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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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.

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

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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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The reader may also be interested in these posts:

Healing through joint replacement

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.