Abstract:BackgroundTranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease blood loss and transfusion rates after hip and knee arthroplasty, with only limited evidence to support its use in shoulder arthroplasty. This study was conducted to determine whether intravenous (IV) TXA is more effective than placebo in reducing blood loss after primary total shoulder arthroplasty (TSA).MethodsIn this prospective, double-blind, placebo-controlled, randomized clinical trial, patients undergoing primary anat… Show more
“…In addition, all patients included in this cohort received TXA, which has also been identified as an independent risk factor for transfusion and postoperative anemia. 3 , 7 In contrast to findings from Howell et al, 15 16 in our TSA group, there was no significant correlation between age, female sex, BMI, or Elixhauser index and postoperative anemia or transfusion. This finding can be explained by the overall lower incidence of transfusion in TSA, as compared with lower-extremity surgery, and the addition of TXA to prevent postoperative anemia and transfusion.…”
Background
Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing.
Methods
We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained.
Results
This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) (
P
< .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions (
P
< .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2;
P
< .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1;
P
< .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87.
Conclusion
Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.
“…In addition, all patients included in this cohort received TXA, which has also been identified as an independent risk factor for transfusion and postoperative anemia. 3 , 7 In contrast to findings from Howell et al, 15 16 in our TSA group, there was no significant correlation between age, female sex, BMI, or Elixhauser index and postoperative anemia or transfusion. This finding can be explained by the overall lower incidence of transfusion in TSA, as compared with lower-extremity surgery, and the addition of TXA to prevent postoperative anemia and transfusion.…”
Background
Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing.
Methods
We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained.
Results
This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) (
P
< .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions (
P
< .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2;
P
< .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1;
P
< .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87.
Conclusion
Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.
“…Conversely, blood management using tranexamic acid (TXA) has been shown to be beneficial in RTSA. In a prospective double-blind randomized trial, TXA was shown to have significantly lower blood loss and less postoperative hemoglobin drop when compared to placebo [57].…”
Section: Intraoperative Factors and Newer Implant Optionsmentioning
Purpose of Review Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years. Recent Findings Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massiveirreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. Summary RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon's armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.Keywords Reverse total shoulder arthroplasty . RTSA . Reverse shoulder . Reverse shoulder arthroplasty . Reverse shoulder prosthesis . Outcomes models: (1) By eliminating the neck, the joint's center of rotation (COR) is in direct contact with the center of the glenosphere, providing a fixed COR and reducing the amount of torque placed on the glenoid component-bone interface; (2) the large-diameter glenosphere improves mobility and stability;(3) medializing the COR recruits more deltoid fibers for elevation and abduction; and (4) distalization of the COR improves the deltoid's moment arm by restoring its length, thereby decreasing the effort necessary for abduction [3][4][5][6][7][8][9]. These modifications allow the deltoid to initiate shoulder abduction in the absence of a functioning supraspinatus [8][9][10].
“…Four published RCTs’ patients underwent full-text review and were included. 27–30 Figure 1.Study selection flow diagram.…”
Section: Resultsmentioning
confidence: 99%
“…Two of the included trials 27,30 (210 patients) reported data on this outcome. No infection events occurred in any of the trials and therefore the effect of TXA on postoperative infection was non-estimable.…”
Background Tranexamic acid efficacy on clinically relevant adverse outcomes in patients undergoing shoulder arthroplasty has been contradictory. The aim of this review was to analyze whether tranexamic acid administration could decrease transfusions, infection and hematoma formation in patients undergoing shoulder arthroplasty. Methods PubMed, EMBASE, and the Cochrane Library were searched up to May 2019 for randomized controlled trials comparing tranexamic acid to placebo in shoulder arthroplasty. Random-effect models were performed to meta-analyze the evidence. Trial sequential analysis was used to calculate and to establish the conclusiveness of the evidence derived from the meta-analysis. Results Four randomized controlled trials comprising 375 patients were included. Meta-analysis showed no effect of tranexamic acid on transfusion rate (RR = 0.48 (adjusted 95% CI 0.05 to 3.85)). The possible effect of tranexamic acid on hematoma formation or infection rates after shoulder arthroplasty is non-estimable with the current evidence. The sample size necessary to reliably determine if tranexamic acid decreases transfusions, infection rates and hematoma formation is not available from the current literature as determined by the trial sequential analysis. Discussion While tranexamic acid has proven its efficacy in decreasing blood loss in shoulder arthroplasty, this meta-analysis of randomized controlled trials clarifies that there is currently no conclusive evidence for a positive effect of tranexamic acid upon transfusion rate, infection rates or hematoma formation in patients undergoing primary shoulder arthroplasty.
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