trials reported different statistical results in postoperative shoulder swelling. No significant differences regarding the need for pressure increase and MAP were reported between groups. No wound complications or infections or cardiac, thrombotic, or thromboembolic complications were recorded in either group.

CONCLUSION

The use of intravenous or local TXA in shoulder arthroscopic surgery did not increase complications or thromboembolic events, but TXA had no obviously effect of reducing bleeding to obtain a clear visual field or pain release in patients undergoing shoulder arthroscopic surgery.

Tranexamic Acid: When is It Indicated in Orthopaedic Surgery?

Tranexamic acid (TXA) has been studied extensively during the last 5-8 years. It inhibits clot dissolution during surgery and can therefore reduce blood loss. However, there has been concern that this could result in more frequent complications, specifically in terms of thromboembolic events. The indications for TXA are widespread, and this review covers the literature on orthopaedic indications such as joint replacement, fracture surgery, and arthroscopic procedures. In general, TXA is safe and can be used in a wide variety of orthopaedic procedures, lowering blood loss without increasing the risk of complications.

Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations

Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.