A cohort of 129 patients who underwent arthroscopic primary RCR by the same surgeon (S.F.) between April 2016 and December 2020 were retrospectively investigated. Since April 2018, we have used intravenous TXA to reduce intraoperative bleeding during arthroscopic procedures. After induction of anesthesia, 1 g of TXA was administered in all patients except in those with a history of deep venous thrombosis, pulmonary embolism, stroke, or cardiac stent placement and in those with allergy to TXA.
The inclusion criteria were as follows: full-thickness supraspinatus and/or infraspinatus tear confirmed by arthroscopy; partial-thickness tear converted to full-thickness tear before repair; and arthroscopic repair by the suture bridge technique. The exclusion criteria included partial repair, single-row or conventional double-row repair, tear involving the subscapularis tendon, a concomitant glenohumeral procedure such as labral repair or capsular release, and revision surgery. Patients treated with anticoagulant agents were also excluded. Patients who underwent concomitant tenotomy or tenodesis of the long head of biceps were not excluded. A total of 137 patients met the eligibility criteria and were divided into 2 groups according to whether or not they received TXA: 64 consecutive patients received TXA from April 2018 to December 2020 (the TXA group), and 65 consecutive patients did not receive TXA from April 2016 to March 2018 (the non-TXA group).
All procedures were performed with the patient in the beach-chair position under general anesthesia with the upper extremity fixed by a limb positioner. Interscalene regional nerve block was not performed in all cases. The irrigation fluid pressure was kept at 40 mmHg by a pressure-controlled pump. Epinephrine was not added to the irrigation bags. Blood pressure was measured in the contralateral extremity using an automatic blood pressure cuff at 5-min intervals intraoperatively. To avoid cerebral ischemia, hypotensive anesthesia was not applied. Blood pressure was controlled within the normal range during surgery.
Diagnostic arthroscopy was performed to evaluate the rotator cuff and associated pathology. Intra-articular lesions were treated appropriately. The arthroscope was then placed into the subacromial space and a complete bursectomy and acromioplasty were performed in all patients. Acromioplasty was limited to removal of a large acromial spur. Minimal release of the coracoacromial ligament was performed if the undersurface of the acromion was free of osteophytes. The torn edge of the rotator cuff was debrided and the footprint was refreshed with a shaver to allow bleeding from cancellous bone. A 5.5-mm anchor preloaded with 3 No. 2 FiberWire sutures (5.5-mm PEEK Corkscrew FT; Arthex, Naples, FL) was inserted at the articular margin of the greater tuberosity. One or two anchors were used for the medial row depending on the size of the tear. A No. 2 FiberLink (Arthex) was passed through the tendon lateral to the musculotendinous junction using a suture passing device (ExpresSew II; Depuy Mitek, Raynham, MA) and one limb of the three sutures from each medial anchor was relayed at the same time with a FiberLink. After each pass, pairs of suture limbs from each medial anchor were retrieved and suture bridges were created over the tendon with 2 lateral row anchors (5.5-mm SwiveLock; Arthex) inserted 10–15 mm distal to the greater tuberosity. After the suture bridges were completed, the remaining medial sutures were tied in a horizontal mattress fashion to press down and secure the cuff to the footprint. If a dog-ear deformity was present after completing the repair, it was treated using a preloaded additional eyelet suture on the lateral anchor
Information on age, sex, height, weight, body mass index, and preoperative and postoperative hemoglobin levels was collected from the clinical records, whereas data on operating time, mean arterial pressure, tear size, and the number of anchors were obtained from the operation notes. Postoperative hemoglobin levels were obtained on days 1 and 7 after surgery. Loss of hemoglobin was calculated by subtracting the levels on postoperative days 1 and 7 from the preoperative value.
Videos of the arthroscopic procedures were reviewed by a single shoulder fellow who was blinded to whether or not TXA was used. Visibility during the arthroscopic procedures was scored using a 10-point numeric rating scale (NRS; 10, best; Figure 1). The arthroscopic procedures were divided into glenohumeral (GH) arthroscopy, arthroscopic subacromial decompression (ASD) including resection of bursal tissue and acromioplasty, and RCR steps. Each step was rated separately.
The statistical analysis included patient demographics, operating time, mean blood pressure, tear size, number of anchors used, postoperative hemoglobin loss, and the NRS score for visual clarity during each arthroscopic step. Descriptive statistics are presented as the mean ± standard deviation for continuous data and as the median when nonparametric testing was necessary. The two-sample unpaired Student’s t-test was used to compare continuous variables. The NRS score was compared between the study groups using the non-parametric Mann–Whitney test. Categorical variables were compared using the chi-squared test. All analyses were performed using IBM SPSS version 21 (IBM Corp., Armonk, NY). A P-value <0.05 was considered statistically significant.