Impact of tranexamic acid on clinical and hematologic outcomes following total shoulder arthroplasty

Abstract

Background

The purpose of this study is to evaluate the impact of intravenous tranexamic acid on clinical and hematologic outcomes after total shoulder arthroplasty.

Methods

Retrospective review was conducted for 282 consecutive patients undergoing either anatomic shoulder arthroplasty or reverse total shoulder arthroplasty. Univariate analysis and multivariate linear regression were used to compare outcomes for patients receiving intravenous tranexamic acid with those who did not.

Results

Of the 282 patients included in this study, 78 patients received intravenous tranexamic acid and 204 did not. Patients who received intravenous tranexamic acid had significantly lower pre- to postoperative change in hemoglobin and hematocrit, and decreased postoperative drain output. In addition, patients receiving intravenous tranexamic acid were significantly less likely to have a postoperative hematocrit <30. There were no significant differences in length of stay, rate of 30 day hematoma, surgical site infection, deep vein thrombosis, or readmission between groups.

Conclusion

Intravenous tranexamic acid is associated with a significant reduction in change in hematocrit and hemoglobin and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, tranexamic acid appears to have little impact on clinical outcomes such as length of stay and 30-day complication rates.

Keywords

Tranexamic acid total shoulder arthroplasty reverse shoulder arthroplasty blood loss length of stay complications

Introduction

The volume of anatomic total shoulder arthroplasties (TSAs) and reverse total shoulder arthroplasties (RTSAs) performed in the United States has been steadily increasing in recent years.^1,2 From 2011 to 2017 the number of primary TSAs performed per year increased by 103.7% making this procedure the fastest growing joint arthroplasty surgery in the US.² Although patient satisfaction rates for shoulder arthroplasty are relatively high,³ these procedures are not without risk of complications. Both TSA and RTSA are associated with risk of significant blood loss, with rates of allogenic blood transfusion ranging from 11.3% to 43%.^4,5 Blood transfusions are associated with several complications such as allergic reactions, immunosuppression, infection, and transfusion-related cardiopulmonary injury.⁶ In addition, patients who receive a transfusion are more likely to experience medical complications including sepsis, pneumonia, myocardial infarction, and venous thromboembolic events. For orthopedic patients, the circumstances leading to requirement for perioperative blood transfusions are associated with increased risk of periprosthetic infections, periprosthetic fractures, and mechanical complications up to two years after surgery.⁷ Tranexamic acid (TXA) has emerged in recent years as a tool to reduce perioperative blood loss, and is increasingly being used across a variety of orthopedic procedures.^8,9 TXA is a synthetic antifibrinolytic agent that competitively inhibits the lysine binding site on plasminogen thus preventing the conversion of plasminogen to plasmin.¹⁰ This inhibition stabilizes blood clots by preventing fibrin degradation. Recent studies have demonstrated significant reduction in perioperative blood loss and risk of blood transfusion in anatomic TSA and RTSA using TXA.^11,12

Although the impact of TXA on hematologic outcomes following shoulder arthroplasty has been previously studied, the impact on clinical outcomes such as length of stay (LOS), surgical site infection (SSI), deep vein thrombosis (DVT), and 30-day readmission is not well understood. The purpose of this study is to evaluate whether patients receiving intravenous TXA at the time of surgery demonstrate superior clinical and hematologic outcomes postoperatively than patients not receiving TXA.

Materials and methods

The institutional clinical research committee deemed this study institutional review board exempt. A retrospective chart review of patients undergoing elective primary anatomic or reverse total shoulder arthroplasty at a single institution was performed. Data were collected using an administrative database (age, sex, body mass index (BMI), LOS, and procedure performed), supplemented with manual chart review. Preoperative blood values (hematocrit (HCT) and hemoglobin (Hgb)) within 30 days before surgery and on postoperative day 1 were recorded and used to calculate the change in these labs from pre- to postoperatively. Estimated intraoperative blood loss and postoperative drain output were also recorded. American Society of Anesthesiologist Score (ASA) was used to quantify preoperative health status.

Perioperative protocol

All procedures were performed at a single institution. There were eight board certified orthopedic surgeons included in this study. Of the eight surgeons, two upper extremity fellowship trained surgeons performed 252 of the 287 cases included in this study (91%). TXA was used by a single surgeon, who performed 188 total cases. TXA was first used in October 2017. After this time, it was used at surgeon discretion as routine practice. While no specific criteria for TXA use were followed, it was withheld in any patient with known hypersensitivity to TXA or a history of VTE or active thromboembolic disease. All patients received general anesthesia, and some received regional supplementation administered via interscalene or supraclavicular block. TSA and RTSA procedures were performed via the deltopectoral surgical approach with the patient in the modified beach chair/semi-fowler position. A single Hemovac drain was placed in the deep space below the deltopectoral musculature at the end of the procedure. The drain was placed on self-suction until it was removed on postoperative day 1. DVT prophylaxis varied slightly among surgeons; however, majority of patients receive mechanical compression intraoperatively and were prescribed aspirin postoperatively. All patients in the TXA group received a preoperative intravenous dose of TXA infused over 10 to 30 min prior to incision. Weight based dosing at 10 mg/kg was followed. No patients received topical TXA at the surgical site.

Study population

All patients included in this study underwent elective primary TSA or RTSA between June 2016 and November 2019. Patients undergoing revision TSA were excluded. Of the 282 patients included in this study, 78 (27.7%) patients received intravenous TXA and 204 (72.3%) did not. Of the 204 patients who did not receive TXA, 82 (40%) patients underwent an RTSA. Of the 78 patients who received intravenous TXA, 29 (37%) underwent an RTSA.

Study outcomes

The primary outcome of this study was the influence of TXA on hematologic indicators such as change in HCT and Hgb, estimated blood loss, and drain output. Secondary outcomes included clinical outcomes such as LOS and 30-day postoperative complications (transfusion, hematoma, SSI, DVT, and readmission rate). In alignment with previous studies,^13,14 change in HCT from the preoperative to postoperative period was used as the main indicator of blood loss, as this measure was routinely captured and inherently less subjective than estimated blood loss. Furthermore, we investigated the prevalence of a postoperative HCT lower than 30% as this value has been used as a possible indicator for red blood cell transfusion.⁶

Statistical analysis

Univariate analysis was performed to compare outcomes between patients receiving and not receiving TXA. Multivariate linear regression was used to assess the impact of TXA administration on the continuous outcome measures of change in pre- to postoperative HCT and LOS hours after controlling for potentially confounding factors. Multivariate regression was not performed to evaluate other clinical outcomes to avoid model overfitting due to the small number of observed instances of each endpoint. p values less than or equal to 0.05 were deemed statistically significant. All statistical analyses were performed using SPSS (SPSS 25.0, IBM Inc, Somers, NY).

Results

Of the 282 patients included in this study, 78 (27.7%) patients received intravenous TXA and 204 (72.3%) did not. Within the TXA group, the average dose was 831.7 ± 182.0 mg. TXA doses ranged from 500 to 1250 mg. There were no significant differences between age, BMI, sex, or race among the groups. Additionally, there were no significant differences in the number of reverse TSA or the number of patients receiving other hemostatic agents between groups. No differences in postoperative outcomes were observed between patients undergoing TSA and RTSA, with the exception of postoperative drain output, which was lower in the RTSA group (Supplementary Appendix). There were significantly more patients with an ASA score ≥ 3 in the group of patients who did not receive TXA (no TXA 55.4% vs. TXA 29.5%, p < 0.001; Table 1).

Table 1.

Patient demographics and clinical details.

Outcome	No TXA (n = 204)	TXA (n = 78)	p value
Demographics
Age—avg, yrs ± SD	70.3 ± 8.5	69.7 ± 7.4	0.579
BMI—avg, kg/m²± SD	31.6 ± 7.0	30.5 ± 6.2	0.246
Female, n (%)	123 (60.3)	44 (56.4)	0.553
Non-white race, n (%)	26 (12.7)	6 (7.7)	0.231
Clinical details
ASA ≥ 3, n (%)	113 (55.4)	23 (29.5)	<0.001
Reverse TSA, n (%)	82 (40.2)	29 (37.2)	0.643
Other hemostatic agent used, n (%)	114 (55.9)	47 (60.3)	0.591

ASA: American Society of Anesthesiologists Score; BMI: body mass index.

p values < 0.05 in bold.

At baseline, the average Hgb was 13.44 ± 1.51 g/dL and the average HCT was 40.28 ± 4.39%. Patients receiving TXA had a significantly lower reduction in both Hgb and HCT from the preoperative to postoperative period (Hgb: no TXA −1.88 ± 1.33 vs. TXA−0.55 ± 1.52, p = 0.022; HCT: no TXA −6.32 ± 3.31 vs. TXA −4.78 ± 3.05, p = 0.002). In addition, there were significantly less patients with a postoperative HCT less than 30 among the group who received intravenous TXA (no TXA 18.0% vs. TXA 2.7%, p = 0.001). No significant difference in estimated blood loss was observed between groups. LOS was not significantly different between groups (no TXA 39.66 ± 20.93 hrs. vs. TXA 35.60 ± 15.57 hrs., p = 0.079). In addition, there were no significant differences in rate of 30 day hematoma, SSI, DVT, and readmission (Table 2). After controlling for age, BMI, and ASA score, the use of TXA was associated with a decreased change in pre- to postoperative HCT of 1.735 units (p < 0.001) but no significant difference in LOS (Tables 3 and 4).

Table 2.

Hematologic and clinical outcomes.

Outcome	No TXA (n = 204)	TXA (n = 78)	p value
Hematologic outcomes, avg ± SD
Change Hgb	−1.88 ± 1.33	−0.55 ± 1.52	0.022
Change HCT	−6.32 ± 3.31	−4.78 ± 3.05	0.002
Postop. HCT < 30, n (%)	34 (18.0)	2 (2.7)	0.001
Estimated blood loss	171.3 ± 96.17	154.15 ± 82.15	0.305
Postop. drain output	209.85 ± 133.55	144.80 ± 92.45	0.002
Clinical outcomes
LOS hours, avg ± SD	39.66 ± 20.93	35.60 ± 15.57	0.079
Transfusion, n (%)	0 (0.0)	0 (0.0)	N/A
30-Day hematoma, n (%)	1 (0.5)	0 (0.0)	1.000*
30-Day SSI, n (%)	1 (0.5)	1 (1.3)	0.477*
30-Day DVT, n (%)	2 (1.0)	0 (0.0)	1.000*
30-Day readmission, n (%)	3 (1.5)	0 (0.0)	0.563

Hgb: hemoglobin (g/dL); HCT: hematocrit volume (%); LOS: hospital length of stay; SSI: surgical site infection; DVT: deep vein thrombosis.

Change in Hgb and HCT was calculated using only patients with both preop. and postop. lab documented (Hgb = 34, HCT = 233). p values < 0.05 in bold.

*Denotes Fisher’s exact test.

Table 3.

Multivariate linear regression analysis of pre- to postoperative change in hematocrit.

Independent variable	Unstandardized β	Std. error	Standardized β	t	p value
Age	−.033	.026	−.083	−1.283	0.201
BMI	−.073	.033	−.151	−2.230	0.027
ASA ≥ 3	−.468	.454	−.071	−1.031	0.304
TXA	−1.735	.482	−.235	−3.598	<0.001

BMI: body mass index (kg/m²); ASA: American Society of Anesthesiologists Score; TXA: tranexamic acid.

p values <0.05 in bold.

Table 4.

Multivariate linear regression analysis of length of stay hours.

Independent variable	Unstandardized β	Std. error	Standardized β	t	p value
Age	.313	.143	.131	2.196	0.029
BMI	−.301	.181	−.104	−1.668	0.097
ASA ≥ 3	4.589	2.492	.117	1.842	0.067
TXA	−2.993	2.649	−.068	−1.130	0.260

BMI: body mass index (kg/m²); ASA: American Society of Anesthesiologists Score; TXA: tranexamic acid.

p values <0.05 in bold.

Discussion

Intravenous TXA was associated with improved hematologic outcomes in our study population of patients undergoing TSA and RTSA. These outcomes included higher postoperative Hgb and HCT and less reduction in these values from the pre- to postoperative period. Postoperative drain output was also significantly lower in the TXA group. There were significantly more patients with a postoperative HCT less than 30 in the cohort that did not receive intravenous TXA. Although TXA was associated with improved hematologic outcomes, these improvements did not translate into a reduced LOS or lower risk of 30 day complications. There were no significant differences in the rate of 30 day hematoma, SSI, DVT, and readmission among groups.

Both topical and intravenous TXA have been associated with decreased blood loss in shoulder arthroplasty in several previous studies.^12,13,15,16 Abildgaard et al.¹³ conducted a retrospective analysis of 77 TSA and 94 RTSA patients with the goal of comparing blood loss of those who received intravenous TXA perioperatively with those who did not. Both TSA and RTSA patients receiving TXA experienced significantly less total blood loss and change in Hgb and HCT. Similarly, total drain output was significantly lower among patients in the TXA group. These results are in alignment with the results of our study demonstrating improved postoperative Hgb and HCT values with the use of TXA. Both studies were limited in the ability to evaluate the effect of TXA in decreasing transfusions because of the overall low rate of transfusion occurrence. Gillespie et al.¹⁶ reported specifically on the impact of topical TXA on overall blood loss and postoperative drain output and demonstrated similar favorable results. When compared to a placebo of 100 mL of normal saline, 100 mL of saline combined with 2 g of topical TXA was associated with significantly reduced postoperative drain output and change in Hgb level. The strength of our study is the analysis of the impact of TXA on important clinical outcomes such as LOS, hematoma, SSI, DVT, and readmission. Our results provide further support for the conclusion that the use of TXA in patients undergoing TSA procedures can improve hematologic outcomes during the early postoperative period but call into question whether these improvements actually translate into differences in the clinical outcomes of these patients.

Although the relationship between TXA and hematologic values has been well studied for orthopedic patients, fewer studies have investigated other clinical outcomes. Friedman et al.¹² compared 106 TSA and RTSA patients who received 20 mg/kg of intravenous TXA with 88 patients who did not. Similar to the previously discussed works, the results of our study indicated a significant reduction in both Hgb and HCT change with the use of intravenous TXA. The researchers also found a significant reduction in time spent in the recovery room and total length of hospitalization for the TXA group. Patients spent 21% less time in the recovery room and had a 16% shorter hospitalization, which contributed to cost savings for the hospital. In our population, the approximately 4 h or 10% LOS reduction observed in patients receiving TXA was not statistically significant even after controlling for potentially confounding factors, and is likely of little clinical or economic significance.

Other complications associated with TSA and RTSA are periprosthetic fracture, hematoma, infection, and venous thromboembolism.¹⁷ Reported rates of hematoma formation after shoulder arthroplasty are highly variable, ranging from 1% to as high as 20% in some studies.^17–20 Patients who undergo an RTSA may be at higher risk of developing hematoma due to increased volumetric dead space because of an absent rotator cuff.¹⁷ The rate of hematoma formation observed in the our study was lower than that of previously published studies, at 0.5% among patients who did not receive TXA and 0.0% in the TXA group. Although the TXA group did have a lower occurrence of 30-day hematoma, the difference was not significant despite the antifibrinolytic effects of TXA. A potentially confounding factor was the standard use of postoperative drains in the population, which have been demonstrated to be of mixed efficacy in patients undergoing primary TSA.^21–23 Although uncommon, hematoma formation has been shown to be an independent risk factor for infection after arthroplasty.²⁴ According to previous findings, infection after shoulder arthroplasty occurs in 0.08%²⁵ to 1.2%¹⁷ of TSA and RTSA patients. Our results indicate similar rate of SSI of 0.5% in the no TXA group and 1.3% in the TXA group. The difference among these study cohorts was not significant. Venous thromboembolism is another possible complication following arthroplasty, however it is more common when arthroplasty is performed for traumatic injury.²⁶ Bohsali et al.¹⁷ conducted a meta-analysis of 19,262 shoulders and found a VTE rate of 0.3%. In our population, we analyzed DVT specifically, and found a similarly low rate of occurrence and no difference in the rate of DVT between the no TXA and TXA groups, suggesting that the drug does not increase the risk for thrombotic complications. In an effort to capture various other complications in our study population, we examined 30-day readmission rate. The rate of 30-day readmissions was not significantly different between cohorts with 1.5% of patients who did not receive TXA being readmitted within 30 days after surgery compared to the TXA group which did not have any 30-day readmissions. These rates observed in the current study are lower than previously reported rates of readmission.²⁷ Overall, our findings do not indicate a relationship between intravenous TXA and a reduction in the occurrence of 30-day postoperative complications.

This study is not without limitations. First, it is a retrospective review conducted at a single institution. Thus, the findings may not be representative of the wider patient population. This limitation is especially notable in the current study, as all patients receiving TXA were treated by a single surgeon. It is possible that patient selection, surgeon technique, or other practice patterns confound our results. Despite this limitation, the use of patients who underwent surgery at a single institution does allow for more standardized pre-, peri-, and postoperative care, which can eliminate some confounding variables that may have impacted our results. A second limitation of this study is the relatively small sample size, and the significant difference in the number of patients who did (n = 78) and did not (n = 204) receive TXA. While a one to one ratio of TXA and non-TXA patients would be preferred to maximize power,²⁸ our study appears to be adequately powered to detect differences in the hematologic outcomes measured, as only estimated blood loss did not achieve statistical significance. Post hoc analysis of LOS indicates that the two-sided independent sample t-test performed achieved 42.5% power at α = 0.05, suggesting that the univariate evaluation of this endpoint was underpowered. However, the multivariate linear regression model for evaluating LOS achieved 83.8% power at α = 0.05, suggesting that the multivariate analysis was adequately powered. Third, while our results do suggest TXA had no impact on transfusion rates, we were unable to formally evaluate the impact of TXA on blood transfusions using statistical techniques because there were no transfusions in either study cohort. A number of previous studies have reported lower transfusion rates associated with the use of intravenous TXA.^11,12,29 However, a recent study conducted by Kissin et al.³⁰ did not find an association between the use of intravenous TXA and reduced postoperative transfusion rates for both elective and trauma indicated TSA. Future studies should further investigate the role of intravenous TXA in reducing the risk of postoperative transfusion for both anatomic and reverse TSA to address the lack of consensus in previously published literature. Fourth, similar to previous studies, ultrasound imaging was not performed unless there was suspicion of DVT. This may lead to an undetected difference in the occurrence of subclinical DVT between the cohorts.¹⁵ Future studies should use prospective, randomized, controlled, blinded studies to analyze the long-term impact of TXA on clinical complications in addition to hematologic outcomes.

Conclusion

Intravenous TXA is associated with a significant reduction in change in HCT and Hgb and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, TXA appears to have little impact on clinical outcomes such as LOS and 30-day complication rates including hematoma, infection, deep venous thrombosis, and readmission.

Supplemental Material

sj-pdf-1-sel-10.1177_17585732211023053 - Supplemental material for Impact of tranexamic acid on clinical and hematologic outcomes following total shoulder arthroplasty

Supplemental material, sj-pdf-1-sel-10.1177_17585732211023053 for Impact of tranexamic acid on clinical and hematologic outcomes following total shoulder arthroplasty by McKayla Kelly, Justin Turcotte, M Brook Fowler, Michaline West, Cyrus Lashgari and Jeffrey Gelfand in Shoulder & Elbow

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

This study was deemed Institutional Review Board exempt by the Institutional Clinical Research Committee (IRBNet ID 1537763-1).

Guarantor

MK.

Contributorship

MK and JT contributed to the data analysis and writing of the manuscript. BF and MW contributed to the protocol development and chart review. CL and JG conceived the study and contributed to the writing of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

ORCID iD

McKayla Kelly

Supplemental material

Supplemental material for this article is available online.

References

Kim

Wise

Zhang

, et al. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am 2011; 93: 2249–2254.

Wagner

Farley

Higgins

, et al. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. J Shoulder Elbow Surg 2020; 29: 2601–2609.

Norris

Iannotti

. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg 2002; 11: 130–135.

Ahmadi

Lawrence

Sahota

, et al. The incidence and risk factors for blood transfusion in revision shoulder arthroplasty: our institution's experience and review of the literature. J Shoulder Elbow Surg 2014; 23: 43–48.

Gruson

Accousti

Parsons

, et al. Transfusion after shoulder arthroplasty: an analysis of rates and risk factors. J Shoulder Elbow Surg 2009; 18: 225–230.

Carson

Grossman

Kleinman

, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med 2012; 157: 49–58.

Grier

Bala

Penrose

, et al. Analysis of complication rates following perioperative transfusion in shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26: 1203–1209.

Cai

Ribkoff

Olson

, et al. The many roles of tranexamic acid: an overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol 2020; 104: 79–87.

Lin

Woolf

. Safety, efficacy, and cost-effectiveness of tranexamic acid in orthopedic surgery. Orthopedics 2016; 39: 119–130.

10.

McCormack

. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs 2012; 72: 585–617.

11.

Alshryda

Sukeik

Sarda

, et al. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J 2014; 96-b: 1005–1015.

12.

Friedman

Gordon

Butler

, et al. Tranexamic acid decreases blood loss after total shoulder arthroplasty. J Shoulder Elbow Surg 2016; 25: 614–618.

13.

Abildgaard

McLemore

Hattrup

. Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2016; 25: 1643–1648.

14.

Kim

Jung

Kim

, et al. Effect of tranexamic acid on hematologic values and blood loss in reverse total shoulder arthroplasty. Biomed Res Int 2017; 2017: Article ID 9590803. DOI: 10.1155/2017/9590803.

15.

Vara

Koueiter

Pinkas

, et al. Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial. J Shoulder Elbow Surg 2017; 26: 1383–1389.

16.

Gillespie

Shishani

Joseph

, et al. Neer Award 2015: a randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty. J Shoulder Elbow Surg 2015; 24: 1679–1684.

17.

Bohsali

Bois

Wirth

. Complications of shoulder arthroplasty. J Bone Joint Surg Am 2017; 99: 256–269.

18.

Cuff

Pupello

Virani

, et al. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am 2008; 90: 1244–1251.

19.

Boileau

Watkinson

Hatzidakis

, et al. Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg 2006; 15: 527–540.

20.

Werner

Steinmann

Gilbart

, et al. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005; 87: 1476–1486.

21.

Frye

Hannon

Santoni

, et al. Drains are not beneficial in primary shoulder arthroplasty. Orthopedics 2019; 42: e29–e31.

22.

Trofa

Paulino

Munoz

, et al. Short-term outcomes associated with drain use in shoulder arthroplasties: a prospective, randomized controlled trial. J Shoulder Elbow Surg 2019; 28: 205–211.

23.

Chan

Cirino

Huang

, et al. Drain use is associated with increased odds of blood transfusion in total shoulder arthroplasty: a population-based study. Clin Orthop Relat Res 2019; 477: 1700–1711.

24.

Cheung

Sperling

Cofield

. Infection associated with hematoma formation after shoulder arthroplasty. Clin Orthop Relat Res 2008; 466: 1363–1367.

25.

Smucny

Menendez

Ring

, et al. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015; 24: 747–753.

26.

Navarro

Inacio

Burke

, et al. Risk of thromboembolism in shoulder arthroplasty: effect of implant type and traumatic indication. Clin Orthop Relat Res 2013; 471: 1576–1581.

27.

Westermann

Anthony

Duchman

, et al. Incidence, causes and predictors of 30-day readmission after shoulder arthroplasty. Iowa Orthop J 2016; 36: 70–74.

28.

Kim

Park

. More about the basic assumptions of t-test: normality and sample size. Korean J Anesthesiol 2019; 72: 331–335.

29.

Box

Tisano

Khazzam

. Tranexamic acid administration for anatomic and reverse total shoulder arthroplasty: a systematic review and meta-analysis. JSES Open Access 2018; 2: 28–33.

30.

Kissin E, Al-Tawil K, Tavakkolizadeh A, et al. Impact of intravenous tranexamic acid on patients undergoing shoulder arthroplasty surgery. Shoulder Elbow. Epub ahead of print 2020. DOI: 10.1177/1758573220970907.

Supplementary Material

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