Systematic reviews on tranexamic acid in shoulder arthroplasty frequently exhibit reporting bias

Tranexamic acid (TXA) is increasingly used in total shoulder arthroplasty to minimize perioperative blood loss; however, the quality and objectivity of evidence supporting its use remain uncertain. Systematic reviews and meta-analyses are critical for informing clinical practice, but their conclusions can be affected by reporting bias-particularly spin, which may distort study findings and mislead clinical decision-making. Despite the rising interest in TXA for total shoulder arthroplasty, the extent to which spin is present in this body of literature has not been evaluated. Therefore, the purpose of this study was to analyze reporting bias in the form of spin present in systematic reviews and meta-analyses related to TXA use in shoulder arthroplasty.

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, systematic reviews were collected from PubMed, Scopus, and Embase using the search "Shoulder Arthroplasty" AND "Tranexamic Acid" OR "TXA" AND "systematic review" OR "meta-analysis" in March of 2025. A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) was used to evaluate the quality of the studies. Associations between these factors and spin presence or type were determined using statistical tests, including t-tests, one-way analysis of variance, Fisher tests, and Spearman's rank coefficients.

The initial database search identified 72 studies, of which 31 duplicates were removed. Twenty-one additional studies were removed after title and abstract screening, and 5 more were removed during full-text screening because they did not meet the inclusion criteria. Spin was present in 12 out of the 15 remaining study abstracts (80.0%), all of which were determined to contain misleading reporting, and 10 (66.7%) of which were also found to contain misleading interpretation. Furthermore, 12 of the 15 reviews (80.0%) received a critically low AMSTAR 2 confidence rating.

The majority of systematic reviews on TXA use in shoulder arthroplasty received critically low AMSTAR 2 ratings, reflecting the poor quality of evidence in this area. This analysis highlights the widespread occurrence of spin and low-quality evidence in TXA use in shoulder arthroplasty reviews, underscoring the importance of critical evaluation and improved research quality.