Tranexamic acid in shoulder surgery: a comprehensive review of efficacy, safety, and clinical use

Tranexamic acid (TXA) is an antifibrinolytic agent used to reduce perioperative blood loss across surgical disciplines, including orthopedics. The well-established efficacy of TXA in hip and knee arthroplasty has contributed to growing interest and utilization in shoulder surgery. This narrative review highlights the current evidence on TXA use in orthopedic shoulder procedures.

A comprehensive literature review was performed using PubMed, ClinicalKey, and Google Scholar. Search terms included 'tranexamic acid', 'TXA', 'shoulder surgery', 'total shoulder arthroplasty (TSA)', 'arthroscopic shoulder surgery', 'rotator cuff repair', and 'proximal humerus fracture'. Articles published between January 1990 and June 2025 were considered. Outcomes of interest included blood loss, transfusion rate, drain output, postoperative hemoglobin change, pain scores, visualization quality, and complication rates. Pharmacokinetic literature and studies of TXA in orthopedic and trauma surgery were also reviewed to give context for safety profile and commonly used administration protocols.

Current evidence demonstrates that TXA reduces total blood loss, postoperative hemoglobin drop, and drain output in anatomic and reverse TSA. Additional benefits reported include reduced length of hospitalization and improved pain scores. Randomized controlled trials, limited by sample size, have yet to report a statistically significant reduction in transfusion rate following TSA. In arthroscopic procedures, bleeding is not typically clinically significant but impairs visualization. Several randomized controlled trials and meta-analyses have investigated TXA's impact on visual clarity, operative time, and postoperative pain. While some evidence points to modest improvements in visualization and reductions in operative time, these findings are not uniformly consistent. In shoulder trauma, specifically surgical management of proximal humerus fractures, TXA has been shown to reduce intraoperative blood loss, hemoglobin drop, and drain output. Complication rates for TXA are exceedingly low. Across multiple large-scale studies, including of high-risk patients with a history of thromboembolism, TXA did not increase rates thromboembolic events, myocardial infarction, stroke, or seizure. TXA is primarily renally excreted, so caution is advised in patients with end-stage renal disease.

TXA is safe and effective for reducing perioperative blood loss in orthopedic shoulder surgery. TXA may offer additional benefits of improved postoperative pain, improved surgical field visualization, and shorter operative time.