Injectable Tranexamic Acid Use in Arthroscopic Rotator Cuff Repair Is Safe and Associated with Reduced Postoperative Opioid Use

<b>Background/Objectives:</b> Tranexamic acid (TXA) is widely used to reduce bleeding in orthopedic surgery, but its safety and impact on outcomes in arthroscopic rotator cuff repair (ARCR) remain unclear. The purpose of this study was to evaluate the safety and effects of injectable TXA on short- and long-term postoperative outcomes and opioid use following ARCR. <b>Methods:</b> The TriNetX Research Network, an insurance claims-based database, was utilized to conduct this retrospective, propensity-matched cohort study. Patients aged ≥18 years undergoing ARCR were identified and divided into TXA (<i>n</i> = 5855) and non-TXA (<i>n</i> = 5855) groups after propensity score matching. Outcomes assessed included 30-day hospital utilization, complications (infection, thromboembolism, hemarthrosis, blood transfusion), one-year revision and shoulder surgery rates, and early, prolonged, and chronic postoperative opioid use. <b>Results:</b> No significant differences were observed between groups in 30-day emergency department visits (2.0% vs. 1.8%, <i>p</i> = 0.502), readmissions, infections, wound dehiscence, blood transfusions, hemarthrosis, or one-year revision and shoulder surgery rates. TXA use was associated with significantly lower rates of early (24.8% vs. 26.8%, <i>p</i> = 0.011), prolonged (9.5% vs. 12.8%, <i>p</i> < 0.001), and chronic opioid use (6.6% vs. 9.6%, <i>p</i> < 0.001). <b>Conclusions:</b> Injectable TXA is safe in ARCR, with no increase in postoperative complications or hospital utilization. Furthermore, TXA use is linked to reduced postoperative opioid consumption, suggesting benefits in pain management and recovery. Prospective studies are warranted to further explore these findings.