Shoulder Arthroplasty Patients Benefit from TXA, Too
A first-of-its-kind study has shown an association between administration of tranexamic acid and a substantial decrease in the risk of blood transfusion in patients undergoing shoulder replacement surgery.
Tranexamic acid (TXA) is commonly used to reduce blood loss and the risk of transfusion in total hip and total knee arthroplasty patients, with demonstrated safety and efficacy. 
Now, surgeons who perform shoulder arthroplasty can be assured that TXA is also safe and effective in their patient population, according to research presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in New Orleans.
This is the first large-scale study of its kind, and it included the records of more than 82,000 patients in the Premier Perspective national claims database who underwent shoulder arthroplasty at 429 hospitals between 2010 and 2016.
“We used big data to look at the use of TXA in the shoulder arthroplasty population, which had not yet been done,” said first author Shawn Anthony, MD, MBA, Assistant Professor in the Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai.
“There have been some smaller studies looking at the effectiveness of using TXA, and a lot of data in the total joint literature for knees and hips, but no one had looked at total shoulder.”
The study is the result of a collaboration at the Icahn School of Medicine at Mount Sinai between surgeons from the Leni and Peter W. May Department of Orthopaedic Surgery and researchers from the Department of Population Health Science and Policy, who have extensive expertise in analyzing complex data from large data sets.
Is TXA Effective in Shoulder Replacement?
For the study presented at the AAOS meeting, Dr. Anthony and his colleagues examined the data for associations between TXA administration and:
- Transfusion risk
- Combined complications such as thromboembolic events, acute renal failure, and cerebral or acute myocardial infarction
- Length of stay (LOS) in the hospital
- Hospital costs
Utilizing multilevel multivariable regression models, they found:
- A 36% decrease in transfusion risk (odds ratio [OR] 0.64; confidence interval [CI] 0.52-0.77; P<0.05)
- A 35% decreased risk for combined complications (OR 0.65; CI 0.50-0.83; P<0.05)
- A 6.2% shorter LOS (CI -8.0%; -4.4%; P<0.05)
No difference was seen in the cost of hospitalization.
Low Usage Overall
Tranexamic acid was used in only 12.8% of patients included in the study. This was surprising, Dr. Anthony said, considering TXA’s widespread use in hip and knee arthroplasty patients and its proven efficacy. He noted, however, that data showed a trend toward greater use of TXA in shoulder arthroplasty patients in more recent years.
One of the reasons for the lower usage in shoulder arthroplasty may be that, “while the incidence of DVT [in shoulder arthroplasty patients] is not zero, it’s much lower than with hip and knee arthroplasty,” said senior author Leesa Galatz, MD, System Chair of Orthopaedics for the Mount Sinai Health System and Professor in the Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai. “So, that’s part of it: People don’t think of shoulder arthroplasty as being a procedure that’s at high risk.”
Educating surgeons about the safety and efficacy of TXA in shoulder arthroplasty patients is needed, especially to allay fears about blood clots developing with the use of TXA. “While [blood clots] have been shown in some case reports, it’s not really been substantiated when looking at the broader literature,” said Dr. Anthony, including in the study presented at the AAOS meeting.
This study did not determine whether certain patients would benefit from TXA use more than others, although Dr. Anthony said that, “the reverse total shoulder population is at higher risk of receiving blood transfusions and at higher risk of blood loss, so it makes sense that that’s the population to target.”
Recommendation for TXA
Dr. Galatz said that based on the study findings, she and her colleagues recommend the use of TXA in shoulder arthroplasty patients – particularly with the finding of a 36% reduction in risk of blood transfusions. “There is increased attention to the use of transfusions, so lowering transfusion risk is one of the most compelling reasons” for using TXA, she said.
The TXA dose is up to the individual surgeon. Dr. Anthony gives 2000 mg intravenously right before the first incision. He said he and his colleagues looked at the data for a dose-response relationship, but did not find one.
“Any exposure to TXA seems to benefit [the patient],” Dr. Anthony said, “with 2000 mg being the most widely used dose.”
Anthony S, Patterson D, Cagle P, Poeran J, Zubizaretta N, Mazumdar M, Galatz L. Utilization and Real-World Effectiveness of Tranexamic Use in Shoulder Arthroplasty: A Population-Based Study (Paper 065). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.
Dr. Anthony and Dr. Galatz have no disclosures relevant to this article.
- Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, Boettner F, Memtsoudis SG. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ. 2014 Aug 12;349:g4829. doi: 10.1136/bmj.g4829.