Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty

Prevention of postoperative bleeding in hip fractures treated with prosthetic replacement: efficacy and safety of fibrin sealant and tranexamic acid. A randomised controlled clinical trial (TRANEXFER study)

INTRODUCTION

We assessed the efficacy of fibrin sealant (FS) and tranexamic acid (TXA) administered topically in patients with a hip fracture treated with prosthetic replacement.

MATERIALS AND METHODS

Parallel, multicentre, open label, randomised, clinical trial. We compared three interventions to reduce blood loss: (1) 10 ml of FS, (2) 1 g of topical TXA, both administered at the end of the surgery, and (3) usual haemostasis (control group). The main outcome was blood loss collected in drains. Other secondary variables were total blood loss, hidden blood loss, transfusion rate, average hospital stay, complications, adverse events, and mortality.

RESULTS

A total of 158 patients were included, 56 in the FS group, 52 in the TXA group, and 50 in the control group. The total amount of blood collected in drains was lower in the TXA group (148.6 ml, SD 122.7 in TXA; 168.2 ml, SD 137.4 in FS; and 201.5 ml, SD 166.5 in control group) without achieving statistical significance (p = 0.178). The transfusion rate was lower in the TXA group (32.7%), compared with FS group (42.9%) and control group (44.0%), without statistical significance (p = 0.341). There were no complications or adverse effects related to the evaluated interventions.

CONCLUSIONS

The use of TXA and FS administered topically prior to surgical closure in patients with a sub-capital femoral fracture undergoing arthroplasty did not significantly reduce either postoperative blood loss or transfusion rate, compared with a group that only received usual haemostasis.

Dose optimization of topical tranexamic acid for primary total hip arthroplasty: A prospective cohort study

BACKGROUND

Recently, the topical application of tranexamic acid has become widespread, and it is effective in reducing postoperative blood loss and transfusion rate in total hip arthroplasty. There is no consensus on the optimal dose of topical tranexamic acid. This study aimed to assess the efficacy and safety of topical tranexamic acid on postoperative blood loss and determine the optimal topical dose for primary total hip arthroplasty.

METHODS

This prospective cohort study with a robust protocol enrolled 79 patients who received either 1 or 2 g of topical tranexamic acid in 30 mL normal saline solution or an equivalent volume of normal saline at the end of surgery. The primary outcomes were postoperative drain blood loss and hemoglobin decrease on postoperative day 7. The secondary outcomes were transfusion rate, d-dimer level on postoperative day 7, symptomatic deep vein thrombosis rate, and duration of hospital stay.

RESULTS

Both 1 and 2 g tranexamic acid significantly reduced postoperative drain blood loss (p < 0.001). These doses also reduced the hemoglobin concentration decrease on postoperative day 7, but not significantly. Furthermore, 1 and 2 g doses of tranexamic acid had similar effects on postoperative blood loss and hemoglobin concentration decrease. There was no difference in the transfusion rate, d-dimer level, symptomatic deep vein thrombosis rate, and length of hospital stay.

CONCLUSIONS

The use of topical tranexamic acid at the end of surgery is effective and safe for reducing postoperative blood loss in primary total hip arthroplasty. Topical tranexamic acid at a dose of 1 g may be sufficient and cost-effective, with fewer side effects than the higher dose.

Tranexamic Acid in Reducing Gross Hemorrhage and Transfusions of Spine Surgeries (TARGETS): study protocol for a prospective, randomized, double-blind, non-inferiority trial

BACKGROUND

Tranexamic acid (TXA) has been routinely delivered in multisegmental spinal decompression and bone graft fusion surgeries with satisfactory outcomes in minimizing gross blood loss and transfusion demands. However, concerns remain that intravenously delivered TXA (ivTXA) may increase risks of postoperative convulsive seizures and systemic thrombogenicity. Topical use of TXA (tTXA), being more targeted to the surgical bleeding site while minimizing patient systemic exposure to ivTXA, has been successfully applied to attenuate blood losses and transfusion requirements in hip and knee arthroplasty. Yet, randomized controlled trials on tTXA efficacy and safety are still lacking in spinal surgeries. With this knowledge gap, we hypothesize that tTXA exhibits non-inferiority to ivTXA in blood conservation and clinical safety in multisegmental spinal decompression and bone graft fusion surgeries.

METHODS

A prospective, randomized, double-blind, non-inferiority study design will be adopted. The target sample size is 176. Eligible patients will be randomly allocated to receive either ivTXA or tTXA treatment. The primary end point is the perioperative total blood loss. Secondary end points consist of visible blood losses (intraoperative, postoperative 0-24 h, postoperative 0-48 h, combined perioperative blood loss, total postoperative blood loss), postoperative hidden blood loss, plasma TXA levels, postoperative conventional coagulation monitoring (prothrombin time, activated partial thromboplastin time, fiber Bragg grating, international normalized ratio), postoperative thromboelastography monitoring (reaction time, clot formation time, clot strength, fibrinolysis), postoperative hemoglobin nadir (within postoperative 48 h), perioperative transfusion amounts and rates, and length of hospital stay. Safety end points will be monitored too.

DISCUSSION

This proposed study will contribute to expanding clinical evidences of tTXA for bleeding management in major spinal surgeries. This will be a high-quality prospective randomized trial with sufficient sample size, strict methodology, and few design deficits. It will investigate the potentiality of tTXA as an alternative to ivTXA in improving the current standard of care in multisegmental spinal surgeries, thereby optimizing the enhanced recovery after surgery scheme in spinal surgeries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03011866 . Registered on 5 January 2017.

Agreement of surgical blood loss estimation methods

BACKGROUND

Surgical blood loss is usually estimated by different formulae in studies of strategies aimed at reducing perioperative bleeding. This study assessed and compared the agreement of the main blood loss estimation formulae using a direct measurement of blood loss as the reference method.

STUDY DESIGN AND METHODS

Eighty consecutive patients undergoing urologic laparoscopic surgery were studied. Only optimal conditions for the direct measurement of surgical blood loss were considered. Surgical blood loss was estimated by six formulae at four different postoperative time points. The agreement of the formulae was evaluated by the Concordance correlation coefficient (CCC) and Bland-Altman analyses. An analysis of the agreement's variability regarding different magnitudes of blood loss was also performed.

RESULTS

Directly measured blood loss ranged from 200 to 2200 mL. The formulae studied showed poor agreement with the direct measurement of blood loss; 95% limits of agreement widely exceeded the criterion of ±560 mL. Significant biases were found, which for most of the formulae led to an overestimation of blood loss. For all formulae, agreement remained constant regardless of the amount of blood loss, with limits between -40 and +120% approximately. Among the formulae, the best agreement was achieved by López-Picado's formula at 48 hours (CCC: 0.577), with a bias of +283 mL and 95% limits of agreement between -477 and +1043 mL.

CONCLUSION

Formulae currently used to estimate surgical blood loss differ substantially from direct measurements; therefore, they may not be reliable methods of blood loss quantification in the surgical setting.

Intra-Articular Tranexamic Acid Injection During the Hip Hemi-Arthroplasty in Elderly Patients: A Retrospective Study

Introduction:

The objective was to evaluate the safety and efficacy of intra-articular injection of tranexamic acid (TXA) in patients between 80 and 100 years of age with femoral neck fracture undergoing hip hemi-arthroplasty (HA).

Material and Methods:

We conducted a retrospective review to assess perioperative blood loss and transfusion rate after intra-articular injection of TXA during HA. This was a single-center, retrospective, single-surgeon, and standard care cohort study covering the period between January and December 2016. One hundred three consecutive patients undergoing HA under spinal or general anesthesia were included. Fifty-four and 49 patients received and did not receive intra-articular injection of TXA during the HA, respectively. After closing the capsule, 50 mL of a TXA solution at a concentration of 1 g/100 mL of saline was injected into joint capsule. We compared the following outcomes: preoperative hemoglobin (HB) level, postoperative day 1 HB level, postoperative day 3 HB level, the net reduction of HB level by postoperative day 3, transfusion rate, and 30- and 90-day postoperative mortality rates. In addition, we use logistic regression to analyze the factors affecting the transfusion rate.

Result:

Day 3 postoperative HB level and the net reduction in HB level within 3 days following surgery were 93.22 ± 11.70 g/L and 25.98 ± 6.29 g/L in TXA group, respectively, while were 87.10 ± 10.52 g/L and 35.44±8.61 g/L in no-TXA group. Transfusion rate was 9% (5/54) in TXA group and 24% (12/49) in no-TXA group, respectively. The differences were statistically significant between the both groups. Logistic regression indicated that the topical administration of TXA would reduce the risk for transfusion, while in male diabetes mellitus would increase the risk. There were no significant differences in the deep venous thrombosis, pulmonary embolism, and mortality rates of 30 and 90 days postoperatively (P > .05).

Discussion:

Because of lower systemic absorption and a higher concentration in the wound, topical use of TXA is safer for elderly patients who may have renal or liver dysfunction. TXA at therapeutic concentration does not affect platelet count, platelet aggregation, or coagulation parameters, and is of value in elderly patients who take antiplatelet drug for secondary prevention of cardiovascular diseases.

Conclusion:

For patients between 80 and 100 years of age with femoral neck fracture undergoing HA, intra-articular injection of TXA may reduce the perioperative blood loss and transfusion rate without increasing risk of thrombosis.

Intravenous Tranexamic Acid Reduces Postoperative Blood Loss After High Tibial Osteotomy

BACKGROUND

Medial opening wedge high tibial osteotomy (HTO) entails extensive soft tissue release that may lead to substantial perioperative bleeding. Although tranexamic acid (TXA) is a well-established blood-conserving agent in total joint arthroplasty, its potential to reduce blood loss in patients undergoing HTO has not been studied extensively.

QUESTIONS/PURPOSES

(1) Does TXA reduce total estimated blood loss in HTO? (2) Does TXA use in HTO affect in-hospital endpoints as measured by visual analog scale (VAS) pain scores at rest the day after surgery, wound complications in the immediate postoperative period, blood transfusions, or symptomatic deep vein thrombosis?

METHODS

Between January 2015 and May 2017, a single surgeon performed 156 HTOs, all of which were done using the medial opening wedge technique. We began using intravenous TXA for all HTOs in June 2016. This left us with 89 patients who were treated during a time when no TXA was used and 67 patients who were treated when all patients received TXA. Two patients in the control group had simultaneous TKA in the contralateral leg and one patient in each group had missing data so these patients were excluded, leaving 86 (97%) patients in the control group and 66 (98.5%) in the TXA group available for analysis in this retrospective study. There were no demographic differences between the groups in terms of age, sex, body mass index, and baseline hemoglobin values. Total estimated blood loss was the primary outcome variable, which was calculated using total blood volume and decrease in hemoglobin values. Secondary outcome variables included pain VAS at rest the day after surgery, wound complications in the immediate postoperative period, allogeneic blood transfusions, and occurrence of symptomatic thromboembolic manifestations. The decision on when to transfuse was based on predetermined criteria. An orthopaedic surgeon not involved in patient care collected the patient data from electronic medical records and did chart review.

RESULTS

The TXA group had less total blood loss (372 ± 36 mL versus 635 ± 53 mL, mean difference 263 mL [95% confidence interval, 248-278]; p < 0.001). Between groups, differences in VAS pain scores at rest the day after surgery favored the TXA group but were small and unlikely to be clinically important. There were two wound complications in the control group (one hematoma and one superficial wound infection) and none in the TXA group. No patients in either group received a blood transfusion, and no symptomatic thromboembolic events were detected in either group.

CONCLUSIONS

This study demonstrates that the systemic administration of TXA reduces postoperative blood loss in medial opening wedge HTO; however, insofar as no transfusions were administered to patients even before the routine use of TXA in this series, and no clinically important differences in pain scores were identified, the clinical benefit of routine use of TXA in patients undergoing HTO is uncertain. Our study was too small to make safety-related claims on rare endpoints such as wound complications or thromboembolic events. Larger, and preferably randomized, trials are needed to help define whether it is important to use TXA in this setting. Our data can help inform sample size calculations for such studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Is topical or intravenous tranexamic acid preferred in total hip arthroplasty? A randomized, controlled, noninferiority clinical trial

Purpose

The present study aimed to confirm the efficacy and safety of topical and intravenous tranexamic acid (TXA) compared with that of topical placebo and to assess the noninferiority between the two application methods of TXA in patients undergoing unilateral primary total hip arthroplasty.

Methods

Our randomized controlled trial investigated 170 patients with 1:1:1 allocation to two doses of 10-mg/kg intravenous TXA, 3-g topical TXA, and topical placebo of 60-ml physiological saline groups. The primary outcome, total blood loss, was calculated with Nadler and Gross formula. The secondary outcomes included allogeneic blood transfusion requirement, drain blood loss, decreased hemoglobin level. Noninferiority would be established when the upper limit 95% CI is lower than 250 ml of the noninferiority margin for the mean difference of total blood loss between topical and intravenous TXA. Thromboembolic complication incidence was considered as a safety outcome.

Results

The total blood loss of patients administered intravenous (mean±standard deviation, 1125±514 ml) and topical TXA (1211±425 ml) was significantly reduced compared with that of those administered topical placebo (1464±556 ml) (p = 0.0012). Drain blood loss and hemoglobin level reduction in patients administered with TXA were also significantly lower than those in patients administered topical placebo. The mean difference of total blood loss between topical and intravenous TXA is 86 ml (95% CI, −88 to 260 ml). The complications were comparable between patients managed with TXA and patients with topical placebo.

Conclusion

The noninferiority of topical TXA to intravenous TXA can not be concluded. Considering no significant difference was found in all efficacy outcomes between the two administration methods. Any of the two TXA administration methods can be adopted for blood loss prevention in total hip arthroplasty.

Efficacy of topical tranexamic acid within a blood-saving programme for primary total hip arthroplasty: a pragmatic, open-label randomised study

BACKGROUND

Total hip arthroplasty entails considerable peri-operative blood loss, which may lead to acute post-operative anaemia and red blood cell transfusion. This study was aimed at assessing whether the addition of topical tranexamic acid to our ongoing blood-saving protocol for total hip arthroplasty was effective and safe.

MATERIALS AND METHODS

A pragmatic, prospective, open-label randomised study of patients scheduled for total hip arthroplasty at a single centre was conducted. Consecutive patients were randomly assigned to receive topical tranexamic acid (2 g) at the end of surgery (tranexamic group, n=125) or not (control group, n=129). A restrictive transfusion protocol was applied. Outcome measures were red blood cell loss at 24 hours after surgery, in-hospital transfusion rate, and incidence of thromboembolic complications.

RESULTS

Topical tranexamic acid was effective in reducing both red cell loss (mean difference: 138 mL [95% CI 87-189 mL]; p<0.001) in the 24h after surgery and in-hospital transfusion rates (12 vs 32.6%, for the tranexamic acid and control groups, respectively; p<0.001; relative risk=0.37 [95% CI 0.22-0.63]). However, relative red cell loss and transfusion rates were higher in females than in males, irrespectively of tranexamic acid use. The beneficial effect of tranexamic acid on transfusion was restricted to patients with pre-operative haemoglobin ≥13 g/dL (5.1 vs 24.8%; p<0.001). Topical tranexamic acid was well tolerated and no clinically apparent thromboembolic complications were witnessed.

DISCUSSION

The use of topical tranexamic acid after hip arthroplasty reduced red cell loss and transfusion rates; the efficacy of this strategy may be improved by reinforcing both pre-operative haemoglobin optimisation and adherence to the practice of transfusing single units of red cells.

The efficacy of oral versus intravenous tranexamic acid in reducing blood loss after primary total knee and hip arthroplasty: A meta-analysis

BACKGROUND

Blood management after arthroplasties has become a serious problem. The objective is to perform a meta-analysis to compare the efficacy and safety between oral tranexamic acid (TXA) and intravenous TXA for blood management in total knee and hip arthroplasty.

METHODS

We systematically searched randomized controlled trials (RCTs) from Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Google scholar. Eligibility criteria: Patients: adult patients with end-stage joint osteoarthritis, rheumatoid arthritis, and osteonecrosis of the femoral head, who prepared for TJA; Interventions: The experiential group received the intravenous form of TXA; Comparisons: Oral form of TXA; Outcomes: Total blood loss, hemoglobin reduction, transfusion requirements, duration of hospitalization, and thrombotic complications including deep vein thrombosis (DVT) and pulmonary embolism (PE); Study design: Randomized control trials (RCTs) and non-RCT. Meta-analysis results were collected and analyzed by the software STATA 11.0. After testing for heterogeneity between studies, data were aggregated for random-effects models when necessary.

RESULTS

Four RCTs and 2 non-RCTs were included in the meta-analysis. The present meta-analysis revealed that there were no significant differences regarding total blood loss (WMD = -25.013, 95% CI: -51.002 to 0.977, P = .059), postoperative hemoglobin decline (WMD = -0.090, 95% CI: -0.205 to 0.024, P = .122), or transfusion rate (RD = -0.039, 95% CI: -0.080 to 0.002, P = .062) between the 2 groups.

CONCLUSION

Oral TXA shows comparable efficacy to that of the intravenous forms after total knee and hip arthroplasty. Due to the limited quality of evidence currently available, higher quality RCTs is necessary.

The Incidence and Risk Factors of Acute Kidney Disease after Total Knee Arthroplasty with Early Postoperative Volume Supplement

Background

Etiology of acute kidney disease (AKD) after total knee arthroplasty (TKA) was considered as multifactorial. However, the role of early postoperative volume supplement in AKD rate has not been investigated. The purpose of this study was to evaluate the incidence and risk factors of AKD in patients with early volume supplement following TKA.

Methods

This was a retrospective study with 458 patients who underwent unilateral TKA. All the patients received 6% tetrastarch, 7.5ml/kg, early in the postoperative period. Postoperative AKD was defined as the postoperative creatinine level ≥ 1.5 times compared with preoperative data. Potential variables associated with AKD were analyzed by multivariate logistic regression model to identify the AKD risk factors in TKA patients after early postoperative volume supplement.

Results

The AKD rate was 3.3% (15 patients) in all patients. Age (OR = 1.09; P = .031) and coronary artery disease (CAD) (OR = 3.63; P = .034) were associated with increased risk of development of postoperative AKD. Other comorbidities as hypertension, diabetes, and CKD were not statistically significant risk factors.

Conclusion

Our study demonstrated that age and CAD were independent risk factors of AKD in TKA patients. However, the common risk factors as hypertension, diabetes, and CKD were not significantly associated with AKD after TKA if early postoperative supplement of tetrastarch is administered.

The Role of Tranexamic Acid in Plastic Surgery: Review and Technical Considerations

Minimizing blood loss during surgery is critical, and many modalities have been used to decrease unwanted surgical bleeding. Among many methods, use of pharmacologic agents such as antifibrinolytic drugs has been shown to significantly reduce blood loss and the rates of postoperative blood transfusion in many articles. Tranexamic acid is an antifibrinolytic agent that has been widely used in other surgical specialties, especially in cardiac, orthopedic, and trauma surgery. Despite its known benefits, the use of tranexamic acid in plastic surgery is extremely limited, primarily because most plastic surgery procedures do not involve the extent of blood loss that can lead to anemia and the need for blood transfusion, as is common in major orthopedic and cardiac surgery procedures. Nevertheless, there are significant benefits to be gained from the use of antifibrinolytic drugs in the full range of plastic surgery. In this article, the authors introduce the benefits, dosages, and technical considerations of using tranexamic acid in plastic surgery procedures.

Effect of Topical Tranexamic Acid on Reducing Blood Loss in Primary Total Knee Arthroplasty in Southern Chinese Population

The objective of this study was to evaluate the efficacy of topical tranexamic acid (TA) on the postoperative blood loss and transfusion rate after primary total knee arthroplasty (TKA). Two hundred ninety-six patients (n = 296) undergoing TKA in Pok Oi Hospital were included in this study from July 2015 to September 2016. The topical TA group (n =154) showed a significant reduction in haemoglobin drop (2.76 g/dL vs. 3.62 g/dL, p < 0.001), haematocrit drop (0.0876 vs. 0.112, p < 0.001), transfusion rate (3.2% vs. 23.9%, p < 0.001), drain output (199 mL vs. 276 mL, p < 0.001) and length of stay (9 days vs. 11 days, p < 0.001) compared with those in the control group (n = 142). There was no thromboembolic complication associated with TA use. The results supported the use of topical TA to control postoperative blood loss after TKA.

Tranexamic acid use during total hip arthroplasty: A single center retrospective analysis

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent that has shown promise in reducing blood loss during total hip arthroplasty (THA). Several studies have reported side effects of high-dose TXA administration, including myocardial infarction (MI), thromboembolic events, and seizures. These possible side effects have prevented the widespread adoption of TXA in the surgical community.

METHODS

We conducted a retrospective chart review of 564 primary and revision THAs performed at a single academic center. Surgical patients received either no TXA or 1 g IV TXA at the beginning of surgery followed by a second bolus just before the surgical wound closure, at the surgeon's discretion. We analyzed differences in hemoglobin (Hb), hematocrit (Hct), estimated blood loss (EBL), and adverse events in patients receiving TXA versus patients not receiving TXA up to 2 days following surgery.

RESULTS

Significantly higher Hb and Hct values were found across all time points among patients undergoing primary posterior or revision THA who had received TXA. In addition, transfusion rates were significantly decreased in both primary posterior THAs and revision THAs when TXA was administered. Patients who received TXA experienced significantly fewer adverse events than those who did not for all surgery types.

CONCLUSION

Administration of low-dose intravenous (IV) and intra-articular (IA) TXA does not appear to increase rates of adverse events and may be effective in minimizing blood loss, as reflected by Hb and Hct values following THA.

Matched cohort study of topical tranexamic acid in cementless primary total hip replacement

PURPOSE

Tranexamic acid has been shown to be effective in reducing blood loss after total hip replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use to reduce blood loss after primary total hip replacement and to compare these outcomes with those of a matched control group from a similar cohort that did not have received tranexamic acid.

METHODS

This is a prospective matched control study to assess the effect of a 2 g topical tranexamic acid in 50 mL physiological saline solution in total hip replacement. Primary outcomes were hemoglobin and hematocrit drop, and total blood loss. Secondary outcomes were transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events.

RESULTS

We could match 100 patients to a control group. There were no statistical significantly differences between the two groups. The hemoglobin and hematocrit postoperative values were significantly higher in topical tranexamic acid group than in control group (P < 0.001). The mean total blood loss was 769 in topical tranexamic acid group and 1163 in control group with significant differences (P = 0.001), which meant 34% reduction in total blood loss. Length of stay was lower in topical tranexamic acid group. The risk of deep vein thrombosis and pulmonary events did not increase.

CONCLUSIONS

A single dose of 2 g tranexamic acid in 50 mL physiological saline solution topical administration was effective and safe in reducing bleeding in patients undergoing unilateral primary non-cemented total hip replacement compared to a matched control group.

Comparison of Cytotoxic Effects of Intra-Articular Use of Tranexamic Acid versus Epinephrine on Rat Cartilage

Background

Adequate visualization is known to be essential to perform arthroscopic procedures effectively and efficiently. We hypothesized that tranexamic acid may be considered as an alternative agent to reduce intra-articular bleeding during arthroscopic procedures, after comparing its potential chondrotoxicity with that of epinephrine.

Material/Methods

Seventy-two rats were randomized into 3 groups with 24 rats each. The injections were performed in the right knees, as follows: Group 1: 0.25 mL of tranexamic acid solution, Group 2: 0.25 mL of epinephrine solution, and Group 3: 0.25 mL of 0.9% saline, serving as control. One week after the injections, the animals were euthanized. Samples were evaluated histologically based on the Osteoarthritis Research Society International (OARSI) Histopathology Grading and Staging System and the “live/dead” staining technique to determine chondrocyte viability.

Results

Comparison of epinephrine and tranexamic acid revealed significantly higher OARSI scores in the epinephrine group (epinephrine: 3.42±1.31, TA: 0.92±0.90; P<0.001). The most significant difference between the 2 groups was in the number of joints diagnosed with OARSI grade III. The percentage of viability was significantly higher in the tranexamic acid group when compared with the epinephrine group (tranexamic acid: 79.74±3.343; epinephrine: 63.81±1.914; P<0.05).

Conclusions

Based on the histologic parameters and chondrocyte viability, tranexamic acid is less cytotoxic than epinephrine in rat chondrocytes at the doses typically used in irrigation fluid, and may be a good alternative to epinephrine in arthroscopic surgery.

Comparison of topical and intravenous administration of tranexamic acid for blood loss control during total joint replacement: Review of literature

Purpose

Many randomised controlled trials and meta-analysis studies have presented the efficacy of tranexamic acid (TXA) without an increase of complications. However, questions still remain about the type of administration, optimal dose and secondary outcomes of TXA in total hip arthroplasty and total knee arthroplasty. The aim of this review is to summarise the existing information in literature concerning the pharmacological characteristics of TXA, forms, doses, types of application and contraindications for its use.

Methods

A literature review containing 63 articles from the PubMed data starting from the first description of tranexamic acid until now was made in trying to present the existing information in a simple and effective way.

Results

TXA leads to statistically significant reduction of peri and postoperative bleeding and in that way decreases blood transfusion rates and the infection risk. Topical and intravenous (IV) use of TXA revealed similar results, with no increase of deep venous thrombosis. Therefore, topical TXA could be a reasonable alternative in patients with contraindications for IV application of TXA.

Conclusions

Blood loss control with TXA, a synthetic analogue of the amino acid lysine, may be an excellent and safe alternative to allogeneic blood transfusion after total hip arthroplasty and total knee arthroplasty. Further studies are needed to establish the efficacy of combined IV and topical administration of TXA with regard to diminishing blood loss and reducing hospital stay.

The Translational Potential of this Article

This review briefly presents the pharmacological characteristics of TXA, forms, doses, types of application and contraindications for its use with regard to diminishing blood loss and reducing hospital stay for better therapeutic strategies in orthopaedics.

Tranexamic acid in total hip arthroplasty: Mixed treatment comparisons of randomized controlled trials and cohort studies

Background

The present study is a network meta-analysis of various routes of tranexamic acid (TXA) in patients with total hip arthroplasty (THA).

Methods

Randomized controlled trials and cohort studies evaluating TXA in patients with THA were included. Number of patients requiring blood transfusion was the primary outcome.

Results

Pooled estimate for TXA use against placebo for blood transfusion rate was 0.30 [0.23, 0.39] favoring TXA. Maximum reduction in the risk of blood transfusion was observed with topical plus intra-operative intravenous TXA.

Conclusion

Combined topical and intravenous TXA during surgery may perform better than other modes in patients undergoing THA.

Extremely Low Transfusion Rates: Contemporary Primary Total Hip and Knee Arthroplasties

BACKGROUND

Considerable blood loss which requires transfusion is frequently reported after total hip and knee arthroplasties (THA and TKA). The purpose of this study is to review the transfusion rates in contemporary THA and TKA with optimized perioperative protocols including minimized surgical trauma and optimal perioperative patient care.

METHODS

This retrospective study included 1442 consecutive patients receiving either a primary THA or a TKA from the same high-volume surgeon between January 2008 and December 2015. Demographics and surgical data were collected from patients' journals. Estimated blood loss, decline in hemoglobin, and use of transfusion were registered.

RESULTS

One (0.0013%) THA and 3 (0.0044%) TKAs required blood transfusion postoperatively. Average measured bleeding was 253 mL ± 142 and 207 mL ± 169 in THA and TKA, respectively. Average decline in hemoglobin was 23.5 g/L ± 11.4 and 22.9 g/L ± 11.6 for THA and TKA, respectively.

CONCLUSION

In contemporary THA and TKA, perioperative protocols and patient optimization can decrease the rate of blood transfusion to near zero.

Topical Tranexamic Acid Reduces Blood Loss in Minimally Invasive Total Knee Arthroplasty Receiving Rivaroxaban

Background

It is unclear whether topical (intra-articular) or intravenous TXA reduces blood loss in minimally invasive TKA patients receiving a direct oral anticoagulant for thromboprophylaxis. This study is to investigate whether TXA given intravenously or intra-articularly is effective in reducing blood loss in minimally invasive TKA patients using rivaroxaban for thromboprophylaxis.

Methods

Ninety-three patients who underwent primary minimally invasive TKA were divided into placebo group (30 patients) that received saline both intravenously and intra-articularly, intravenous (IV) group (31 patients) that received 1 g TXA intravenously, and topical group (32 patients) that received 3 g TXA in 100 ml saline intra-articularly. All patients received oral rivaroxaban of 10 mg daily for 14 days postoperatively.

Results

p < 0.001 and p = 0.041. The mean total blood loss was 1131 mL (567–1845) in placebo, which was higher than that in the IV group (921 mL; range, 465–1495; p = 0.014) and the topical group (795 mL; range, 336–1350; p < 0.001). The total blood loss did not differ between the IV and the topical group (p = 0.179).

Conclusion

This prospective, randomized, controlled trial demonstrated an equal efficacy of TXA in blood conservation when administered intravenously or topically in minimally invasive TKA patients receiving rivaroxaban for thromboprophylaxis.

Efficacy and Safety of Topical Use of Tranexamic Acid in Reducing Blood Loss During Primary Lumbar Spinal Surgery: A Retrospective Case Control Study

STUDY DESIGN

A retrospective case-control study.

OBJECTIVE

To compare postoperative blood loss, amount of allogeneic blood transfusion, removal time of drainage tube, length of hospital stay, and complications associated with tranexamic acid (TXA).

SUMMARY OF BACKGROUND DATA

Spinal fusion surgery can be associated with significant blood loss. To the best of our knowledge, very few published studies exist reporting the effect of topical use of tranexamic acid (tTXA) on decreasing the blood loss in patients undergoing posterior lumbar spinal fusions.

METHODS

We conducted a retrospective nonrandomized case-control study of 100 adults undergoing posterior lumbar spinal fusion surgery. In the tTXA group (n = 50), wound surface was soaked with TXA (1 g in 100 mL saline solution) for 5 minutes before wound closure. In the control group (n = 50), wound surface was soaked with the same volume of normal saline. The postoperative blood loss, removal time of drainage tube, amount of allogeneic blood transfusion, and length of hospital stay were compared between the two groups. And the complications of TXA were also collected.

RESULTS

In the tTXA group, the postoperative blood loss, removal time of drainage tube, postoperative length of hospital stay were significantly lower than those in the control group (155.2 ± 104.3 mL vs. 278.6 ± 124.1 mL, 2.0 ± 0.6 d vs. 2.4 ± 0.5 d, 4.7 ± 1.4 d vs. 5.6 ± 2.3 d, P < 0.05, respectively). There was no significant difference in blood transfusion between two groups. No significant changes were noticed in terms of coagulation function, and no complications associated with TXA were observed.

CONCLUSION

tTXA can significantly reduce postoperative blood loss, accelerate removal of drainage tube, shorten the duration of hospital stay, while not increasing the complication incidence in patients undergoing posterior lumbar spinal fusion surgery.

LEVEL OF EVIDENCE

3.

Efficacy and safety of tranexamic acid in total hip replacement: A PRISMA-compliant meta-analysis of 25 randomized controlled trials

BACKGROUND

Hip osteoarthritis is one of the most prevalent musculoskeletal degenerative diseases in elderly. Total hip arthroplasty (THA) is the most effective surgical treatment for end stage hip osteoarthritis. Tranexamic acid (TA) is a potent drug to reduce surgical blood loss in surgery, therefore, as a potential drug for application in THA.

OBJECTIVES

To identify the combined efficacy of TA administration in THA. A meta-analysis including 25 randomized controlled trials was conducted for generating synthesized effects.

METHODS

This meta-analysis followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines for reporting systematic reviews and meta-analysis. A total of 25 Randomized controlled trials (RCTs) were included for meta-analysis.

RESULTS

The pooled results illustrated that total blood loss, intraoperative blood loss, postoperative blood loss, hemoglobin drop, transfusion rate, and average hospital stay were significantly lower than controls (standardized mean difference or odds ratio (OR) (95%CI): -0.87, (-1.13,-0.61), -0.68, (-0.96,-0.39), -1.41, (-2.24,-0.59), -1.11, (-1.63,-0.58), 0.28, (0.20,-0.38), -0.17, (-0.49,0.14), P < .05, respectively). Moreover, TA acts efficiently without increasing risk of thromboembolic events with OR = 1.14, 95%CI = 0.50-2.62, P = .75. Subgroup analysis indicated no statistically significant differences between a higher dose of topical TA (≥2 g or 15 mg/kg) or a lower dose (<2 g or 15 mg/kg).

CONCLUSION

The findings indicated that TA is clinically effective and safe in patients receiving total hip arthroplasty.

Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study

OBJECTIVE

To evaluate the efficacy of topical tranexamic acid topical in cementless total hip arthroplasty from the point of view of bleeding, transfusion requirements and length of stay, and describe the complications of use compared to a control group.

MATERIAL AND METHODS

A prospective, randomised, double-blinded and controlled study including all patients undergoing cementless total hip arthroplasty in our centre between June 2014 and July 2015. Blood loss was estimated using the formula described by Nadler and Good.

RESULTS

The final analysis included 119 patients. The decrease in haemoglobin after surgery was lower in the tranexamic acid group (3.28±1.13g/dL) than in the controls (4.03±1.27g/dL, P=.001) and estimated blood loss (1,216.75±410.46mL vs. 1,542.12±498.97mL, P<.001), the percentage of transfused patients (35.9% vs. 19.3%, P<.05) and the number of transfused red blood cell units per patient (0.37±0.77 vs. 0.98±1.77; P<.05). There were no differences between groups in the occurrence of complications or length of stay.

CONCLUSIONS

The use of topical tranexamic acid in cementless total hip arthroplasty results in a decrease in bleeding and transfusion requirements without increasing the incidence of complications.

The efficacy of tranexamic acid using oral administration in total knee arthroplasty: a systematic review and meta-analysis

Background

Total knee arthroplasty (TKA) is gradually regarded as an effective choice for end-stage osteoarthritis or rheumatic arthritis. In the past, the management of tranexamic acid (TXA) using intravenous injection or topical application has been extensively researched. However, several studies have reported that oral TXA has an effect on blood loss. Therefore, a meta-analysis should be performed to determine whether oral TXA helps to prevent blood loss.

Methods

Randomized controlled trials or retrospective cohort studies about relevant studies were searched in PubMed (1996–April 2017), Embase (1980–April 2017), and the Cochrane Library (CENTRAL, April 2017). Six studies that compared oral TXA to non-TXA were included in our meta-analysis. Meta-analyses (PRISMA) guidelines, the Cochrane Handbook, and the Jadad scale were used to evaluate the included studies and the results to ensure that the meta-analysis was viable.

Results

In accordance with inclusion and exclusion, six studies with 2553 patients (oral TXA = 1386, without TXA = 1167) were eligible and accepted into this meta-analysis. Pooled data indicated that the oral TXA group was effective compared to the without TXA group in terms of hemoglobin (Hb) drop (P < 0.05), blood loss at 24 h (P < 0.05), total blood loss (P < 0.05), and the transfusion rate (P < 0.05). No significant differences were found in the length of hospital stay (P = 0.96) and complications (P = 0.39).

Conclusion

Compared to the non-TXA group, the oral TXA group showed effects of blood sparing. Considering the cost and effectiveness, oral TXA is useful for TKA.

Oral Tranexamic Acid Reduces Transfusions in Total Knee Arthroplasty

BACKGROUND

Tranexamic acid (TXA) reduces intraoperative blood loss and transfusions in patients undergoing total knee arthroplasty. Although numerous studies demonstrate the efficacy of intravenous and topical TXA in these patients, few demonstrate the effectiveness and appropriate dosing recommendations of oral formulations.

METHODS

A retrospective cohort study was performed to evaluate differences in transfusion requirements in patients undergoing primary unilateral total knee arthroplasty with either no TXA (n = 866), a single-dose of oral TXA (n = 157), or both preoperative and postoperative oral TXA (n = 1049). Secondary outcomes included postoperative hemoglobin drop, total units transfused, length of stay, drain output, and cell salvage volume.

RESULTS

Transfusion rates decreased from 15.4% in the no-oral tranexamic acid (OTA) group to 9.6% in the single-dose OTA group (P < .001) and 7% in the 2-dose group (P < .001), with no difference in transfusion rates between the single- and 2-dose groups (P = .390). In addition, postoperative hemoglobin drop was reduced from 4.2 g/dL in the no-OTA group to 3.5 g/dL in the single-dose group (P < .01) and to 3.4 g/dL in the 2-dose group (P < .01), without a difference between the single- and 2-dose groups (P = .233).

CONCLUSION

OTA reduces transfusions, with greater ease of administration and improved cost-effectiveness relative to other forms of delivery.

What is the optimal approach for tranexamic acid application in patients with unilateral total hip arthroplasty?

PURPOSE

In the total hip arthroplasty (THA), the optimal administration route of tranexamic acid (TXA) remains controversial. This study was designed to investigate the impact of topical injection of TXA on blood loss during primary unilateral THA as well as short-term safety and adverse side effects compared with intravenous administration of TXA.

MATERIAL AND METHODS

In this study, 75 patients who underwent unilateral THA were randomly divided into 3 groups receiving intra-articular TXA (IA group), intravenous TXA (IV group) or no TXA (control group C). Blood loss, postoperative drainage, covert blood loss, total blood volume, the number of blood transfusions after surgery and transfusion rate, incidence of deep venous thrombosis and pulmonary embolism were recorded and evaluated in the three groups after 1 week and 1 month.

RESULTS

There were significant differences in the quantity of postoperative drainage, covert blood loss, total blood volume, the number of blood transfusions after surgery and transfusion rates between the three groups (P < 0.05), but blood loss during surgery showed no significant differences among the three groups (P > 0.05). In the IV group, 1 patient suffered from deep venous thrombosis of the lower limbs and in the C group, 2 patients suffered from superficial venous thrombosis of the lower limbs 2 and 4 days after surgery, respectively. In the IA group no complications occurred during the follow-up period.

CONCLUSION

Preoperative intravenous TXA and postoperative topical TXA significantly reduced postoperative blood loss and transfusion rates among the patients who underwent primary unilateral THA and the short-term safety was good. The data suggest that topical injection of TXA is safer and more effective, without postoperative complications.

What is the Ideal Route of Administration of Tranexamic Acid in TKA? A Randomized Controlled Trial

BACKGROUND

TKA commonly involves substantial blood loss and tranexamic acid has been used to reduce blood loss after TKA. Numerous clinical trials have documented the efficacy and safety of intravenous (IV) or intraarticular (IA) use of tranexamic acid. Combined administration of tranexamic acid also has been suggested; however, there is no consensus regarding the ideal route of tranexamic acid administration.

QUESTIONS/PURPOSES

(1) To compare the efficacy of tranexamic acid in terms of total blood loss and the allogeneic transfusion rate among three routes of administration: IV alone, IA alone, and combined IV and IA. (2) To compare these regimens in terms of venous thromboembolism (VTE) and the frequency of wound complications.

METHODS

In total, 376 patients undergoing TKA between March 2014 and March 2015 were randomized to four groups by the route of tranexamic acid administration: IV only, IA only, low-dose combined (IV + IA injection of 1 g), and high-dose combined (IV + IA injection of 2 g). The calculated total blood loss, allogeneic transfusion rate, decrease in hemoglobin, the frequency of symptomatic deep vein thrombosis and pulmonary embolism, wound complications, and periprosthetic joint infection were compared among the groups. Total blood loss was calculated using estimated total body blood volume and hemoglobin loss. The decision regarding when to transfuse was determined based on preset criteria.

RESULTS

The high- and low-dose combined groups and the IA-only group had lower total blood loss (564 ± 242 mL, 642 ± 242 mL, and 633 ± 205 mL, respectively) than the IV-only group (764 ± 217 mL; mean differences = 199 mL [95% CI, 116-283 mL], p < 0.001; 121 mL [95% CI, 38-205 mL], p = 0.001; 131 mL [95% CI, 47-214 mL], p < 0.001); no differences were found among the other three groups. No patients in any study group received an allogeneic transfusion. One patient in the IV-only group had a symptomatic pulmonary embolism develop, but no other symptomatic VTE events occurred in any group. In addition, no differences were observed in wound complications, such as superficial wound necrosis (one patient in the IV-only and the high-dose combined group, respectively) and oozing (IV-only, IA-only, low-dose combined, high-dose combined = 3%, 4%, 4%, and 7%; p = 0.572) between the groups. No patients had a periprosthetic joint infection.

CONCLUSION

IA tranexamic acid administration further reduces blood loss after TKA in comparison to IV use alone; no additional effect in further reducing blood loss was found in combination with IV tranexamic acid. Appropriately powered studies are needed to confirm the safety of this route of administration as the preferred route of administration in TKA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Effect of Tranexamic Acid on Hematologic Values and Blood Loss in Reverse Total Shoulder Arthroplasty

Purpose

Use of tranexamic acid (TXA) in the setting of arthroplasty of the lower extremity has been previously described. The aim of this study was to evaluate the benefit of a single dose of TXA (500 mg vial) administered intravenously just prior to RTSA in an Asian population.

Methods

The records of 48 patients (no TXA, n = 24, versus TXA, n = 24) that underwent RTSA for cuff tear arthropathy were retrospectively reviewed. All patients had a Hemovac drain positioned for 2 days after surgery. Hemoglobin (Hb) and hematocrit (Hct) were checked on postoperative day 2 and compared with preoperative levels.

Results

Hematologic change on postoperative day 2 as determined by Hb level after surgery was statistically lower in the TXA group (2.8 ± 0.8 versus 2.1 ± 0.8 (mg/dL), P = 0.006). Mean fall in Hct level was also significantly less in the TXA group (8.0 ± 2.5 versus 6.1 ± 2.6 (L/L), P = 0.012). Total Hemovac drainage tended to be lower in the TXA group (263.4 ± 129.3 versus 203.5 ± 84.2 (ml), P = 0.064). TXA was found to have no noticeable side effects.

Conclusion

The use of a single intravenous dose of TXA immediately prior to RTSA reduces hematologic deterioration postoperatively and the amount of Hemovac drainage. TXA could avoid unnecessary transfusion and its associated medical side effects and cost.

Topical tranexamic acid reduces transfusion rates in simultaneous bilateral total knee arthroplasty: a retrospective case series

BACKGROUND

Topical tranexamic acid (TA) has been reported to be effective in reducing postoperative bleeding and transfusions after total knee arthroplasty (TKA). The main objective of this study was to retrospectively assess the effectiveness and safety of topical TA administration in patients undergoing simultaneous bilateral TKA.

METHODS

We conducted a retrospective chart review of consecutive cohorts of patients undergoing simultaneous bilateral TKA. We compared the patients who received TA with patients from a similar time frame who did not receive TA. For those who received TA, a topical concentration of 2 g per 30 mL of normal saline was used in each knee. Preoperative and postoperative hemoglobin, transfusions, length of stay (LOS) and postoperative complications were recorded for each patient until discharge. Outcome measures were analyzed using independent t test, χ² test and logistic regression.

RESULTS

We included 49 patients in our analysis: 25 who received TA and 24 who did not. There were no statistical differences in demographics between the groups. The rate of transfusion in the TA group was 4% compared with 67% in the non-TA group (p < 0.001). The net hemoglobin loss in the TA group was 4.1 g/dL versus 6.2 g/dL in the non-TA group (p < 0.001). The use of TA was found to be associated with a greater than 99% reduced risk of receiving a transfusion (odds ratio 0.003, 95% confidence interval < 0.001-0.072, p < 0.001). There were no thromboembolic events in patients who received TA, and there was 1 pulmonary embolus in the non-TA group. Postoperative LOS was significantly reduced in the TA group (mean difference 1.1 d, p = 0.005).

CONCLUSION

Topical administration of TA in patients undergoing simultaneous bilateral TKA significantly reduced transfusions, blood loss and postoperative LOS, with no increased risk of thromboembolic events.

The efficiency and safety of tranexamic acid for reducing blood loss in open myomectomy: A meta-analysis of randomized controlled trials

OBJECTIVE

This meta-analysis aimed to perform a meta-analysis including randomized controlled trials (RCTs) to assess the efficiency and safety of tranexamic acid (TXA) for reducing blood loss and transfusion requirements in patients undergoing open myomectomy.

METHODS

A systematic search was performed in Medline (1966-2017.03), PubMed (1966-2017.03), Embase (1980-2017.03), ScienceDirect (1985-2017.03,) and the Cochrane Library. Study evaluated the efficiency and safety of TXA in myomectomy was selected. Meta-analysis was performed using Stata 11.0 software.

RESULTS

Four RCTs including 328 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of total blood loss (standard mean difference [SMD] = -1.512, 95% confidence interval [CI]: -2.746 to -0.278, P = .016), postoperative hemoglobin level (SMD = 0.650, 95% CI: 0.045-1.255, P = .035), transfusion requirements (SMD = -0.102, 95% CI: -0.199 to -0.006, P = .038), and duration of surgery (SMD = -0.514, 95% CI: -0.749 to -0.280, P = .000). In addition, no adverse effect was identified in treatment groups.

CONCLUSIONS

Intravenous administration of TXA in open myomectomy was associated with significantly reduced total blood loss, postoperative hemoglobin decline, duration of surgery, and transfusion requirements. Based on the limitations of the current meta-analysis, high-quality RCTs with long-term follow-up are still required.

Topical Tranexamic Acid is Equivalent to Targeted Preoperative Autologous Blood Donation in Total Hip Arthroplasty

BACKGROUND

Topical tranexamic acid (TXA) was introduced to replace the previous targeted preoperative autologous blood donation (PABD) program. This study aims to analyze the efficacy of topical TXA compared with targeted PABD in anemic patients undergoing primary total hip arthroplasty (THA).

METHODS

Two thousand two hundred fifty-one patients underwent primary THA between 2009 and 2013 using targeted autologous blood donation for 280 anemic patients (12%; Hb <12.5 g/dL). One thousand nine hundred seventy-one nonanemic patients (88%; ≥12.5 Hb/dL) received no blood management intervention. Starting in 2014, 505 consecutive patients were operated using 3 grams of topical TXA and abandoning PABD. Ninety-one patients (18%) were anemic and 414 (82%) nonanemic.

RESULTS

The utilization of topical TXA in anemic patients resulted in higher hemoglobin levels on the first postoperative day (P = .014), but not on the second postoperative day (P = .198) compared with PABD. There was no difference in allogeneic transfusion rates between both groups: 12% vs 13% (P = .848). In the nonanemic group, TXA significantly increased hemoglobin levels on the first postoperative day (P = .001) as well as on the second postoperative day (P < .001), and resulted in a reduction in allogeneic transfusion rates from 8% to 1%.

CONCLUSION

The present study suggests that topical TXA is equivalent to PABD in anemic patients and reduces transfusion rates and increases Hb-levels in nonanemic patients.

Blood Sparing Efficacy of Oral Tranexamic Acid in Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Purpose

Tranexamic acid (TXA) is effective in reducing blood loss in primary total knee replacement. Almost all studies used an intravenous form or a topical form. The aim of this study was to assess the blood sparing efficacy and the safety of oral TXA.

Materials and Methods

All patients with primary total knee replacement performed in our institute from January 2015 to October 2015 were eligible. Oral TXA group was given 1 g oral TXA 2 hours before induction of anesthesia and 6 hours and 12 hours postoperatively. The control group was not given TXA.

Results

There were 94 cases in the oral TXA group and 95 cases in the control group. There was no difference in the baseline characteristics. The oral TXA group had a significantly lower hemoglobin drop (1.7 g/dL vs. 2.5 g/dL), lower drain output (154 mL vs. 203 mL), lower hidden blood loss (244 mL vs. 423 mL) and lower total blood loss (398 mL vs. 626 mL). There was no difference in transfusion rate (1.1% vs. 3.2%) and thromboembolic complication. There was no infection or mortality in both groups.

Conclusions

Oral TXA is effective in reducing blood loss in primary total knee replacement. It is a safe alternative to the intravenous or topical form.

Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials

Background

This study aims to compare the effectiveness and safety of topical versus intravenous tranexamic acid (TXA) in reducing blood loss in primary total knee arthroplasty (TKA).

Methods

PubMed, Embase, the Cochrane Library, Web of Science, Chinese Biomedicine Literature (CBM), Wanfang Database and China National Knowledge Infrastructure (CNKI), and Google Scholar were searched for randomized controlled studies (RCTs) that compared topical versus intravenous TXA in terms of reducing blood loss during TKA from their inception to September 2015. This systematic review and meta-analysis was performed according to PRISMA criteria.

Results

Twelve studies reporting 12 RCTs comprising 1130 patients were included. Compared with the intravenous administration of TXA, the topical administration of TXA showed no significant differences in total blood loss (MD 2.08, 95% CI −68.43 to 72.60, P = 0.95), blood loss in drainage (MD 18.49, 95% CI −40.01 to 76.98, P = 0.54), hidden blood loss (MD 4.75, 95% CI −337.94 to 347.44, P = 0.99), need for transfusion (RR = 0.92, 95% CI 0.67~1.25, P = 0.58), hemoglobin (Hb) decline (MD −0.42, 95% CI −0.89 to 0.05, P = 0.08), and DVT occurrence (RR = 1.17, 95% CI 0.55~2.50, P = 0.68).

Conclusions

Compared with intravenous administration TXA, topical administration TXA exhibits comparable effectiveness and safety in terms of reducing blood loss during TKA. Due to the poor quality of the included studies, more high-quality RCTs are needed to identify the optimal method and dose of TXA after TKA.

Intravenous Combined with Topical Administration of Tranexamic Acid in Primary Total Hip Arthroplasty: A Randomized Controlled Trial

OBJECTIVE

Although there are still some controversies, large previous studies have confirmed that intravenous (i.v.) tranexamic acid (TXA) can effectively reduce blood loss and transfusions in total hip arthroplasty (THA) without increasing the risk of deep venous thrombosis. However, few studies have investigated the combination of i.v. and topical application of TXA in primary THA. The purpose of our current study is to examine whether i.v. combined with topical administration of TXA decreases postoperative blood loss and transfusion rates after THA.

METHODS

From December 2013 to May 2014, all adult patients undergoing primary THA at our arthroplasty center were considered for inclusion in the present study. Included patients were randomly assigned to two groups by computer-generated list number: a TXA group and a placebo group. Patients in the TXA group received i.v. (15 mg/kg) combined with topical administration (1.0 g) of TXA during the THA procedure, and patients in the other group received the same dosage of normal saline both i.v. and topically. Our primary outcome measures were total blood loss (calculated using Gross's equation), hemoglobin, hematocrit and platelet concentration changes on the third postoperative day, the amount of drainage, the amount of intraoperative blood loss, the frequency of transfusion, and the number of blood units transfused. Secondary outcome measures were the length of postoperative stay, range of hip motion (measured by goniometer), Harris hip scores (HHS), and any perioperative complications or events such as infection, DVT or PE. Range of motion and HHS were measured at 3 week follow-up and compared with preoperative values.

RESULTS

This trial included 100 patients (50 in each group). Patients in the TXA group had significantly higher postoperative hemoglobin (103 vs 87.7 g/dL, P < 0.01), lower hemoglobin changes (32.2 vs 44.9 g/dL, P < 0.01), higher postoperative hematocrit (0.32 vs 0.27 L/L, P < 0.01), lower hematocrit changes (0.1 vs 0.14 L/L, P < 0.01), lower total blood loss (822 vs 1100 mL, P = 0.004), lower drainage (117.8 vs 242.4 mL, P < 0.01), lower intraoperative blood loss (193.8 vs 288.2 mL, P < 0.01), and lower transfusion rate (2% vs 34%, P < 0.01) compared with those in the placebo group. No statistical difference was found in postoperative platelets between the two groups. There were no differences in perioperative complications or venous thromboembolism (VTE) events.

CONCLUSIONS

The combined administration of i.v. and topical TXA resulted in a clinically relevant reduction in blood loss, compared with placebo group. No thromboembolic complications were observed. This randomized controlled trial supports the combined i.v. and topical administration of TXA in primary THA.

Intravenous versus topical tranexamic acid in primary total hip replacement: A meta-analysis

BACKGROUND

As the prevalence of total hip arthroplasty (THA) is increasing, it is usually associated with considerable blood loss. Tranexamic acid (TXA) has been reported to reduce perioperative blood loss in hip joint arthroplasty. But the best route of TXA administration continues to be controversial. So, we conducted a meta-analysis that integrated all data from the 7 included trials to compare the effectiveness and safety of topical and intravenous TXA administration in primary THA. The endpoints assessed in this meta-analysis include the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of deep vein thrombosis (DVT), pulmonary embolisms (PE), and wound infection.

METHODS

Literature searches of PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature database, the CNKI database, and Wan Fang Data were performed up to August 30, 2016. Randomized controlled trials (RCTs) were included in our meta-analysis if they compared the efficiency and safety of intravenous versus topical administration of TXA in patients who underwent primary THA. The endpoints included the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of DVT, PE, and wound infection. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. The pooling of data was carried out by using RevMan 5.3, Denmark.

RESULTS

Seven RCTs involving 964 patients met the inclusion criteria. Our meta-analysis indicated that there were no significant differences in the 2 groups in terms of total blood loss ([mean difference (MD) = -14.74, 95% confidence interval (CI): -89.21 to 59.74, P = 0.7], transfusion rates [RD = -0.02, 95% CI: -0.05 to 0.02, P = 0.39]; no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis [DVT] [RD = 0.00, 95% CI: -0.01 to 0.01, P = 1.00], PE [RD = 0.00, 95% CI: -0.01 to 0.01, P = 0.71], or wound infection [RD = -0.01, 95% CI: -0.06 to 0.04, P = 0.66]). The pooled results showed that the intravenous groups had a lower postoperative hemoglobin decline (MD = -0.47, 95% CI: -0.74 to -0.20, P = 0.0006). It was probably due to insufficient data and the varied reporting of outcomes. There was some inherent heterogeneity due to the small sample size of each primary study.

CONCLUSION

The topical and intravenous administrations of TXA have a similar effect on the decrease of blood loss without an increased risk of complications (DVT, PE, and wound infection). Intravenous TXA administration may have a maximum efficacy. Topical TXA administration may be preferred in patients who with high risk of thromboembolic events. However, larger, high-quality RCTs are required to explore the optimal regimen, dosage, timing still in the future in order to recommend TXA widespread use in total joint arthroplasty.

The Efficacy and Safety of Combination of Intravenous and Topical Tranexamic Acid in Revision Hip Arthroplasty: A Randomized, Controlled Trial

BACKGROUND

Revision total hip arthroplasty (THA) is associated with substantial blood loss and a high probability of blood transfusion in the perioperative period. This study aimed to evaluate the efficacy and safety of combination of intravenous (IV) and topical tranexamic acid (TXA) in revision THA.

METHODS

Eighty-four consecutive patients undergoing revision THA were randomized into combined group and IV-TXA group. Patients in the combined group were given intravenously 15 mg/kg TXA as a preoperative, and topical TXA solution was applied at a concentration of 3 g TXA per 100-mL saline during the different procedure points. Patients in the IV-TXA group were given intravenously 15 mg/kg TXA alone.

RESULTS

The mean total blood loss, drainage volume, and maximum hemoglobin drop were significantly lower in the combined group than the IV-TXA group (P < .001, P < .001, P < .001, respectively). Compared with the IV-TXA group, the amount of blood transfusions and number of blood transfusions required were decreased dramatically in the combined group (P = .027, P < .001, respectively). One deep vein thrombosis and 4 calf muscular vein thrombosis in the combined group and 3 calf muscular vein thrombosis in the IV-TXA were detected by the Doppler ultrasound. No pulmonary embolism was observed and no significant differences were found in other complications between the 2 groups.

CONCLUSION

This study showed that combined administration of IV and topical TXA in revision THA can effectively decrease total blood loss and number of blood transfusions required without increasing the risk of deep vein thrombosis or/and pulmonary embolism compared with IV-TXA alone.

Intravenous vs Topical Tranexamic Acid in Total Knee Arthroplasty Without Tourniquet Application: A Randomized Controlled Study

BACKGROUND

Use of tranexamic acid (TXA) is effective and safe in reducing the blood loss in total knee arthroplasty (TKR) performed using a tourniquet, but, data in TKR performed without tourniquet are limited, and there is no study comparing the topical (T) with intravenous (IV) TXA administration. Our aim was to compare the topical (T) with intravenous (IV) TXA administration in TKR performed without tourniquet.

MATERIAL AND METHODS

A total of 120 patients undergoing unilateral TKR for knee osteoarthritis were included in a prospective randomized study. Operations were performed under spinal anesthesia, no tourniquet was used, and the postoperative regime was the same for all patients. Patients were divided into 3 groups; in group C (control), 40 patients received no TXA, in group IV, 40 patients received 1 g of TXA intravenously, and in group L, 1 g of TXA was applied locally to 40 patients. The primary outcome measures included the calculated blood loss, the transfusion rate, and quantity of allogeneic blood units, whereas secondary outcome measures were complications.

RESULTS

There was no statistically significant difference in patient's demographics and perioperative results. Calculated blood loss, allogeneic blood transfusion rate, and quantity in group C were significantly higher compared with those of TXA groups (P < .001). There was no significant difference in complications rate between the 3 groups.

CONCLUSIONS

According to the results of this study, IV or T administration of 1-g TXA significantly reduced the blood loss and the need for allogeneic blood transfusion in patients undergoing TKR without a tourniquet (with no significant difference between the 2 routes of administration).

Are Preoperative Serologic Type and Screen Tests Necessary for Primary Total Joint Arthroplasty Patients in Specialty Surgical Hospitals?

BACKGROUND

Blood loss during total joint arthroplasty (TJA) has been a major concern requiring routine preoperative patient type and screen (T&S); however, with the implementation of blood conserving therapy, a marked decrease for perioperative transfusions has been observed. Many TJAs are now being performed in T&S mandated specialty surgical hospitals (SSHs) that lack on-site blood banks; therefore, the purpose of our study was to determine whether T&S (1) is necessary in SSH for TJA patients and (2) identifies patient risk factors associated with perioperative blood transfusion in SSH.

METHODS

A retrospective study was conducted on 1034 consecutive primary TJAs performed between 2013 and 2014 at a 12-bed SSH who all received T&S. Patients were matched (1:1) to 964 inpatient TJA patients performed at a university hospital without routine T&S. Data on surgery type, patient demographics, hemoglobin and hematocrit results, and transfusion rates were collected. Multivariate logistic regression identified perioperative transfusion risk factors.

RESULTS

Overall transfusion rates for the matched SSH (1.8% [17/964]) and university hospital populations (2.9% [28/964]) were similar (P = .13), with no emergent transfusions. SSH transfusion rates for simultaneous bilateral THA, simultaneous bilateral TKA, unilateral THA, and unilateral TKA were 21.1% (4/19), 3.1% (4/128), 2.7% (12/439), and 0.0% (0/448), respectively. Multivariate logistic regression identified unilateral THA (P ≤ .001), simultaneous bilateral TJA (P = .001), age (P = .05), and abnormal preoperative hemoglobin (P = .02) as significant transfusion risk factors at SSH.

CONCLUSION

Due to low transfusion rates and lack of emergency transfusions, we recommend routinely ordering T&S for bilateral THA but not for unilateral TJA patients, at SSHs.

A comparative, retrospective study of peri-articular and intra-articular injection of tranexamic acid for the management of postoperative blood loss after total knee arthroplasty

BACKGROUND

Intra-articular injection of tranexamic acid (TXA) is known to be effective in controlling blood loss after total knee arthroplasty (TKA). However, this method has some disadvantages, such as TXA leakage due to soft tissue release. Peri-articular injection provides an alternative to intra-articular administration of TXA. This study aimed to evaluate the effects of peri-articular injection of TXA in reducing blood loss after TKA and compare them to those of intra-articular TXA injection.

METHODS

This was a retrospective analysis of 127 patients who underwent primary, unilateral TKA for knee osteoarthritis in our hospital between January 2014 and December 2014. Cases were classified into 3 comparison groups: 49 patients in the peri-articular TXA group, 36 in the intra-articular group, and 42 in the control group (TXA not administered). Demographic variables, hemoglobin (Hb) measured before and after surgery, operation time, total amount of drained volume, time of removing drains, units of blood transfused peri- and postoperatively, estimated volume of blood loss, and preoperative comorbidities were retrieved from the patients' medical charts. Statistical analyses were performed using SPSS 19.0 software.

RESULTS

There were no significant differences of demographic variables and operation time among three groups (P > 0.05). Compared to the control group, both TXA groups had a significantly reduced volume of blood loss, postoperative knee joint drainage, hemoglobin concentration, time of removing drains, and need for blood transfusion (P < 0.05). The effects of TXA were comparable for the two methods of injection (P > 0.05). There were no deep venous thrombosis or thromboembolic complications in any group.

CONCLUSIONS

Peri-articular injection of TXA is as effective as an intra-articular injection in reducing postoperative blood loss during TKA. Both methods had a statistically significant benefit in reducing the change in Hb concentration, volume of joint drainage, and estimated volume of blood loss when compared to the control group. Peri-articular injection of TXA can significantly reduce the blood transfusion rate compared to the control group.

Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty

BACKGROUND

Efficacy of tranexamic acid (TXA) remains unproven in the setting of shoulder arthroplasty. The purpose of this study was to determine the effects of TXA on perioperative blood loss and drain output in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We conducted a retrospective comparison of 77 TSAs and 94 RTSAs performed in 168 patients. TXA was administered intravenously in 35 TSA and 42 RTSA patients. Changes in hemoglobin (Hgb), hematocrit (Hct), drain output, and total blood loss were reviewed with univariate analysis and additional multivariate regression examining the cofactors of age, body mass index, American Society of Anesthesiologists status, and gender of each patient.

RESULTS

Use of TXA in TSA led to a significant decrease in total blood loss (679 mL vs. 910 mL; P < .001), change in Hgb (1.8 mg/dL vs. 2.6 mg/dL; P < .001), and drop in Hct (5.2 vs. 7.0; P < .001). Similarly, RTSA also had significantly less total blood loss with the use of TXA (791 mL vs. 959 mL; P < .001), change in Hgb (2.3 mg/dL vs. 2.9 mg/dL; P < .001), and change in Hct (6.4 vs. 8.3; P < .001). TXA also significantly decreased drain output in both TSA (99 mL vs. 235 mL; P < .001) and RTSA (180 mL vs. 370 mL; P < .001).

CONCLUSIONS

Use of TXA perioperatively among patients undergoing primary shoulder arthroplasty can decrease perioperative blood loss, change in Hgb and Hct, and postoperative drain output.

Comparison of efficacy and safety of topical versus intravenous tranexamic acid in total hip arthroplasty: A meta-analysis

BACKGROUND

The study aimed to compare the effectiveness and safety of topical versus intravenous (IV) tranexamic acid (TXA) for reducing blood loss in primary total hip arthroplasty (THA).

METHODS

This systematic review and meta-analysis were performed according to the preferred reporting items for systematic reviews and meta-analyses statement criteria. PubMed, Embase, the Cochrane Library, Web of Science, Chinese Biomedicine Literature (CBM), Wanfang Database, China National Knowledge Infrastructure (CNKI), and Google Scholar were searched for randomized controlled trials (RCTs) and non-RCTs that compare topical versus IV-TXA administration for reducing blood loss during TKA from their inception to February, 2016. Meta-analysis was performed by Stata 12.0 software.

RESULTS

Seven studies comprising 2056 patients were included in this meta-analysis. No significant difference is found between topical TXA groups and IV-TXA groups regarding transfusion requirements (RR = 1.37, 95% confidence interval [CI]: 0.96-1.97, P = 0.083), total blood loss (MD 17.09, 95% CI: -33.74-67.91, P = 0.510), and hemoglobin decline (MD 0.32, 95%CI: -0.04-0.69, P = 0.122). Meanwhile, there is no significant difference in terms of the occurrence of deep venous thrombosis (RR = 1.09, 95% CI: 0.40-3.90, P = 0.869).

CONCLUSION

Topical TXA has a similar efficacy to IV-TXA in reducing both blood loss and transfusion rate without sacrificing safety in primary THA.

Physicians With Defined Clear Care Pathways Have Better Discharge Disposition and Lower Cost

BACKGROUND

There is a pronounced need for a sustainable care model for total joint arthroplasty in the United States. Total hip and knee arthroplasty is expected to increase 673% by 2030, and Medicare is the payor for a majority of these episodes. Our objective was to compare orthopedic cohort groups with and without defined postacute care pathways and the effects of the care pathways on service utilization and cost for Medicare patients in the Bundled Payments for Care Improvement program.

METHODS

Claims data for elective hip and knee arthroplasty episodes from a national bundled payments for care improvement database were the source of our study data. Independent reviewers were used to determine which groups had defined clinical pathways. The 2 cohort groups were then compared between those with defined clinical pathways and those without. Outcomes measures included postacute care costs, utilization rates (both frequency and length of time) for inpatient rehabilitation facilities, skilled nursing facilities, home health, and readmissions.

RESULTS

Orthopedic physicians with defined postacute care pathways showed consistent decreases in cost and utilization as compared to physicians without defined postacute care pathways. Elective hip arthroplasty per episode cost differential was $3189 per episode between physicians with care pathways ($19,005) and those without ($22,195; P < .001). Elective knee arthroplasty per episode cost difference was $2466 per episode between physicians with care pathways ($18,866) and those without ($21,332; P < .001). Incident rates of utilization for postacute care services displayed significant differences between physicians with and without postacute care pathways. Physicians with defined postacute pathways demonstrated utilization reductions ranging from 7% to 79% with incident rate reductions ranging from 44% to 79%.

CONCLUSION

The results suggest that orthopedic physicians with defined postacute care pathways affect discharge disposition. The findings show significant cost and utilization reductions for physicians with defined postacute care pathways.

The Efficacy of Preoperative Oral Tranexamic Acid on Intraoperative Bleeding During Rhinoplasty

BACKGROUND

Perioperative bleeding is a common side effect of rhinoplasty which may impose the blood transfusion to the patients. As a result of risks and cost of blood transfusion, this study is planned to reduce blood loss in these surgeries. Since tranexamic acid (TXA) has been reported to reduce bleeding and subsequent possible need for blood transfusion, the purpose of this study was to evaluate the efficacy of oral TXA on blood loss during rhinoplasty.

METHODS AND MATERIALS

In this double-blind, randomized, placebo-controlled clinical trial, 50 participants underwent rhinoplastic surgery. These participants were divided into 2 groups; 25 were randomly assigned to each 1. The patients in the first group received 1 g (2 × 500 mg) tranexamic acid tablets, and the patients in the second group received placebo 2 hours before starting the surgery. All patients were operated by the same surgical team and the same anesthetic techniques were used during the surgery. Gender, age, BMI, duration of operation, the amount of blood loss, and surgeon's satisfaction rate were the variables studied.

RESULTS

The first group (TXA group) consisted of 11 males (44%) and 14 females (56%) and the second group consisted of 13 males (52%) and 12 females (48%). There was no statistical difference in the distribution of the variables between the 2 groups, except for the blood loss, duration of operation, and surgeon's satisfaction. The mean total blood loss was 144.6 ± 60.28 mL in "group 1" and 199.6 ± 73.05 mL in "group 2" (P < 0.05). Duration of operation in the first group was less than the second group (2.60 ± 0.53 hours vs. 2.99 ± 0.59 hours) (P = 0.017). The surgeon was more satisfied with the quality of surgical field and visualization in "group 1" (3.76 ± 0.72) than "group 2" (2.16 ± 0.50) (P = 0.001).

CONCLUSION

The preoperative administration of 1 g oral tranexamic acid significantly decreased the blood loss in patients undergoing rhinoplastic surgery without any significant adverse effects.Iranian registry no:IRCT201312271674N10 (www.irct.ir).

Comparison of Blood Loss After Total Hip Arthroplasty Between Ankylosing Spondylitis and Osteoarthritis

BACKGROUND

This study was conducted to compare the blood loss during primary total hip arthroplasty (THA) between ankylosing spondylitis (AS) and hip osteoarthritis (OA).

METHODS

We reviewed 120 THAs in 68 patients comprising 3 groups: AS with total bony ankylosis of the hips (ASB), AS with stiff hips (ASS), and OA. Demographics, perioperative laboratory values, intraoperative data, blood loss, transfusion rate, transfusion reactions, surgical complications, hospitalization cost, and length of stay (LOS) were collected and analyzed among ASB, ASS, and OA groups.

RESULTS

The patients of the ASB and ASS groups were much younger and thinner than those of the OA group. There were no significant differences in the preoperative values of activated partial thromboplastin time, prothrombin time, and international normalized ratio among the 3 groups (all P > .05). The intraoperative blood loss, volume of drainage, hidden blood loss, transfusion rate, transfusion reactions, and hospitalization cost in the ASB group were significantly higher than in the other 2 groups, although not significantly different between the ASS and OA groups (P > .05).

CONCLUSION

Both AS and OA can cause hyperosteogeny to the hips, but ASB patients have more serious symptoms in their affected hips. This may cause more blood loss in THA surgery because of bone surface bleeding. The reason that ASB patients suffered more blood loss may be related to the high difficulty and long duration of the operation.