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).

Tranexamic acid in shoulder arthroplasty - effectiveness and safety

 A Single Dose of Tranexamic Acid Reduces Blood Loss After Reverse and Anatomic Shoulder Arthroplasty: A Randomized Control Trial

These authors conducted a double-blinded randomized controlled trial comparing intravenous TXA to placebo in 60 patients undergoing primary anatomic and reverse shoulder arthroplasty. 29 patients received a placebo whilst 31 received a single dose of 2g of intravenous TXA.

Patients who received TXA had lower drain tube outputs at all time points. They also had higher postoperative Hb (12.3 vs 11.4; P=0.009), lower change in Hb (1.7 vs 2.3; P=0.011), lower total Hb loss (0.078g vs 0.103g; P=0.042) and blood volume loss (0.55L vs 0.74L; P=0.021), higher postoperative hematocrit (36.7 vs 34.6; P=0.020) and lower hematocrit change (5.4 vs 7.6; P=0.022). 

The authors found no differences detected in occurrence of complications, need for transfusion, pain scores or length of hospital stay. 

Comment: This relatively small study does not address the safety of TXA in patients at higher risk for thromboembolic events. The study below does address this point:

Administration of tranexamic acid during total shoulder arthroplasty is not associated with increased risk of complications in patients with a history of thrombotic events 

These authors point out that tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in shoulder arthroplasty, but that concerns exist regarding its safety in patients with a history of thrombotic events. 

They used national claims data to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. 

Overall, TXA was used in 13.7% (n . 9735) of patients, whereas 10.5% (n . 7475) of patients had a history of a thrombotic event.

TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48), whereas no increased odds for complications were observed (OR, 0.83). 

Similar results were observed in patients with a history of thrombotic events.

Moreover, in this subgroup, TXA use was associated with a 8.9% reduction in hospitalization cost.

As shown below, patients with a history of thromboembolic events had a higher risk of a thromboembolic event after shoulder arthroplasty, but TXA use did not increase this use.

 Comment: These data appear to support the use of TXA in patients at increased risk for thromboembolic events (TEEs). Note that according to these statistics 4.6 patients out of 100 with a prior history of TEEs would have a new TEE, so surgeons should be prepared for the possibility that a patient receiving TXA could have a thromboembolic event. The question of causation could arise. In this light, consideration might be given to the use of topical TXA (rather than IV TXA) in patients at increased risk for thromboembolic events.

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Our approach to total shoulder arthroplasty can be viewed by clicking here.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

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How you can support research in shoulder surgery Click on 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

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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Total shoulder arthroplasty - how safe is tranexamic acid?

Administration of tranexamic acid during total shoulder arthroplasty is not associated with

increased risk of complications in patients with a history of thrombotic events

These authors point out that tranexamic acid (TXA) has been shown to reduce blood loss and transfusion risk in shoulder arthroplasty, but that concerns exist regarding its safety in patients with a history of thrombotic events. 

They used national claims data to study the safety of TXA administration in shoulder arthroplasty patients with a history of thrombotic events such as myocardial infarction, deep venous thrombosis, pulmonary embolism, transient ischemic attack, or ischemic stroke. 

Overall, TXA was used in 13.7% (n . 9735) of patients, whereas 10.5% (n . 7475) of patients had a history of a thrombotic event.

TXA use (compared with no TXA use) in patients without a history of thrombotic events was associated with decreased odds of blood transfusions (OR, 0.48), whereas no increased odds for complications were observed (OR, 0.83). 

Similar results were observed in patients with a history of thrombotic events.

Moreover, in this subgroup, TXA use was associated with a 8.9% reduction in hospitalization cost.

As shown below, patients with a history of thromboembolic events had a higher risk of a thromboembolic event after shoulder arthroplasty, but TXA use did not increase this use.

 Comment: It is important to have these data to support the use of TXA in patients at increased risk for thromboembolic events (TEEs). Note that according to these statistics 4.6 patients out of 100 with a prior history of TEEs wold have a new TEE. One of those patients might be tempted to sue the surgeon that gave the TXA. These data suggest that the prescribing surgeon may actually be reducing the risk of a new TEE.

Our approach to total shoulder arthroplasty can be viewed by clicking here.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

===
How you can support research in shoulder surgery Click on 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

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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Periprosthetic infections and tranexamic acid

 Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty

These authors point out that revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. They hypothesized that the administration of tranexamic acid (TXA) during revision arthroplasty is protective against subsequent PJI.

They identified 1,731 patients who underwent aseptic revision; of these patients, 83 (4.8%) developed

PJI. 

Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%. 

In their multivariate analysis, 

(1) preoperative anemia was independently associated with over a 2-fold increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003).

(2) antibiotic administration was independently associated with a reduced risk of PJI (OR, 0.25 [95% confidence interval (CI), 0.07 to 1.02]; p = 0.034). 

(3) female sex was independently associated with a reduced risk of PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016). 

(4) TXA administration was independently associated with a reduced risk of PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030). 

Comment: It has not been suggested that tranexamic acid has antibiotic properties; instead the authors suggest, "It would stand to reason that, if one could limit blood loss and avoid the need for allogeneic blood transfusion, a reduction in infection may be possible." The question that remains to be answered is whether - in addition to the presence of preoperative anemia - blood loss and/or transfusion are indeed major risk factors for PJI. 

There are some data that may be missing from the univariate analysis table as indicated below, especially the data related to blood loss and units of blood received (see yellow highlights). 

If the data show that blood loss (rather than the use or non-use of TXA) drives the rate of periprosthetic infection, it may be the case that other anti-blood-loss steps (topical thrombin, careful coagulation, controlling intraoperative blood pressure) may be comparably effective in reducing PJI. Further studies are need to determine: (1) is PJI related to the amount of blood loss into the wound, to the amount of external blood loss (drains and soaked dressing), or to the resulting drop in the number of circulating red blood cells? (2) which has the stronger association with PJI, the estimated blood loss or the units of blood received? (3) should antibiotics be routinely administered in apparently "aseptic" revisions? and (4) is management of preoperative anemia effective in reducing PJI?

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'

 

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.

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

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How you can support research in shoulder surgery Click on 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

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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

The effect of tranexamic acid on post op pain and swelling

Tranexamic acid for the Latarjet procedure: a randomized controlled trial


These authors assessed whether tranexamic acid (TXA) could reduce the incidence of postoperative swelling and hematoma formation and pain and opioid use in the early postoperative period. They conducted a randomized controlled trial in 100 patients undergoing open Latarjet surgery for anterior shoulder instability by an individual surgeon.

Patients were randomized to receive either 1 g TXA or a placebo intravenously preoperatively. 

While there was no significant difference in intraoperative blood loss (60.9 vs. 68.9 mL), there was significantly lower postoperative blood loss (measured by drain output) 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) assessed by an examiner who was blinded to the treatment group of the patients.

Additionally, they 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).

Comment: In the Latarjet, as in many shoulder procedures, the amount of blood lost is not as much a concern as the swelling and pain that result from the accumulation of blood in the surgical field postoperatively. This randomized controlled trial nicely demonstrates the effectiveness of TXA in reducing hematoma formation and the discomfort related to it.

l===

How you can support research in shoulder surgery Click on this link.

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reducing the bleeding after total shoulder replacement

Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis

These authors 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 tranexamic acid (TXA)

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.

They 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, less change in hemoglobin, and reduced estimated blood loss, especially in patients with RTSA.

All six included studies reported data on the proportion of  patients who developed complications and thromboembolic events during the study period. There were no significant differences in overall complications or thromboembolic events between the TXA and the non-TXA groups.

Comment: It is uncommon for our patients to need a transfusion after a shoulder arthroplasty. In our view, the principal rationale for tranexamic acid is to reduce bleeding into the arthroplasty after surgery - such bleeding can increase pain and interfere with the achievement of early range of motion. We use one dose at the beginning and one at the end of the case. Contraindications for us are prior thromboembolic events, evidence of coronary artery or cerebrovascular disease, and diagnosis of cancer. 

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

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 as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Intravenous and Topical Tranexamic Acid - what can we learn from knee surgeons?

Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty A Prospective, Randomized Controlled Trial

These authors randomized 150 patients having total knee arthroplasty to 3 groups.
Group A was treated with a tourniquet as well as multiple doses of intravenous tranexamic acid (TXA) (20 mg/kg 5 to 10 minutes before the skin incision and 10 mg/kg 3, 6, 12, and 24 hours later) along with 1 g of topical TXA,
Group B was treated the same as Group A but without the tourniquet, and
Group C was treated with the tourniquet only.

The amount of intraoperative blood loss was similar for the 3 groups.
Group B had significantly less hidden blood loss than Group A (p = 0.018) and Group C (p < 0.001).
No significant differences (p > 0.05) were observed between Group A and Group B with regard to total blood loss, drainage volume, intraoperative blood loss, transfusion rate, or maximum change in the hemoglobin (Hb) level.
They also found significantly more benefits for Group B compared with Groups A and C with regard to postoperative swelling ratio, levels of inflammatory biomarkers, visual analog scale (VAS) pain scores, range of motion at discharge, Hospital for Special Surgery (HSS) score, and patient satisfaction.

Neither DVT nor PE occurred in any patient. Postoperatively, routine Doppler ultrasound showed that 13 patients (6 from Group A, 4 from Group B, and 3 from Group C) developed intramuscular venous thrombosis.
One patient from Group A and 3 patients from Group C developed superficial infection, which was controlled with dressing changes and oral antibiotics. Wound secretion occurred in 15 patients (6 from Group A and 9 from Group C).
No wound secretion was observed in Group B during the entire follow-up period, and this represented a significant difference compared with Group A (p = 0.027) and Group C (p = 0.003).
Blistering was reported in 3 patients from Group C and no patients in Group A or B

They concluded that patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less postoperative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tourniquet.

Comment: Bruising and swelling are not uncommon after shoulder arthroplasty as shown below. This swelling (resulting from 'hidden blood loss') can be quite painful and can interfere with the patient's ability to perform range of motion exercises.  The reduction in inflammatory markers in this study is of interest; perhaps due to the damage from a tourniquet.

For these reasons, TXA is an appealing approach to reducing preoperative blood loss in shoulder surgery.  This study combined topical and a vigorous IV administration protocol. We currently use 1 gm before and 1 gm at the conclusion of surgery along with 1 gm administered topically, but there is uncertainty regarding the optimal dosage.

====
The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

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 as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Reducing bleeding in total shoulder arthroplasty

Tranexamic acid decreases blood loss in shoulder arthroplasty A meta-analysis

These authors conducted a meta-analysis to evaluate the efficacy and safety of tranexamic acid (TXA) in shoulder arthroplasty. They identified articles from the Cochrane Library, Medline (1966–2017.2), PubMed (1966–2017.2), Embase (1980–2017.2), and ScienceDirect (1966–2017.2).  Two RCTs and 2 non-RCTs met their inclusion criteria.

The meta-analysis found significant differences in postoperative hemoglobin reduction (Mean difference (MD) = –0.71 g/dL), drainage volume (MD = –133.21 mL), and total blood loss (MD = –226.82 mL) between TXA groups and controls. There were no significant differences in blood transfusion requirements, operation time, or length of hospital stay.

The included studies did not report any postoperative complications or side effects of TXA.

Comment: The results of this study call for additional data to demonstrate the cost effectiveness of tranexamic acid. Other means of blood loss control, such as good surgical technique, attention to hemostasis and short operating time may obviate much of the apparent benefit of TSA.

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Bleeding from reverse total shoulder - effect of tranexamic acid

Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial

These authors conducted a prospective, double-blinded, single-surgeon trial, of 102 patients undergoing primary reverse total shoulder arthroplasty who were randomized to receive intravenous tranexamic acid (TXA) (n = 53) or placebo (n = 49).

Total blood loss was less for the TXA group (1122.4 ± 411.6 mL) than the placebo group
(1472.6 ± 475.4 mL, P < .001). 

Total drain output was less for the TXA group (221.4 ± 126.2 mL) than the placebo group (371.9 ± 166.3 mL , P < .001). 

Total Hb loss was less in the TXA group (154.57 ± 60.29 g) compared with the placebo group (200.1 ± 65.5 g, P = .001). 

Seven patients (14.3%) and 12 units were transfused in the placebo group compared with 3 patients (5.7%) and 3 units in the TXA group.

Comment: This is a well-done randomized controlled trial showing the effectiveness of TXA. In our view, the major value of TXA is not reducing the need for transfusion, but rather reduction in the postoperative bleeding into the shoulder that can increase infection risk and pain. 

In our practice we do not use drains and almost never need to transfuse a patient after a primary, reverse or revision shoulder arthroplasty. We use TXA primarily to minimize bleeding and swelling the wound area. The principal contraindications for its use are (1) a prior thromboembolic event or (2) increased risk of a thromboembolic event (cancer, atrial fibrillation, hormone replacement therapy).