Both intra-articular and intravenous tranexamic acid enhance visual clarity and reduce postoperative pain following arthroscopic rotator cuff repair: a comparison study using propensity score-matched analysis

Both intra-articular and intravenous tranexamic acid enhance visual clarity and reduce postoperative pain following arthroscopic rotator cuff repair: a comparison study using propensity score-matched analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Both intra-articular and intravenous tranexamic acid enhance visual clarity and reduce postoperative pain following arthroscopic rotator cuff repair: a comparison study using propensity score-matched analysis Hyojune Kim, Taeho Oh, Min Sun Yoon, In-Ho Jeon, Kyoung Hwan Koh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5297248/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Previous research has highlighted the efficacy of tranexamic acid (TXA) in Arthroscopic rotator cuff repair (ARCR), emphasizing the need for a detailed exploration of its benefits and risks across different administration methods (intra-venous; IV, and intra-articular; IA). We aimed to find the distinctions between IV and IA TXA concerning intraoperative visual clarity, postoperative pain management, and the incidence of complications like thromboembolism during ARCR. Methods In our retrospective cohort, propensity score matching study, we included patients who had a history of rotator cuff tears and at least six months of unsuccessful conservative treatment. The primary outcome, visual clarity during surgery, was evaluated using a five-grade arthroscopic visual scale (AVS) by the operating surgeon. This scale ranged from grade 1, indicating optimal clarity, to grade 5, the least clarity necessitating a switch to open surgery. These assessments were made at 10-minute intervals during the review of the operation’s video footage. We also measured the duration of the surgery and postoperative pain levels as secondary outcomes. Results IA group included 30 patients and the IV group had 31 patients, with no significant differences in demographics or tear dimensions (P = 0.686). The IA and IV groups showed similar irrigation fluid volumes, operation times, and AVS mean scores. IA group had lower grade of AVS grade 1–2 compared to IV group (90.0% vs 64.5%, p = 0.011). Pain assessment using the Visual Analog Scale (VAS) suggested a trend towards less pain in the IA group at various postoperative times, and less pain at postoperative 48 hours (IA 2.7 vs IV 4.2, p = 008). Notably, 4 patients in the IA group required anticoagulants due to thromboembolic events, a contraindication for intravenous TXA administration. Conclusions Both IA and IV routes are effective and safe for the administration of TXA in ARCR. However, given the increased distribution of low grade of AVS in IA group, the slight trend towards reduced postoperative pain, and context of patients with thromboembolic events requiring anticoagulants, IA administration presents a more viable alternative. Level of evidence: Retrospective cohort study (Level 3) Tranexamic acid shoulder arthroscopy arthroscopic visual clarity rotator cuff tear intraoperative bleeding Figures Figure 1 Figure 2 Figure 3 Background Arthroscopic rotator cuff repair (RCR) represents a significant advancement in the treatment of full-thickness rotator cuff tears, offering benefits such as reduced complication rates, and expedited return to daily activities.[ 1 , 2 ] A critical component in optimizing the outcomes of this procedure is maintaining clear visual fields during surgery, which is directly impacted by the management of intraoperative bleeding.[ 3 , 4 ] Despite advancements in surgical techniques and equipment[ 5 , 6 ], the challenge of optimizing visual clarity while minimizing postoperative pain remains a pivotal concern in arthroscopic RCR. Tranexamic Acid (TXA), known for its well-established hemostatic properties, has become a valuable agent in reducing blood loss and minimizing postoperative complications.[ 3 , 4 , 7 – 9 ] It has a proven safety profile across various fields of orthopedic surgery, making it a viable option for arthroscopic procedures.[ 10 – 13 ] Until now, TXA has typically been administered via intravenous injection prior to arthroscopic surgery, showing improvements in visual clarity.[ 4 ] Recently, however, the administration of TXA has the disadvantage of being only limitedly usable in some patients with thromboembolic events.[ 14 ] Some studies have indicated that intra-articular TXA injections in patients undergoing arthroscopic rotator cuff repair can also enhance visual clarity.[ 15 ] However, the existing literature predominantly investigates the effects of TXA without distinguishing between its modes of administration, specifically intra-articular (IA) and intravenous (IV).[ 15 ] This lack of differentiation results in an incomplete understanding for orthopedic surgeons and clinical practitioners on how to fully maximize the benefits of TXA in arthroscopic RCR. Though prior studies have confirmed the effectiveness of TXA in arthroscopic RCR[ 8 ], a more nuanced understanding of its benefits and potential risks, depending on the method of administration; IA and IV, should be required. Therefore, we conduct a detailed comparative analysis of IA versus IV administration of TXA in the context of arthroscopic RCR. The purpose of this study was to elucidate the distinctions between these administration routes concerning intraoperative visual clarity, postoperative pain management, and the incidence of complications. It was hypothesized that compared to IV administration of TXA, IA TXA can more improve visual field clarity, shorten the operation time during ARCR, and more reduce initial postoperative pain, effectively. Methods Study design and patient selection This retrospective study conformed to the principles of the Declaration of Helsinki and was approved by the local research ethics committee (EMC 2023-07-023). The study sample included individuals who were diagnosed with a magnetic resonance imaging-confirmed full-thickness rotator cuff rupture and had a history of failure of conservative treatment for > 6 months. Patients diagnosed between March 2022 and November 2023 and those who had rotator cuff repair surgery. Patients who are presence of an inferior vena cava filter; abnormal prothrombin time, activated partial thromboplastin time, and/or bleeding time; history of cardiac, renal, and/or hepatic disease; diagnosis of TXA allergy; acute RCT and conservative treatment for < 6 months were excluded from this study. In IV group, those with history of coagulopathy, deep venous thrombosis, and/or tendency for thrombotic events; administration of anticoagulant therapy was additionally excluded, but not in IA group (Table 1 ). The patient groups of the IA group and IV group were randomly selected after considering the selection criteria and contraindications mentioned above. Demographic characteristics including age, sex, average tear dimension(mm), mean arterial pressure (MAP), surgery time, arthroscopic visual scale (AVS score), and visual analog scale (VAS score) were recorded. Table 1 Inclusion and exclusion criteria Inclusion criteria History of failure of conservative treatment for ≥ 6 months MRI and sonography confirmed rotator cuff rupture Exclusion criteria Intra-articular group Intra-venous group History of acute rotator cuff rupture Conservative treatment for < 6months Inferior vena cava filter Abnormal coagulation parameters (prothrombin time, activated partial thromboplastin time, and/or bleeding time) History of cardiac, renal, and/or hepatic disease Diagnosis of TXA allergy History of acute rotator cuff rupture Conservative treatment for < 6months History of coagulopathy, deep venous thrombosis, and/or tendency for thrombotic events (TXA contra-indication) Anticoagulant therapy (TXA contra-indication) Inferior vena cava filter Abnormal coagulation parameters (prothrombin time, activated partial thromboplastin time, and/or bleeding time) History of cardiac, renal, and/or hepatic disease Diagnosis of TXA allergy MRI , magnetic resonance imaging; TXA , tranexamic acid. Preparation of irrigation solution and TXA injection Three liters of arthroscopic irrigation solution (normal saline solution) was prepared by an operating nurse; in the intra-articular injection group, 500mg of TXA; 0.16mg/ml (to prevent chondrocyte death and damage to peri-articular tissues as reported earlier[ 16 – 18 ]) was injected into the irrigation solution (TXA intra-articular injection group), whereas in the TXA intra-venous injection group, the irrigation solution was left TXA free, with TXA 500mg intra-venous injection just before surgery.[ 15 ] No epinephrine was used in either group’s irrigation solution. Surgical technique and postoperative management Each procedure was carried out by the same surgeon, HK., with patients undergoing general anesthesia in lazy lateral position, avoiding the use of regional anesthesia. This standardized approach ensured that the same surgical steps were consistently followed in the same order for every patient, regardless of their allocation to the IA or IV TXA group. The surgical protocol involved a comprehensive assessment of the glenohumeral joint and the rotator interval. In instances where a degenerative biceps tendon was identified, a biceps tenotomy was performed (involving 15 patients from the intra-articular group and 13 from the intra-venous group). Acromioplasty was conducted on all patients across both groups. No additional procedure was undertaken alongside this. The repair of the supraspinatus tendon was executed using a double-row suture bridge technique. A pressure-regulated pump (CONMED comp.) maintained the irrigation solution’s pressure at a steady 60mm Hg throughout the surgery, and no cases involved the use of flush irrigation. The anesthesiologist monitored and recorded the mean arterial pressure (MAP) during each operation. Immediately following the surgery, patients were fitted with an abduction brace and instructed to minimize active shoulder movement and abduction while in the hospital. For pain control, every patient received a 500mg paracetamol injection every 12 hours, consistent across both groups. A suprascapular nerve block was administered to all patients, and paracetamol was the exclusive medication used for pain management. Patients were discharged on the second day after the operation, once their condition was stable and their pain levels were manageable. Assessment of intraoperative arthroscopic visual clarity and secondary outcome parameters The entire surgical process of all patients was recorded. To assess the clarity during surgery, a unique arthroscopic visual scale (AVS), akin to the system employed by van Montfoort et al.[ 19 ], was used by the two surgeons, HK. and THO. This AVS comprised five levels: Grade 1signified complete absence of visual obstruction due to bleeding; grade 2 represented mild visual disruption; grade 3 indicated moderate interference; grade 4implied severe disturbance; and grade 5, the most extreme, necessitated a shift to open surgery due to overwhelming visual impairment (Fig. 1 ). The AVS rating for each patient was determined as follows: Surgeons reviewed the video recordings of the arthroscopic procedure post-surgery, noting the AVS every 10 minutes-a chosen interval reflecting the dynamic nature of bleeding in arthroscopy in a blinded for the interventions. Subsequently, an average score per patient was computed. Although grade 5 was an on-the-spot assessment and was intended for postoperative review, it was not applicable in this case. For a comprehensive evaluation, HK. and THO re-watched the videos after two weeks later, and separately reviewed them. The consistency of these observations was confirmed with an intraclass correlation coefficient ranging from 0.81 to 0.97, indicating strong intra-observer reliability. And another orthopaedic surgeon, MSY., watched and reviewed AVS score. The inter-observer reliability of radiographic outcome measurements was determined using the intraclass correlation coefficient, showing values of 0.81–0.97. Pain levels were measured by ward nurses, who were not aware of the study details, using the visual analog scale (VAS) at 8, 24, 48 and 72 hours after the operation. Additionally, the mean arterial pressure (MAP) and total duration of the surgery were documented. The average values of all these parameters were then compared between the two groups. Statistical Analysis To calculate the sample size, G*Power software (version 3.1.9.7;gpower.hhu.de) was used prior to the study, and statistical power (1 - β), alpha error, and impact value were calculated as 0.8, 0.05, and 0.8, respectively. As a result of this a priori power analysis model, it was calculated that 26 patients were required in each group. Data analysis was performed using the SPSS software (version 19.0; Chicago, Illinois). Data are expressed as mean standard deviation or as average values. Age, sex, surgery time, mean arterial blood pressure, surgical visualization score (AVS score), and postoperative pain score were compared between group using independent-samples test after 1:1 propensity score matching (PSM). Normality was assessed using Kolmogorov-Smirnov test for categorical variables and the Shapiro-Wilk test for continuous variables. Student’s t test was used to compare continuous variables between IA and IV groups, including age, sex, average tear dimension, MAP, surgery time, AVS score, VAS pain score. Bonferroni correction was applied to account for multiple comparisons across groups, depending on the postoperative time points. The significant p-value was 0.0125 for VAS pain score. Fisher’s exact test was performed to compare the AVS grade distribution ratio. Results were reported at a confidence interval of 95%, and P < .05 was considered statistically significant. Results Of the 107 patients who had rotator cuff repair surgery, 31 were excluded based on the inclusion and exclusion criteria (16 were receiving anticoagulant therapy; 7 had a history of cardiac, hepatic, and/or renal disease; 4 had an abnormal prothrombin time or activated partial thromboplastin time at the time of surgery; 2 had acute RCTs). The remaining 76 patients were enrolled in the study (Fig. 2). After 1:1 PSM, the IA group was composed of 30 patients (14 female and 16 male patients) with a mean age of 60.8 ± 10.2 years (range, 31–73 years). The IV group was composed of 31 patients (14 female and 17 male patients) with a mean age of 63.1 ± 9.5 years (range, 46–81 years). The groups showed no statistically significant differences in terms of age (P = .800), sex (P = .724), tear dimension (22.8 mm in IA group vs. 24.1 mm in IV group, P = .686), and Goutallier classification (range, 0–4 in both group; P = .545)[ 20 ] (Table 2 ). Table 2 Demographic data of patients and evaluation of intergroup differences Variable IA group IV group P value Age, year Mean ± SD 60.8 ± 10.2 63.1 ± 9.5 .800 Range 31–73 46–81 Sex, number Female 14 14 .724 Male 16 17 Average tear dimension, mm Average size 22.8 24.1 .686 MAP, mmHg Mean ± SD 101.9 ± 14.3 99.0 ± 10.5 .423 Range 66.3-133.7 84.67–118.7 Surgery time, minutes Mean ± SD 112.3 ± 55.0 121.9 ± 57.1 .566 Range 40–230 20–250 AVS score Mean ± SD 1.5 ± 0.4 1.7 ± 0.3 .190 Range 1–3 1–3 Average VAS pain score 8 h 6.7 7.2 .218 24 h 4.4 5.6 .014 48 h 2.7 4.2 .008* 72 h 1.8 2.9 .020 TXA, tranexamic acid; SD, standard deviation; MAP, mean arterial pressure; AVS, arthroscopic visual scale; VAS, visual analog scale. *Significant at p < 0.0125. The average volume of irrigation fluid used was 36.9 L for the IA group and 39.2 L for the IV group (P = .751). The mean duration of operation time in the IA and IV group was 112.3 minutes and 121.9 minutes, respectively (P = .566). The mean AVS score in the IA group (1.5 ± 0.4) was not significantly different with the mean AVS score in the IV group (1.7 ± 0.3) (P = .19). IA group was reported to have percentages with AVS score of grades 1–2 (90.0%), grade 2–3 (6.7%) and grade 3 (3.3%). IV group was reported to have percentages with AVS score of grades 1–2 (64.5%), grade 2–3 (35.5%) and grade 3 (0%). No AVS score of grades more than 4 was reported in either group (Table 2 ). The AVS grade distribution ratio was significantly different between two groups (p = 0.011) (Fig. 3). MAP was assessed in both groups to examine its influence on visual clarity. The MAP was noted to be 101.8 ± 14.3 mm Hg in the IA group and 98.9 ± 10.5 mm Hg in the IV group, showing no statistically significant difference (P = .423). The Pearson correlation analysis also indicated no significant relationship between MAP and AVS score (coefficient = 0.16, P = .915) (Table 2 ). Analysis of VAS pain scores showed that there was tendency of increased improvement in the IA group compared with the IV group at 24 hours after surgery (4.4 vs. 5.6, P = .014), 48 hours (2.7 vs. 4.2, P = .008), 72 hours (1.8 vs. 2.9, P = .020). Considering the Bonferroni correction, VAS at postoperative 48 hours in IA group showed significant improvement compared to IV group (p < 0.0125). After no thromboembolic events or other complications were observed in either group until discharge. Notably, 4 patients in the IA group with history of thromboembolic events like angina requiring anticoagulants were identified, but no patients required anticoagulants in the IV group, as such conditions contraindicate intravenous TXA administration. These 4 patients had no complication like thromboembolism, pulmonary embolism, seizure until next outpatient clinic follow up (Table 2 ). Discussion In our study, we observed that the group receiving intra-articular (IA) tranexamic acid (TXA) exhibited a lower grade of arthroscopic visibility score (AVS) and experienced reduced postoperative pain compared to the intravenous (IV) TXA group. Notably, the IA TXA group included patients with contraindications to IV TXA, yet no complications arose, highlighting the broader applicability of the IA route. A critical observation from our study was the lack of significant difference in immediate postoperative visual analogue scale (VAS) pain scores between the two groups. However, a notable improvement in VAS scores was observed in the IA group at the 2-day postoperative mark, suggesting a delayed, yet significant, benefit in pain reduction. This delayed effect might be attributed to IA TXA's role in minimizing hemarthrosis, thereby reducing hematoma formation and subsequent pain. Prospective double-blind study by Li et al.[ 4 ] reported that intravenous administration of TXA before shoulder arthroscopy significantly improved intra-operative bleeding, but not affected post-operative blood loss, red cell count, hemoglobin or hematocrit. Otherwise, Zhu et al.[ 21 ] reported that intra-articular TXA injection during shoulder arthroscopy successfully prevented blood loss and hemoglobin loss—in line with the similar knee surgery studies[ 22 , 23 ]. In addition, intraarticular injection in arthroscopic anterior cruciate ligament reconstruction showed the reduced amount of postoperative hemarthrosis, and it could reduce the pain in the early postoperative period.[ 24 ] The substantial decrease in pain, especially in the early postoperative phase, provides a strong case for favoring IA administration in clinical settings. Furthermore, while the mean AVS did not significantly differ between the groups, a higher number of patients in the IA group achieved lower AVS grades (grade 1–2) than IV group. Even though total volume of TXA in each group was totally different, that it was one of our limitations, this difference could be supported from previous study that local injection have more effective to control bleeding in postoperative status.[ 25 , 26 ] Although the efficacy of TXA in reducing blood loss and improving surgical visibility in orthopedic procedures is well-documented[ 10 , 15 , 27 ], the optimal route of administration, particularly in arthroscopic rotator cuff repair (RCR), remains underexplored. Our findings suggest that the IA method might be more advantageous for managing surgical visibility and reducing postoperative pain in arthroscopic RCR. Contrary to our expectations, we found no conclusive evidence to suggest that the improved visual clarity directly translates to shorter surgical times. This aspect warrants further investigation to understand the relationship between visual field clarity and operative duration. Lastly, the absence of thromboembolic events or other complications in both groups underscores the safety profile of TXA in arthroscopic RCR, aligning with existing literature that highlights TXA’s safety across various orthopedic procedures.[ 13 , 14 ] The inclusion of patients with a history of thromboembolic events in the IA group without subsequent complications further illustrates the potential of IA administration as a safer alternative for patients at higher risk of thromboembolic complications. This aspect of our findings highlights the need for personalized approaches in the administration of TXA, considering patient-specific risk factors and contraindication. These findings have important implications for optimizing surgical outcomes and patient care in arthroscopic rotator cuff repair, advocating for a tailored approach to TXA administration based on individual patient profiles and clinical circumstances. It is important to acknowledge the limitations inherent in a retrospective cohort study, including the potential for selection bias and the influence of unmeasured confounding variables. Additionally, the relatively small sample size and single-center design, as well as the absence of a controlgroup like the non-TXA administered group, may limit the generalizability of our findings. Future research should aim to replicate these results in larger, multicenter randomized controlled trials to provide more definitive evidence on the comparative efficacy and safety of IA versus IV TXA administration in arthroscopic RCR. Lastly, there was possibility of risk that IA TXA could have negative effect on articular cartilage. There were some reports that TXA could make chondral injury through chondrocytes apoptosis.[ 18 ] Even though we did not confirm there was a negative effect of TXA on articular cartilage by long-term follow-up, we applied IA TXA at low concentration based on the previous finding of Want et al., which TXA concentrations of less than 50 mg/ml in joint could not have toxic effect on chondrocyte.[ 18 ] Conclusion Both intra-articular and intra-venous routes are effective for the administration of TXA in arthroscopic rotator cuff repair. However, given the increased distribution of low grade of AVS in IA group, the slight trend towards reduced postoperative pain, and context of patients with thromboembolic events requiring anticoagulants, IA administration presents a more viable alternative. Declarations Ethics approval and consent to participate : IRB number (EMC 2023-07-023) Human Ethics and Consent to Participate declarations: not applicable Clinical trial number: not applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to the ethical issue, but are available from the corresponding author on reasonable request. Competing Interests and Funding Hyojune Kim, Taeho Oh, Min Sun Yoon, In-Ho Jeon, and Kyoung Hwan Koh declare that they have no conflict of interest. Funding This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government(MSIT) (RS-2023-00278547), awarded to HK. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors ’ contributions MSY analyzed and interpreted the patient data regarding the arthroscopic image visuality. HK and TO performed data analysis and validation and were a major contributor in writing the manuscript. IHJ and KHK gave the conceptualization of this study and design, and KHK finally reviewed. .All authors read and approved the final manuscript Acknowledgment This research was supported by EMBRI Grants 2023-EMBRIDJ0003 from the Eulji University. References Day M, Westermann R, Duchman K, Gao Y, Pugely A, Bollier M, Wolf B: Comparison of Short-term Complications After Rotator Cuff Repair: Open Versus Arthroscopic . Arthroscopy 2018, 34 (4):1130-1136. Plachel F, Jo OI, Rüttershoff K, Andronic O, Ernstbrunner L: A Systematic Review of Long-term Clinical and Radiological Outcomes of Arthroscopic and Open/Mini-open Rotator Cuff Repairs . Am J Sports Med 2023, 51 (7):1904-1913. 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Janapala RN, Tran QK, Patel J, Mehta E, Pourmand A: Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis . Am J Emerg Med 2022, 51 :169-175. Haddad AF, Ames CP, Safaee M, Deviren V, Lau D: The Effect of Systemic Tranexamic Acid on Hypercoagulable Complications and Perioperative Outcomes Following Three-Column Osteotomy for Adult Spinal Deformity . Global Spine J 2022, 12 (3):423-431. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5297248","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":372373061,"identity":"747b227e-363a-4f73-acff-2993baf2fc88","order_by":0,"name":"Hyojune Kim","email":"","orcid":"","institution":"Hospital of Chung-Ang University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hyojune","middleName":"","lastName":"Kim","suffix":""},{"id":372373062,"identity":"a9176953-4c67-43e1-a6b6-6fc9e8ba7f19","order_by":1,"name":"Taeho Oh","email":"","orcid":"","institution":"Eulji University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Taeho","middleName":"","lastName":"Oh","suffix":""},{"id":372373063,"identity":"a573a455-a3f4-400c-9638-58158c528a32","order_by":2,"name":"Min Sun Yoon","email":"","orcid":"","institution":"Eulji University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"Sun","lastName":"Yoon","suffix":""},{"id":372373064,"identity":"69e4ce40-261c-4805-85dc-2700169cbb34","order_by":3,"name":"In-Ho Jeon","email":"","orcid":"","institution":"Asan Medical Center, University of Ulsan","correspondingAuthor":false,"prefix":"","firstName":"In-Ho","middleName":"","lastName":"Jeon","suffix":""},{"id":372373065,"identity":"ffb8f526-96b6-40d2-a684-b6b6d50b117b","order_by":4,"name":"Kyoung Hwan Koh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYHACAyBOYDBgbwCxLUjRwnMAxJYgRYtEAohDhBZ+/sMbH/xgSJMzl3x+dcOPAgkG/vbuBLxaJGekFRv2MOQYW87OKbvZA3SYxJmzG/C76gaPmTQDQ0Xihts5aTd4gFoMJHIJaDl/Bqrl5pm0m3+I0nIgB6QlJ3HDDfZjt4myBeIXgzRjgzM5bLdlDCR4CPoFEmIVyXIGx48/u/nmj40cf3svfi1Q54EIHghJhHI4YH9AiupRMApGwSgYQQAAlstEaDrGPmwAAAAASUVORK5CYII=","orcid":"","institution":"Asan Medical Center, University of Ulsan","correspondingAuthor":true,"prefix":"","firstName":"Kyoung","middleName":"Hwan","lastName":"Koh","suffix":""}],"badges":[],"createdAt":"2024-10-20 07:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5297248/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5297248/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69079620,"identity":"197e2dca-8125-4ec4-b8bb-f5013a6eddf0","added_by":"auto","created_at":"2024-11-15 11:43:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107465,"visible":true,"origin":"","legend":"\u003cp\u003eArthroscopic visual scale grade used to assess clarity of view during arthroscopic procedure: grade 1 (A), grade 2 (B), grade 3 (C), grade 4 (D).\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5297248/v1/c1a707bf7fce20b6523a3a98.jpg"},{"id":69079619,"identity":"bd2ef744-8903-4421-af6d-7aa66c39a651","added_by":"auto","created_at":"2024-11-15 11:43:39","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":142094,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of study population.\u003c/p\u003e","description":"","filename":"Figure2.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5297248/v1/361ed33a4c1f5433c94bad3f.jpg"},{"id":69079621,"identity":"b5d04655-5a24-4f94-b111-2ca69d8ad987","added_by":"auto","created_at":"2024-11-15 11:43:39","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":85500,"visible":true,"origin":"","legend":"\u003cp\u003eArthroscopic visual scale grade distribution.\u003c/p\u003e","description":"","filename":"Figure3.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5297248/v1/a22aebef8855a3a3e635816c.jpg"},{"id":92572085,"identity":"a1ae73cb-c38a-446c-8936-f9650c4d2d82","added_by":"auto","created_at":"2025-10-01 07:54:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2430004,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5297248/v1/c1e07db4-edfc-4b97-a564-7380c36339e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Both intra-articular and intravenous tranexamic acid enhance visual clarity and reduce postoperative pain following arthroscopic rotator cuff repair: a comparison study using propensity score-matched analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eArthroscopic rotator cuff repair (RCR) represents a significant advancement in the treatment of full-thickness rotator cuff tears, offering benefits such as reduced complication rates, and expedited return to daily activities.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] A critical component in optimizing the outcomes of this procedure is maintaining clear visual fields during surgery, which is directly impacted by the management of intraoperative bleeding.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Despite advancements in surgical techniques and equipment[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the challenge of optimizing visual clarity while minimizing postoperative pain remains a pivotal concern in arthroscopic RCR.\u003c/p\u003e \u003cp\u003eTranexamic Acid (TXA), known for its well-established hemostatic properties, has become a valuable agent in reducing blood loss and minimizing postoperative complications.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] It has a proven safety profile across various fields of orthopedic surgery, making it a viable option for arthroscopic procedures.[\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Until now, TXA has typically been administered via intravenous injection prior to arthroscopic surgery, showing improvements in visual clarity.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Recently, however, the administration of TXA has the disadvantage of being only limitedly usable in some patients with thromboembolic events.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Some studies have indicated that intra-articular TXA injections in patients undergoing arthroscopic rotator cuff repair can also enhance visual clarity.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] However, the existing literature predominantly investigates the effects of TXA without distinguishing between its modes of administration, specifically intra-articular (IA) and intravenous (IV).[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This lack of differentiation results in an incomplete understanding for orthopedic surgeons and clinical practitioners on how to fully maximize the benefits of TXA in arthroscopic RCR.\u003c/p\u003e \u003cp\u003eThough prior studies have confirmed the effectiveness of TXA in arthroscopic RCR[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], a more nuanced understanding of its benefits and potential risks, depending on the method of administration; IA and IV, should be required. Therefore, we conduct a detailed comparative analysis of IA versus IV administration of TXA in the context of arthroscopic RCR. The purpose of this study was to elucidate the distinctions between these administration routes concerning intraoperative visual clarity, postoperative pain management, and the incidence of complications. It was hypothesized that compared to IV administration of TXA, IA TXA can more improve visual field clarity, shorten the operation time during ARCR, and more reduce initial postoperative pain, effectively.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patient selection\u003c/h2\u003e \u003cp\u003e This retrospective study conformed to the principles of the Declaration of Helsinki and was approved by the local research ethics committee (EMC 2023-07-023). The study sample included individuals who were diagnosed with a magnetic resonance imaging-confirmed full-thickness rotator cuff rupture and had a history of failure of conservative treatment for \u0026gt;\u0026thinsp;6 months. Patients diagnosed between March 2022 and November 2023 and those who had rotator cuff repair surgery. Patients who are presence of an inferior vena cava filter; abnormal prothrombin time, activated partial thromboplastin time, and/or bleeding time; history of cardiac, renal, and/or hepatic disease; diagnosis of TXA allergy; acute RCT and conservative treatment for \u0026lt;\u0026thinsp;6 months were excluded from this study. In IV group, those with history of coagulopathy, deep venous thrombosis, and/or tendency for thrombotic events; administration of anticoagulant therapy was additionally excluded, but not in IA group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient groups of the IA group and IV group were randomly selected after considering the selection criteria and contraindications mentioned above. Demographic characteristics including age, sex, average tear dimension(mm), mean arterial pressure (MAP), surgery time, arthroscopic visual scale (AVS score), and visual analog scale (VAS score) were recorded.\u003c/p\u003e Table 1 Inclusion and exclusion criteria\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInclusion criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHistory of failure of conservative treatment for \u0026ge;\u0026thinsp;6 months\u003c/p\u003e \u003cp\u003eMRI and sonography confirmed rotator cuff rupture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eExclusion criteria\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-articular group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntra-venous group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of acute rotator cuff rupture\u003c/p\u003e \u003cp\u003eConservative treatment for \u0026lt;\u0026thinsp;6months\u003c/p\u003e \u003cp\u003eInferior vena cava filter\u003c/p\u003e \u003cp\u003eAbnormal coagulation parameters (prothrombin time, activated partial thromboplastin time, and/or bleeding time)\u003c/p\u003e \u003cp\u003eHistory of cardiac, renal, and/or hepatic disease\u003c/p\u003e \u003cp\u003eDiagnosis of TXA allergy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory of acute rotator cuff rupture\u003c/p\u003e \u003cp\u003eConservative treatment for \u0026lt;\u0026thinsp;6months\u003c/p\u003e \u003cp\u003eHistory of coagulopathy, deep venous thrombosis, and/or tendency for thrombotic events (TXA contra-indication)\u003c/p\u003e \u003cp\u003eAnticoagulant therapy (TXA contra-indication)\u003c/p\u003e \u003cp\u003eInferior vena cava filter\u003c/p\u003e \u003cp\u003eAbnormal coagulation parameters (prothrombin time, activated partial thromboplastin time, and/or bleeding time)\u003c/p\u003e \u003cp\u003eHistory of cardiac, renal, and/or hepatic disease\u003c/p\u003e \u003cp\u003eDiagnosis of TXA allergy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMRI\u003c/em\u003e, magnetic resonance imaging; \u003cem\u003eTXA\u003c/em\u003e, tranexamic acid.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreparation of irrigation solution and TXA injection\u003c/h3\u003e\n\u003cp\u003eThree liters of arthroscopic irrigation solution (normal saline solution) was prepared by an operating nurse; in the intra-articular injection group, 500mg of TXA; 0.16mg/ml (to prevent chondrocyte death and damage to peri-articular tissues as reported earlier[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]) was injected into the irrigation solution (TXA intra-articular injection group), whereas in the TXA intra-venous injection group, the irrigation solution was left TXA free, with TXA 500mg intra-venous injection just before surgery.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] No epinephrine was used in either group\u0026rsquo;s irrigation solution.\u003c/p\u003e\n\u003ch3\u003eSurgical technique and postoperative management\u003c/h3\u003e\n\u003cp\u003eEach procedure was carried out by the same surgeon, HK., with patients undergoing general anesthesia in lazy lateral position, avoiding the use of regional anesthesia. This standardized approach ensured that the same surgical steps were consistently followed in the same order for every patient, regardless of their allocation to the IA or IV TXA group. The surgical protocol involved a comprehensive assessment of the glenohumeral joint and the rotator interval. In instances where a degenerative biceps tendon was identified, a biceps tenotomy was performed (involving 15 patients from the intra-articular group and 13 from the intra-venous group). Acromioplasty was conducted on all patients across both groups. No additional procedure was undertaken alongside this. The repair of the supraspinatus tendon was executed using a double-row suture bridge technique. A pressure-regulated pump (CONMED comp.) maintained the irrigation solution\u0026rsquo;s pressure at a steady 60mm Hg throughout the surgery, and no cases involved the use of flush irrigation. The anesthesiologist monitored and recorded the mean arterial pressure (MAP) during each operation.\u003c/p\u003e \u003cp\u003eImmediately following the surgery, patients were fitted with an abduction brace and instructed to minimize active shoulder movement and abduction while in the hospital. For pain control, every patient received a 500mg paracetamol injection every 12 hours, consistent across both groups. A suprascapular nerve block was administered to all patients, and paracetamol was the exclusive medication used for pain management. Patients were discharged on the second day after the operation, once their condition was stable and their pain levels were manageable.\u003c/p\u003e\n\u003ch3\u003eAssessment of intraoperative arthroscopic visual clarity and secondary outcome parameters\u003c/h3\u003e\n\u003cp\u003eThe entire surgical process of all patients was recorded. To assess the clarity during surgery, a unique arthroscopic visual scale (AVS), akin to the system employed by van Montfoort et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], was used by the two surgeons, HK. and THO. This AVS comprised five levels: Grade 1signified complete absence of visual obstruction due to bleeding; grade 2 represented mild visual disruption; grade 3 indicated moderate interference; grade 4implied severe disturbance; and grade 5, the most extreme, necessitated a shift to open surgery due to overwhelming visual impairment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The AVS rating for each patient was determined as follows: Surgeons reviewed the video recordings of the arthroscopic procedure post-surgery, noting the AVS every 10 minutes-a chosen interval reflecting the dynamic nature of bleeding in arthroscopy in a blinded for the interventions. Subsequently, an average score per patient was computed. Although grade 5 was an on-the-spot assessment and was intended for postoperative review, it was not applicable in this case.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor a comprehensive evaluation, HK. and THO re-watched the videos after two weeks later, and separately reviewed them. The consistency of these observations was confirmed with an intraclass correlation coefficient ranging from 0.81 to 0.97, indicating strong intra-observer reliability. And another orthopaedic surgeon, MSY., watched and reviewed AVS score. The inter-observer reliability of radiographic outcome measurements was determined using the intraclass correlation coefficient, showing values of 0.81\u0026ndash;0.97.\u003c/p\u003e \u003cp\u003ePain levels were measured by ward nurses, who were not aware of the study details, using the visual analog scale (VAS) at 8, 24, 48 and 72 hours after the operation. Additionally, the mean arterial pressure (MAP) and total duration of the surgery were documented. The average values of all these parameters were then compared between the two groups.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eTo calculate the sample size, G*Power software (version 3.1.9.7;gpower.hhu.de) was used prior to the study, and statistical power (1 - β), alpha error, and impact value were calculated as 0.8, 0.05, and 0.8, respectively. As a result of this a priori power analysis model, it was calculated that 26 patients were required in each group. Data analysis was performed using the SPSS software (version 19.0; Chicago, Illinois). Data are expressed as mean standard deviation or as average values. Age, sex, surgery time, mean arterial blood pressure, surgical visualization score (AVS score), and postoperative pain score were compared between group using independent-samples test after 1:1 propensity score matching (PSM). Normality was assessed using Kolmogorov-Smirnov test for categorical variables and the Shapiro-Wilk test for continuous variables. Student\u0026rsquo;s t test was used to compare continuous variables between IA and IV groups, including age, sex, average tear dimension, MAP, surgery time, AVS score, VAS pain score. Bonferroni correction was applied to account for multiple comparisons across groups, depending on the postoperative time points. The significant p-value was 0.0125 for VAS pain score. Fisher\u0026rsquo;s exact test was performed to compare the AVS grade distribution ratio. Results were reported at a confidence interval of 95%, and P\u0026thinsp;\u0026lt;\u0026thinsp;.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 107 patients who had rotator cuff repair surgery, 31 were excluded based on the inclusion and exclusion criteria (16 were receiving anticoagulant therapy; 7 had a history of cardiac, hepatic, and/or renal disease; 4 had an abnormal prothrombin time or activated partial thromboplastin time at the time of surgery; 2 had acute RCTs). The remaining 76 patients were enrolled in the study (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eAfter 1:1 PSM, the IA group was composed of 30 patients (14 female and 16 male patients) with a mean age of 60.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 years (range, 31\u0026ndash;73 years). The IV group was composed of 31 patients (14 female and 17 male patients) with a mean age of 63.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 years (range, 46\u0026ndash;81 years). The groups showed no statistically significant differences in terms of age (P\u0026thinsp;=\u0026thinsp;.800), sex (P\u0026thinsp;=\u0026thinsp;.724), tear dimension (22.8 mm in IA group vs. 24.1 mm in IV group, P\u0026thinsp;=\u0026thinsp;.686), and Goutallier classification (range, 0\u0026ndash;4 in both group; P\u0026thinsp;=\u0026thinsp;.545)[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of patients and evaluation of intergroup differences\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIA group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIV group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAge, year\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u0026ndash;81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSex, number\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAverage tear dimension, mm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMAP, mmHg\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.3-133.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.67\u0026ndash;118.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSurgery time, minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112.3\u0026thinsp;\u0026plusmn;\u0026thinsp;55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121.9\u0026thinsp;\u0026plusmn;\u0026thinsp;57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.566\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026ndash;250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAVS score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAverage VAS pain score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e48 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e72 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eTXA, tranexamic acid; SD, standard deviation; MAP, mean arterial pressure; AVS, arthroscopic visual scale; VAS, visual analog scale. *Significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.0125.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average volume of irrigation fluid used was 36.9 L for the IA group and 39.2 L for the IV group (P\u0026thinsp;=\u0026thinsp;.751). The mean duration of operation time in the IA and IV group was 112.3 minutes and 121.9 minutes, respectively (P\u0026thinsp;=\u0026thinsp;.566). The mean AVS score in the IA group (1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4) was not significantly different with the mean AVS score in the IV group (1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3) (P\u0026thinsp;=\u0026thinsp;.19). IA group was reported to have percentages with AVS score of grades 1\u0026ndash;2 (90.0%), grade 2\u0026ndash;3 (6.7%) and grade 3 (3.3%). IV group was reported to have percentages with AVS score of grades 1\u0026ndash;2 (64.5%), grade 2\u0026ndash;3 (35.5%) and grade 3 (0%). No AVS score of grades more than 4 was reported in either group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The AVS grade distribution ratio was significantly different between two groups (p\u0026thinsp;=\u0026thinsp;0.011) (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eMAP was assessed in both groups to examine its influence on visual clarity. The MAP was noted to be 101.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3 mm Hg in the IA group and 98.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 mm Hg in the IV group, showing no statistically significant difference (P\u0026thinsp;=\u0026thinsp;.423). The Pearson correlation analysis also indicated no significant relationship between MAP and AVS score (coefficient\u0026thinsp;=\u0026thinsp;0.16, P\u0026thinsp;=\u0026thinsp;.915) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnalysis of VAS pain scores showed that there was tendency of increased improvement in the IA group compared with the IV group at 24 hours after surgery (4.4 vs. 5.6, P\u0026thinsp;=\u0026thinsp;.014), 48 hours (2.7 vs. 4.2, P\u0026thinsp;=\u0026thinsp;.008), 72 hours (1.8 vs. 2.9, P\u0026thinsp;=\u0026thinsp;.020). Considering the Bonferroni correction, VAS at postoperative 48 hours in IA group showed significant improvement compared to IV group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0125). After no thromboembolic events or other complications were observed in either group until discharge. Notably, 4 patients in the IA group with history of thromboembolic events like angina requiring anticoagulants were identified, but no patients required anticoagulants in the IV group, as such conditions contraindicate intravenous TXA administration. These 4 patients had no complication like thromboembolism, pulmonary embolism, seizure until next outpatient clinic follow up (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, we observed that the group receiving intra-articular (IA) tranexamic acid (TXA) exhibited a lower grade of arthroscopic visibility score (AVS) and experienced reduced postoperative pain compared to the intravenous (IV) TXA group. Notably, the IA TXA group included patients with contraindications to IV TXA, yet no complications arose, highlighting the broader applicability of the IA route.\u003c/p\u003e \u003cp\u003eA critical observation from our study was the lack of significant difference in immediate postoperative visual analogue scale (VAS) pain scores between the two groups. However, a notable improvement in VAS scores was observed in the IA group at the 2-day postoperative mark, suggesting a delayed, yet significant, benefit in pain reduction. This delayed effect might be attributed to IA TXA's role in minimizing hemarthrosis, thereby reducing hematoma formation and subsequent pain. Prospective double-blind study by Li et al.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] reported that intravenous administration of TXA before shoulder arthroscopy significantly improved intra-operative bleeding, but not affected post-operative blood loss, red cell count, hemoglobin or hematocrit. Otherwise, Zhu et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported that intra-articular TXA injection during shoulder arthroscopy successfully prevented blood loss and hemoglobin loss\u0026mdash;in line with the similar knee surgery studies[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In addition, intraarticular injection in arthroscopic anterior cruciate ligament reconstruction showed the reduced amount of postoperative hemarthrosis, and it could reduce the pain in the early postoperative period.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The substantial decrease in pain, especially in the early postoperative phase, provides a strong case for favoring IA administration in clinical settings.\u003c/p\u003e \u003cp\u003eFurthermore, while the mean AVS did not significantly differ between the groups, a higher number of patients in the IA group achieved lower AVS grades (grade 1\u0026ndash;2) than IV group. Even though total volume of TXA in each group was totally different, that it was one of our limitations, this difference could be supported from previous study that local injection have more effective to control bleeding in postoperative status.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Although the efficacy of TXA in reducing blood loss and improving surgical visibility in orthopedic procedures is well-documented[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the optimal route of administration, particularly in arthroscopic rotator cuff repair (RCR), remains underexplored. Our findings suggest that the IA method might be more advantageous for managing surgical visibility and reducing postoperative pain in arthroscopic RCR. Contrary to our expectations, we found no conclusive evidence to suggest that the improved visual clarity directly translates to shorter surgical times. This aspect warrants further investigation to understand the relationship between visual field clarity and operative duration.\u003c/p\u003e \u003cp\u003eLastly, the absence of thromboembolic events or other complications in both groups underscores the safety profile of TXA in arthroscopic RCR, aligning with existing literature that highlights TXA\u0026rsquo;s safety across various orthopedic procedures.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The inclusion of patients with a history of thromboembolic events in the IA group without subsequent complications further illustrates the potential of IA administration as a safer alternative for patients at higher risk of thromboembolic complications. This aspect of our findings highlights the need for personalized approaches in the administration of TXA, considering patient-specific risk factors and contraindication. These findings have important implications for optimizing surgical outcomes and patient care in arthroscopic rotator cuff repair, advocating for a tailored approach to TXA administration based on individual patient profiles and clinical circumstances.\u003c/p\u003e \u003cp\u003eIt is important to acknowledge the limitations inherent in a retrospective cohort study, including the potential for selection bias and the influence of unmeasured confounding variables. Additionally, the relatively small sample size and single-center design, as well as the absence of a controlgroup like the non-TXA administered group, may limit the generalizability of our findings. Future research should aim to replicate these results in larger, multicenter randomized controlled trials to provide more definitive evidence on the comparative efficacy and safety of IA versus IV TXA administration in arthroscopic RCR. Lastly, there was possibility of risk that IA TXA could have negative effect on articular cartilage. There were some reports that TXA could make chondral injury through chondrocytes apoptosis.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Even though we did not confirm there was a negative effect of TXA on articular cartilage by long-term follow-up, we applied IA TXA at low concentration based on the previous finding of Want et al., which TXA concentrations of less than 50 mg/ml in joint could not have toxic effect on chondrocyte.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBoth intra-articular and intra-venous routes are effective for the administration of TXA in arthroscopic rotator cuff repair. However, given the increased distribution of low grade of AVS in IA group, the slight trend towards reduced postoperative pain, and context of patients with thromboembolic events requiring anticoagulants, IA administration presents a more viable alternative.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e: IRB number (EMC 2023-07-023)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analysed during the current study are not publicly available due to the ethical issue, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests and Funding\u0026nbsp;\u003c/strong\u003eHyojune Kim, Taeho Oh,\u0026nbsp;Min Sun Yoon,\u0026nbsp;In-Ho Jeon, and Kyoung Hwan Koh declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThis work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government(MSIT) (RS-2023-00278547), awarded to HK. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u0026nbsp;\u003c/strong\u003eMSY analyzed and interpreted the patient data regarding the arthroscopic image visuality. HK and TO performed data analysis and validation and were a major contributor in writing the manuscript. IHJ and KHK gave the conceptualization of this study and design, and KHK finally reviewed. .All authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003eThis research was supported by EMBRI Grants 2023-EMBRIDJ0003 from the Eulji University.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDay M, Westermann R, Duchman K, Gao Y, Pugely A, Bollier M, Wolf B: \u003cstrong\u003eComparison of Short-term Complications After Rotator Cuff Repair: Open Versus Arthroscopic\u003c/strong\u003e. \u003cem\u003eArthroscopy \u003c/em\u003e2018, \u003cstrong\u003e34\u003c/strong\u003e(4):1130-1136.\u003c/li\u003e\n\u003cli\u003ePlachel F, Jo OI, R\u0026uuml;ttershoff K, Andronic O, Ernstbrunner L: \u003cstrong\u003eA Systematic Review of Long-term Clinical and Radiological Outcomes of Arthroscopic and Open/Mini-open Rotator Cuff Repairs\u003c/strong\u003e. \u003cem\u003eAm J Sports Med \u003c/em\u003e2023, \u003cstrong\u003e51\u003c/strong\u003e(7):1904-1913.\u003c/li\u003e\n\u003cli\u003eBelk JW, McCarty EC, Houck DA, Dragoo JL, Savoie FH, Thon SG: \u003cstrong\u003eTranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies\u003c/strong\u003e. \u003cem\u003eArthroscopy \u003c/em\u003e2021, \u003cstrong\u003e37\u003c/strong\u003e(4):1323-1333.\u003c/li\u003e\n\u003cli\u003eLiu YF, Hong CK, Hsu KL, Kuan FC, Chen Y, Yeh ML, Su WR: \u003cstrong\u003eIntravenous Administration of Tranexamic Acid Significantly Improved Clarity of the Visual Field in Arthroscopic Shoulder Surgery. 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We aimed to find the distinctions between IV and IA TXA concerning intraoperative visual clarity, postoperative pain management, and the incidence of complications like thromboembolism during ARCR.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn our retrospective cohort, propensity score matching study, we included patients who had a history of rotator cuff tears and at least six months of unsuccessful conservative treatment. The primary outcome, visual clarity during surgery, was evaluated using a five-grade arthroscopic visual scale (AVS) by the operating surgeon. This scale ranged from grade 1, indicating optimal clarity, to grade 5, the least clarity necessitating a switch to open surgery. These assessments were made at 10-minute intervals during the review of the operation\u0026rsquo;s video footage. We also measured the duration of the surgery and postoperative pain levels as secondary outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIA group included 30 patients and the IV group had 31 patients, with no significant differences in demographics or tear dimensions (P\u0026thinsp;=\u0026thinsp;0.686). The IA and IV groups showed similar irrigation fluid volumes, operation times, and AVS mean scores. IA group had lower grade of AVS grade 1\u0026ndash;2 compared to IV group (90.0% vs 64.5%, p\u0026thinsp;=\u0026thinsp;0.011). Pain assessment using the Visual Analog Scale (VAS) suggested a trend towards less pain in the IA group at various postoperative times, and less pain at postoperative 48 hours (IA 2.7 vs IV 4.2, p\u0026thinsp;=\u0026thinsp;008). Notably, 4 patients in the IA group required anticoagulants due to thromboembolic events, a contraindication for intravenous TXA administration.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBoth IA and IV routes are effective and safe for the administration of TXA in ARCR. However, given the increased distribution of low grade of AVS in IA group, the slight trend towards reduced postoperative pain, and context of patients with thromboembolic events requiring anticoagulants, IA administration presents a more viable alternative.\u003c/p\u003e\u003ch2\u003eLevel of evidence:\u003c/h2\u003e \u003cp\u003eRetrospective cohort study (Level 3)\u003c/p\u003e","manuscriptTitle":"Both intra-articular and intravenous tranexamic acid enhance visual clarity and reduce postoperative pain following arthroscopic rotator cuff repair: a comparison study using propensity score-matched analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:43:34","doi":"10.21203/rs.3.rs-5297248/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ce9d678-ade3-44b8-a4fa-d16c5cf904aa","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-01T07:54:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:43:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5297248","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5297248","identity":"rs-5297248","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}