Restricted accessReview articleFirst published online 2024-10
The efficacy of preoperative tranexamic acid administration among patients undergoing arthroscopic rotator cuff repair: A systematic review and meta-analysis of randomized controlled trials
To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) that investigated the effectiveness of tranexamic acid (TXA) among patients undergoing arthroscopic rotator cuff repair (ARCR).
Methods
Five databases were screened until December 18, 2022. The included RCTs were assessed for risk of bias, and the endpoints were summarized as mean difference/standardized mean difference (MD/SMD) or risk ratio (RR) with the 95% confidence interval (CI) in a random-effects model.
Results
Seven RCTs with 510 patients (TXA = 261 and control/placebo = 249) were analyzed. The overall risk of bias was “low” and “unclear” in four and three RCTs, respectively. The mean operative time (n = 5 RCTs, MD = −9.64 min, 95% CI [−15.74, −3.54], p = 0.002) and mean postoperative pain score on postoperative day 1 (n = 5 RCTs, MD = −0.56, 95% CI [−1.06, −0.05], p = 0.03) were significantly reduced in the TXA group compared with the control group. However, there were no significant differences between both groups regarding visual clarity, amount of irrigation solution, and estimated intraoperative blood loss.
Conclusion
Among patients undergoing ARCR, preoperative TXA did not reduce intraoperative blood loss or improve visual clarity. However, TXA administration correlated with significant reductions (statistically) in operative time and postoperative day 1 pain score compared with the control group.
Level of evidence: Level I; Systematic Review and Meta-analysis of Randomized Controlled Trials
MillsteinESSnyderSJ. Arthroscopic management of partial, full-thickness, and complex rotator cuff tears: indications, techniques, and complications. Arthroscopy2003; 19: 189–199.
2.
van MontfoortDOvan KampenPMHuijsmansPE. Epinephrine diluted saline-irrigation fluid in arthroscopic shoulder surgery: a significant improvement of clarity of visual field and shortening of total operation time. A randomized controlled trial. Arthroscopy2016; 32: 436–444.
3.
JensenKHWertherKStrygerV, et al.Arthroscopic shoulder surgery with epinephrine saline irrigation. Arthroscopy2001; 17: 578–581.
4.
AveryDMGibsonBWCarolanGF. Surgeon-rated visualization in shoulder arthroscopy: a randomized blinded controlled trial comparing irrigation fluid with and without epinephrine. Arthroscopy2015; 31: 12–18.
5.
NhoSJFreedmanKBBansalSL, et al.The effect of radiofrequency energy on nonweight-bearing areas of bone following shoulder and knee arthroscopy. Orthopedics2005; 28: 392–399.
6.
AmpatGBrugueraJCopelandSA. Aquaflo pump vs FMS 4 pump for shoulder arthroscopic surgery. Ann R Coll Surg Engl1997; 79: 341–344.
7.
TuijthofGJde VaalMMSiereveltIN, et al.Performance of arthroscopic irrigation systems assessed with automatic blood detection. Knee Surg Sports Traumatol Arthrosc2011; 19: 1948–1954.
8.
MorrisonDSSchaeferRKFriedmanRL. The relationship between subacromial space pressure, blood pressure, and visual clarity during arthroscopic subacromial decompression. Arthroscopy1995; 11: 557–560.
9.
DunnCJGoaKL. Tranexamic acid: a review of its use in surgery and other indications. Drugs1999; 57: 1005–1032.
10.
ZhengCMaJXuJ, et al.The optimal regimen, efficacy and safety of tranexamic acid and aminocaproic acid to reduce bleeding for patients after total hip arthroplasty: a systematic review and Bayesian network meta-analysis. Thromb Res2022; 221: 120–129.
11.
LingTZhangLHuangL. The efficacy and safety of combined administration of intravenous and intra-articular tranexamic acid in total knee arthroplasty: an update meta-analysis. J Clin Pharm Ther2022; 47: 1312–1321.
12.
DonovanRLVarmaJRWhitehouseMR, et al.Tranexamic acid use to decrease blood loss in primary shoulder and elbow replacement: a systematic review and meta-analysis. J Orthop2021; 24: 239–247.
13.
CunninghamGHughesJBornerB, et al.A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg2021; 30: 1553–1560.
14.
LiuYFHongCKHsuKL, et al.Intravenous administration of tranexamic acid significantly improved clarity of the visual field in arthroscopic shoulder surgery. A prospective, double-blind, and randomized controlled trial. Arthroscopy2020; 36: 640–647.
15.
ErsinMDemirelMBugetMI, et al.The effect of intravenous tranexamic acid on visual clarity during arthroscopic rotator cuff repair: a randomized, double-blinded, placebo-controlled pilot study. Acta Orthop Traumatol Turc2020; 54: 572–576.
16.
NicholsonTAKirschJMChurchillR, et al.The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: a blinded, randomized controlled trial. J Shoulder Elbow Surg2022; 31: 2211–2216.
17.
TakahashiRKajitaYIwahoriY, et al.Tranexamic acid administration for arthroscopic rotator cuff repair: a prospective, double-blind, randomized controlled trial. J Orthop Sci2023; 28: 328–332.
18.
MackenzieSPSpasojevicMSmithM, et al.The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial. J Shoulder Elbow Surg2022; 31: 1399–1408.
19.
GaoHLZhangJCHeY, et al.Clinical study on the control of intra-articular hemorrhage by tranexamic acid after shoulder arthroscopy. Zhongguo Gu Shang2020; 33: 238–241.
20.
BildikCPehlivanogluT. Arthroscopic rotator cuff repair performed with intraarticular tranexamic acid. Could it provide improved visual clarity and less postoperative pain? A prospective, double blind, randomized study of 63 patients. J Shoulder Elbow Surg2023; 32: 223–231.
21.
MoherDLiberatiATetzlaffJ, et al.Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med2009; 6: e1000097.
22.
Cochrane Handbook for Systematic Reviews of Interventions | Wiley Online Books. 2022. DOI:10.1002/9781119536604.
23.
HigginsJPAltmanDGGøtzschePC, et al.The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. Br Med J2011; 343: d5928.
24.
KirschJMBediAHornerN, et al.Tranexamic acid in shoulder arthroplasty: a systematic review and meta-analysis. JBJS Rev2017; 5: e3.
25.
CvetanovichGLFillinghamYAO'BrienM, et al.Tranexamic acid reduces blood loss after primary shoulder arthroplasty: a double-blind, placebo-controlled, prospective, randomized controlled trial. JSES Open Access2018; 2: 23–27.
26.
KuoLTHsuWHChiCC, et al.Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord2018; 19: 60.
27.
KaraaslanFKaraoğluSYurdakulE. Reducing intra-articular hemarthrosis after arthroscopic anterior cruciate ligament reconstruction by the administration of intravenous tranexamic acid: a prospective, randomized controlled trial. Am J Sports Med2015; 43: 2720–2726.
28.
FelliLRevelloSBurasteroG, et al.Single intravenous administration of tranexamic acid in anterior cruciate ligament reconstruction to reduce postoperative hemarthrosis and increase functional outcomes in the early phase of postoperative rehabilitation: a randomized controlled trial. Arthroscopy2019; 35: 149–157.
29.
ChiangERChenKHWangST, et al.Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: a prospective randomized study. Arthroscopy2019; 35: 2127–2132.
30.
PauzenbergerLDomejMAHeubererPR, et al.The effect of intravenous tranexamic acid on blood loss and early post-operative pain in total shoulder arthroplasty. Bone Joint J2017; 99-B: 1073–1079.
31.
ZhangPLiangYChenP, et al.Intravenous versus topical tranexamic acid in primary total hip replacement: a meta-analysis. Medicine (Baltimore)2016; 95: e5573.
32.
AlshrydaSSukeikMSardaP, et al.A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J2014; 96-B: 1005–1015.
33.
AhlbergAErikssonOKjellmanH. Diffusion of tranexamic acid to the joint. Acta Orthop Scand1976; 47: 486–488.
34.
ErikssonOKjellmanHPilbrantA, et al.Pharmacokinetics of tranexamic acid after intravenous administration to normal volunteers. Eur J Clin Pharmacol1974; 7: 375–380.
35.
HurleyETLim FatDPauzenbergerL, et al.Tranexamic acid for the Latarjet procedure: a randomized controlled trial. J Shoulder Elbow Surg2020; 29: 882–885.
36.
HartlandAWTeohKHRashidMS. Clinical effectiveness of intraoperative tranexamic acid use in shoulder surgery: a systematic review and meta-analysis. Am J Sports Med2021; 49: 3145–3154.
37.
LeeJWKimSGKimSH, et al.Intra-articular administration of tranexamic acid has no effect in reducing intra-articular hemarthrosis and postoperative pain after primary ACL reconstruction using a quadruple hamstring graft: a randomized controlled trial. Orthop J Sports Med2020; 8: 2325967120933135.
