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Revista Española de Cirugía Ortopédica y Traumatología
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Inicio Revista Española de Cirugía Ortopédica y Traumatología The efficacy of topical tranexamic acid in reverse shoulder arthroplasty
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The efficacy of topical tranexamic acid in reverse shoulder arthroplasty
Eficacia del ácido tranexámico tópico en la artroplastia invertida de hombro
B. Garcia-Mayaa,
Corresponding author
beatriz.garcia.maya@gmail.com

Corresponding author.
, S. Moraisb, J. Diez-Sebastianc, S. Antuñad, R. Barcod
a Hospital Universitario Infanta Elena, Madrid, Spain
b Araba University Hospital Txagorritxu Campus, Araba, Spain
c Hospital La Paz Institute for Health Research, Madrid, Spain
d La Paz University Hospital, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tranexamic acid &#40;TXA&#41; is an antifibrinolytic agent that functions as a competitive inhibitor with lysine by blocking its binding to plasminogen molecules&#46; It is currently a widely used drug that has been shown to be safe and cost-effective in hip and knee arthroplasty in terms of decreased systemic bleeding&#44; fewer transfusions and reduced drainage debit&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a> It is a well-tolerated drug with few side effects&#59; the most common are digestive &#40;nausea or diarrhoea&#41; and&#44; in exceptional cases&#44; seizures in patients with a history of high doses or allergy to the drug&#46; There is concern about the potential increased risk of thromboembolic events following intravenous administration&#44; although recent studies have demonstrated its safety and efficacy regardless of the individual patient&#39;s risk of death&#44; not only in the field of orthopaedics but also in other surgical fields&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the current evidence in favour of the use of TXA in knee and hip arthroplasty&#44; there is still reluctance to use it in patients with a history of thromboembolism or concomitant renal pathology and the optimal dose and route of administration is not yet established&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> The use of the topical route has proven to be as effective as intravenous administration in hip and knee arthroplasty&#46; Typically&#44; between 1 and 3<span class="elsevierStyleHsp" style=""></span>g of TXA is administered topically before closure&#44; alone or in combination with saline &#40;SSF&#41; and sometimes other drugs such as local anaesthetic&#44; corticosteroid&#44; non-steroidal anti-inflammatory drug &#40;NSAID&#41; or antibiotic&#44; and has been shown to reduce postoperative bleeding in different joints&#44; including the shoulder&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The rate of transfusion in shoulder arthroplasty varies in the literature&#44; from less than 1&#37; in selected cohorts to 43&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;6</span></a> As recently as 2015&#44; the first study analysing TXA in shoulder arthroplasty evaluated its efficacy when administered topically&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> Other authors have subsequently demonstrated the efficacy of TXA in shoulder arthroplasty with different intravenous doses when compared with placebo&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#8211;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The reduction in bleeding would allow a reduction in the number of transfusions&#44; with a decrease in infections&#44; allergic reactions and other associated complications&#46; In addition&#44; less bleeding could avoid the systematic use of drains&#44; so that TXA could help to improve and facilitate perioperative patient management&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of the study is to determine whether 1&#46;5<span class="elsevierStyleHsp" style=""></span>g of TXA in a low volume solution &#40;30<span class="elsevierStyleHsp" style=""></span>mL&#41; would reduce bleeding in patients undergoing reverse shoulder arthroplasty &#40;RTSA&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective observational cohort study was designed to review patients undergoing primary RTSA of the shoulder between January 2013 and March 2020&#59; cohorts were established according to whether they had received TXA or not&#46; Hospital ethics committee approval was obtained &#40;PI-4267&#41;&#46; Inclusion criteria were patients undergoing primary RTSA surgery&#46; Revision surgeries or tumour surgeries were excluded&#44; so after reviewing 177 arthroplasties a sample of 169 patients was obtained&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Demographic data were collected&#44; as well as the existence of comorbidities&#44; preoperative risk according to the American Society of Anaesthesiologists &#40;ASA&#41; scale&#44; the reason for surgery&#44; hospital stay&#44; haemoglobin &#40;Hb&#41; and haematocrit &#40;Hto&#41; pre-surgery and 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#44; as well as drain debit &#8211; in patients in whom it was placed &#8211; and immediate postoperative complications&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 63 patients &#40;35 in the TXA group&#41; were excluded due to incomplete clinical history &#40;no blood tests at 24<span class="elsevierStyleHsp" style=""></span>h or drainage volume in millilitres &#91;mL&#93;&#41;&#46; Finally&#44; 106 patients were included with a mean age of 76&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;5 years&#44; of whom 85&#37; &#40;90 patients&#41; were women&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients were operated using interscalene block and general anaesthesia&#46; With the patient in a beach chair&#44; a deltopectoral approach was performed&#44; using the same implant and surgical technique in all cases&#46; The administration of TXA was performed according to the surgeon&#39;s preference&#44; although it was observed that with familiarisation with its use there was an increasing trend over the years since until 2015 it was used in less than 50&#37; of cases to&#44; from 2017&#44; administer it to more than 70&#8211;80&#37; of patients&#46; The administration pattern was local injection of 1&#46;5<span class="elsevierStyleHsp" style=""></span>g of TXA in deep and superficial planes before closure&#46; Each &#46;5<span class="elsevierStyleHsp" style=""></span>g ampoule has a volume of 10<span class="elsevierStyleHsp" style=""></span>mL for a total injection volume of 30<span class="elsevierStyleHsp" style=""></span>mL&#46; The drain was placed intra-articularly&#44; kept closed for 2<span class="elsevierStyleHsp" style=""></span>h and removed at 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients on anticoagulant therapy &#40;warfarin&#41; were discontinued and low molecular weight heparin &#40;LMWH&#41; was administered every 12<span class="elsevierStyleHsp" style=""></span>h as indicated by the anaesthesia department&#46; Patients on acetylsalicylic acid &#40;ASA&#41; 100<span class="elsevierStyleHsp" style=""></span>mg did not change their regimen&#46; Transfusion was indicated in cases where Hb was &#8804;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL or presented symptoms of anaemia &#40;tachycardia&#44; hypotension&#44; etc&#46;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The primary study variable was the variation of post-surgical Hb &#40;&#916;Hb&#41; and Hto &#40;&#916;Hto&#41;&#46; Secondary variables were drainage debit &#40;mL&#41;&#44; hospitalisation time &#40;days after surgery&#41; and occurrence of complications in the first 6 months postoperatively&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Data were analysed using SPSS &#40;version 21&#46;0&#44; SPSS&#44; Chicago&#44; IL&#41;&#46; The <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test was used to contrast the proportions of the variables&#46; The normal distribution of quantitative variables was assessed using the Kolmogorov&#8211;Smirnov test&#46; The ANOVA test and the Mann&#8211;Whitney test for non-parametric variables were used to compare the means of normally distributed variables&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Statistically significant differences were considered to be those in which <span class="elsevierStyleItalic">p</span> was &#60;&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">A first analysis was performed to determine which preoperative characteristics could be associated with an increased risk of bleeding&#46; Patients undergoing elective surgery had less bleeding than patients undergoing surgery for fractures of the proximal humerus &#40;FPH&#41; &#40;&#916;Hb 1&#46;50 vs&#46; 2&#46;14<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;032&#59; &#916;Hto 5&#46;00&#37; vs&#46; 6&#46;53&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;034&#41;&#44; so separate groups were established according to the preoperative diagnosis&#58; 73 patients were operated for arthropathy and 33 corresponded to the fracture group&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">It was also observed that 3 patients had coagulopathies previously assessed by the haematology service&#58; 2 patients had idiopathic thrombocytopenia and another patient had lupus anticoagulant&#46; This group of patients presented higher bleeding &#40;&#916;Hb 3&#46;9 vs&#46; 1&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; &#916;Hto 11&#46;87 vs&#46; 6&#46;14&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41; and were excluded&#46; Of these patients&#44; one patient underwent RTSA for fracture and required postoperative transfusion for an Hb of 7<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#46; The other 2 patients underwent elective surgery and despite increased bleeding did not require transfusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">No differences were observed in &#916;Hb or &#916;Hto with respect to sex &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;557&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;154&#41;&#44; hypertension &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;183&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;433&#41;&#44; diagnosis of heart disease &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;420&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;694&#41;&#44; anticoagulant or antiplatelet use &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;885&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;533&#41;&#44; or ASA classification &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;488&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;466&#41;&#46; The characteristics of both groups are comparable and are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding bleeding&#44; no statistically significant differences in &#916;Hb or &#916;Hto were observed between patients who received TXA and those who did not&#44; both in patients who underwent elective surgery and those who underwent FPH &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; a 40&#37; decrease in local bleeding was observed&#58; in patients operated for arthropathy who received TXA the mean bleeding was 104&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>76&#46;7<span class="elsevierStyleHsp" style=""></span>mL&#44; while the control group collected 195&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>132<span class="elsevierStyleHsp" style=""></span>mL &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41;&#59; in the case of RTSA for fracture the control group drained 78&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>67&#46;6<span class="elsevierStyleHsp" style=""></span>mL vs&#46; 47&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;5<span class="elsevierStyleHsp" style=""></span>mL in the group receiving TXA &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; Patients undergoing elective surgery who received TXA had a slightly shorter postoperative hospital stay&#44; although this difference did not reach statistical significance &#40;2&#46;0 vs&#46; 2&#46;3 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;34&#41;&#44; as was the case for the fracture group &#40;2&#46;3 vs&#46; 2&#46;5 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;56&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Fewer complications were observed in the arthropathy RTSA &#40;7&#37;&#41; than in the fracture RTSA &#40;15&#46;6&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#46; In patients with arthropathy&#44; 4&#46;2&#37; of TXA patients &#40;2 patients&#41; and 13&#37; of those in the control group &#40;3 patients&#41; had some complication &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;18&#41;&#44; none related to possible adverse effects of the drug &#40;thrombotic events&#44; change in colour vision&#44; etc&#46;&#41;&#46; In the TXA group&#44; one episode of desaturation with hypotension and dizziness was observed&#44; in which an embolic cause was ruled out and a subcutaneous haematoma was recorded&#44; to which a dose of TXA &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#41; was administered orally with no subsequent problems in the wound&#46; In the control group&#44; one patient presented a seroma that required an additional 24<span class="elsevierStyleHsp" style=""></span>h of drainage&#44; a second patient had a periprosthetic infection at 4 months due to C&#46; acnes that required a second surgery for debridement and implant retention&#44; and a third patient presented with respiratory infection during admission&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the RTSA fracture group&#44; 5 patients presented complications &#40;15&#46;6&#37;&#41;&#44; 2 in the control group &#40;15&#46;3&#37;&#41; and 3 in the TXA group &#40;15&#46;7&#37;&#41;&#46; Of the control group&#44; one patient required transfusion and another patient presented an episode of disorientation during admission due to a change in his medication&#46; In the TXA group&#44; a transfusion was also necessary&#44; one patient suffered a small segmental PTE due to immobility at home without antithrombotic prophylaxis&#59; the patient was studied and no signs of DVT were found on echo-Doppler&#46; The third patient had a reactivation of a previous chronic hip infection&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">All patients requiring transfusion &#8211; including the patient with coagulopathy &#8211; were women over 82 years of age who underwent FPH&#59; the need for transfusion was related to RTSA due to fracture &#40;0&#37; vs&#46; 6&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#44; being over 80 years of age &#40;0&#37; vs&#46; 8&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41; and previous use of anticoagulants &#40;1&#46;8&#37; vs&#46; 16&#46;7&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;07&#41;&#46; However&#44; no association was found with drain use &#40;3&#46;3&#37; vs&#46; 2&#46;3&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;29&#41; or TXA use &#40;5&#37; vs&#46; 7&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;66&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our data show that topical administration of 1&#46;5<span class="elsevierStyleHsp" style=""></span>g reduces local bleeding after RTSA by 40&#37;&#44; without significantly influencing systemic bleeding or the need for transfusion&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">As in other joints&#44; bleeding in shoulder arthroplasty is a major concern&#46; Although reported transfusion rates are lower than in hip or knee arthroplasty&#44; the incidence is highly variable and increases in cases of surgery after fracture or revision arthroplasty&#46; Revision&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;12</span></a> In hip and knee arthroplasty&#44; there are multiple quality studies that endorse the efficacy of TXA&#44; not only in reducing bleeding&#44; but also other associated risks such as transfusion or infection&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;13</span></a> so that recently&#44; with the increase in the number of shoulder arthroplasties in recent years&#44; interest in its use in this surgery has increased&#46; As in the hip and knee&#44; there is no consensus on the optimal dose and the ideal route of administration&#46; Regarding the route of administration&#44; only Gillespie et al&#46; published data after topical administration of TXA&#58; they used 2<span class="elsevierStyleHsp" style=""></span>g in a high-volume formulation &#40;100<span class="elsevierStyleHsp" style=""></span>mL&#41; in patients undergoing anatomical &#40;44 patients&#41; and inverted &#40;67 patients&#41; prostheses&#44; observing less bleeding from drainage and less bleeding in patients with anatomical prostheses&#44; but not in those with inverted prostheses&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> Subsequent studies have used the intravenous or combined route&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#8211;9&#44;14&#8211;17&#44;10&#44;18</span></a> The use of these alternatives has shown similar results&#58; Vara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> observed less systemic bleeding&#44; less local debit and a lower transfusion rate after administration of 2 i&#46;v&#46; doses&#46; Pauzenberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> also used 2 i&#46;v&#46; doses and observed less haematoma and decreased pain&#46; Other authors have also found favourable results for TXA using a single dose&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;9&#44;15</span></a> Yoon et al&#46; compared in a clinical trial both routes of administration and combined administration without finding any differences between them&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> Theoretical advantages of intravenous administration include its antifibrinolytic effect from the start of the procedure&#44; while the topical route avoids potential systemic side effects and allows the surgeon to administer it independently of the anaesthetist&#46; With the data currently available&#44; it is not possible to determine the superiority of one route over the other&#44; but all data point to TXA reducing bleeding associated with surgery&#44; both topically and intravenously&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In our study&#44; a dose of 3 ampoules of TXA was administered for a low volume formulation of 30<span class="elsevierStyleHsp" style=""></span>mL and&#44; although we observed a lower bleeding trend in both groups&#44; these differences are not significant in systemic anaemisation &#40;&#916;Hb and &#916;Hto&#41;&#46; What we did observe was 65&#8211;80&#37; higher local bleeding in patients without TXA &#40;elective surgery&#58; 104 vs&#46; 195<span class="elsevierStyleHsp" style=""></span>mL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#59; RTSA for fracture&#58; 79 vs&#46; 47<span class="elsevierStyleHsp" style=""></span>mL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; The use of TXA reduces haematoma formation and makes it possible to consider the possibility of safely abandoning drains&#44; simplifying postoperative care and reducing the associated cost&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Analysing post-surgical transfusion&#44; different risk factors for its use have been proposed&#44; including anaemia&#44; heart disease&#44; age&#44; traumatic indication&#44; type of implant &#40;RTSA&#44; TSA&#44; hemiarthroplasty&#44; revision&#44; etc&#46;&#41; or even the use of cement or obstructive pulmonary disease &#40;COPD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;19&#8211;22</span></a> These studies often include heterogeneous populations and use different implant designs&#46; This heterogeneity partly explains the variability found in the transfusion rate&#44; ranging from 43&#37; to 0&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;5</span></a> Our study includes a population that underwent surgery using the same RTSA model&#44; corroborating that elective arthroplasty has a lower anaemisation rate than fracture RTSA&#44; as has been observed previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">19&#44;23</span></a> Another factor that significantly affects the transfusion rate is the protocol used in each centre&#46; In our hospital the transfusion criteria follow the restrictive criteria set out in the recommendations of the guidelines for blood saving in patients undergoing major surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> Our transfusion rate was 0&#37; in elective surgery patients and 6&#37; in those operated on for fractures&#44; which is lower than other published series&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The concern to reduce transfusion needs is amply justified&#46; Recently&#44; Grier et al&#46; identified 7794 patients transfused after TSA and RTSA in whom a higher rate of complications was observed&#44; ranging from thromboembolic disease to pneumonia or surgical site infection&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> In hip and knee arthroplasty&#44; several studies have found a correlation between the administration of TXA and a reduction in these complications&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> There are in vitro studies in favour of TXA to prevent infection by preventing the formation of bacterial biofilm through direct inhibition of lysine&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> so its local application would be a possible advantage&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">While it is true that other studies have found differences in favour of TXA in reducing the need for transfusion&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;28</span></a> the only published study on shoulder arthroplasty that analyses its relationship with infection has not found significant differences between administering it or not to reduce this rate&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> In our study&#44; being a relatively small series with a very low incidence of complications&#44; these relationships could not be established either in the elective surgery group &#40;0 patients transfused&#41;&#44; or even in the fracture surgery patients &#40;7&#37; in the control group vs&#46; 5&#37; with TXA&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;66&#41;&#59; it was only possible to relate the risk of transfusion to patient characteristics &#40;&#62;80 years&#44; female&#44; fracture surgery&#44; etc&#46;&#41;&#46; Similarly&#44; no thromboembolic events associated with the use of TXA were observed&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">This study has several limitations&#46; Firstly&#44; the retrospective collection of data implies a significant loss of patients&#44; although they were similar in both groups&#46; On the other hand&#44; the inclusion of a limited number of patients &#8211; although similar to other series &#8211; with a low incidence of complications does not allow the establishment of associations that have been seen in registry-based studies&#46; As a strength&#44; this study presents a homogeneous population with a single implant&#44; so the differences observed cannot be attributed to implant design or surgical technique&#46; In addition&#44; this is the first study to examine the use of TXA in patients undergoing RTSA surgery for fracture&#44; who have not been included in previous studies&#46; Many of these patients have a history of thromboembolic disease or heart disease&#44; and it is precisely these patients with increased bleeding and risk of transfusion who may benefit most from TXA&#46; Larger studies are needed to determine the specific impact on transfusion needs in this more fragile population&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The use of locally administered low volume 1&#46;5<span class="elsevierStyleHsp" style=""></span>g TXA in a low volume formulation effectively reduces bleeding in patients undergoing RTSA surgery&#59; in addition&#44; in patients undergoing RTSA surgery for arthropathy&#44; the average hospital stay was also reduced&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Level of evidence</span><p id="par0145" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iii</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">None of the authors received any funding for this research study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span><span id="sec1065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1125">Right to privacy and informed consent</span><p id="par1240" class="elsevierStylePara elsevierViewall">The authors have obtained informed consent from the patients and&#47;or subjects referred to in the article&#46; This document is held by the corresponding author&#46;</p></span><span id="sec1070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1130">Ethics committee approval</span><p id="par0245" class="elsevierStylePara elsevierViewall">Research approved by the Ethics Committee of the hospital &#40;PI-4267&#41;&#46;</p></span></span>"
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        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Funding"
        ]
        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflict of interests"
        ]
        12 => array:2 [
          "identificador" => "sec1065"
          "titulo" => "Right to privacy and informed consent"
        ]
        13 => array:2 [
          "identificador" => "sec1070"
          "titulo" => "Ethics committee approval"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2023-01-16"
    "fechaAceptado" => "2023-04-05"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1809134"
          "palabras" => array:5 [
            0 => "Tranexamic acid"
            1 => "Shoulder arthroplasty"
            2 => "Blood"
            3 => "Proximal humeral fracture"
            4 => "Shoulder arthropathy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1809133"
          "palabras" => array:5 [
            0 => "&#193;cido tranex&#225;mico"
            1 => "Artroplastia de hombro"
            2 => "Sangre"
            3 => "Fractura de h&#250;mero proximal"
            4 => "Artropat&#237;a de hombro"
          ]
        ]
      ]
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    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Topical tranexamic acid &#40;TXA&#41; has been shown to decrease blood loss in knee and hip arthroplasty&#46; Despite there is evidence about its effectiveness when administered intravenous&#44; its effectiveness and optimal dose when used topically have not been established&#46; We hypothesised that the use of 1&#46;5<span class="elsevierStyleHsp" style=""></span>g &#40;30<span class="elsevierStyleHsp" style=""></span>mL&#41; of topical TXA could decrease the amount of blood loss in patients after reverse total shoulder arthroplasty &#40;RTSA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">One hundred and seventy-seven patients receiving a RSTA for arthropathy or fracture were retrospectively reviewed&#46; Preoperative-to-postoperative change in haemoglobin &#40;&#916;Hb&#41; and hematocrit &#40;&#916;Hct&#41; level drain volume output&#44; length of stay and complications were evaluated for each patient&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients receiving TXA has significant less drain output in both for arthropathy &#40;ARSA&#41; &#40;104 vs&#46; 195<span class="elsevierStyleHsp" style=""></span>mL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; and fracture &#40;FRSA&#41; &#40;47 vs&#46; 79<span class="elsevierStyleHsp" style=""></span>mL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Systemic blood loss was slightly lower in TXA group&#44; but this was not statistically significant &#40;ARSA&#44; &#916;Hb 1&#46;67 vs&#46; 1&#46;90<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; FRSA 2&#46;61 vs&#46; 2&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;79&#41;&#46; This was also observed in hospital length of stay &#40;ARSA 2&#46;0 vs&#46; 2&#46;3 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;34&#59; 2&#46;3 vs&#46; 2&#46;5&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#41; and need of transfusion &#40;0&#37; AIHE&#59; AIHF 5&#37; vs&#46; 7&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;66&#41;&#46; Patients operated for a fracture had a higher rate of complications &#40;7&#37; vs&#46; 15&#46;6&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; There were no adverse events related to TXA administration&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Topical use of 1&#46;5<span class="elsevierStyleHsp" style=""></span>g of TXA decreases blood loss&#44; especially on the surgical site without associated complications&#46; Thus&#44; haematoma decrease could avoid the systematic use of postoperative drains after reverse shoulder arthroplasty&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El &#225;cido tranex&#225;mico &#40;ATX&#41; t&#243;pico ha demostrado disminuir de forma significativa el sangrado en artroplastia de cadera y rodilla&#46; A pesar de que en la artroplastia de hombro la mayor&#237;a de trabajos han demostrado su eficacia por v&#237;a intravenosa&#44; la eficacia y dosis por v&#237;a t&#243;pica a&#250;n no est&#225; determinada&#46; El objetivo fue comprobar si 1&#44;5<span class="elsevierStyleHsp" style=""></span>g de ATX en bajo volumen &#40;30<span class="elsevierStyleHsp" style=""></span>ml&#41; administrado de manera t&#243;pica disminuir&#237;a el sangrado tras la artroplastia invertida de hombro &#40;AIH&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se revisaron de manera retrospectiva 177 pacientes consecutivos intervenidos de AIH por artropat&#237;a y fractura&#46; Se recogieron datos de &#916;Hb y &#916;Hto a las 24<span class="elsevierStyleHsp" style=""></span>h&#44; d&#233;bito del drenaje &#40;ml&#41;&#44; estancia media y complicaciones&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los pacientes que recibieron ATX presentaron menor d&#233;bito del drenaje tanto en artroplastia electiva &#40;AIHE&#41; &#40;104 vs&#46; 195<span class="elsevierStyleHsp" style=""></span>ml&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; como por fractura &#40;AIHF&#41; &#40;47 vs&#46; 79<span class="elsevierStyleHsp" style=""></span>ml&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Aunque fue ligeramente menor en el grupo de ATX&#44; no se observaron diferencias estad&#237;sticamente significativas en el sangrado sist&#233;mico &#40;AIHE &#916;Hb 1&#44;67 vs&#46; 1&#44;90<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; AIHF 2&#44;61 vs&#46; 2&#44;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;79&#41;&#44; estancia media &#40;AIHE 2&#44;0 vs&#46; 2&#44;3 d&#237;as&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;34&#59; 2&#44;3 vs&#46; 2&#44;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;56&#41; o necesidad de transfusi&#243;n &#40;0&#37; en AIHE&#59; AIHF 5 vs&#46; 7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;66&#41;&#46; Los pacientes intervenidos por fractura presentaron mayor tasa de complicaciones que aquellos que lo hicieron por artropat&#237;a &#40;7 vs&#46; 15&#44;6&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46; No se observaron complicaciones asociadas al uso de ATX&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La administraci&#243;n t&#243;pica de 1&#44;5<span class="elsevierStyleHsp" style=""></span>g de ATX reduce el sangrado de manera significativa en el sitio quir&#250;rgico&#44; sin observarse complicaciones asociadas&#46; La disminuci&#243;n del hematoma posquir&#250;rgico permitir&#237;a evitar el uso sistem&#225;tico de drenajes posquir&#250;rgicos&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;2&#46;1&#41; &#916;Hb in patients undergoing RTSA for arthropathy &#40;1&#46;67<span class="elsevierStyleHsp" style=""></span>g&#47;dL for the TXA group vs&#46; 1&#46;90<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;31&#41; and &#916;Hto &#40;5&#46;67&#37; vs&#46; 5&#46;61&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;94&#41;&#46; &#40;2&#46;2&#41; &#916;Hb in patients undergoing RTSA for FPH &#40;2&#46;61<span class="elsevierStyleHsp" style=""></span>g&#47;dL in TXA group vs&#46; 2&#46;70<span class="elsevierStyleHsp" style=""></span>g&#47;dL in control group&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;31&#41; and &#916;Hto &#40;7&#46;26&#37; vs&#46; 7&#46;90&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;94&#41;&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">15 &#40;62&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">39 &#40;81&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;76&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACO&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ASA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;34&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;35&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;93&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">HTA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9 &#40;69&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18 &#40;94&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">27 &#40;84&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4 &#40;30&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4 &#40;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                      "titulo" => "Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach"
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                          "etal" => true
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                            2 => "E&#46;C&#46; Rodr&#237;guez-Merch&#225;n"
                            3 => "N&#46;G&#46; Padilla-Eguiluz"
                            4 => "H&#46; P&#233;rez-Chrzanowska"
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                      "titulo" => "Effect of tranexamic acid by baseline risk of death in acute bleeding patients&#58; a meta-analysis of individual patient-level data from 28<span class="elsevierStyleHsp" style=""></span>333 patients"
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                            3 => "T&#46;J&#46; Coats"
                            4 => "H&#46; Shakur-Still"
                            5 => "I&#46; Roberts"
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                    0 => array:2 [
                      "doi" => "10.1016/j.bja.2020.01.020"
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                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2020"
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                      "titulo" => "Neer Award 2015&#58; a randomized&#44; prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty"
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Article information
ISSN: 18884415
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos