Tranexamic acid use in arthroscopic rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials

Abstract

Background: Rotator cuff disease, a prevalent cause of shoulder disability and pain among middle-aged and older adults, has seen an uptick in arthroscopic repairs in the last 2 decades. These repairs necessitate optimal visualization and controlled hemostasis to prevent complications. This study aimed to assess the efficacy of tranexamic acid (TXA) in arthroscopic rotator cuff repairs by evaluating all available randomized controlled trials (RCTs) in the literature.

Methods: A systematic search was conducted in PubMed, Cochrane Library, Embase, Science Direct, Web of Science, Google Scholar, and CINAHL databases from inception through November 2022 for RCTs investigating the use of TXA in arthroscopic rotator cuff repair. The studies selected reported on the primary outcomes, which include visual clarity during surgery, postoperative pain, and operative time. The quality of the studies was evaluated using the RoB 2 (Risk of Bias) tool.

Results: A total of 7 studies, with level I and II of evidence, comprising 510 randomized patients (253 females, 257 males) were included, with mean ages of 59 and 58 years for the TXA and control groups, respectively. Bias was graded "Low" in 2 RCTs and "Some concerns" in 5 RCTs. Visual analog scale for pain was significantly different with TXA use at postoperative day 1 (weighted mean difference (WMD) = -0.55; 95% confidence interval (CI): -1.07 to -0.04, P = .04). Operative time was significantly higher for the control group with a mean difference of 7.97 minutes (WMD = -7.97; 95% CI: -15.19 to -0.74, P = .04). The impact of TXA on visual clarity during shoulder arthroscopy remains uncertain. However, postoperative shoulder swelling results were comparable in both groups (WMD = -1.71; 95% CI: -3.72 to 0.29, I² = 99% (where I² = heterogeneity statistic), P = .69). Considerable heterogeneity was seen in some results.

Conclusion: Pooled data suggest that the use of TXA in shoulder arthroscopy does reduce postoperative shoulder pain and has a positive effect on decreasing operative time. However, the reduction in pain may not be clinically significant, and there is no effect on reducing shoulder swelling. The impact of TXA on visual clarity remains inconclusive, and further research is needed using methodologically rigorous articles that incorporate objective measures and controlled factors to eliminate subjective bias.

Keywords: Arthroscopy; Meta-analysis; Rotator cuff; Systematic review; TXA; Tranexamic acid.

Figure 1

PRISMA flow diagram of the systematic search process detailing article identification, screening, eligibility and inclusion steps. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Summary charts for the risk of bias assessments for all included RCTs in all 5 different domains across all studies. RCT, randomized controlled trial.

Figure 3

Summary of the GRADE assessments for all 7 primary pooled outcomes and risk ratings for the studies included within each outcome. Explanations for grades of evidence and most serious risk classifications are shown below the GRADE table. GRADE, Grading of Recommendations, Assessment, Development and Evaluation.

Figure 4

Forest plots from the TXA vs. no TXA main analysis for visual analog scale (VAS) for pain at postoperative day 1. TXA, Tranexamic acid; VAS, Visual analog scale; WMD, weighted mean difference; CI, confidence interval.

Figure 5

Forest plots from the TXA vs. no TXA main analysis for calculated operative time. TXA, Tranexamic acid; WMD, weighted mean difference; CI, confidence interval.

Figure 6

Forest plot from the TXA vs. no TXA main analysis for image quality score for visual clarity. TXA, Tranexamic acid; WMD, weighted mean difference; CI, confidence interval.

Figure 7

Forest plot from the TXA vs. no TXA main analysis for visual clarity grade 1. TXA, Tranexamic acid; WMD, weighted mean difference; CI, confidence interval.

Figure 8

Forest plot from the TXA vs. no TXA main analysis for visual clarity grade 3. TXA, Tranexamic acid; WMD, weighted mean difference; CI, confidence interval.

Figure 9

Forest plot from the TXA vs. no TXA main analysis for postoperative shoulder swelling. TXA, Tranexamic acid; WMD, weighted mean difference; CI, confidence interval.