The effect of tranexamic acid and epinephrine on visual clarity during arthroscopic shoulder surgery: A meta-analysis of RCTs

Introduction: Visual clarity in arthroscopic rotator cuff repair is essential to reduce the operative time and for efficiency of repair. Tranexamic acid (TXA) in open shoulder surgery has been shown to reduce blood loss but its use in shoulder arthroscopy for rotator cuff repair for improved clarity is not understood. The purpose of this SR is to determine the effect of TXA and epinephrine on visual clarity in shoulder arthroscopy for rotator cuff repair. Hypothesis: We hypothesise that visual clarity should improve in those that have TXA compared to those who do not receive TXA. Methods: A review of the online databases MEDLINE and Embase was conducted on 8th October 2022 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Randomised clinical trials reporting visual clarity and/or, operative time, volume of irrigation fluid used and mean arterial pressure were included. The studies were appraised using the CONSORT tool. Results: Seven studies met eligible criteria, all of which were double-blinded RCTs. Five studies reported no difference in visual clarity between TXA vs. saline, while two reported a significant improvement with TXA. Pooling of data showed that visual clarity was significantly better in the TXA group vs. saline, on a standardised 10-point Likert scale (mean difference 0.73 points, p = 0.03). However, the use of epinephrine was reported in two studies and its administration offered significantly better visual clarity than TXA (mean difference 0.9 points, p = 0.02). There was no significant difference with TXA use in MAP (mean difference 1.2 mmHg, p = 0.14), operative time (mean difference 6.8 minutes, p = 0.11), irrigation volume used (mean difference 0.2 L, p = 0.88), or postoperative pain (mean difference 3.89 on a 0–100 VAS, p = 0.34). Conclusion: The use of TXA in shoulder arthroscopy has shown to have significantly improved visual clarity in comparison to saline irrigation alone. This may not necessarily result in a significant clinical difference and may not translate to significantly less operative time or postoperative pain score. Furthermore, epinephrine use alone offers significantly better clarity than TXA. There may not be an added benefit to give both, but this area requires further research. Level of evidence: II; systematic review.