Tranexamic acid in high-risk shoulder arthroplasty patients: safety across thromboembolic, cardiac, renal, and neurologic risk profiles.

introductionTranexamic acid (TXA) effectively reduces blood loss and transfusion requirements in shoulder arthroplasty. However, concerns regarding thromboembolic, neurologic, cardiac, and renal complications have limited its use in medically high-risk patients. This study evaluated temporal trends and the safety of TXA in high-risk patients undergoing total shoulder arthroplasty (TSA).

methodsA retrospective cohort study was conducted using TriNetX, identifying patients who underwent shoulder arthroplasty (2012-2025). Patients were stratified by preexisting high-risk conditions, including prior thromboembolism, renal failure, atrial fibrillation, seizure disorders, and visual disturbances. Within each subgroup, patients receiving TXA were propensity score-matched to those who did not. Perioperative TXA utilization trends were assessed. Ninety-day postoperative outcomes were compared, including transfusion requirements, thromboembolic events, cardiac complications, renal failure, neurologic events, infections, readmissions, emergency department visits, and mortality. Outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs).

resultsReported perioperative TXA use began in 2012 and increased through 2025, with over 70% of patients in both standard- and high-risk cohorts receiving TXA. TXA use was associated with significantly lower transfusion rates (OR range 0.53-0.62) and readmissions (OR range 0.63-0.75) across all high-risk cohorts (all p ≤ 0.01). TXA use was not associated with increased risk of deep vein thrombosis, pulmonary embolism, stroke, or postoperative seizures in any subgroup. Notably, TXA demonstrated a protective association against myocardial infarction, cardiac ischemia, acute renal failure, and mortality in select high-risk populations. No increase in infection-related complications was observed.

conclusionsIn patients undergoing shoulder arthroplasty, TXA use was safe across multiple high-risk medical populations and was consistently associated with lower transfusion and readmission rates, with reduced mortality in select cohorts. These findings support the broader use of TXA for blood conservation in shoulder arthroplasty, even among patients with traditionally high-risk comorbidities, while underscoring the need for future prospective, shoulder-specific safety studies. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.