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Tranexamic Acid in Reverse Total Shoulder Arthroplasty (TXA)

Primary Purpose

Shoulder Joint Disease, Complications; Arthroplasty, Intraoperative Complications

Status
Completed
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Tranexamic Acid
Placebo
Sponsored by
William Beaumont Hospitals
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Shoulder Joint Disease focused on measuring reverse shoulder arthroplasty, Rotator cuff, Orthopedic joint surgery, Total shoulder, Perioperative bleeding, Tranexamic acid, Orthopedic complications, Hemorrhage, Postoperative Hemorrhage, Pathologic Processes, Arthritis, Joint Diseases, Musculoskeletal Diseases, Postoperative Complications, Antifibrinolytic Agents, Fibrin Modulating Agents, Molecular Mechanisms of Pharmacological Action, Pharmacologic Actions, Hemostatics, Coagulants, Hematologic Agents, Therapeutic Uses

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. Patients undergoing scheduled primary reverse total shoulder arthroplasty performed by J. Michael Wiater, MD.
  2. Patients age 18 and older

Exclusion Criteria:

  1. Pregnant* or breast-feeding women
  2. Allergy to tranexamic acid
  3. Acquired disturbances of color vision
  4. Use of estrogen containing medications (i.e. oral contraceptive pills)
  5. Hormone replacement therapy
  6. Preoperative anemia [Hemoglobin (Hb) < 11g/dL in females, Hb < 12 g/dL in males]
  7. Refusal of blood products
  8. Preoperative use of anticoagulant therapy within 5 days prior to surgery

    1. Coumadin
    2. Heparin
    3. Low molecular weight heparin
    4. Factor Xa inhibitors
  9. Thrombin inhibitors
  10. Coagulopathy
  11. Thrombophilia
  12. Antithrombin deficiency
  13. Factor V Leiden
  14. Antiphospholipid Syndrome
  15. Protein C and S deficiency
  16. History of heparin induced thrombocytopenia
  17. Sickle cell anemia
  18. Myeloproliferative disorders
  19. Platelet < 150,00 mm3
  20. International Normalized Ratio (INR) > 1.4
  21. Partial Thromboplastin Time (PTT) > 1.4 times normal
  22. A history of arterial or venous thromboembolism
  23. Cerebral Vascular Accident
  24. Deep Vein Thrombosis
  25. Pulmonary Embolism
  26. Subarachnoid hemorrhage
  27. Active intravascular clotting
  28. Major comorbidities
  29. Coronary artery disease (New York Heart Association Class III or IV)
  30. Previous MI
  31. Severe pulmonary disease (FEV <50% normal)
  32. Plasma creatinine > 115 μmol/L in males, > 100 μmol/L in females, or hepatic failure)

34. Participation in another clinical trial 35. *All women of child bearing potential must have a negative serum or urine pregnancy test.

Sites / Locations

  • William Beaumont Hospital

Arms of the Study

Arm 1

Arm 2

Arm Type

Active Comparator

Placebo Comparator

Arm Label

Tranexamic acid

Normal Saline

Arm Description

Infusion Tranexamic acid on study subjects. They will be randomized to receive an infusion of the standard dose of Tranexamic acid (10mg/kg) One dose will be given by the bedside nurse within 60 minutes prior to surgery and a second dose will be given at wound closure. Infusion will be given along with standard preoperative and operative infusion; no additional infusion will be necessary.

Infusion of placebo on study subjects. They will be randomized to receive an infusion of placebo (an equivalent volume of normal saline). One dose will be given by the bedside nurse within 60 minutes prior to surgery and a second dose will be given at wound closure. Infusion will be given along with standard preoperative and operative infusion; no additional infusion will be necessary.

Outcomes

Primary Outcome Measures

Total Blood Loss
Total Blood Loss as calculated according to method as described by Good et al. Total Blood Loss (mL) = 1000 X Hb(loss)/Hb(initial)
Total Hemoglobin Loss
Total hemoglobin loss estimated using the formula for total blood volume described by Nadler et al Hb(loss) = blood volume (L) x [Hb(initial)(g/L) - Hb(final)(g/L)] + Hb(transfused)
Total Drain Output
Total Drain Output as measured postoperatively 0-48 hours

Secondary Outcome Measures

Number of Participants Experiencing Pulmonary Embolism
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Pulmonary Embolism
Number of Participants Experiencing Myocardial Infarction
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Myocardial infarction
Number of Participants Experiencing Deep Vein Thrombosis
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Deep venous thrombosis
Number of Participants Experiencing Hematoma as a Surgical Site Complication
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Hematoma
Number of Participants Experiencing Infection as a Surgical Site Complication
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Infection

Full Information

First Posted
January 15, 2014
Last Updated
May 19, 2017
Sponsor
William Beaumont Hospitals
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1. Study Identification

Unique Protocol Identification Number
NCT02043132
Brief Title
Tranexamic Acid in Reverse Total Shoulder Arthroplasty
Acronym
TXA
Official Title
Intravenous Tranexamic Acid to Reduce Blood Loss in Reverse Total Shoulder Arthroplasty
Study Type
Interventional

2. Study Status

Record Verification Date
May 2017
Overall Recruitment Status
Completed
Study Start Date
September 2013 (undefined)
Primary Completion Date
December 2015 (Actual)
Study Completion Date
February 2016 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
William Beaumont Hospitals

4. Oversight

Data Monitoring Committee
Yes

5. Study Description

Brief Summary
To the Investigators' knowledge, TXA has not been studied in the setting of reverse total shoulder arthroplasty. We propose a double-blinded, randomized, controlled trial comparing perioperative administration of TXA to placebo in the setting of RTSA. The purpose of this study is to examine the efficacy of TXA in reducing overall blood loss and transfusion rates in patients undergoing reverse total shoulder arthroplasty.
Detailed Description
Shoulder arthroplasty is a procedure used to relieve pain and dysfunction associated with arthritic destruction of the gleno-humeral joint. It has been demonstrated that in patients with concomitant rotator cuff deficiency, reverse total shoulder arthroplasty (rTSA) is an efficacious procedure that relieves pain as well as increases the lever-arm of the deltoid muscle, thus improving post-operative strength and range of motion. However, perioperative blood loss in total shoulder arthroplasty can be significant, with an overall rate of allogeneic blood transfusion reported to be 7.4%-43% [1-5]. Patients undergoing reverse total shoulder arthroplasty are at even further risk of requiring a postoperative blood transfusion [2]. Blood transfusions are associated with significant risks to patient health that range from mild to life threatening. Tranexamic acid (TXA) is an antifibrinolytic medication (reduces the destruction of blood clots, thus promoting the ability to stop bleeding) that is frequently used to reduce perioperative blood loss, blood transfusions and associated costs in major cardiac, vascular, obstetric, and orthopedic procedures. Currently, TXA is increasingly used in orthopedic joint reconstructive surgery and has proven to be safe and effective in reducing blood loss following total knee arthroplasty (TKA) and total hip arthroplasty (THA) [11-33]. Multiple recent meta-analyses have found that use of TXA in the setting of TKA and THA leads to significantly less overall blood loss and lower rates of blood transfusion without increasing rates of venous thromboembolism (VTE) or other complications [34-37]. TXA is now on formulary at William Beaumont Hospital. 100 patients slated to undergo elective reverse total shoulder arthroplasty will be recruited and randomized to receive either an infusion of the standard dose of TXA (10mg/kg) or placebo (an equivalent volume of normal saline) within 60 minutes prior to surgery and at wound closure. Adult subjects 18 years of age or older will participate in this study after the objectives, methods, and potential hazards of the study have been fully explained, and after they have signed the informed consent form. The Investigator or designee is responsible for keeping a record of all subjects who sign an informed consent form for entry into this study DATA AND SAFETY MONITORING PLAN Beaumont Research will follow their standard operating policy and procedure for establishing a group of designated Beaumont Hospital faculty that will be responsible for data and safety monitoring. This group will include a clinician, physician, scientific member and statistician. They will meet twice throughout the course of the study. A medical monitor was not appointed since this is a single-site study; Dr. J. Michael Wiater will personally oversee the health and well-being of all patients and submit AE reports, and the designated group will directly review all adverse event reports. Beaumont's Human Investigation Committee will review the data safety monitoring plan as part of their IRB approval process. Study data will be transcribed by study personnel from the source documents into an electronic database maintained in Excel. The data collections forms are to be completed by the research nurse at the time of the data collection so that they always reflect the latest observations on the subjects participating in the study. Demographic data will be filled in preoperatively, intraoperative blood loss will be recorded in the OR, postoperative blood loss and transfusion will be collected retrospectively, and complications will be recorded as they occur or at 2 and 6 week follow-up. All data entries, corrections and alterations must be made by the investigator or other authorized study personnel. The Research Institute will complete internal auditing at random intervals during the study for data integrity, proper informed consent process implementation and documentation, protocol adherence, and patient safety reporting compliance to regulatory bodies. Descriptive statistics will be provided for all data collected. Missing data will remain missing and will not be replaced by substitutions or interpolations. Statistical software (SPSS, IBM, Inc) will be used for all analyses. Baseline and demographic data will be compared between the 2 randomization arms to determine if any imbalances exist. Categorical variables will be shown as counts and % frequencies. They will be examined using Pearson's Chi-square where appropriate (expected frequency>5), otherwise a Fisher's Exact test will be used. Continuous variables will be examined for normality. Normally distributed variables will be analyzed using t-tests and non-normally distributed variables will be examined using non-parametric Wilcoxon rank tests. All continuous variables will be shown as means+/- the standard deviation followed by the median and (25th, 75th percentiles) where needed. The primary outcome of intraoperative and postoperative blood loss and postoperative drop in Hb will be examined for normality. Normally distributed variables will be analyzed using t-tests and non-normally distributed variables will be examined using non-parametric Wilcoxon rank tests. Total number of postoperative transfusions and total number of patients requiring postoperative transfusions will be shown as counts and % frequencies. They will be examined using Pearson's Chi-square where appropriate (expected frequency>5), otherwise a Fisher's Exact test will be used. The secondary outcomes of systemic and surgical site complications will be examined between the two randomization arms using Pearson's Chi-square where appropriate (expected frequency>5), otherwise a Fisher's Exact test will be used.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Shoulder Joint Disease, Complications; Arthroplasty, Intraoperative Complications, Blood Loss, Surgical
Keywords
reverse shoulder arthroplasty, Rotator cuff, Orthopedic joint surgery, Total shoulder, Perioperative bleeding, Tranexamic acid, Orthopedic complications, Hemorrhage, Postoperative Hemorrhage, Pathologic Processes, Arthritis, Joint Diseases, Musculoskeletal Diseases, Postoperative Complications, Antifibrinolytic Agents, Fibrin Modulating Agents, Molecular Mechanisms of Pharmacological Action, Pharmacologic Actions, Hemostatics, Coagulants, Hematologic Agents, Therapeutic Uses

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2, Phase 3
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
116 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Tranexamic acid
Arm Type
Active Comparator
Arm Description
Infusion Tranexamic acid on study subjects. They will be randomized to receive an infusion of the standard dose of Tranexamic acid (10mg/kg) One dose will be given by the bedside nurse within 60 minutes prior to surgery and a second dose will be given at wound closure. Infusion will be given along with standard preoperative and operative infusion; no additional infusion will be necessary.
Arm Title
Normal Saline
Arm Type
Placebo Comparator
Arm Description
Infusion of placebo on study subjects. They will be randomized to receive an infusion of placebo (an equivalent volume of normal saline). One dose will be given by the bedside nurse within 60 minutes prior to surgery and a second dose will be given at wound closure. Infusion will be given along with standard preoperative and operative infusion; no additional infusion will be necessary.
Intervention Type
Drug
Intervention Name(s)
Tranexamic Acid
Other Intervention Name(s)
TXA, Antifibrinolytic
Intervention Description
Patients randomized to TXA receive an infusion of the standard dose of Tranexamic acid (10 mg/kg) within 60 minutes prior to surgery and at wound closure. The pharmacy uses the randomization list in sequential order to determine whether that patient will receive Tranexamic acid or placebo and will provide two unlabeled IV bags (patient receives two doses) of the appropriate solution.
Intervention Type
Drug
Intervention Name(s)
Placebo
Other Intervention Name(s)
Normal Saline
Intervention Description
Patients randomized to placebo receive an infusion of 10 mg/kg of normal saline within 60 minutes prior to surgery and at wound closure. The pharmacy uses the randomization list in sequential order to determine whether that patient will receive Tranexamic acid or placebo and will provide two unlabeled IV bags (patient receives two doses) of the appropriate solution.
Primary Outcome Measure Information:
Title
Total Blood Loss
Description
Total Blood Loss as calculated according to method as described by Good et al. Total Blood Loss (mL) = 1000 X Hb(loss)/Hb(initial)
Time Frame
Preoperative through Postoperative Days 1 and 2
Title
Total Hemoglobin Loss
Description
Total hemoglobin loss estimated using the formula for total blood volume described by Nadler et al Hb(loss) = blood volume (L) x [Hb(initial)(g/L) - Hb(final)(g/L)] + Hb(transfused)
Time Frame
Preoperative through Postoperative Days 1 and 2
Title
Total Drain Output
Description
Total Drain Output as measured postoperatively 0-48 hours
Time Frame
0-48 hours postoperatively
Secondary Outcome Measure Information:
Title
Number of Participants Experiencing Pulmonary Embolism
Description
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Pulmonary Embolism
Time Frame
up to 6-weeks post-operatively
Title
Number of Participants Experiencing Myocardial Infarction
Description
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Myocardial infarction
Time Frame
up to 6-weeks post-operatively
Title
Number of Participants Experiencing Deep Vein Thrombosis
Description
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Deep venous thrombosis
Time Frame
up to 6-weeks post-operatively
Title
Number of Participants Experiencing Hematoma as a Surgical Site Complication
Description
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Hematoma
Time Frame
up to 6-weeks post-operatively
Title
Number of Participants Experiencing Infection as a Surgical Site Complication
Description
The occurrence of the following systemic and surgical site complications within 6 weeks of surgery will be recorded. Data will be obtained from EMR and from patient at standard of care 2 week and 6 week follow-up appointment. Infection
Time Frame
up to 6-weeks post-operatively

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients undergoing scheduled primary reverse total shoulder arthroplasty performed by J. Michael Wiater, MD. Patients age 18 and older Exclusion Criteria: Pregnant* or breast-feeding women Allergy to tranexamic acid Acquired disturbances of color vision Use of estrogen containing medications (i.e. oral contraceptive pills) Hormone replacement therapy Preoperative anemia [Hemoglobin (Hb) < 11g/dL in females, Hb < 12 g/dL in males] Refusal of blood products Preoperative use of anticoagulant therapy within 5 days prior to surgery Coumadin Heparin Low molecular weight heparin Factor Xa inhibitors Thrombin inhibitors Coagulopathy Thrombophilia Antithrombin deficiency Factor V Leiden Antiphospholipid Syndrome Protein C and S deficiency History of heparin induced thrombocytopenia Sickle cell anemia Myeloproliferative disorders Platelet < 150,00 mm3 International Normalized Ratio (INR) > 1.4 Partial Thromboplastin Time (PTT) > 1.4 times normal A history of arterial or venous thromboembolism Cerebral Vascular Accident Deep Vein Thrombosis Pulmonary Embolism Subarachnoid hemorrhage Active intravascular clotting Major comorbidities Coronary artery disease (New York Heart Association Class III or IV) Previous MI Severe pulmonary disease (FEV <50% normal) Plasma creatinine > 115 μmol/L in males, > 100 μmol/L in females, or hepatic failure) 34. Participation in another clinical trial 35. *All women of child bearing potential must have a negative serum or urine pregnancy test.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Michael J Wiater, M.D.
Organizational Affiliation
William Beaumont Hospitals
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
Kevin Baker, PhD
Organizational Affiliation
William Beaumont Hospitals
Official's Role
Study Director
Facility Information:
Facility Name
William Beaumont Hospital
City
Royal Oak
State/Province
Michigan
ZIP/Postal Code
48073
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No
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Tranexamic Acid in Reverse Total Shoulder Arthroplasty

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