Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis

Tranexamic Acid and Heterotopic Ossification Formation Following Elbow Surgery: A Prospective Randomized Controlled Trial

OBJECTIVES

This study investigates whether the intraoperative administration of intravenous tranexamic acid (TXA), known for its hemostatic and potential anti-inflammatory properties, affects the incidence of heterotopic ossification (HO) following surgery for elbow fracture dislocations.

METHODS

DESIGN

Prospective, randomized clinical trial.

SETTING

Hand and Upper Extremity Surgery Unit.

PATIENT SELECTION CRITERIA

Patients aged 18-75 years with acute traumatic elbow fracture dislocations requiring surgical management from June 1, 2016, to October 31, 2022, were eligible. Inclusion criteria included traumatic nonpathological elbow fracture dislocations. Patients were randomized 1:1 to receive either intraoperative TXA or no additional treatment.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the occurrence of HO, defined by new bone formation observed in radiographic exams during postoperative follow-ups. Secondary outcomes included the presence of clinically relevant HO, reoperation rate due to symptomatic HO, and time to HO reoperation. Compared were patients who received TXA with controls.

RESULTS

Out of 47 patients with elbow fracture dislocations who completed the follow-up, 23 (49%) received TXA prophylaxis while 24 (51%) were controls. The average age was 51.2 years (range, 18-77 years) with a mean follow-up of 12.9 months (range, 6.11-34.2). In the TXA group, 11 (47.8%) were men and 12 (52.2%) were women, while in the control group, 14 (58.3%) were men and 10 (41.7%) were women. HO was observed in 30% of patients, primarily around the radial head (71%). In this study, 43.5% of patients in the TXA group developed HO compared with 16.7% in the control group. The differences in HO formation suggest a potentially higher risk in the TXA group (relative risk = 2.6, 95% 1.0 to 8.5, P = 0.06). Clinically relevant HO led to reoperation in 2 of 10 (20%) patients in the TXA group, while none of the patients in the control group required reoperation, resulting in an overall reoperation rate of 14.3% in the study cohort.

CONCLUSIONS

This prospective trial identified a possible increased risk of HO formation in patients receiving TXA, however, with the sample size available a statistically significant difference was unable to be detected. These findings highlight the need for further research emphasizing larger prospective comparative studies to assess TXA's impact on HO. A deeper understanding of this relationship will enable clinicians to balance TXA's potential risks and benefits more effectively, optimizing outcomes in orthopedic surgery.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Hemostatic Agents, Surgical Hemostasis, and Hypotensive Anesthesia May Conserve Irrigation Fluid and Improve Visualization During Shoulder Arthroscopy

Intraoperative bleeding impedes visual clarity during shoulder arthroscopy and leads to longer operative times, greater use of irrigation fluid, and greater blood loss. Epinephrine in the irrigation fluid and intravenous tranexamic acid are common interventions that have been found to maintain hemostasis and improve visual clarity during arthroscopy. Intravenous carbazochrome sodium sulfonate may also offer similar benefit during shoulder arthroscopy, but more robust study of effectiveness and safety as well as Food and Drug Administration approval are needed before it can be recommended for use.

Tranexamic Acid Has A Limited Role in Improving Visual Clarity and Pain in Arthroscopic Shoulder Surgery: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this systematic review was to evaluate the effects of tranexamic acid (TXA) compared to placebo or other comparators with regard to visual clarity, pain, total operative time, and volume of blood loss in patients undergoing arthroscopic shoulder surgery.

METHODS

CENTRAL, EMBASE, and MEDLINE were searched from inception until January 4th, 2025. Study selection and data extraction were carried out in duplicate. Randomized controlled trials that compared TXA versus placebo or another comparator in patients undergoing arthroscopic shoulder surgery were included. All outcomes were assessed in duplicate for risk of bias (RoB) using the RoB-2 tool and for certainty of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Results were pooled in a meta-analysis using a random-effects model when appropriate or were synthesized narratively when data could not be pooled.

RESULTS

Overall, 12 randomized controlled trials involving 1009 patients were included. The pooled estimate for visual clarity shows a slight increase in visual clarity (Standardized Mean Difference 0.64 [0.05, 1.24]). The pooled estimate for pain shows a mean difference of a reduction of pain by 0.38 points in the TXA group on a visual analog scale of 0 to 10 (0 = no pain) (Mean Difference -0.38 [-0.76, 0.00]).

CONCLUSIONS

There is moderate-certainty evidence suggesting that TXA likely results in a slight increase in visual clarity. The evidence also suggests that TXA has little to no difference in pain, operative time, and volume of blood loss.

LEVEL OF EVIDENCE

Level I, systematic review of Level I studies.

Validation of Novel Image Processing Method for Objective Quantification of Intra-Articular Bleeding During Arthroscopic Procedures

Visual clarity is crucial for shoulder arthroscopy, directly influencing surgical precision and outcomes. Despite advances in imaging technology, intraoperative bleeding remains a significant obstacle to optimal visibility, with subjective evaluation methods lacking consistency and standardization. This study proposes a novel image processing system to objectively quantify bleeding and assess surgical effectiveness. The system uses color recognition algorithms to calculate a bleeding score based on pixel ratios by incorporating multiple color spaces to enhance accuracy and minimize errors. Moreover, 200 three-second video clips from prior arthroscopic rotator cuff repairs were evaluated by three senior surgeons trained on the system's color metrics and scoring process. Assessments were repeated two weeks later to test intraobserver reliability. The system's scores were compared to the average score given by the surgeons. The average surgeon-assigned score was 5.10 (range: 1-9.66), while the system scored videos from 1 to 9.46, with an average of 5.08. The mean absolute error between system and surgeon scores was 0.56, with a standard deviation of 0.50, achieving agreement ranging from [0.96,0.98] with 96.7% confidence (ICC = 0.967). This system provides a standardized method to evaluate intraoperative bleeding, enabling the precise detection of blood variations and supporting advanced technologies like autonomous arthropumps to enhance arthroscopy and surgical outcomes.

Intravenous Tranexamic Acid Does Not Improve Visual Field Clarity During Hip Arthroscopy: A Double-Blind, Randomized, Placebo-Controlled Trial

PURPOSE

To determine the effectiveness of administering intravenous (IV) tranexamic acid (TXA) on altering visual field clarity (VFC) during arthroscopic hip preservation surgery for patients with femoroacetabular impingement syndrome (FAIS).

METHODS

This randomized, double-blind, parallel-design trial was conducted over a 7-month period between October 2023 and May 2024 at a single tertiary musculoskeletal hospital. The inclusion criteria were consecutive patients who received a diagnosis of FAIS through clinical history, physical examination, and advanced imaging and was indicated for hip arthroscopy after failure of conservative management. This trial prospectively randomized 78 participants (39 assigned to receive 1,000 mg of TXA in a 100-mL/0.9% normal saline solution bolus and 39 assigned to receive a 100-mL/0.9% normal saline solution bolus only). Treatment intervention was administered within 15 minutes of incision. The primary outcome was arthroscopic VFC assessed on a Likert-style numeric rating scale and graded by the surgeon at 15-minute intervals as follows: 1, poor visibility (active bleeding to the degree that vision was too poor to perform the operation); 2, fair visibility (mild bleeding that interfered with vision, but the operation could still be performed); or 3, good visibility (clear vision without obvious blood). The percentage of good VFC ratings (i.e., the percentage of surgeon ratings equal to 3 on the numeric rating scale throughout the procedure) was quantified for each patient. No minimum follow-up was required because the primary endpoint was intraoperative.

RESULTS

The baseline characteristics of the TXA cohort (mean age, 37.3 years; 61.5% male sex; 76.9% white) were not significantly different from those of the placebo group (mean age, 33.6 years; 59% male sex; 86.8% white) (P > .05 for all). TXA was not associated with improved VFC compared with placebo at any intraoperative time point or when considering composite overall VFC scores (2.51 ± 0.41 in TXA group vs 2.64 ± 0.42 in placebo group, P = .16). Furthermore, no significant difference was observed in the percentage of good VFC ratings between treatment groups (56.4% in TXA group vs 66.4% in placebo group, P = .17). Multivariate regression analysis adjusted for demographic and intraoperative covariates did not show an association between TXA and VFC ratings (β = -0.14, P = .14) or percentage of good VFC ratings (β = -11.6, P = .15). No medical or intraoperative complications related to the treatment intervention were observed in either treatment arm.

CONCLUSIONS

Among patients with FAIS undergoing arthroscopic hip preservation surgery, administration of TXA did not improve arthroscopic VFC when compared with placebo. Therefore, the results of this randomized trial do not support the routine use of TXA in arthroscopic hip preservation surgery for improvement in arthroscopic visualization.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

The Effect of Postoperative Tranexamic Acid and Dexamethasone on Quality of Recovery After Arthroscopic Rotator Cuff Repair: a Double-Blinded, Randomized Controlled Trial

PURPOSE

Arthroscopic rotator cuff repair (ARCR) commonly results in significant postoperative pain. Adjuncts like dexamethasone (DEX) and tranexamic acid (TXA) are used to enhance postoperative recovery. This study aimed to determine whether the combined application of TXA and DEX could improve postoperative recovery during the first 24 hours in ARCR patients. Our goal is to relieve the acute postoperative pain and promote fast recovery and rapid discharge for ARCR patients.

PATIENTS AND METHODS

Ninety-six patients who underwent ARCR from December 2023 to March 2024 were enrolled in this double-blinded, randomized control trial (Registration number, ChiCTR2300078507). Patients were randomized to intravenously receive 200mL of normal saline (control group), 200mL of 1g TXA in saline (TXA group), or 200 mL of 1g TXA and 5mg DEX in saline (TXA+DEX group) within 2 hours postoperatively. The primary outcome was the Quality of Recovery-15 (QoR-15) score at 24 hours post-surgery. Secondary outcomes included mean visual analog scale (VAS) scores every four hours within 24 hours, postoperative blood test results the day after surgery, and American Shoulder and Elbow Surgeons (ASES) score at 3 months postoperatively.

RESULTS

No significant differences in QoR-15 scores at 24 hours were observed among the groups [control, 127.0 (112.8, 138.0); TXA, 125.0 (116.5, 136.8); TXA+DEX, 132.0 (120.3, 140.8), p = 0.176]. VAS scores at 5-8 (placebo vs TXA+DEX, p = 0.014; TXA vs TXA+DEX, p = 0.002), 9-12 (placebo vs TXA+DEX, p = 0.008; TXA vs TXA+DEX, p < 0.001), and 13-16 (placebo vs TXA+DEX, p = 0.035; TXA vs TXA+DEX, p = 0.013) hours postoperatively showed a significant decrease for the TXA+DEX group compared with the control or TXA group. There were no significant differences in postoperative blood test results and ASES score at 3 months postoperatively.

CONCLUSION

Postoperative application of TXA alone could not facilitate postoperative recovery during the first 24 hours in ARCR patients. Although the combination of TXA and DEX presented better levels of postoperative pain between 5 and 16 hours than the control and TXA alone, it did not significantly improve postoperative recovery quality. Further large-scale and multi-center investigation is required to determine if the combined application of TXA and DEX or TXA alone is beneficial for postoperative recovery in ARCR patients.

Tranexamic Acid Can Reduce Early Tendon Adhesions After Rotator Cuff Repair and Is Not Detrimental to Tendon-Bone Healing: A Comparative Animal Model Study

PURPOSE

To determine the effects of topical tranexamic acid (TXA) administration on tendon adhesions, shoulder range of motion (ROM), and tendon healing in an acute rotator cuff repair rat model.

METHODS

A total of 20 Sprague Dawley rats were used. Tendon adhesion, ROM, and biomechanical and histological analysis of tendon-bone healing was conducted at 3 and 6 weeks after surgery. The rats underwent rotator cuff repair surgery on both shoulders and were administered TXA via subacromial injections. The tendon adhesion was evaluated macroscopically and histologically. Biomechanical tendon healing was measured using a universal testing machine, and histological analysis was quantified by H&E, Masson's trichrome, and picrosirius red staining.

RESULTS

At 3 weeks after surgery, the adhesion score was significantly lower in the TXA group (2.10 ± 0.32) than in the control group (2.70 ± 0.48) (P = .005), but there was no significant difference between the 2 groups at 6 weeks. Regarding ROM, compared with the control group, the TXA group showed significantly higher external rotation (36.35° ± 4.52° vs 28.42° ± 4.66°, P < .001) and internal rotation (45.35° ± 9.36° vs 38.94° ± 5.23°, P = .013) 3 weeks after surgery. However, at 6 weeks, there were no significant differences in external and internal rotation between the 2 groups. In the biomechanical analysis, no significant differences in gross examination (3 weeks, P = .175, 6 weeks, P = .295), load to failure (3 weeks, P = .117, 6 weeks, P = .295), or ultimate stress (3 weeks, P = .602, 6 weeks, P = .917) were noted between the 2 groups 3 and 6 weeks after surgery. In the histological analysis of tendon healing, no significant differences in the total score (3 weeks, P = .323, 6 weeks, P = .572) were found between the 2 groups 3 and 6 weeks after surgery.

CONCLUSIONS

Topical TXA administration showed a beneficial effect in reducing tendon adhesions and improving ROM 3 weeks postoperatively and had no effect at 6 weeks. This suggests that additional intervention with TXA may be useful in achieving long-term improvement in shoulder stiffness. Additionally, TXA may increase tissue ground substance accumulation in the late postoperative period but does not adversely affect tendon-bone interface healing.

CLINICAL RELEVANCE

The use of TXA after rotator cuff repair has no effect on tendon-bone interface healing in clinical practice and can improve shoulder stiffness in the early postoperative period. Additional research on the long-term effects is needed.