Skip to main content
NCBI home page
Journal of Orthopaedics logoLink to Journal of Orthopaedics
. 2024 Dec 25;65:119–125. doi: 10.1016/j.jor.2024.12.022

Tranexamic acid use in rotator cuff repair: A systematic review of perioperative outcomes

Neil Jain a, Jonathan McKeeman a,⁎, Kyle Schultz b, Wayne Chan c, Daniel Aaron c, Brian Busconi c, Tyler Smith a
PMCID: PMC11754154  PMID: 39867651

Abstract

Background

Tranexamic acid (TXA) use has become the gold standard in total joint arthroplasty to limit intraoperative blood loss and transfusion rates. More recently, the indications for TXA have expanded to knee and shoulder arthroscopy with promising early results. However, the effectiveness of TXA during arthroscopic rotator cuff repair (RCR) is unclear. Therefore, the purpose of this study was to investigate perioperative outcomes following the use of TXA during RCR.

Methods

A systematic review was performed via the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, MEDLINE, Embase, and Cochrane databases in November 2024. Studies were assessed for quality of visual clarity, operative time, mean arterial pressure (MAP), volume of arthroscopy irrigation used, arthroscopic pump pressure, and clinical outcomes.

Results

A total of 12 clinical trials involving 999 patients were included. 9 studies reported on visual clarity and 6 of these reported improvements in visual clarity with TXA administration. Four studies reported improvements in postoperative pain, however outcomes varied greatly depending on when follow-up assessment occurred. A majority of studies did not report differences in operative time, irrigation volume, or postoperative swelling. There were no venous thromboembolism events reported in the included studies.

Conclusion

TXA dosing during RCR surgery may improve visual clarity, however its effect on other perioperative outcomes remains unclear.

Level of evidence

Level I.

1. Introduction

Tranexamic acid (TXA) is now used routinely in orthopedics, and has been shown to be both safe and efficacious in reducing blood loss and transfusion rates during total joint arthroplasty (TJA).1,2 The drug works by inhibiting enzymatic breakdown of fibrin blood clots as a reversible competitive inhibitor, binding at lysine sites on plasminogen.3,4 TXA can be used orally, intravenously, or topically. Each form is similarly effective without demonstrating an increased risk of stroke or venous thromboembolism (VTE).5, 6, 7 TXA has been studied extensively in TJA, orthopedic trauma, and various other surgical subspecialties. However, only recently have authors investigated the clinical uses of TXA in arthroscopic surgery.8,9 A recent systematic review on TXA use in anterior cruciate ligament reconstruction (ACLR) demonstrated reduced drain output and hemarthrosis, as well as improved pain scores and range of motion in the initial post-operative period.10 However, there is a paucity of literature regarding TXA use during arthroscopic shoulder surgery and rotator cuff repair (RCR).

Visual clarity during arthroscopic surgery is critical to efficient and effective workflow. Disruptions in visual clarity are most commonly related to bleeding, which mixes with arthroscopic fluid to produce a cloudy and opaque image.11,12 This can prolong operative times and increase the technical complexity of the case. While pneumatic tourniquets are not an option during shoulder arthroscopy, other commonly used methods to combat bleeding include electrocautery devices, pressurized irrigation, and hypotensive anesthesia.11 Pressurized irrigation, when sustained, can lead to increased fluid extravasation, significant soft tissue swelling, and rarely life-threatening complications.13 Controlled hypotensive anesthesia can be challenging in the setting of significant patient medical comorbidities, baseline hypertension, and use of the beach chair positioning.11 The addition of epinephrine to arthroscopic irrigation bags has demonstrated improved visual clarity, decreased blood loss, and reduced arthroscopic pump pressure during shoulder arthroscopy.12,14, 15, 16 However, several epinephrine induced complications have been reported, and while rare, may lead to potentially fatal cardiac arrhythmias.17,18

The potential benefits of TXA administration during arthroscopic shoulder surgery and RCR include improving visual clarity, reducing operative time and blood loss, lowering the arthroscopic pump pressure, decreasing soft tissue swelling, and potentially altering the threshold for controlled hypotensive anesthesia. However, both the effectiveness of this medication and the long term sequalae of TXA on rotator cuff healing are unclear. TXA administration may theoretically reduce blood induced growth factor extravasation to the repair site and potentially impact tendon healing. In addition, prior authors have demonstrated a concern regarding the safety of topical TXA use around articular cartilage.19 The purpose of this study is to investigate perioperative outcomes following the use of tranexamic acid (TXA) during arthroscopic rotator cuff repair (RCR). We hypothesized that TXA utilization would improve visual clarity and reduce operative time during arthroscopic RCR.

2. Methods

2.1. Literature search

A systematic review was registered with PROSPERO and performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed using the PubMed, Medline (Ovid), EMBASE (Elsevier), and Cochrane Library (Wiley) electronic databases in November 2024. The following terms were searched for keyword, title, and abstract fields: “tranexamic acid”, “TXA”, “rotator cuff”, “rotator cuff repair”, and “shoulder arthroscopy”. Additionally, citations in the included studies were cross-referenced to identify articles that were missed by the initial search. The final search was completed on November 28th, 2024, independently, by 2 authors (N.J, J.M).

2.2. Study eligibility

Trials were eligible for inclusion if they met the following criteria: Human subjects >18 years old undergoing arthroscopic or arthroscopic assisted rotator cuff tear repair with the use of TXA. Oral, topical, and intravenous TXA were all included along a spectrum of dosing regimens. Concomitant subacromial decompression, distal clavicle excision, subscapularis repair, and biceps tenotomy or tenodesis were included. Included studies were limited to Level I-II evidence. No minimum follow-up period was selected due to the limited follow-up among available studies. Studies involving concomitant procedures other than subacromial decompression, distal clavicle excision, or biceps surgery were excluded. Additionally, studies involving animals, patients <18 years of age, revision rotator cuff repair procedures, irreparable rotator cuff tears, cases with uncontrolled hypertension during surgery, cases with thrombophilia and/or coagulopathy were excluded. Operative technique articles without reported outcomes, cadaver studies, biomechanical studies, review/background articles, ongoing or unpublished clinical trials, comments, letters, editorials, duplicates, and non-relevant studies were excluded. Abstracts without available full text and foreign language articles without direct translation were excluded, as well.

2.3. Study selection and data abstraction

A full-text review was performed by two authors to confirm appropriateness for inclusion. Any disagreement between authors during each step of the review process was resolved by discussion. If consensus could not be reached, final inclusion was decided by a third author. A flow diagram outlining the selection process can be found in Fig. 1. Clinical studies were assessed for multiple outcomes of interest, including level of evidence, concomitant procedures, visual quality or clarity, total operative time, mean arterial pressure (MAP), alterations in arthroscopic pump pressure, complications, myocardial infarction, stroke, and symptomatic VTE.

Fig. 1.

Fig. 1

Open in a new tab

PRISMA flow diagram outlining the selection process of excluded and included articles.

2.4. Data analysis

R software version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria) was used to create forest plots and visualize changes in variables of interest. A meta-analysis was not performed due to high heterogeneity between studies. Summary data was reported using forest plots. Standard deviations were taken from the originating studies as reported. If the standard deviation was not reported, previously validated methods of estimating the standard deviation were utilized.20

2.5. Risk of bias assessment

Two authors independently assessed the risk of bias of the included RCTs using the Cochrane Collaboration's tool.21,22 A third author arbitrated when the two authors disagreed to form a consensus response. We evaluated the bias of the trials in the following domains: randomization, blinding, completeness of outcomes, selection of outcomes reported, and additional sources of bias.22 For each domain, the randomized controlled trials were rated as having a low risk of bias, unclear risk of bias, or high risk of bias according to the quality of the trial.

3. Results

3.1. Study identification and assessment

The initial keyword search returned 322 articles for review. After screening for duplicate citations, 97 articles remained. After screening abstracts for editorials, comments, letters to the editor, ongoing clinical trials, and non-applicable articles, 13 articles remained. On full text review, one article23 was found to be a retrospective cohort study (Level III evidence) and was excluded. The remaining twelve articles24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 were included in the review (Table 1).

Table 1.

A summary of author conclusions from the included clinical studies. ∗TXA = tranexamic acid; EPI = epinephrine; NS = normal saline; SS = statistically significant; ROM = range of motion; EPI+ = epinephrine was administered to arthroscopy fluid in both TXA and control groups.

Author Year Control Conclusions
Bayram et al.24 2019 EPI TXA group demonstrated similar visual clarity, operative time, and pump pressure.
Bildik et al.25 2023 NS TXA group demonstrated SS improved visual clarity, shorter operative time, and reduced pain scores at 8 and 24 h postoperatively
Ersin et al.26 2020 NS TXA group demonstrated SS improved visual clarity, decreased arthroscopy fluid used, and fewer increases in arthroscopic pump pressure.
Liu et al.28 2019 NS TXA group demonstrated SS improved visual clarity, decreased pain, and lower opioid consumption.
Mackenzie et al.29 2022 EPI+ TXA group demonstrated SS improvements in ROM at 6 months and reduced rates of secondary adhesive capsulitis.
Nicholson et al.30 2022 NS TXA group did not improve any measures of pump pressure, number of times a change in pump pressure was made, visual clarity, or pain scores.
Shin et al.31 2024 NS TXA group demonstrated SS improved visual clarity.
Suter et al.32 2024 NS TXA group did not improve visual clarity when compared to control or epinephrine groups.
Takahashi et al.33 2023 EPI+ TXA group demonstrated SS improved visual clarity and similar operative time.
Takahashi et al.34 2023 EPI+ TXA group did not improve postoperative pain scores or shoulder joint swelling.
Wang H. et al.27 2024 NS TXA group significantly reduced intraoperative bleeding, however it did not affect postoperative pain scores.
Wang T. et al.35 2023 NS TXA applied topically and intravenously significantly improved visual clarity, and combination of these two modalities reduced irrigation fluid usage.
Open in a new tab

3.2. Study and patient characteristics

The 12 clinical studies included a total of 999 patients who underwent RCR with TXA or placebo. Five hundred and thirty-eight were male (53.9 %) and 461 were female (46.1 %). All patients underwent primary RCR. Eleven articles involved arthroscopic RCR and 1 article29 also included patients who underwent arthroscopic assisted mini-open RCR. Four articles24,26,28,29 utilized double row techniques, 1 article25 used a single row technique, and 331−33 utilized both single and double row techniques.33 All repairs were performed with the use of suture anchor fixation with a various assortment of vendors, suture material, and anchor materials. Six studies24, 25, 26,30,33,34 were performed in the beach chair position, two28,35 utilized lateral positioning, and two29,32 utilized both positions. Concomitant procedures included subacromial decompression, biceps tenodesis or tenotomy, distal clavicle excision, and subscapularis repair. Four studies24, 25, 26,35 evaluated only intra-operative outcomes and no patient data was obtained during follow up. Four studies27,30, 31, 32 evaluated intra-operative and post-operative outcomes within 2 weeks. Four studies28,29,33,34 evaluated intra-operative and post-operative outcomes from 3 months to 1 year.

3.3. TXA protocols

Five hundred and thirty-seven patients received TXA (53.8 %). TXA modality, dosing, and administration protocols varied significantly between studies and can be found in Table 2. Eight studies26, 27, 28, 29, 30, 31, 32, 33 administered IV TXA, two24,25 administered topical TXA mixed with the saline arthroscopy irrigation, one34 administered topical TXA after surgery, and one35 administered TXA both IV and topically. Control protocols varied among included studies. Three studies29,33,34 administered epinephrine in the arthroscopy fluid in both the TXA and control groups. Two studies24,32 administered epinephrine in the arthroscopy fluid of a control or individual experimental arm. Seven studies used normal saline arthroscopy fluid in both the TXA and control groups.25, 26, 27, 28,30,31,35

Table 2.

A summary of tranexamic acid (TXA) dosing regimens and protocol between clinical studies. ∗IV = intravenous; NS = normal saline; mL = milliliters; L = liters; mg = milligrams; g = grams; kg = kilograms.

Author Modality Dosing Protocol
Bayram et al.24 Topical 1.26 g/3 L TXA mixed with saline arthroscopy irrigation fluid
Bildik et al.25 Topical 250 mg/3 L TXA mixed with saline arthroscopy irrigation fluid
Ersin et al.26 IV 10 mg/kg 100 mL NS bolus after induction of anesthesia
Liu et al.28 IV 1 g 20 mL NS bolus 10 min prior to incision
Mackenzie et al.29 IV 2 g 20 mL NS bolus after induction of anesthesia
Nicholson et al.30 IV 1 g Bolus given 30 min prior to induction of anesthesia
Shin et al.31 IV 1 g 100 mL NS bolus 10 min prior to induction
Suter et al.32 IV 1 g Bolus given prior to induction of anesthesia
Takahashi et al.33 IV 1 g 20 mL NS bolus 10 min prior to incision
Takahashi et al.34 Topical 100 mg/mL 10 mL as a local periarticular injection after surgery
Wang H. et al.27 IV 1 g 20 mL NS bolus prior to 10 min prior to induction
Wang T. et al.35 IV, topical 1 g; 1.26 g/3 L 100 mL NS bolus 10 min prior to induction; TXA mixed with saline arthroscopy irrigation fluid
Open in a new tab

3.4. Visual clarity

Nine studies evaluated the effect of TXA administration on intra-operative visual clarity (Fig. 2). Four studies28,31, 32, 33 reported visual clarity scores from 1 (poor visual clarity) to 3 (clear visual clarity). These studies additionally reported the percentage of the case spent in each visual clarity grade. Liu et al.28 found a statistically significant increase in overall visual clarity in the TXA group vs the placebo group (2.5 vs 2.3, respectively; p = 0.048) as well as a greater percentage of grade 3 operative time (53.7 vs 40.5, respectively; p = 0.04). Similarly, Takahashi et al. demonstrated a statistically significant increase in operative time spent in grade 3 visual clarity (75.6 vs 68.1, p = 0.045).33 Four of the included studies24,26,30,35 reported visual clarity scores on a scale of 1 (poor visual quality) to 10 (perfect visual quality) as described by Avery.14 Two of these studies26,35 individually demonstrated a statistically significant difference in visual clarity in favor of the TXA group. One study25 graded visual clarity from 1 (perfect visual clarity) to 5 (poor visual clarity) and found that intraarticular TXA administration significantly increased percentage of grade 1 visual clarity (p = <0.001) and lowered percentage of grade 4 visual clarity (p = 0.003).

Fig. 2.

Fig. 2

Open in a new tab

Changes in Visual Clarity summarized. Studies with staged grading or multiple TXA study groups were not included. TXA, Tranexamic Acid. MD, Mean Difference. CI, Confidence Interval.

3.5. Operative time

Nine studies24, 25, 26, 27, 28,30, 31, 32, 33 compared overall operative time between TXA and control groups (Fig. 3). Only one25 reported a statistically significant reduction in operative time.

Fig. 3.

Fig. 3

Open in a new tab

Changes in Operative Time summarized. Studies with multiple TXA study groups were not included. TXA, Tranexamic Acid. MD, Mean Difference. CI, Confidence Interval.

3.6. Controlled hypotensive anesthesia

Five studies24,25,30, 31, 32 compared the difference in MAP between TXA and control groups, all of which demonstrated no significant difference. Bayram et al.24 additionally evaluated the number of patients requiring administration of IV antihypertensive agents intra-operatively and found no difference between TXA and control groups (9 % vs 12 %, respectively; p = 0.45). Nicholson et al.30 found similar results with 12 (24 %) TXA group patients requiring blood pressure readjustments compared to 8 (16 %) of the control group (p = 0.44).

3.7. Arthroscopy fluid and pump pressure

Six studies compared total volume of arthroscopy fluid used during the operation between TXA and control groups (Fig. 4).24, 25, 26,30,32,35 Bildik et al.25 and Ersin et al.26 found a statistically significant reduction in arthroscopic irrigation volume in the TXA group vs control (p = <0.001, p = 0.01, respectively).

Fig. 4.

Fig. 4

Open in a new tab

Changes in total amount of irrigation fluid used summarized. Studies with multiple TXA study groups were not included. TXA, Tranexamic Acid. MD, Mean Difference. CI, Confidence Interval.

Three studies26,28,30 compared the number of times the surgeon manually increased the arthroscopic pump pressure (Fig. 5).26,28 Ersin et al.26 demonstrated a statistically significant decrease in the number of times the pump pressure was adjusted (5.8 TXA vs 9.6 control, p = 0.04). Liu et al.28 and Nicholson et al.30 demonstrated no difference between TXA and control groups (p = 0.33, p = 0.92, respectively).

Fig. 5.

Fig. 5

Open in a new tab

Counts of Pump Pressure Adjustments summarized. Studies with multiple TXA study groups were not included. TXA, Tranexamic Acid. MD, Mean Difference. CI, Confidence Interval.

3.8. Blood loss and swelling

Two studies27,33 evaluated differences in perioperative blood loss between TXA and control groups. Wang et al.27 found TXA administration significantly reduces intraoperative blood loss (p < 0.001). However, Takahashi et al.33 found no difference in estimated peri-operative blood loss between TXA and control groups (p = 0.66). Four studies27,28,33,34 evaluated shoulder circumference between groups and reported no difference.

3.9. Clinical outcomes

Eight studies25,27, 28, 29, 30,32, 33, 34 compared post-operative VAS pain scores between TXA and control groups. Bildik et al.25 reported a significant reduction in pain scores in the TXA group at 8 and 24 h, but not at 48 h (p = 0.002, p < 0.001, p = 0.78, respectively). Liu et al.28 reported a statistically significant reduction in pain scores in the TXA group on POD 1 (3.0 vs 4.3, respectively; p = 0.01). Takahashi et al.33 reported a statistically significant reduction in VAS in the TXA group on POD 7 both at rest (p < 0.001) and at night (p = 0.01). Mackenzie et al.29 demonstrated significantly improved VAS at 8 weeks postoperatively.

Liu et al.28 additionally reported a decrease in overall narcotic use in the TXA group vs control (9.6 vs 14.7 MME, respectively; p = 0.04).28 However, Suter et al.32 found no difference in total MME use evaluated at postoperative day 14 in their study (p = 0.41). Mackenzie et al.29 reported improved internal and external rotation in the TXA group at 24 weeks post-operatively, but no difference was seen at 52 weeks. The authors also reported no difference in Constant or ASES scores between TXA and control groups in this study. There were no reported cardiac or venous thromboembolism events reported in any of the included studies within the follow-up interval.

4. Discussion

The findings of the present systematic review suggested TXA administration improves visual clarity during RCR use, but may not affect operative time, irrigation volume, arthroscopic pump pressure, or postoperative swelling. While the clinical efficacy of this experimental treatment remains unclear for these outcomes, TXA appears to be safe for patients undergoing rotator cuff surgery.

TXA has been studied extensively in arthroplasty literature, and is now the standard of care for reducing blood loss and transfusion rates following TJA.5 However, there is minimal literature regarding the use of TXA in orthopedic sports medicine and arthroscopic surgery.8, 9, 10 Several authors have reported concerns regarding the safety of topical TXA use in the setting of native articular cartilage, however in vivo studies have not demonstrated a major cytotoxic effect.19,36,37 In addition, residual arthroscopic fluid and blood may further dilute the true concentration of TXA intra-articularly. Of the 12 studies in the present systematic review, only four studies24,25,34,35 evaluated topical TXA use (Table 2). Concerns with articular cartilage toxicity can be further avoided by the use of intravenous administration.

Six of the 9 studies examining visual clarity in the present review demonstrated statistically significant improvements for the TXA group. Bayram et al.24 compared topical TXA to a control group using epinephrine laden arthroscopy fluid, which multiple studies have shown to improve visual clarity during arthroscopic shoulder surgery.12,14, 15, 16 These factors may explain why this study failed to show a statistical advantage of the TXA group in regards to visual clarity scoring. Visual clarity was most frequently affected during work in the subacromial space and during rotator cuff repair.23 Adequate visualization during this portion of the procedure is crucial for successful repair and efficient workflow. TXA does not prevent the occurrence of bleeding, but instead limits continued bleeding by suppressing the fibrinolytic process. Therefore, image visual clarity can still be affected when subacromial bleeding occurs, however sustained visual disturbances may be less likely. The total volume of arthroscopic irrigation used may also be representative of TXA efficacy since the need for higher pressure and lavage may be reduced when bleeding ceases and does not continue. Further investigation with standardized TXA administration protocols, control groups, and outcome reporting strategies may provide a more effective analysis.

TXA has demonstrated an anti-inflammatory effect and may therefore potentially impact post-operative pain and narcotic consumption.38 While several individual studies did demonstrate advantages in the TXA group for these outcomes, a pooled meta-analysis could not be performed in this review due to study heterogeneity and variations in outcome assessment protocols. This may limit the ability to make definitive conclusions regarding the efficacy of TXA on these outcomes. In addition to the anti-inflammatory effect, TXA may theoretically reduce blood induced growth factor extravasation to the tendon repair site. Studies involving TXA use in ACL reconstruction have not demonstrated any differences in tendon or ligament healing within the short-term follow up period.10 No differences between groups in regard to rotator cuff failures or re-tears were observed in any of the included studies.

The price of TXA at our institution is $6.62 per gram, with other sources reporting prices in a similar range.39 The cost of operating room time has been estimated to range from 16 to 37$ per minute.40,41 Therefore, TXA may theoretically be cost effective during rotator cuff repair if it saves a single minute of operating room time. While the present review did not suggest a significant improvement in total operating room time between TXA and control groups, significant heterogeneity precluded a meta-analysis and may have limited to ability to make such conclusions. Additional high-quality studies with homogenous protocols and outcome measures are needed to determine whether or not this medication is cost-effective.

4.1. Limitations

This study had several limitations warranting discussion. First, there was heterogeneity among the recorded outcome measures of the included studies. These differences hindered the ability to perform additional statistical comparisons or meta-analyses. Second, there was significant heterogeneity among TXA dosing protocols in terms of route of administration, concentration, timing, epinephrine addition to arthroscopy irrigation, and variations among the control groups. Third, there are a large variety of confounding factors that may alter visual clarity during shoulder arthroscopy. These factors include but are not limited to standard versus high-definition arthroscopy towers, use of cannulas, radiofrequency ablation devices, gravity versus automated pressure pumps, pump pressure, patient blood pressure, patient positioning, and many more. Fourth, follow-up periods for the included studies were short with a range of 0 days–1 year. Due to the lack of existing literature on the subject, we were unable to exclude studies with such limited follow-up. In addition, many of the included studies focused on the intra-operative effect of TXA use and therefore experimental design intentionally lacked follow up. However, for these reasons both the short-term and long-term outcomes after TXA use during RCR remain unknown. Finally, many studies failed to control for confounding patient and/or procedural variables such as pre-operative shoulder function and/or concomitant acromial, clavicular, and biceps surgeries.

5. Conclusion

TXA dosing during RCR surgery may improve visual clarity, however its effect on other perioperative outcomes remains unclear.

CRediT authorship contribution statement

Neil Jain: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript. Jonathan McKeeman: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript. Kyle Schultz: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript. Wayne Chan: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript. Daniel Aaron: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript. Brian Busconi: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript. Tyler Smith: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing/Review of the manuscript.

Guardian/patient consent

N/A-exempt systematic review.

Ethical statement

This study was exempt from IRB review as it was a systematic review of publicly available data.

Data statement

A deidentified data sheet is available from the corresponding author upon reasonable request.

Ethical statement

This was an IRB exempt study.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations of competing interest

Brian Busconi reports the following:

American Orthopaedic Society for Sports Medicine: Board or committee member.

Arthrex, Inc: Paid presenter or speaker.

CONMED Linvatec: Paid presenter or speaker.

DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant.

Mitek: Paid consultant; Paid presenter or speaker.

Saunders/Mosby-Elsevier: Publishing royalties, financial or material support

Tyler Smith reports the following:

Stryker Corporation: consulting or advisory.

Daniel Aaron reports the following:

Journal of Shoulder and Elbow Arthroplasty: Editorial or governing board.

Zimmer: Paid consultant.

Acknowledgements

None.

References

  • 1.Ho K.M., Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. Oct 2003;31(5):529–537. doi: 10.1177/0310057x0303100507. [DOI] [PubMed] [Google Scholar]
  • 2.Cid J., Lozano M. Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion. Aug 2005;45(8):1302–1307. doi: 10.1111/j.1537-2995.2005.00204.x. [DOI] [PubMed] [Google Scholar]
  • 3.McCormack P.L. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs. Mar 26 2012;72(5):585–617. doi: 10.2165/11209070-000000000-00000. [DOI] [PubMed] [Google Scholar]
  • 4.Levy J.H., Koster A., Quinones Q.J., Milling T.J., Key N.S. Antifibrinolytic therapy and perioperative considerations. Anesthesiology. Mar 2018;128(3):657–670. doi: 10.1097/aln.0000000000001997. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Fillingham Y.A., Ramkumar D.B., Jevsevar D.S., et al. The efficacy of tranexamic acid in total knee arthroplasty: a network meta-analysis. J Arthroplasty. Oct 2018;33(10):3090–3098.e1. doi: 10.1016/j.arth.2018.04.043. [DOI] [PubMed] [Google Scholar]
  • 6.North W.T., Mehran N., Davis J.J., Silverton C.D., Weir R.M., Laker M.W. Topical vs intravenous tranexamic acid in primary total hip arthroplasty: a double-blind, randomized controlled trial. J Arthroplasty. May 2016;31(5):1022–1026. doi: 10.1016/j.arth.2015.11.003. [DOI] [PubMed] [Google Scholar]
  • 7.Zhang L.K., Ma J.X., Kuang M.J., et al. The efficacy of tranexamic acid using oral administration in total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. Oct 27 2017;12(1):159. doi: 10.1186/s13018-017-0660-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Belk J.W., McCarty E.C., Houck D.A., Dragoo J.L., Savoie F.H., Thon S.G. Tranexamic acid use in knee and shoulder arthroscopy leads to improved outcomes and fewer hemarthrosis-related complications: a systematic review of level I and II studies. Arthroscopy. Apr 2021;37(4):1323–1333. doi: 10.1016/j.arthro.2020.11.051. [DOI] [PubMed] [Google Scholar]
  • 9.Nugent M., May J.H., Parker J.D., et al. Does tranexamic acid reduce knee swelling and improve early function following arthroscopic meniscectomy? A double-blind randomized controlled trial. Orthop J Sports Med. Aug 2019;7(8) doi: 10.1177/2325967119866122. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Johns W.L., Walley K.C., Hammoud S., Gonzalez T.A., Ciccotti M.G., Patel N.K. Tranexamic acid in anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. Dec 2021;49(14):4030–4041. doi: 10.1177/0363546521988943. [DOI] [PubMed] [Google Scholar]
  • 11.Walker-Santiago R., Maldonado D.R., Domb B.G., Lall A.C. Fundamentals of arthroscopy fluid management and strategies to safely improve visualization. J Am Acad Orthop Surg. Oct 15 2021;29(20):862–871. doi: 10.5435/jaaos-d-20-01057. [DOI] [PubMed] [Google Scholar]
  • 12.Jensen K.H., Werther K., Stryger V., Schultz K., Falkenberg B. Arthroscopic shoulder surgery with epinephrine saline irrigation. Arthroscopy. Jul 2001;17(6):578–581. doi: 10.1053/jars.2001.23590. [DOI] [PubMed] [Google Scholar]
  • 13.Memon M., Kay J., Gholami A., Simunovic N., Ayeni O.R. Fluid extravasation in shoulder arthroscopic surgery: a systematic review. Orthop J Sports Med. May 2018;6(5) doi: 10.1177/2325967118771616. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Avery D.M., 3rd, Gibson B.W., Carolan G.F. Surgeon-rated visualization in shoulder arthroscopy: a randomized blinded controlled trial comparing irrigation fluid with and without epinephrine. Arthroscopy. Jan 2015;31(1):12–18. doi: 10.1016/j.arthro.2014.08.010. [DOI] [PubMed] [Google Scholar]
  • 15.van Montfoort D.O., van Kampen P.M., Huijsmans P.E. 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. Arthroscopy. Mar 2016;32(3):436–444. doi: 10.1016/j.arthro.2015.08.027. [DOI] [PubMed] [Google Scholar]
  • 16.Kuo L.T., Chen C.L., Yu P.A., Hsu W.H., Chi C.C., Yoo J.C. Epinephrine in irrigation fluid for visual clarity in arthroscopic shoulder surgery: a systematic review and meta-analysis. Int Orthop. Dec 2018;42(12):2881–2889. doi: 10.1007/s00264-018-4021-9. [DOI] [PubMed] [Google Scholar]
  • 17.Cho S.H., Yi J.W., Kwack Y.H., Park S.W., Kim M.K., Rhee Y.G. Ventricular tachycardia during arthroscopic shoulder surgery: a report of two cases. Arch Orthop Trauma Surg. Mar 2010;130(3):353–356. doi: 10.1007/s00402-009-0820-1. [DOI] [PubMed] [Google Scholar]
  • 18.Karns J.L. Epinephrine-induced potentially lethal arrhythmia during arthroscopic shoulder surgery: a case report. AANA J (Am Assoc Nurse Anesth) Oct 1999;67(5):419–421. [PubMed] [Google Scholar]
  • 19.Parker J.D., Lim K.S., Kieser D.C., Woodfield T.B.F., Hooper G.J. Is tranexamic acid toxic to articular cartilage when administered topically? What is the safe dose? Bone Joint Lett J. Mar 1 2018;100-b(3):404–412. doi: 10.1302/0301-620x.100b3.Bjj-2017-1135.R1. [DOI] [PubMed] [Google Scholar]
  • 20.Hozo S.P., Djulbegovic B., Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005/04/20 2005;5(1):13. doi: 10.1186/1471-2288-5-13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Higgins J.P.T., Altman D.G., Gøtzsche P.C., et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343 doi: 10.1136/bmj.d5928. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Higgins J.P.T., Thomas J., Chandler J., et al. Cochrane; 2024. Cochrane Handbook for Systematic Reviews of Interventions Version 6.5. [Google Scholar]
  • 23.Kawaguchi S., Fukuta S., Kano M., Sairyo K. Reduction of perioperative blood loss and operating time for arthroscopic rotator cuff repair by intravenous administration of tranexamic acid. Asia Pac J Sports Med Arthrosc Rehabil Technol. Jan 2023;31:6–10. doi: 10.1016/j.asmart.2023.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Bayram E., Yıldırım C., Ertürk A.K., Yılmaz M., Atlıhan D. Comparison of the efficacy of irrigation with epinephrine or tranexamic acid on visual clarity during arthroscopic rotator cuff repair: a double-blind, randomized-controlled study. Jt Dis Relat Surg. 2021;32(1):115–121. doi: 10.5606/ehc.2021.78393. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Bildik C., Pehlivanoglu T. Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients. J Shoulder Elbow Surg. Feb 2023;32(2):223–231. doi: 10.1016/j.jse.2022.10.007. [DOI] [PubMed] [Google Scholar]
  • 26.Ersin M., Demirel M., Büget M., Edipoğlu İ.S., Atalar A.C., Erşen A. 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 Turcica. Nov 2020;54(6):572–576. doi: 10.5152/j.aott.2020.19164. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Wang H., Ouyang Y., Chen Y., Zeng L. Clinical application of tranexamic acid in arthroscopic rotator cuff repair surgery: a randomized controlled trial. Medicine (Baltim) Jun 28 2024;103(26) doi: 10.1097/md.0000000000038515. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Liu Y.F., Hong C.K., Hsu K.L., 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. Arthroscopy. Mar 2020;36(3):640–647. doi: 10.1016/j.arthro.2019.10.020. [DOI] [PubMed] [Google Scholar]
  • 29.Mackenzie S.P., Spasojevic M., Smith M., 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 Surg. Jul 2022;31(7):1399–1408. doi: 10.1016/j.jse.2022.02.023. [DOI] [PubMed] [Google Scholar]
  • 30.Nicholson T.A., Kirsch J.M., Churchill R., Lazarus M.D., Abboud J.A., Namdari S. The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial. J Shoulder Elbow Surg. Nov 2022;31(11):2211–2216. doi: 10.1016/j.jse.2022.06.027. [DOI] [PubMed] [Google Scholar]
  • 31.Shin H.J., You H.S., Lee K., et al. Intravenous tranexamic acid improves visual clarity during synovectomy in patients undergoing arthroscopic rotator cuff repair: a double-blind, randomized controlled study. Arthroscopy. May 2024;40(5):1409–1419. doi: 10.1016/j.arthro.2023.10.019. [DOI] [PubMed] [Google Scholar]
  • 32.Suter T., McRae S., Zhang Y., et al. The effect of intravenous tranexamic acid on visual clarity in arthroscopic shoulder surgery compared to epinephrine and a placebo: a double-blinded, randomized controlled trial. J Shoulder Elbow Surg. Mar 2024;33(3):628–639. doi: 10.1016/j.jse.2023.10.001. [DOI] [PubMed] [Google Scholar]
  • 33.Takahashi R., Kajita Y., Iwahori Y., Harada Y. Tranexamic acid administration for arthroscopic rotator cuff repair: a prospective, double-blind, randomized controlled trial. J Orthop Sci. Mar 2023;28(2):328–332. doi: 10.1016/j.jos.2021.11.015. [DOI] [PubMed] [Google Scholar]
  • 34.Takahashi R., Kajita Y., Iwahori Y., Harada Y. Tranexamic acid has no effect on postoperative pain control after arthroscopic rotator cuff repair: a prospective, double-blind, randomized controlled trial. Asia Pac J Sports Med Arthrosc Rehabil Technol. Jul 2023;33:32–35. doi: 10.1016/j.asmart.2023.08.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Wang T.C., Guo J.L., Tian Q.P., et al. Application of tranexamic acid in shoulder arthroscopic surgery: a randomised controlled trial. Chin Med Sci J. Dec 2023;38(4):273–278. doi: 10.24920/004295. [DOI] [PubMed] [Google Scholar]
  • 36.McLean M., McCall K., Smith I.D.M., et al. Tranexamic acid toxicity in human periarticular tissues. Bone Joint Res. Jan 2019;8(1):11–18. doi: 10.1302/2046-3758.81.Bjr-2018-0181.R1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Bolam S.M., O'Regan-Brown A., Paul Monk A., Musson D.S., Cornish J., Munro J.T. Toxicity of tranexamic acid (TXA) to intra-articular tissue in orthopaedic surgery: a scoping review. Knee Surg Sports Traumatol Arthrosc. Jun 2021;29(6):1862–1871. doi: 10.1007/s00167-020-06219-7. [DOI] [PubMed] [Google Scholar]
  • 38.Wang D., Luo Z.Y., Yu Z.P., et al. The antifibrinolytic and anti-inflammatory effects of multiple doses of oral tranexamic acid in total knee arthroplasty patients: a randomized controlled trial. J Thromb Haemostasis. Dec 2018;16(12):2442–2453. doi: 10.1111/jth.14316. [DOI] [PubMed] [Google Scholar]
  • 39.Ehresman J., Pennington Z., Schilling A., et al. Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies. J Neurosurg Spine. Aug 1 2020;33(2):177–185. doi: 10.3171/2020.1.Spine191464. [DOI] [PubMed] [Google Scholar]
  • 40.Childers C.P., Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg. Apr 18 2018;153(4) doi: 10.1001/jamasurg.2017.6233. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Moody A.E., Gurnea T.P., Shul C.P., Althausen P.L. True cost of operating room time: implications for an orthopaedic trauma service. J Orthop Trauma. May 2020;34(5):271–275. doi: 10.1097/bot.0000000000001688. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Orthopaedics are provided here courtesy of Indo Korean Orthopaedic Foundation and Prof. PK Surendran Memorial Educational Foundation

RESOURCES