Tranexamic acid use in total shoulder arthroplasty continues to increase and is safe in high-risk patients

Abstract

Background: Tranexamic acid (TXA) is increasingly utilized in total shoulder arthroplasty (TSA) to minimize blood loss. Despite its benefits, concerns persist regarding its use in patients at elevated risk of postoperative venous thromboembolism (VTE). This study evaluates trends in TXA use and assesses its safety in both general and high-risk patient populations.

Methods: Patients who underwent primary, elective anatomic TSA, and reverse TSA from January 1st, 2016, to December 31st, 2020, were identified using the Premier database. TXA use trends and the proportion of patients requiring blood transfusions were reported. Patients were divided on the basis of having received TXA on the day of surgery or not. To account for confounding variables, a propensity score was generated for the probability of treatment with TXA. A subanalysis of high-risk patients, defined as those with a history of VTE, was performed using multivariable regression analyses. Endpoints included the 90-day risk of pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion.

Results: In total, 86,356 patients underwent TSA from 2016 to 2020. Of these, 41,380 (47.9%) received TXA, and 44,976 (52.1%) did not. After matching, 28,232 received TXA, and 28,232 did not. The use of TXA increased from 33.4% in 2016 to 60.3% in 2020. The rates of transfusion decreased from 1.05% to 0.47%. Following matching, the risk of all thromboembolic complications (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.72-1.33, P = .874), DVT (OR: 1.11, 95% CI: 0.71-1.71, P = .655), and PE (OR: 0.87, 95% CI: 0.56-1.33, P = .513) were similar between cohorts. The high-risk cohort comprised 4757 patients with a history of VTE, of which 1850 (38.9%) received TXA, and 2907 (61.1%) did not. The use of TXA for high-risk patients increased from 27.4% to 52.0% while rates of transfusion decreased from 1.76% to 0.70%. Following multivariable regression, there was similar risk of all thromboembolic complications (adjusted OR [aOR]: 0.77, 95% CI: 0.47-1.28, P = .316), DVT (aOR: 0.96, 95% CI: 0.39-2.36, P = .92), and PE (aOR: 0.54, 95% CI: 0.23-1.28, P = .163) between high-risk cohorts.

Discussion: TXA in shoulder arthroplasty usage has nearly doubled from 2016 to 2020 and is now administered to 60% of all patients. This rise in TXA use has been coupled with a significant decrease in the risk of blood transfusion. Patients receiving TXA were not at increased risk of thromboembolic, infectious, epileptogenic, surgical, and medical complications even if they had a history of VTE.

Keywords: Total shoulder arthroplasty; deep vein thrombosis; hematoma; pulmonary embolism; tranexamic acid; venous thromboembolism.