Wednesday, June 24, 2020

The value of hemostatic agents in total shoulder arthroplasty

Intravenous tranexamic acid versus topical thrombin in total shoulder arthroplasty: a comparative study

These authors assessed the utility of topical thrombin in TSA, and compared the effectiveness of topical thrombin to intravenous tranexamic acid.

They queried an institutional database to identify 283 patients having primary anatomic shoulder arthroplasty.

There was no statistically significant difference in the baseline characteristics with age, BMI or ASA. 

This study used a validated formula in hip and knee arthroplasty literature to calculate blood volume loss taking into account patient weight, height, pre- and  postoperative hemoglobin.

Hemoglobin loss (Hgb-loss) was calculated by the  following equation: (k1 x Height^3 + k2 x Weight + k3) x (Hgb-initial – Hgb-end) x 0.001 + Hgb-transfused, where k1 = 0.3669 or 0.3561, k2 = 0.03219 or 0.03308, and k3 = 0.6041 or  0.1833 for males and females, respectively. 

Total volume loss was calculated by: 1000 x (Hgb-loss/ Hgb-initial)

Postoperative Hgb (mg/dL) was higher in the group that received either IV TXA or thrombin compared to no hemostatic agents. 

Calculated blood loss in TSA was significantly higher in the group without hemostatic agents, 369.8 ml compared to IV TXA or  topical thrombin, 344.3 ml and 342.9 ml. 

Operative time was highest in the group that received no hemostatic agents.

Transfusion rate for TSA treated with IV TXA or topical thrombin was equivalent (2.2%)  but significantly lower than no intervention group (12%) (p=0.01). Odd’s ratio for  transfusion with IV TXA was 0.16, and topical thrombin  was 0.1 (95% CI 0.02-0.42, p = 0.02). 

The authors concluded that topical thrombin is an effective adjunct to reduce blood loss and transfusion risk after total shoulder arthroplasty (TSA) and a reasonable intraoperative alternative for TXA for patients with contraindication to IV TXA.

Comment: While blood loss is not usually a problem after shoulder arthroplasty; however, bleeding into the wound after surgery can cause pain and even neurological problems from nerve compression. Whether or not TXA is contraindicated in some patients because of prior thromboembolic events remains uncertain. This study suggests that topical thrombin (or possibly topical TXA) may have benefit in those patients not receiving IV TXA.


To see a YouTube of on how we do total shoulder arthroplasty, please see this link.


We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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