Tranexamic acid may improve visualization, OR time for arthroscopic rotator cuff repair
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Key takeaways:
- Tranexamic acid improved visualization, operative time and pain scores for patients undergoing arthroscopic rotator cuff repair.
- Further research is needed to evaluate the optimal dosing of tranexamic acid.
Published results from a systematic review and meta-analysis showed tranexamic acid improved visualization, operative time and postoperative pain scores for patients undergoing arthroscopic rotator cuff repair.
Eoghan T. Hurley, MB, MCh, PhD, and colleagues from Duke University performed a level 1 systematic review and meta-analysis of six randomized controlled trials which compared the use of tranexamic acid in 231 patients who underwent arthroscopic rotator cuff repair vs. a control group of 219 patients who underwent the same procedure without tranexamic acid.
Outcome measures included intraoperative arthroscopic visual scores, postoperative VAS pain scores, operative time, pump pressures and shoulder swelling, according to the study.
Among the five studies which reported on visualization, three studies found patients who received tranexamic acid had “significantly superior” mean arthroscopic visual scores compared with the control group. Mean postoperative VAS score was 3.3 for patients who received tranexamic acid and 4.1 for control patients. Researchers noted this was a statistically significant difference.
Researchers also found a statistically significant difference in mean weighted operative time for patients who received tranexamic acid (79.3 minutes) vs. control patients (88.8 minutes). They found no differences between the groups for intraoperative pump pressures or shoulder swelling.
“Further research should be done to evaluate the optimal dosing of tranexamic acid in these patients as well as the optimal administration rout — intra-articular or intravenous,” the researchers wrote in the study.
Perspective
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Arthroscopic surgery utilizes pressurized water to maintain a consistent field of view, allow for hemostasis and distend the working space. This strategy is helpful, but in cases that are outside of joints (technically endoscopy, not arthroscopy) such as arthroscopic rotator cuff repair, the surgeon is often confronted with a dilemma: Working at a higher pump pressure can improve visualization, distend the working space and provide some hemostasis, but without the specialized structures of a joint capsule, extravasation into the deltoid muscle eventually causes “the walls to close in.” Working at a lower pressure allows a longer “shot clock” for the operation, but the surgeon may have to spend more time with hemostasis and visualization can be impaired.
As the main reason for raising the pump pressure is hemostasis and orthopedic surgeons are now well aware of the hemostatic benefits of tranexamic acid, could tranexamic acid be helpful in the setting of arthroscopic cuff repair? Certainly, the blood loss is negligible and the infection rate is minimal so any clinical benefit would not be on those factors. But Eoghan T. Hurley, MB, MCh, PhD, and colleagues, systematically reviewing the literature on this topic, identified six studies to help answer this question. Overall, they concluded that the use of tranexamic acid improved visualization, operative time and, most surprisingly, subsequent postoperative pain levels in patients undergoing arthroscopic rotator cuff repair. The Duke shoulder team should be saluted for a helpful systematic review that truly may change management as surgeons incorporate this into their practice.
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