TXA and Shoulder Arthroplasty - what we wish we knew

For shoulder surgeons it's not so much about reducing total blood loss (which is usually <400cc and rarely requires transfusion) but rather it's about minimizing hematoma/brusing/swelling - especially when it is a priority to get the shoulder moving soon after arthroplasty, such as in anatomic arthroplasty for a preoperatively stiff shoulder.

Tranexamic acid (TXA) is a synthetic lysine derivative that competitively inhibits plasminogen activation, preventing its conversion to plasmin, and stabilizing fibrin clots; this is its anti-fibrinolytic effect. It can be administered intravenously, topically, or orally.

Much of what we have learned about TXA comes from hip and knee arthroplasty. Here's a summary of what can be pulled from that literature: 

1. Interestingly, more is not better - low dose IV TXA (total of 1 or 2 grams) is as effective as higher doses. 

2. Pre-incision administration is more effective than post incision administration.

3. A common protocol is1 gram pre-incision and 1 gram at closure. A protocol of 2 grams IV at incision plus 2 grams IV at closure (total 4 grams) is NOT standard and exceeds what most studies have investigated. 

4. The 2021 TRAC-24 Trial revealed that in addition to intraoperative IV TXA,  postoperative oral TXA reduced blood loss in total knee arthroplasty as well as reduced length of stay, lower readmission rates, ER visits and need for transfusion.

5. A 2024 randomized controlled trial showed that for total knees, 1 gram IV before and at closure plus1.95 grams orally daily on post operative days 1, 2 and 3 resulted in improved motion, less pain and better functional scores at 2 and 6 weeks in comparison to those receiving only the IV perioperative TXA. The authors suggested that the benefit resulted from an anti-inflamatory effect rather than diminished blood loss. This postoperative regimen significantly reduced CRP and IL-6 levels in TKA patients

Tranexamic acid attenuates inflammatory effect and modulates immune response in primary total knee arthroplasty: a randomized, placebo-controlled, pilot trial

The antifibrinolytic and anti‐inflammatory effects of multiple doses of oral tranexamic acid in total knee arthroplasty patients: a randomized controlled trial

Anti-inflammatory effect of multi-dose tranexamic acid in hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

 

Safety Considerations

1. The 2018 guidelines provide STRONG evidence that TXA administration (IV, topical, and oral) does not increase the risk of venous thromboembolism in patients without known history of VTE. Direct meta-analysis of 77 high-quality and 1 moderate-quality randomized clinical trials (92% of which excluded patients with history of thromboembolic events) demonstrated no significant difference in VTE rates between TXA and placebo.

2. For high-risk patients - those with a history of VTE, myocardial infarction, cerebrovascular accident, or vascular stent placement - the guidelines provide only MODERATE support that TXA does not increase thromboembolic risk.

Extrapolating the hip and knee evidence to shoulder arthroplasty, a reasonable approach to the use of TXA in shoulder arthroplasty may be:

(1) One gram IV at the time of incision and one gram at closure (alternative: two grams IV at incision).

(2) For patients with a history of prior VTE, myocardial infarction, cerebrovascular accident, or vascular stent placement, avoid IV TXA and, after the wound has been irrigated, topically administer 2 grams TXA in 50 mL normal saline and close the wound without further irrigation.

(3) Consider oral tranexamic acid: three 650mg tablets once daily on postoperative days 1, 2, and 3 in an attempt to reduce postoperative brusing, improve motion, reduce pain and improve function. Check with patient's insurance company to be sure it is covered for this use.

Staying on top of the situation

Nesting Grebe

Montlake Fill

2024

REFERENCES

1. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. Tranexamic Acid Use in Total Joint Arthroplasty: The Clinical Practice Guidelines Endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2018 Oct;33(10):3065-3069.

2. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-Analysis. J Arthroplasty. 2018;33(10):3083-3089.

3. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis. J Arthroplasty. 2018;33(10):3090-3098.

4. Magill P, Hill JC, Bryce L, Martin U, Dorman A, Hogg R, Campbell C, Gardner E, McFarland M, Bell J, Benson G, Beverland D. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J. 2021 Oct;103-B(10):1595-1603.

5. Magill P, Hill JC, Bryce L, Martin U, Dorman A, Hogg R, Campbell C, Gardner E, McFarland M, Bell J, Benson G, Beverland D. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total hip arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J. 2021 Jul;103-B(7):1197-1205.

6. Karayiannis PN, Agus A, Bryce L, Hill JC, Beverland D. Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial. Bone Jt Open. 2022 Jul;3(7):536-542.

7. Mihalko WM, Brimmo O, Siddiqi A, Mannava S, Kremers HM, Sierra RJ. The AAHKS Clinical Research Award: Extended Postoperative Oral Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Pilot Study. J Arthroplasty. 2024 Sep;39(9S):S2-S8.

8. Yuenyongviwat V, Dissaneewate K, Iamthanaporn K. Efficacy of Extended Oral Tranexamic Acid on Blood Loss in Primary Total Knee Arthroplasty. Acta Ortop Bras. 2022 Jul-Aug;30(4):e245411.

9. Lloyd TD, Deakin AH, Gregg-Smith SJ, Melling L, Dall GF, Yates P, Hui ACW, et al. Perioperative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study. Anaesthesia. 2020 Aug;75(8):1050-1058.

10. Grosso MJ, Boddapati V, Cooper HJ, Geller JA, Shah RP, Neuwirth AL, Rubin LE. One Dose Versus Two Doses of Intravenous Tranexamic Acid in Total Joint Arthroplasty. J Bone Joint Surg Am. 2021 Jun 2;103(11):e45.

11. 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 Feb 15;2(1):28-33.

12. Kirsch JM, Bedi A, Horner N, Wiater JM, Pauzenberger L, Koueiter DM, Miller BS, Bhandari M, Khan M. Tranexamic Acid in Shoulder Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev. 2017 Sep;5(9):e3.

13. Friedman RJ, Gordon E, Butler RB, Mock L, Dumas B. Tranexamic acid decreases blood loss after total shoulder arthroplasty. J Shoulder Elbow Surg. 2016 Apr;25(4):614-8.

14. Pauzenberger L, Domej MA, Heuberer PR, Hexel M, Grieb A, Laky B, Blasl J, Anderl W. A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2021 Mar;30(3):e55-e67.

15. Sun C, Zhang X, Ma J, Jiang C, Xia Y, Xiong Y, Pan Z. Oral and intravenous tranexamic acid are equivalent at reducing blood loss following shoulder arthroplasty: A multicenter, double-blinded, randomized, placebo-controlled trial. J Shoulder Elbow Surg. 2022 May;31(5):907-915.

16. Abildgaard JT, McLemore R, Hattrup SJ. Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2016 Oct;25(10):1643-8.

17. Koutserimpas C, Chamakos E, Raptis K, Samoladas E. Tranexamic Acid in Shoulder Arthroplasty. A Comprehensive Review. Acta Biomed. 2021 Jun 7;92(3):e2021213.

18. StatPearls. Tranexamic Acid. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532909/

19. Hill J, Magill P, Dorman A, et al. Assessment of the effect of addition of 24 hours of oral tranexamic acid post-operatively to a single intraoperative intravenous dose of tranexamic acid on calculated blood loss following primary hip and knee arthroplasty (TRAC-24): a study protocol for a randomised controlled trial. Trials. 2018 Jul 31;19(1):422.

20. Jones AM, Greenwood R, Bochert M, Gibbons M. Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial. Br J Anaesth. 2023 Feb;130(2):234-242.

21. Budge M, et al. Topical and Intravenous Tranexamic Acid Are Equivalent in Decreasing Blood Loss in Total Shoulder Arthroplasty. J Shoulder Elbow Surg 2019.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Total shoulders - to drain or not to drain?

Drain Use is Associated with Increased Odds of Blood Transfusion in Total Shoulder ArthroplastyA Population-Based Study

These authors used the nationwide Premier Healthcare claims database to evaluate the trends in frequency of drain usage in shoulder arthroplasty procedures over time, as well as the association between drain usage and blood transfusion usage,  length of stay (LOS), and readmission or early infection within 30 days.

They examined 105,116 cases performed in Northeast, West, and Midwest between 2006-2016 including total, reverse, and partial shoulder arthroplasties, in which drains were used in 20% [20,886] and no drain was used in 80% [84,230]).

They found that the usage of drains decreased over time, from 25% in 2006 to 16% in 2016. After adjusting for relevant covariates, drain use was associated with an increased usage of blood transfusions (OR, 1.49; 95% CI, 1.35–1.65; p < 0.001). This represents an almost 50% increased odds for blood transfusions.

They noted a small increase in LOS (+6%, 95% CI, +4% to +7%; p < 0.001). Drain use was not associated with increased odds for early postoperative infection or 30-day readmission. 

Comment: These authors have demonstrated a highly significant association between drain use in shoulder arthroplasty and the use of transfusion. As they point out, this association does not prove that drain use causes the need for transfusion. So one must consider some possible explanation for the results:

(1) In the absence of closed wound drainage, any postoperative blood loss will provide a hemostatic effect in the form of a tamponade. With the use of a drain, that effect is lost and a conduit for blood loss is introduced.

(2) Patients who are bleeding more at the end of the case are more likely to receive a drain

(3) Surgeons who take less care in establishing hemostasis are more likely to use drains

Bleeding after shoulder arthroplasty is an issue that has not been eliminated by the use of tranexamic acid. Factors that can contribute to postoperative bleeding are many

(1) Shoulder arthroplasty requires resection of osteophytes and soft tissue releases, which can lead to bleeding.

(2) The procedure is often performed in a beach chair position with the patient's blood pressure being kept at low physiologic levels. As a result potential bleeding sources may not be recognized. When the patient returns to the recovery room, he or she is supine and postoperative discomfort may drive the blood pressure up - both of which factors may increase bleeding.

(3) Early implementation of range of motion exercises may prevent effective clot formation.

Our practice is to strive for excellent hemostasis after asking the anesthesiologist to establish normal blood pressure, and using topical thrombin and oxidized regenerated cellulose

as necessary.

We do not use drains. We close the wound with staples, which provides a one-way valve allowing blood to escape if a substantial hematoma is forming. In patients that seem likely to bleed excessively (for example those who have recently been on anticoagulants or anti-inflammatory medications), we hold postoperative motion until the next morning. We reassure patients that some postoperative bleeding and bruising is not uncommon.

Using this protocol we have avoided the need for transfusion in over 99% of our cases and no longer obtain a blood type and screen unless the patient presents with a known bleeding problem or comes to the OR with a very low hematocrit.

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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

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Arthritis from recurrent bleeding into the shoulder

Hemophilic Arthropathy of Shoulder Joints: Clinical, Radiographic, and Ultrasonographic Characteristics of Seventy Patients - J Bone Joint Surg Am, 2013 Apr 03;95(7):e43 1-8

The authors present the clinical, radiographic, and ultrasonographic characteristics of the shoulder joint were studied in a cohort of seventy consecutive patients with hemophilia.  Sixty-six patients had hemophilia A, and four had hemophilia B. The median age was thirty-four years (range, ten to sixty-three years). Fifty-six shoulders in thirty-five patients had shoulder bleeds, and twenty-seven patients (38.6%) had shoulder pain or limited motion. As determined with radiographs, eighteen (25.7%) of the seventy patients had hemophilic shoulder arthropathy. A strong correlation between the functional Oxford shoulder score and the radiographic Pettersson score was also noted (r = 0.749, p < 0.001). The ultrasonographic abnormalities in the fifty-six hemarthrotic shoulders included chondromalacia (76.8%), osseous irregularity (60.7%), bicipital tenosynovitis (60%), partial-thickness rotator cuff tear (35.7%), and full-thickness rotator cuff tear (17.9%). Older age, the absence of any previous prophylaxis therapy, and higher frequency of crutch use were the most significant factors associated with shoulder bleeds.

The authors found that shoulder arthropathy is relatively common in patients with hemophilia. Rotator cuff tears were common in the present study, and there was a strong correlation between shoulder function and the radiographic severity of the arthropathy. 

The authors did not provide an example radiograph; we offer the one below as an example.

While we do not see much of true hemophiliac arthropathy in our practice we do see patients who are on anticoagulants with similar finding that appear to result from recurrent bleeds into the shoulder.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.


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