Utilization and Real-World Effectiveness of Tranexamic Use in Shoulder Arthroplasty

A Population-Based Study

Shawn G. Anthony, MD, MBA; Diana C. Patterson, MD; Paul J. Cagle, Jr, MD; Jashvant Poeran, MD, PhD; Nicole Zubizarreta, MPH; Madhu Mazumdar, PhD; Leesa M. Galatz, MD


J Am Acad Orthop Surg. 2019;27(19):736-742. 

In This Article

Abstract and Introduction


Introduction: Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty, but limited data exist for its effectiveness in patients undergoing shoulder arthroplasty. We aimed to use national data to assess the frequency of use and effectiveness of TXA in patients undergoing shoulder arthroplasty.

Methods: Using national claims data from patients undergoing shoulder arthroplasty (Premier Healthcare; 2010 to 2016; n = 82,512; 429 hospitals), we categorized patients according to whether they received perioperative TXA. Multilevel multivariable regression models measured associations between TXA and blood transfusion risk, combined complications (including thromboembolic events, acute renal failure, cerebral infarction, and acute myocardial infarction), and length and cost of hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

Results: Overall, TXA was used in 12.8% (n = 10,582) of patients with a strong increasing trend. After adjustment for relevant covariates, TXA use (compared with no TXA use) was associated with a 36% decrease in transfusion risk (OR, 0.64; 95% CI, 0.52 to 0.77; P < 0.05) and a 35% decreased risk for combined complications (OR, 0.65; 95% CI, 0.50 to 0.83; P < 0.05). Moreover, TXA use was associated with 6.2% shorter hospital stay (95% CI, −8.0% to −4.4%; P < 0.05), whereas no difference was observed with the cost of hospitalization.

Conclusion: In this first large-scale study assessing TXA use and effectiveness in patients undergoing shoulder arthroplasty, we found that although TXA utilization is still low, it is associated with a marked decrease in transfusion risk with no increases in complication risk. Effects on the length and cost of hospitalization appeared minor. Future studies should assess whether higher volumes of TXA utilization would translate into more gains on the length and cost of hospitalization.

Level of Evidence: Level III


The demand for total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RTSA) continues to increase rapidly because of an aging population, an increasing life expectancy, good outcomes, and broader indications for reverse arthroplasty.[1] With this comes the risk for an increase in postoperative complications, particularly major bleeding and its associated comorbidities. The impact of blood loss in shoulder arthroplasty has been extensively reported in previous orthopaedic literature.[2–4] Complications relating to blood loss range from postoperative hematoma to the need for allogeneic blood transfusion.[4–6] Rates of blood transfusion following TSA range from 7.4% to 43% in the literature;[2,3,5,6] in general, RTSA is an additional risk factor for transfusion[1–3,5,7] and higher risk of postoperative hematoma, which ranges from 1% to 20% in previous studies.[7,8] The use of allogeneic blood transfusions after orthopaedic surgery, particularly total hip and knee arthroplasty (THA and TKA), has been associated with a greater risk of surgical site infections.[9,10] Methods to reduce blood loss are critical to improving the safety of shoulder arthroplasty.

In many studies, tranexamic acid (TXA) has been shown to be safe and effective in reducing blood transfusion requirements in the postoperative period following a wide variety of surgical procedures.[11] This has been shown particularly in patients undergoing TKA and THA.[12–19] TXA is a synthetic derivative of the amino acid, lysine, which prevents progression of the fibrinolytic pathway by competitively inhibiting the activation of plasmin by plasminogen, thereby stabilizing clot formation.[11,20] Despite its widespread use in THA and TKA as well as spine and cardiac surgery, its use has not been widely established or studied in TSA. This may be because (1) TSA/RTSA procedures have not historically been performed with such frequency, and thus, the issue of transfusion was not realized to be significant; (2) the risks of the medication itself; and (3) the changing health care landscape in general in which complication rates and medical costs are being watched with ever-increasing scrutiny. Although rare, commonly mentioned complications of TXA include allergic reactions or complications secondary to its hypercoagulable properties, such as deep vein thrombosis (DVT), pulmonary embolism (PE), acute myocardial infarction, or cerebral infarction. Indeed, a few small studies have shown it to be safe and effective in reducing blood loss, transfusion requirement, and other complications.[20–24]

This study identifies (1) the current utilization rate of TXA in TSA and RTSA procedures in the United States and (2) the effectiveness of TXA use in reducing the rate of blood transfusions in the postoperative period and other associated complications. We hypothesized that TXA use in TSA would lead to reduced risks of transfusion, lower complication rate, and shorter hospital stay.