Is the Indication for RTSA a Risk Factor for Transfusion after Surgery?

    The need for blood transfusion is a known risk of reverse total shoulder arthroplasty (RTSA). [1] What’s unknown is whether the indication for RTSA – traumatic, post-traumatic, or non-traumatic – is a factor in that risk.

    Turns out, it is.

    In a study presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, Thomas W. (Quin) Throckmorton, MD, and his colleagues from the University of Tennessee-Campbell Clinic in Memphis found that about 20% of patients undergoing RTSA for traumatic or post-traumatic indications will need a transfusion, making them about 8 times more likely than patients with non-traumatic indications to receive a transfusion after surgery.

    To determine if some indications for RTSA are more likely to lead to transfusion than others, the study authors retrospectively reviewed data from 291 patients who had undergone RTSA at their institution. They grouped the reasons for RTSA into 3 categories:

    • Traumatic indications: acute fracture and fracture-dislocation (n=27)
    • Post-traumatic indications: non-union, malunion, and chronic dislocation (n=37)
    • Non-traumatic indications: chronic rotator cuff insufficiency and glenohumeral arthritis with advanced glenoid wear (n=227)

    No statistically significant differences were seen among the groups for age, gender, laterality, body mass index, or co-morbidities (P>0.05).

    The overall transfusion rate was 6.5% (19/291). Although the non-traumatic indications group was the largest, its transfusion rate was the lowest:

    • 22.2% (6/27) for traumatic indications
    • 18.9% (7/37) for post-traumatic indications
    • 2.6% (6/227) for non-traumatic indications

    The difference in transfusion rates was statistically significant for traumatic indications compared with non-traumatic indications (P<0.01) and for post-traumatic indications compared with non-traumatic indications (P<0.01). The difference between the traumatic and post-traumatic groups was not statistically significant (P=0.74).

    “We were not surprised that traumatic and post-traumatic patients had higher transfusion rates,” Dr. Throckmorton said. “What was surprising was the magnitude of the difference: 3% of RTSAs done for degenerative conditions required transfusions, but essentially 20% of RTSAs for fracture or fracture sequelae also did. We were not expecting that rate to be so high.”

    Dr. Throckmorton and his co-authors recommend that surgeons consider “more aggressive perioperative blood management and conservation strategies in patients undergoing RTSA for acute trauma or post-traumatic sequelae,” and they practice what they preach. They now routinely administer tranexamic acid to minimize blood loss in patients undergoing RTSA for fracture or fracture sequelae, Dr. Throckmorton said.


    Pharr ZK, Blickenstaff B, Brolin J, Smith RA, Azar FM, Throckmorton TW. Does the Transfusion Rate Following Reverse Total Shoulder Arthroplasty Warrant Aggressive Blood Management? (Paper 381). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.


    1. Gruson KI, Accousti KJ, Parsons BO, Pillai G, Flatow EL. Transfusion after shoulder arthroplasty: an analysis of rates and risk factors. J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):225-30. doi: 10.1016/j.jse.2008.08.005. Epub 2008 Dec 31.