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, 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).
