The efficacy of tranexamic acid in primary anatomic and reverse total shoulder arthroplasty: A systematic review and meta-analysis of level I randomized controlled trials

Purpose: The purpose of this study was to systematically review the available level I evidence regarding the impact of tranexamic acid (TXA) on early postoperative outcomes in patients undergoing anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). Methods: A systematic review of the literature through April 2023 was performed to identify level I RCTs examining the use of TXA at the time of primary TSA or RTSA. Results: Among 5 included studies, a total of 435 patients (219 TXA, 216 control) were identified. Superior hematologic outcomes were observed among the TXA cohort, including lower 24-hour drain output (MD −112.70 mL: p < 0.001), lower pre- to postoperative change in hemoglobin (MD: −0.68 g/dL, p < 0.001), and less total perioperative blood loss (MD: −249.56 mL, p < 0.001). Postoperative Visual Analog Scale for pain (VAS-pain) scores were lower in the TXA group, but not significantly (MD: −0.46, p = 0.17). Postoperative blood transfusion was required in 3/219 TXA patients (1.4%) and 7/216 control patients (3.2%) (RR: 0.40, p = 0.16). Conclusion: Perioperative TXA reduces drain output and total blood loss without increasing the risk of adverse events. TXA was not shown to decrease postoperative transfusion rates when compared to placebo controls. Level of Evidence: Level I, meta-analysis.