Advertisement

Tranexamic Acid Administration in Arthroscopic Surgery Is a Safe Adjunct to Decrease Postoperative Pain and Swelling: A Systematic Review and Meta-analysis

Published:October 13, 2021DOI:https://doi.org/10.1016/j.arthro.2021.10.001

      Purpose

      To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications.

      Methods

      In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model.

      Results

      There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: –1.65, 95% confidence interval [CI] –3.41 to 0.10, P = .06, I2 = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I2 = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: –61.14 mL, 95% CI –104.43 to –17.85, I2 = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: –0.76, 95% CI –0.97 to –0.54, I2 = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI –3.43 to 4.50, I2 = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups.

      Conclusions

      This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery.

      Level of Evidence

      II.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Okamoto S.
        • Sato S.
        • Takada Y.
        • Okamoto U.
        An active stereo-isomer (trans-form) of amcha and its antifibrinolytic (anti-plasminic) action in vitro and in vivo.
        Keio J Med. 1964; 13: 177-185
        • Coats T.J.
        Tranexamic acid: There’s new life in the old drug.
        Emerg Med J. 2016; 33: 524
        • Tengborn L.
        • Blombäck M.
        • Berntorp E.
        Tranexamic acid—An old drug still going strong and making a revival.
        Thromb Res. 2015; 135: 231-242
        • Chauncey J.M.
        • Wieters J.S.
        Tranexamic Acid-StatPearls-NCBI Bookshelf. StatsPearls Publishing.
        (Published 2019. Accessed July 21, 2020)
        • Henry D.A.
        • Carless P.A.
        • Moxey A.J.
        • et al.
        Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion.
        in: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd., New York2011
        • Shakur H.
        • Elbourne D.
        • Gülmezoglu M.
        • et al.
        The WOMAN Trial (World Maternal Antifibrinolytic Trial): Tranexamic acid for the treatment of postpartum haemorrhage: An international randomised, double blind placebo controlled trial.
        Trials. 2010; 11: 40
        • Dunn C.J.
        • Goa K.L.
        Tranexamic acid: A review of its use in surgery and other indications.
        Drugs. 1999; 57: 1005-1032
        • McCormack P.L.
        Tranexamic acid: A review of its use in the treatment of hyperfibrinolysis.
        Drugs. 2012; 72: 585-617
        • Chang R.
        • Holcomb J.B.
        • Leibner E.
        • Pommerening M.
        • Kozar R.A.
        Hemostasis, Surgical Bleeding, and Transfusion.
        in: Brunicardi F.C. Andersen D.K. Billiar T.R. Schwartz’s principles of surgery. 11th ed. McGraw-Hill Education, New York, NY2019
        • Zehnder J.L.
        Drugs Used in Disorders of Coagulation.
        in: Katzung B.G. Basic & Clinical Pharmacology. 14th ed. McGraw-Hill Education, New York, NY2017
        • Mielke R.T.
        • Obermeyer S.
        The use of tranexamic acid to prevent postpartum hemorrhage.
        J Midwifery Womens Health. 2020; 65: 410-416
        • Nugent M.
        • May J.H.
        • Parker J.D.
        • et al.
        Does tranexamic acid reduce knee swelling and improve early function following arthroscopic meniscectomy? a double-blind randomized controlled trial.
        Orthop J Sport Med. 2019; 7: 1-7
        • Busse J.W.
        • Craigie S.
        • Juurlink D.N.
        • et al.
        Guideline for opioid therapy and chronic noncancer pain.
        CMAJ. 2017; 189: E659-E666
        • Goesling J.
        • Moser S.E.
        • Zaidi B.
        • et al.
        Trends and predictors of opioid use after total knee and total hip arthroplasty.
        Pain. 2016; 157: 1259-1265
        • Pande A.
        • Bhaskarwar A.P.
        Assessing the effect of per operative intravenous injection of tranexamic acid in patients undergoing arthroscopic anterior cruciate ligament reconstruction.
        Int J Res Orthop. 2019; 5: 639
        • Institute of Medicine
        Finding What Works in Health Care: Standards for Systematic Reviews. 2011.
        (Accessed April 15, 2020)
        • Kung J.
        From systematic reviews to clinical recommendations for evidence-based health care: Validation of Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) for Grading of Clinical Relevance.
        Open Dent J. 2010; 4: 84-91
        • Higgins J.
        Chapter 8: Assessing risk of bias in a randomized trial | Cochrane Training.
        • Poehling G.
        • Jenkins C.
        Levels of evidence and your therapeutic study: What’s the difference with cohorts, controls, and cases?.
        Arthroscopy. 2004; 20: 563
      1. Wright J. Levels of evidence and grades of recommendations: An evaluation of literature. American Academy of Orthopaedic Surgeons, 2005.

        • McHugh M.L.
        Interrater reliability: The kappa statistic.
        Biochem Medica. 2012; 22: 276-282
        • Karaaslan F.
        • Seijas R.
        • Sallent A.
        • et al.
        Tranexamic acid in bolus alone vs bolus and continuous infusion in hip arthroscopy.
        Int J Orthop. 2017; 4: 749-752
        • Mantel N.
        • Haenszel W.
        Statistical aspects of the analysis of data from retrospective studies of disease.
        J Natl Cancer Inst. 1959; 22: 719-748
        • Karaaslan F.
        • Karaoʇlu S.
        • Yurdakul E.
        Reducing intra-articular hemarthrosis after arthroscopic anterior cruciate ligament reconstruction by the administration of intravenous tranexamic acid.
        Am J Sports Med. 2015; 43: 2720-2726
        • Chiang E.R.
        • Chen K.H.
        • Wang S.T.
        • et al.
        Intra-articular injection of tranexamic acid reduced postoperative hemarthrosis in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized study.
        Arthroscopy. 2019; 35: 2127-2132
        • Liu Y.F.
        • Hong C.K.
        • Hsu K.L.
        • et al.
        Intravenous administration of tranexamic acid significantly improved clarity of the visual field in arthroscopic shoulder surgery. A prospective, double-blind, and randomized controlled trial.
        Arthroscopy. 2020; 36: 640-647
        • Felli L.
        • Revello S.
        • Burastero G.
        • et al.
        Single Intravenous administration of tranexamic acid in anterior cruciate ligament reconstruction to reduce postoperative hemarthrosis and increase functional outcomes in the early phase of postoperative rehabilitation: A randomized controlled trial.
        Arthroscopy. 2019; 35: 149-157
        • Coupens S.D.
        • Yates C.K.
        The effect of tourniquet use and hemovac drainage on postoperative hemarthrosis.
        Arthroscopy. 1991; 7: 278-282
        • Collins N.J.
        • Misra D.
        • Felson D.T.
        • Crossley K.M.
        • Roos E.M.
        Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee O.
        Arthritis Care Res (Hoboken). 2011; 63: S208-S228
        • Small N.C.
        Complications in arthroscopic surgery performed by experienced arthroscopists.
        Arthroscopy. 1988; 4: 215-221
        • Bahl V.
        • Goyal A.
        • Jain V.
        • Joshi D.
        • Chaudhary D.
        Effect of haemarthrosis on the rehabilitation of anterior cruciate ligament reconstruction-single bundle versus double bundle.
        J Orthop Surg Res. 2013; 8: 5
        • Spencer J.D.
        • Hayes K.C.
        • Alexander I.J.
        Knee joint effusion and quadriceps reflex inhibition in man.
        Arch Phys Med Rehabil. 1984; 65: 171-177
        • Seijas R.
        • Espinosa W.
        • Sallent A.
        • Cuscó X.
        • Cugat R.
        • Ares O.
        Comparison of pre- and postoperative hemoglobin and hematocrit levels in hip arthroscopy.
        Open Orthop J. 2015; 9: 432-436
        • Shin J.J.
        • McCrum C.L.
        • Mauro C.S.
        • Vyas D.
        Pain management after hip arthroscopy: Systematic review of randomized controlled trials and cohort studies.
        Am J Sports Med. 2018; 46: 3288-3298
        • Kelly A.
        The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain.
        Emerg Med J. 2001; 18: 205-207
        • Bodian C.A.
        • Freedman G.
        • Hossain S.
        • Eisenkraft J.B.
        • Beilin Y.
        The visual analog scale for pain: Clinical significance in postoperative patients.
        Anesthesiology. 2001; 95: 1356-1361
      2. McKesson Canada. https://www.mckesson.ca/. Accessed July 24, 2020.

        • Bohensky M.A.
        • Ademi Z.
        • deSteiger R.
        • et al.
        Quantifying the excess cost and resource utilisation for patients with complications associated with elective knee arthroscopy: A retrospective cohort study.
        Knee. 2014; 21: 491-496
      3. World Health Organziation Model List of Essential Medicines 21st List.
        (Published 2019. Accessed September 10, 2020)
      4. Cyklokapron product monograph. Pfizer Canada Inc., Quebec2018
        • McLean M.
        • McCall K.
        • Smith I.D.M.
        • et al.
        Tranexamic acid toxicity in human periarticular tissues.
        Bone Joint Res. 2019; 8: 11-18
        • Goderecci R.
        • Giusti I.
        • Necozione S.
        • et al.
        Short exposure to tranexamic acid does not affect, in vitro, the viability of human chondrocytes.
        Eur J Med Res. 2019; 24: 15
        • Ambra L.F.
        • de Girolamo L.
        • Niu W.
        • Phan A.
        • Spector M.
        • Gomoll A.H.
        No effect of topical application of tranexamic acid on articular cartilage.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 931-935
        • Buchko J.Z.
        • Gurney-Dunlop T.
        • Shin J.J.
        Knee chondrolysis by infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter after arthroscopic ACL reconstruction.
        Am J Sports Med. 2015; 43: 337-344
        • Martimbianco A.L.C.
        • Gomes da Silva B.N.
        • de Carvalho A.P.V.
        • Silva V.
        • Torloni M.R.
        • Peccin M.S.
        Effectiveness and safety of cryotherapy after arthroscopic anterior cruciate ligament reconstruction. A systematic review of the literature.
        Phys Ther Sport. 2014; 15: 261-268
        • Kuo L.T.
        • Chen C.L.
        • Yu P.A.
        • Hsu W.H.
        • Chi C.C.
        • Yoo J.C.
        Epinephrine in irrigation fluid for visual clarity in arthroscopic shoulder surgery: A systematic review and meta-analysis.
        Int Orthop. 2018; 42: 2881-2889
        • Van Montfoort D.O.
        • Van Kampen P.M.
        • Huijsmans P.E.
        Epinephrine diluted saline-irrigation fluid in arthroscopic shoulder surgery: A significant improvement of clarity of visual field and shortening of total operation time. a randomized controlled trial.
        Arthroscopy. 2016; 32: 436-444
      5. Avery DM, Gibson BW, Carolan GF. Surgeon-rated visualization in shoulder arthroscopy: A randomized blinded controlled trial comparing irrigation fluid with and without epinephrine. Arthroscopy 22015;31:12-18.

        • Jensen K.H.
        • Werther K.
        • Stryger V.
        • Schultz K.
        • Falkenberg B.
        Arthroscopic shoulder surgery with epinephrine saline irrigation.
        Arthroscopy. 2001; 17: 578-581
        • Belk J.W.
        • McCarty E.C.
        • Houck D.A.
        • Dragoo J.L.
        • Savoie F.H.
        • Thon S.G.
        Tranexamic acid use in knee and shoulder arthroscopy leads to improved outcomes and fewer hemarthrosis-related complications: A systematic review of level I and II studies.
        Arthroscopy. 2021; 37: 1323-1333