Use of Tranexamic Acid Reduces Opioid Consumption After Arthroscopic Rotator Cuff Repair

Abstract

Background: Tranexamic acid (TXA) is an anti-fibrinolytic agent that has effectively reduced transfusion risk and minimized blood loss after total joint arthroplasty. TXA use has had mixed results on postoperative pain after arthroscopic rotator cuff repair (ARCR). The purpose of this prospective, double-blind, randomized, controlled trial was to examine the impact of TXA on prescription opioid consumption for three postoperative days in an outpatient population after ARCR. Intraoperative visualization and postoperative pain scores also were collected.

Methods: Patients scheduled to have ARCR with one surgeon at one institution were eligible for inclusion in a prospective, double-blind, randomized, and placebo-controlled trial comparing a cohort receiving intravenous (IV) administration of TXA 1,000 mg with a cohort receiving an equivalent volume of IV saline. The primary outcome was opioid consumption as measured by morphine milligram equivalents (MME) for the first 3 days after surgery. Secondary outcome was subjective measurement of pain as measured by the visual analog scale (VAS) for the first 3 days after surgery.

Results: A total of 165 patients were enrolled, with 82 patients in the TXA group and 81 in placebo after two exclusions. No significant differences between groups were found for age, race, sex, size of rotator cuff tear, number of anchors used, or modifiable risk factors including preoperative opioid use and smoking tobacco status. TXA use independently reduced opioid consumption significantly for the first 3 days after ARCR by 18 MME [β=-18.0 (-35.4, -0.5), p=0.044]. Age also affected opioid use, with older patients consuming slightly less opioid than younger patients per year of age [β=-1.5 (-2.5, -0.5), p=0.003]. Factors that significantly increased opioid use included prior opioid use [β=64.2 (32.0, 96.3), p<0.001] and increasing number of anchors used (per anchor, [β=7.9 (4.0, 11.7), p<0.001].

Conclusion: TXA use significantly reduced opioid consumption after ARCR. Advancing age modulated postoperative opioid consumption, whereas preoperative opioid use and number of anchors used increased opioid consumption in the first 3 days after ARCR. No differences were found in subjective pain score as measured by VAS for the first 3 days after ARCR.

Keywords: Level of Evidence: Level I; Randomized Controlled Trial; TXA; Treatment Study; VAS; arthroscopic rotator cuff repair; opioid consumption; outpatient ARCR; postoperative pain control; shoulder arthroscopy; tranexamic acid.