Thursday, October 22, 2015

Total shoulder arthroplasty - the role of topical tranexamic acid in reducing blood loss

A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty

Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. These authors evaluated the effect of TXA on postoperative blood loss after shoulder arthroplasty in 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty. 

Patients discontinued the use of aspirin and nonsteroidal antiinflammatory medications 7 days before surgery. Exclusion criteria for this study were revision surgery, history of cardiac disease, liver disease, renal disease, preoperative hemoglobin level <11.5 g/dL or hematocrit <35%, severe joint deformity, history of joint infection, history of bleeding or metabolic disorder, history of peripheral vascular disease, history of prior deep venous thrombosis (DVT) or pulmonary embolism (PE), any patient unwilling to accept a blood transfusion, and any patient with a documented allergy to TXA.

Patients were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application. Before closure of the deltopectoral interval, each patient in the treatment group had 100 mL of normal saline infused with 2 g of TXA poured into the surgical wound and left in place for 5 minutes. The control group had 100 mL of normal saline poured into the wound and left in place for the same duration. Neither the patient nor the surgeon had knowledge of whether TXA solution or placebo was being administered, and this blinding remained in place until analysis of data at completion of the study. Before closure of the deltopectoral interval, a standard Hemovac drain was placed deep to the deltoid muscle. The estimated blood loss (EBL) for the procedure was determined at this point, and all additional blood loss through the drain was recorded for the purposes of the study.

The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P ..017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group.

Comment: This is a well-done randomized and carefully controlled trial.  The goal of reducing blood loss in shoulder arthroplasty is not so much to reduce the need for transfusion, but to minimize the local swelling/hematoma that can result from a surgery that involves soft tissue releases, osteotomy, and osteophyte resection. The local accumulation of blood can increase the patient's discomfort and can interfere with early range of motion exercises.

The protocol used here is the  topical application of TXA for 5 minutes near the end of the procedure.  Alternatively, TXA can be administered intravenously with a gram at the beginning and a gram at the end of the case. While there is a theoretical risk of thromboembolic events when intravenous TXA is
given because of its antifibrinolytic properties; a number of lower extremity arthroplasty studies have not demonstrated an increased incidence of these events.


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