Practical issues for the use of tranexamic acid in total knee arthroplasty: a systematic review

Role of Tranexamic Acid in Controlling Blood Loss in Hemiarthroplasty of the Hip: A Prospective and Observational Study

INTRODUCTION

Tranexamic acid, an antifibrinolytic drug, is well-established for its efficacy in reducing intraoperative and postoperative blood loss in major orthopedic surgeries, particularly total knee replacement (TKR) and spine surgeries. However, there is limited research on the role of tranexamic acid in hemiarthroplasty of the hip. This study aims to investigate the efficacy of tranexamic acid in controlling blood loss in hemiarthroplasty of the hip.

OBJECTIVES

The primary objective was to analyze the pre- and postoperative changes in hemoglobin levels among patients undergoing hemiarthroplasty of the hip with and without intravenous tranexamic acid administration.

METHODS

A prospective observational study was conducted at the Department of Orthopedics of Government Medical College, Kannur, and St. Joseph's Hospital, Karuvanchal, Kannur. Patients undergoing hemiarthroplasty of the hip with 1 gm of intravenous tranexamic acid were compared with those without tranexamic acid. The sample size was calculated to be 33 in each group. Data were collected using a standardized proforma, entered into an Excel sheet (Redmond, USA), and analyzed using IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.

RESULTS

The study comprised mainly elderly females with a mean age of 74.84 ± 8 years. There was a significant reduction in postoperative hemoglobin drop, requirement for postoperative blood transfusion, and total drain output for the initial three postoperative days among patients who received intravenous tranexamic acid.

CONCLUSION

Preoperative administration of intravenous tranexamic acid significantly reduced postoperative hemoglobin drop and the need for postoperative blood transfusion in patients undergoing hemiarthroplasty of the hip. This highlights the efficacy and safety of tranexamic acid in controlling blood loss in this surgical setting.

Comparative effectiveness of combined peri-articular and intra-articular injection versus intravenous and intra-articular injection of tranexamic acid in total knee arthroplasty: a randomized controlled trial study

INTRODUCTION

Tranexamic acid (TXA) administration is supported by numerous evidence in reducing blood loss after total knee arthroplasty (TKA). The combination of intravenous (IV) and intra-articular (IA) TXA administration revealed good result in blood loss reduction with less evidence of venous thromboembolism event (VTE). Several literature reviews portray that peri-articular (PA) administration yields similar hemostasis in comparison to IV route. However, there is no report on the clinical effect of combining PA + IA TXA in blood loss reduction and its complications, compared to combining IV + IA TXA after TKA.

MATERIALS AND METHODS

We conducted a double-blind, randomized controlled trial comparing the use of PA + IA TXA administration and IV + IA TXA administration in 70 patients who were scheduled for unilateral primary TKA. Thirty-five patients were assigned for PA + IA injection (Group 1) and anoter 35 patients were assigned for IV + IA injection (Group 2). Primary outcomes included total blood loss at 48 h, and the need for blood transfusion. Secondary outcomes included thigh and leg circumference, degree of knee flexion, and postoperative complications.

RESULTS

The calculated blood loss at 48 h showed no difference between Groups 1 and 2 (617 ml vs. 632 ml, p = 0.425). The total hemoglobin and hematocrit changes were not different (1.89 g/dL vs. 1.97 g/dL, p = 0.371 and 5.66% vs. 5.87%, p = 0.391). There was no need for blood transfusion in either group. However, lower thigh swelling was significant in Group 1 (2.15 cm vs. 2.79 cm, p = 0.04). Leg circumferences at 48 h was also lower in Group 1 (42.12 cm vs. 42.77 cm, p = 0.04). There was no significant difference in knee flexion decrease between the two groups (38° vs. 37°, p = 0.425). There were no VTE complications or infections found in either group.

CONCLUSIONS

Combined PA + IA TXA administration had similar efficacy in blood loss reduction and blood transfusion when compared to combined IV + IA TXA. The first group displayed less soft tissue swelling. The combination of PA + IA TXA administration can be used as an alternative regimen to avoid IV TXA administration.

Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study

PURPOSE

To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty.

METHODS

A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events.

RESULTS

By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported.

CONCLUSION

In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.

Use of Tranexamic Acid in Aesthetic Surgery: A Retrospective Comparative Study of Outcomes and Complications

Background

Bleeding is a potential complication of aesthetic surgery. Surgeons have adhered to the principle of minimizing blood loss. Tranexamic acid (TXA) is an antifibrinolytic medication capable of reducing bleeding. This study aimed to investigate TXA and its effect on complications and overall outcomes in aesthetic surgery patients.

Methods

This retrospective chart review of patients undergoing various aesthetic procedures between 2019 and 2022 was conducted in Riyadh, Saudi Arabia. Preoperative and postoperative hemoglobin levels, blood transfusions, and complications were the primary outcomes. Furthermore, the predictors of giving TXA were studied.

Results

In total, 435 patients were included in the study. TXA was administered to 181 patients (41.6%). Significantly higher proportions of patients who received TXA underwent trunk aesthetic surgery (P < 0.001), and those who received TXA underwent combined procedures more frequently than non-users (P < 0.001). The mean operative time and length of hospital stay were significantly longer among patients who did not receive TXA (P < 0.001, and P < 0.001, respectively). Most predictors for using TXA were significantly associated with performing liposuction (OR = 5.5), trunk aesthetic surgery (OR = 4.9), and undergoing combined procedures (OR = 2.7). No significant difference was noted in the rate of complications between the two cohorts.

Conclusions

Although our data show improvement in patient outcomes in multiple aspects, the heterogeneity of our cohort makes us unable to draw definite conclusions to recommend the use of TXA in aesthetic surgery. Thus, a randomized controlled trial is necessary to support the findings of this study.

The limited use of a tourniquet during total knee arthroplasty under a contemporary enhanced recovery protocol has no meaningful benefit: a prospective randomized controlled trial

PURPOSE

This prospective randomized controlled trial aimed to determine whether the limited use of tourniquets during total knee arthroplasty (TKA) would be more beneficial under the contemporary enhanced recovery after surgery (ERAS) protocol than the conventional use of tourniquets.

METHODS

One hundred patients with knee osteoarthritis who underwent primary TKA were randomly assigned to the limited tourniquet (LT, n = 51) and conventional tourniquet (CT, n = 49) groups. Operation time, serial hemoglobin drops, calculated blood loss, transfusion rate, D-dimer levels, and the presence of deep vein thrombosis (DVT) were assessed. In addition, visual analog scale (VAS) scores for pain around the knee and thigh were measured while resting during the day, at night, and during ambulation. Opioid consumption, range of motion, knee circumference, and postoperative complications were also analyzed. Isokinetic muscle strength, knee injury and osteoarthritis outcome scores, and Euro-QoL-5D scores were also assessed before and 3 months after TKA. For statistical analysis, Chi-square and Fisher's exact tests were performed to compare the differences in categorical variables. Continuous variables were compared using an independent t test or Mann‒Whitney U test.

RESULTS

The average tourniquet time was 46.7 min in the CT group and 5.4 min in the LT group. Knee pain on the first night after surgery was significantly higher in the CT group (3.2 vs. 4.6, p = 0.033). However, daytime pain in the thigh at 2 weeks and in the knee at 3 months after TKA were higher in the LT group than in the CT group (p = 0.048 and p = 0.036, respectively). The D-dimer level 3 months after TKA was also higher in the LT group than in the CT group (p = 0.028), but there was no difference in DVT incidence between the two groups (n.s.). Additionally, there were no significant differences in the other variables between the groups.

CONCLUSIONS

Although the limited use of tourniquets did not increase the operation time, blood loss, or transfusion rate, this study found that the limited use of tourniquets would not provide additional meaningful benefit in reducing pain and early functional restoration after TKA when applying the ERAS protocol.

LEVEL OF EVIDENCE

I.

The role of tranexamic acid in reducing post-operative bleeding and seroma formation in breast surgery: A meta-analysis

INTRODUCTION

Tranexamic acid (TXA) reduces blood loss and blood transfusion requirements in surgery. Seroma and haematoma formation occur as complications of breast surgery. We aimed to perform a meta-analysis evaluating TXA in reducing post-operative haematoma and seroma formation for breast surgery.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Results were expressed as dichotomous variables pooled as odds ratios (OR) with corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method.

RESULTS

Seven studies including 1446 patients were included. There were 1830 breast surgery procedures performed with TXA administered in 797 cases (43.6%). There was a significant reduction in haematoma rates in the TXA group (TXA: 3.184% (22/691) vs Control: 6.787% (64/943), OR: 0.41, 95% CI: 0.20-0.86, P = 0.020). Based on surgical procedure, haematoma rates were similar for TXA and control groups in cancer surgery (P = 0.230). Haematoma rates reduced following TXA use in cosmetic procedures (TXA: 3.807% (15/394) vs. Control: 9.091% (34/374), OR: 0.41, 95% CI: 0.22-0.75, P = 0.004). Haematoma rates were also reduced in procedures where axillary lymph node dissection (ALND) was not performed; in the TXA group, 3.379% (22/651) developed a haematoma versus 6.623% (60/906) in the control group (OR: 0.45, 95% CI 0.27-0.77, P = 0.003). TXA administration did not impact seroma formation or infection rates.

CONCLUSION

Perioperative administration of TXA may impact the incidence of haematoma in breast surgery, particularly in cosmetic procedures and procedures without ALND. Well-designed randomised studies are required to determine its true efficacy. TXA has no effect on seroma formation or infection in breast surgery.

INTRAARTICULAR EPSILON AMINOCAPROIC ACID VERSUS TRANEXAMIC ACID IN TOTAL KNEE ARTHROPLASTY

OBJECTIVE

To examine and compare the clinical efficacy of intraarticular epsilon aminocaproic acid (EACA) and tranexamic acid (TXA) in total knee arthroplasty (TKA).

METHODS

This study was a prospective, single-center, double-blinded randomized controlled trial, including sixty patients with osteoarthritis of the knee divided into two groups of 30 patients. In the TXA group, 1 g of TXA (0.05 g/ml) was applied intraarticularly, and in the EACA group, 4 g of EACA (0.2 g/ml) was applied intraarticularly. Serum hemoglobin (Hgb) and hematocrit (Htb) were measured during the preoperatively and 24 and 48 hours postoperatively. The range of motion and pain were evaluated by clinical examination. To evaluate knee function before and 2 months after surgery, the Western Ontario and McMaster Universities Index (WOMAC) questionnaire was used.

RESULTS

In total, 56 (93.3%) patients were evaluated up to the second postoperative month. No significant difference between the groups (p > 0.05) was found in the decrease in Hgb or Htb at 24 or 48 hours. Regarding assessment of the pain, WOMAC score and gain in knee flexion, no significant advantages up to 60 days after surgery (p > 0.05) were found.

CONCLUSIONS

The decrease in Hgb and Htb during the first 48 hours postoperatively and the risk of transfusion were similar with the intraarticular use of 1 g of TXA and 4 g of EACA in TKA. The possible benefits regarding knee pain, gain in flexion and function were also similar for the two drugs. Level of Evidence II, Randomized, Double-Blinded, Single-Centre, Prospective Clinical Trial.

Significantly reducing blood loss via a peri-articular injection of tranexamic acid during total knee arthroplasty: a retrospective study

Background

The administration of an intra-articular injection (IAI) of tranexamic acid (TXA) has been demonstrated to be effective in reducing both blood loss and transfusion rate during total knee arthroplasty (TKA); however, few studies have reported the efficiency of a peri-articular injection (PAI) of TXA. We studied the efficiency of a PAI of TXA in reducing blood loss during TKA.

Methods

Fifty patients undergoing primary simultaneous bilateral TKA were enrolled in this retrospective study. The right knee received a PAI of 1 g of TXA (Group I), and the left knee received an IAI of 1 g of TXA (Group II). The clinical outcome measures were a change in blood loss from Hemovac drains and surgical time.

Results

The decrease in blood loss from the Hemovac was significantly lower in Group I (460.1 ± 36.79 vs. 576.0 ± 34.01, P < 0.001) than in Group II, and no significant difference in surgical times was observed. The blood transfusion rate in the present study was 16 %.

Conclusions

A PAI of TXA may reduce blood loss more efficiently than an IAI of TXA during TKA without increased complications such as surgical site infection, poor wound healing, skin necrosis, pulmonary embolism, and deep vein thrombosis.

Evaluation of local tranexamic acid on septoplastic surgery quality

BACKGROUND

Even a small amount of bleeding during nose surgery can impair the surgeon's vision, prolong the duration of operation, and affect surgery quality; therefore, various techniques have been proposed to control the bleeding. The aim of this study was to compare the efficacy of the local use of tranexamic acid (TXA) in the dry field of surgery.

METHOD

This randomized, double-blinded, controlled trial was conducted in the operation room of Imam Reza Hospital, Tehran, Iran, from January 10, 2016 to February 8, 2017. Sixty patients with age range from 20 to 60 years and the American Society of Anesthesiologists physical status classes I candidates who require septoplasty enrolled. Patients were randomized through white and black cards to receive either syringes. Thirty patients in the intervention group received lidocaine + adrenaline + TXA and 30 patients in the control group received lidocaine + adrenaline. Bleeding volume accumulated in the suction chamber, the nasopharyngeal pack, and hemodynamic variations were measured. Surgeon's satisfaction scores and suitability of operation field were obtained from the surgeon by using the Likert scale and Boezaart grading scale, respectively.

RESULTS

The intervention group had a higher score of surgeon satisfaction [4.1 vs 3.16 in the control group (P = 0.001)] and fewer hemodynamic variations. The mean bleeding volume in the intervention was 187.23 ± 54.61 mL and in the control group was 341.22 ± 49.17 mL (P = 0.001). The mean Boezaart score (suitability of operation field) in the intervention group was 1.8 (score range: 1-3) and in the control group was 2.53 (score range: 2-4) and it was statistically significant (P = 0.001).

CONCLUSION

The local use of TXA + lidocaine + adrenaline is associated with reduced bleeding, greater surgeon satisfaction, reduced need for Karpol injection, and better hemodynamic stability.

Daily blood loss transition after total knee arthroplasty with topical administration of tranexamic acid: Paradoxical blood loss after action of tranexamic acid

PURPOSE

The purpose of this study was to compare the daily blood loss transition between groups with and without topical administration of tranexamic acid (TXA) after cruciate retaining (CR) and posterior stabilized (PS) total knee arthroplasty (TKA).

METHODS

A total of 220 patients undergoing unilateral TKA were enrolled in CR and PS TKAs, which were divided into groups that received topical administration of TXA (TXA group) or without TXA (non-TXA group). Each group in both types of TKA included 55 patients. The daily transition of blood loss was compared between the TXA and the non-TXA groups in CR and PS TKAs. The blood loss was calculated through Nadler formula using the patient's blood volume and hemoglobin reduction rate.

RESULTS

Total blood loss was significantly lower in the TXA group in both CR and PS TKAs (p < 0.001, respectively). The blood loss was lower for 0-24 h and 24-48 h after TKA. However, from 48 h to 72 h, it was greater in the TXA group (253.1 vs. 34.6 mL; p < 0.001) in CR TKAs. These tendencies were similar in PS TKAs after 48 h (186.2 vs. 134.9 mL, p = 0.223).

CONCLUSIONS

Topical administration of TXA for reduction of blood loss seemed to be effective up to 48 h after both CR and PS TKAs. The blood loss after 48 h tended to be even greater in the TXA group. Future studies will be required to identify the pharmacokinetic evidence for this clinical finding.

LEVEL OF EVIDENCE

Level II.

Impact of Tranexamic Acid on Chondrocytes and Osteogenically Differentiated Human Mesenchymal Stromal Cells (hMSCs) In Vitro

The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations of TXA on proliferation rates, gene expression and differentiation capacity of chondrocytes and human mesenchymal stromal cells (hMSCs), which underwent osteogenic differentiation. Chondrocytes and hMSCs were isolated and multiplied in monolayer cell cultures. Osteogenic differentiation of hMSCs was induced for 21 days using a differentiation medium containing specific growth factors. Cell proliferation was analyzed using ATP assays. Effects of TXA on cell morphology were examined via light microscopy and histological staining, while expression levels of tissue-specific genes were measured using semiquantitative RT-PCR. After treatment with 50 mg/mL of TXA, a decrease in cell proliferation rates was observed. Furthermore, treatment with concentrations of 20 mg/mL of TXA for at least 48 h led to a visible detachment of chondrocytes. TXA treatment with 50 mg/mL for at least 24 h led to a decrease in the expression of specific marker genes in chondrocytes and osteogenically differentiated hMSCs. No significant effects were observed for concentrations beyond 20 mg/mL of TXA combined with exposure times of less than 24 h. This might therefore represent a safe limit for topical application in vivo. Further research regarding in vivo conditions and effects on hMSC functionality are necessary to fully determine the effects of TXA on articular and periarticular tissues.

Prospective randomized trial comparing efficacy and safety of intravenous and intra-articular tranexamic acid in total knee arthroplasty

Background

Total knee arthroplasty (TKA) is associated with significant perioperative blood loss and postoperative allogenic blood transfusion. Tranexamic acid (TXA) reversibly blocks lysine binding sites on plasminogen molecules and inhibits plasmin formation. Comparisons of the efficacy and safety of intra-articular and intravenous TXA in primary TKA have not previously been reported.

Methods

A prospective randomized trial was conducted in 150 patients who underwent TKA, and these patients were randomized into three groups. Patients in Group A were injected by intra-articular TXA according to body weight (20 mg/kg). Patients in Group B received a standard dose of intra-articular TXA (2000 mg), and those in Group C were infused with TXA according to body weight (20 mg/kg) before tourniquet deflation and again 3 h later. Baseline characteristics and data collected at blood transfusion were compared. Differences among four time points (baseline, day 0, day 2, and day 5) were carried out using ANOVA.

Results

The hemoglobin levels at postoperative day 5 were 10.6 g/dL for Group A, 10.6 g/dL for Group B, and 10.7 g/dL for Group C. The drain output was 399 ml for Group A, 314 ml for Group B, and 305 ml for Group C (p = 0.03). Group C had significantly less drain output than Group A after post hoc comparisons (p = 0.05), whereas no significant difference was observed between Group A and B (p = 0.09) or between Group B and C.

Conclusion

The weight-adjusted dose of TXA administered intravenously significantly reduced the drain output but not the total blood loss when compared with the weight-adjusted dose of TXA administered intra-articularly. No significant difference was observed in the other parameters among the three groups.

Trial registration

The Joint CUHK-NTEC CREC, CRE-2013.644-T. Registered 1 March 2014.

The optimal regimen of oral tranexamic acid administration for primary total knee/hip replacement: a meta-analysis and narrative review of a randomized controlled trial

Background

Oral tranexamic acid (TXA) has been demonstrated to reduce the blood loss in primary total knee and hip arthroplasty, but the optimal regimen of oral TXA administration is still unknown. This study aimed to find the best number of administrations of oral TXA for primary total knee and hip arthroplasty.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies published before March 20, 2020. Studies clearly reporting a comparison of multiple administrations of oral TXA for total hip/knee replacement were included, and the total blood loss (TBL), intraoperative blood loss (IBL), decline in hemoglobin (DHB), deep vein thrombosis (DVT), intramuscular venous thrombosis (IVT), length of hospital stay (LOS), and transfusion rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed effects or random effects model.

Results

Nine studies involving 1678 patients were included in this meta-analysis (TXA 1363 (one administration, 201; two administrations, 496; three administrations, 215; four administrations, 336; five administrations, 115); placebo 315); the results show that compared with placebo groups, oral TXA could significantly reduce the TBL, IBL, DHB, LOS, and transfusion rate. In addition, the incidences of IVT and DVT were similar between the TXA and placebo groups. Moreover, two administrations of oral TXA significantly reduced the TBL and DHB compared with one administration, three administrations of oral TXA were better than two administrations, and four administrations of oral TXA were better than three administrations.

Conclusion

Our results suggested that oral TXA could significantly reduce the blood loss and the length of hospital stay but could not increase the incidence of DVT and IVT for total joint replacement patients; additionally, the effectiveness of oral TXA administration increased as the number of administrations increased.

Periarticular injection of tranexamic acid promotes early recovery of the range of knee motion after total knee arthroplasty

PURPOSE

Tranexamic acid (TXA) is a commonly used compound that reduces postoperative blood loss. Periarticular injection of TXA is a recently reported procedure with some advantages such as cost-effectiveness and the ease of performance over an intravenous or topical administration. However, its association with functional recovery remains unclear. This study aimed to examine the effect of periarticular injection of TXA on early postoperative recovery of knee functionality after total knee arthroplasty (TKA).

METHODS

Eighty-four patients who underwent primary unilateral TKA from February 2013 to August 2016 were classified into two groups based on whether they received TXA injection (44 cases each in the TXA and control groups). Patients in the TXA group received periarticular injection of TXA (1000 mg) just prior to incision closure. Ten-meter walk test (s), pain visual analog scale, knee extension muscle force (N), range of motion (ROM) (maximum flexion angle, maximum extension angle, and motion arc), and blood loss (mL) were assessed.

RESULTS

The maximum flexion angle and maximal extension angle on postoperative day (POD) 4, POD7, POD10, and POD14 in the TXA group were significantly larger than those in the control group. The postoperative drained blood in the TXA group was significantly less than that of the control group (543.9 ± 464.3 mL and 814.9 ± 481.4 mL, respectively, p < 0.05). No significant difference was observed in the other parameters at any time point.

CONCLUSION

Periarticular injection of TXA significantly promotes early recovery of knee ROM after TKA. Level of Evidence: Level IV, therapeutic case series.

Tranexamic Acid in Aesthetic Facial Plastic Surgery: A Systematic Review of Evidence, Applications, and Outcomes

Background

Tranexamic acid (TXA) is an antifibrinolytic that has become widely used in aesthetic facial plastic surgery, although its efficacy has not been well investigated.

Objectives

To evaluate the existing evidence for use of TXA in aesthetic facial plastic surgery, highlighting routes of administration, dosing, surgical applications, and clinical outcomes.

Methods

Systematic review of primary literature evaluating TXA in aesthetic facial plastic surgery.

Results

Eleven studies met inclusion criteria: 8 prospective randomized controlled trials, 2 retrospective case series/cohort studies, and 1 clinical opinion. Six studies evaluated TXA in rhinoplasty, 4 in rhytidectomy, and 1 in blepharoplasty. Significant reductions in intraoperative blood loss were found in 5 rhinoplasty studies. Three rhinoplasty and 2 rhytidectomy studies found significantly reduced postoperative edema and ecchymosis. One rhinoplasty and 1 rhytidectomy study reported reduced operative time and time to achieve hemostasis. One rhytidectomy study reported reduced postoperative drain output and faster time to drain removal. No studies reported an adverse outcome directly related to TXA.

Conclusions

Existing literature investigating TXA in aesthetic facial plastic surgery is sparse with varying levels of evidence and heterogeneous data. Literature suggests systemic TXA reduces intraoperative blood loss during rhinoplasty, although the clinical significance of this blood loss reduction is unclear. TXA may also reduce postoperative edema and/or ecchymosis in rhytidectomy and rhinoplasty, although the lack of validated grading scales yields insufficient evidence to support this claim. Topical and subcutaneously injected TXA are emerging administration routes in rhytidectomy, with evidence suggesting TXA mixed with tumescent may reduce postoperative drain output, thereby expediting drain removal.

Level of Evidence: 2

[Fast-track arthroplasty-intra- and post-operative management]

Fast-track concepts in hip and knee arthroplasty focus on an early and safe mobilisation after surgery using a multi-modal pain concept with local infiltration anaesthesia. No drains, femoral nerve blocks or urinary catheters are used. Tranexamic acid reduces blood loss and transfusion rates. Cortisone is helpful in reducing pain, PONV and postsurgical stress response. Minimal invasive surgical techniques and the renouncement of a tourniquet lead to a better functional result and less pain. Restrictions and precautions are not evidence-based and should, therefore, be abandoned.

ASSESSMENT OF THE USE OF TRANEXAMIC ACID AFTER TOTAL KNEE ARTHROPLASTY

Objective:

To evaluate the profile of blood loss and blood transfusions after the introduction of Tranexamic acid (TXA) in a tertiary university hospital in Brazil.

Methods:

173 patients were retrospectively divided into two groups: the ones who received TXA and the control group. Hemoglobin levels (Hb), drain output, transfusion rates, and thromboembolic events were measured.

Results:

Among the patients included in this study, 82 cases received TXA. Blood transfusion occurred in 3 cases of the TXA group (3.7%), and in 27 control group cases (29.7%; p < 0.001). The average Hb decrease was 2.7 g/dl (± 1.39) and the median drain output was 270 mL in the TXA group. In the control group, the values were 3.41 g/dl (± 1.34; p < 0.001) and 460 mL (p < 0.001), respectively. Thromboembolic events occurred in 2 TXA group cases (2.4%) and in 3 control group cases (3.3%; p > 0.999).

Conclusion:

TXA was effective in reducing blood transfusion rates, Hb decrease, and drain output on the 1st postoperative day without increasing thromboembolic events. Level of evidence III, Retrospective comparative study.

Comparison of efficacy and safety between oral and intravenous administration of tranexamic acid for primary total knee/hip replacement: a meta-analysis of randomized controlled trial

Background

Tranexamic acid (TXA) has been demonstrated to reduce blood loss following primary total knee and hip arthroplasty. This study aimed to compare the efficacy and safety of oral and intravenous tranexamic acid for primary total knee and hip arthroplasty.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies published before June 20, 2019. Studies clearly reporting a comparison of oral and intravenous TXA were selected, and total blood loss (TBL), the decline in hemoglobin (DHB), deep vein thrombosis (DVT), intramuscular venous thrombosis (IVT), the length of hospital stay, and the transfusion rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed-effects or random-effects model.

Results

Ten studies involving 1140 (oral 557; intravenous 583) patients were included in this meta-analysis. There was no significant difference in terms of total blood loss, the decline in hemoglobin, the length of hospital stay, the incidence of DVT or IVT, or the transfusion rate between the oral and intravenous groups, and five studies reported that oral TXA was associated with a lower cost.

Conclusion

Our research suggests that compared with intravenous use of TXA, the oral approach has similar clinical outcomes and is less expensive for total joint replacement patients.

Effect of tranexamic acid on symptomatic venous thromboembolism in patients undergoing primary total knee arthroplasty

INTRODUCTION

This study aimed to investigate the effect of tranexamic acid (TXA) with sequential routine anticoagulation on postoperative symptomatic venous thromboembolism (VTE) in patients undergoing primary total knee arthroplasty (TKA).

MATERIAL AND METHODS

This was a prospective study with randomized trials. From January 2013 to May 2015, 1880 patients undergoing primary TKA were enrolled in this study. Seven hundred and twenty patients who received TXA injection were included in the TXA group while 1160 patients who received placebo injection were included in the control group. Patients in the TXA group were treated with intravenous TXA or topical intravenous TXA, and all received sequential routine anticoagulation 12 h after the operation. We extracted data of patients' sex, age, primary diagnoses, and comorbidities that could potentially affect the prevalence rate of VTE. To discuss the risk factors of symbolic VTE, comparisons were made within the TXA group between patients with symbolic VTE and non-symbolic VTE. Logistic regression analysis was performed to analyze the concurrent effects of various factors on the prevalence rate of postoperative VTE.

RESULTS

Thigh perimeter was not closely associated with TXA injection. Within the TXA group, 24 (3.3%) patients had perioperative symptomatic VTE, 16 (2.2%) deep vein thrombosis (DVT) and 8 (1.1%) pulmonary embolism. High body mass index (BMI), low fibrinogen (Fbg) and simultaneous bilateral TKA were significant risk factors in both univariate analysis and multivariate analysis.

CONCLUSIONS

Increased BMI, low Fbg, and simultaneous bilateral TKA could act as risk factors for postoperative symptomatic VTE treated with TXA.

Efficacy and Safety of Tranexamic Acid Combined with Rivaroxaban in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Tranexamic acid (TXA) combined with rivaroxaban (RA) has been widely used in total knee replacement (TKA). This meta-analysis explored the clinical effects of TXA combined with RA on reducing bleeding and preventing venous thrombosis in patients with unilateral TKA.

METHODS

Five controlled clinical studies that met the inclusion criteria were collected from PubMed, Embase and Cochrane libraries. Fixed effect model and random effect model were used to compare the TXA + RA group with the RA group in 731 patients.

RESULTS

Decrease of hemoglobin (Hb), total blood loss, transfusion rate and wound complications of the TXA + RA group is lower than the RA group, the difference was statistically significant (p < 0.05). Deep venous thrombosis (DVT) occurs in the TXA + RA group and the RA group showed no statistically significant difference (p > 0.05). There was no obvious difference of two ways of drug given that intra-articular (IA) and intravenous (IV) effect on Hb decrease, total blood loss, transfusion rate, wound complications, DVT (p > 0.05).

CONCLUSION

The application of TXA combined with RA in the TKA can effectively reduce blood loss without increasing the risk of DVT. However, it should be noted that TXA combined with RA after TKA has a potential increased risk of wound complications.

Intra-articular 1 g tranexamic acid administration during total knee arthroplasty is safe and effective for the reduction of blood loss and blood transfusion

INTRODUCTION

The effect of tranexamic acid (TXA) on the incidence of venous thromboembolic events (VTEs) in total knee arthroplasty (TKA) as assessed by contrast-enhanced computed tomography (CT) is unclear. Thus, we investigated the efficacy and safety profiles of TXA administration during TKA. We hypothesised that intra-articular 1 g TXA administration would have a sufficient effect on the reduction of blood loss and transfusion rates without increasing VTE risk.

MATERIALS AND METHODS

We retrospectively analysed 86 patients who underwent primary TKA from January 2014 to September 2017. The study comprised control (n = 45) and TXA (n = 41) groups. All patients underwent navigation-assisted TKA via the medial parapatellar approach. In those who received TXA, 1 g of intra-articular TXA was injected via a drain immediately following wound closure. The drain was clamped for 2 h and then reopened. Contrast-enhanced CT was performed 5-6 days after surgery to detect deep venous thrombosis (DVT) and pulmonary embolism (PE). Blood loss was calculated using the haemoglobin balance method.

RESULTS

The mean postoperative volume of blood loss was 900 ± 296 mL vs 1216 ± 445 mL in the TXA vs control group (p < 0.01). Allogeneic blood transfusion was required for 0 (0%) vs 6 (13.3%) patients in the TXA vs control group (p = 0.013). There were no significant inter-group differences regarding DVT and PE incidence (p > 0.05). No case of symptomatic PE occurred.

CONCLUSIONS

This study demonstrated that intra-articular 1 g TXA administration during TKA is safe and effective for reducing blood loss and blood transfusion without increasing VTE risk.

Multi-route applications of tranexamic acid to reduce blood loss after total knee arthroplasty: a randomized controlled trial

BACKGROUND

Perioperative bleeding during total knee arthroplasty (TKA) is an ongoing problem for surgeons. Intravenous or topical application of tranexamic acid (TXA) can effectively stop bleeding, but there is still no uniform standard for the best method of administration and dose.

METHODS

From October 2016 to September 2018, 218 patients with unilateral primary knee osteoarthritis requiring knee replacement were enrolled and randomly divided into four groups. Group 1 (n = 55) received intra-articular injection (IAI) of TXA and peri-articular injection (PAI) of placebo, group 2 (n = 55) received IAI of placebo and PAI of TXA, group 3 (n = 51) received IAI of TXA and PAI of TXA, and group 4 (n = 57) received double placebo (IAI of placebo and PAI of placebo). The demographic characteristics, surgical indices, hematological indices, wound healing history, and thromboembolic events were investigated.

RESULTS

Eight patients were lost to follow-up and 210 patients were included in the analysis. The median TBLs in patients who received IAI of TXA and PAI of placebo and those who received IAI of placebo and PAI of TXA were 470.81 ml and 481.54 ml, respectively. These TBL levels were significantly higher compared to those in patients who received IAI of TXA and PAI of TXA (359.18 ml, P ≤ .001), but significantly lower compared to those in patients who received the double placebo (522.71 ml, P ≤ .001). Compared to other groups, more patients in the double placebo group needed a blood transfusion (P = .013). In the short-term, the double placebo group had higher VAS pain scores and less ROM after surgery (P = .011 and P = .001, respectively). In the long-term (6-month follow-up), there were no significant differences in ROM, VAS, DVT, PE, or wound-related complications.

CONCLUSION

The combined use of IAI and PAI of TXA can significantly reduce the TBL and the need for blood transfusion without delaying wound healing or increasing the risk of DVT and PE. In the short-term after surgery, this combined method reduces the pain VAS scores and improves the ROM; however, there are no long-term effects on VAS and ROM.

Intra-Articular Tranexamic Acid Mitigates Blood Loss and Morphine Use After Total Knee Arthroplasty. A Randomized Controlled Trial

BACKGROUND

Tranexamic acid (TXA) has been widely used in total knee arthroplasty (TKA) for blood loss reduction. Given limited evidence on potential relationship between the TXA and improvement of pain control and functional outcome after TKA, this study aimed at comparing the blood loss, pain scores, morphine consumption, and knee flexion across the TXA administration routes.

METHODS

The 228 primary TKA were randomized into no TXA use (No-TXA), intra-articular TXA (15 mg/kg) use (IA-TXA), and intravenous TXA (10 mg/kg) use (IV-TXA). A multivariate regression analysis was used for comparing perioperative blood loss (PBL), drain output, average number of units of blood transfused (ANUBT), visual analogue scales (VAS) for pain, amount of morphine consumption, and knee flexion angle.

RESULTS

The IA-TXA and IV-TXA group had 193.26 (P < .01) and 160.30 mL (P < .01) less PBL than No-TXA, respectively. No-TXA significantly required higher ANUBT than IA-TXA and IV-TXA (P = .03). The IA-TXA group had lower VAS at 6 (P = .04), 12 (P = .03), and 24 hours (P = .02) postoperative when compared to No-TXA, while IV-TXA had no effect. The IA-TXA required 18.26 mg less total morphine at 48 hours than No-TXA (P = .02), whereas IV-TXA used insignificantly (5.31 mg; P = .31) less total morphine at 48 hours than No-TXA. Both TXA routes tended to improve knee flexion, but not statistically significant.

CONCLUSION

Both IA-TXA and IV-TXA could significantly reduce PBL and ANUBT. The IA-TXA could significantly mitigate VAS and morphine use after TKA. Hence, IA-TXA could minimize blood loss and may be considered as an adjunct to pain control following TKA.

Tranexamic acid is effective in lower doses with infusion in total knee arthroplasty

Objective

To identify the most effective intravenous regimen with reduced doses of tranexamic acid (TXA).

Methods

We retrospectively evaluated the two most frequently used TXA regimens (infusion and divided-dose regimens) in total knee arthroplasty in comparison with patients not treated with TXA, in three groups. Group NO (n = 134; 19 men and 115 women; mean age: 66.48 ± 7.66) (patients who were not treated with TXA); group DIV (n = 158; 14 men and 144 women; mean age: 65.67 ± 7.98) (total dose of 10 mg/kg intravenous TXA divided into two doses: 15 minutes before tourniquet inflation and 15 minutes before tourniquet deflation), an extra 5 mg/kg intravenous TXA dose was administered 2 hours after surgery in the orthopedic ward, if needed; and group INF (n = 193; 33 men and 160 women; mean age: 67.08 ± 7.2) (10 mg/kg TXA perioperative intravenous infusion starting 15 minutes before surgery until closure of the wound, and 5 mg/kg additional intravenous dose was administered 12 hours after surgery). Pre-postoperative hemoglobin (Hb) and hematocrit (Htc) difference, total blood loss (TBL), number of transfused packed red blood cells (pRBC), and length of hospital stays (LOS) were compared between the groups.

Results

TBL was lower in group INF (531.61 ± 316.76 mL) in comparison with group DIV (999.91 ± 352.62 mL). TBL was statistically significantly higher in Group NO (1139.23 ± 43 mL). The mean number of transfused pRBC was significantly higher in the control group (1.22 ± 0.58 units) than the in the other TXA groups. The mean number of transfused pRBC was significantly lower in INF group (0.33 ± 0.56 units) than DIV group (0.75 ± 0.63 units). The number of patients requiring transfusion was significantly lower in INF group (28.5%) than DIV group (65.2%). Group NO had the highest number of patients requiring transfusion (96.3%). Pre-postoperative Hb and Htc difference was significantly lower in INF group (−1.19 ± 0.9 gr/dL and −3.74 ± 2.96%). The mean LOS of the control group, group DIV and group INF were 7.16 ± 2.29, 6.93 ± 2.39 and 5.06 ± 1.24 days, respectively. Group INF had the lowest hospital stay time in comparison with the other groups (p < 0.005). There was no statistically significant difference between the control group and group DIV in the LOS.

Conclusion

A total dose of 10 mg/kg of TXA perioperative intravenous infusion starting 15 minutes before the surgery until wound closure can significantly decrease TBL. Intraoperative infusion regimen is more effective than the divided-dose regimen.

Level of Evidence

Level III, Therapeutic Study.

Short exposure to tranexamic acid does not affect, in vitro, the viability of human chondrocytes

BACKGROUND

Only few studies have investigated the effect of topical application of tranexamic acid (TXA) on "minimally" invasive joint surgical procedures in which articular cartilage is preserved; for this reason, actually many surgeons avoid the use of topical TXA even if the disadvantage related to a blood loss can occur. The aim of this study was to evaluate the cytotoxicity, on human chondrocytes, of TXA at different concentrations and times of exposure and the mechanisms of cell death.

METHODS

Experiments were carried out on isolated human chondrocytes harvested from eight patients who underwent total knee replacement. Cell viability was determined using XTT assay and was assessed at 0, 24 and 48 h intervals after a 10-min-long treatment, followed by thorough washes, or at 24 and 48 h of treatment at TXA concentrations of 20, 50, 70 and 100 mg/ml. Cell cycle alterations and occurrence of cell death for apoptosis or necrosis were assessed by cytofluorimetry. Data were analyzed using Proc Mixed Procedure; LSMEANS was used to compare multiple group means with Tukey's honestly significant difference test.

RESULTS

A significant correlation between the controlled for factors (type of treatment, time and concentration) was found in the performed experiment. No significant effect on cell viability was observed when the TXA exposure was limited to 10 min, while for increased exposure, 24 and 48 h, a remarkable reduction was found; cell death occurred by apoptosis and was already appreciable after 24 h, reaching a statistical significance after the 48-h-long treatment.

CONCLUSION

A prolonged exposure to TXA may cause cartilage damage, thus its topical application can be expanded also to clinical scenarios that include retention of native cartilage chondrocytes, only if it is limited to few minutes and used at concentrations of 70 mg/ml or less.

Reducing Blood Loss in Revision Total Hip and Knee Arthroplasty: Tranexamic Acid Is Effective in Aseptic Revisions and in Second-Stage Reimplantations for Periprosthetic Infection

Introduction

The aim of the study was to determine the usefulness of tranexamic acid (TXA) in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA). We analyzed the perioperative blood loss with and without TXA in aseptic rTHA and rTKA as well as in second-stage reimplantation for hip and knee periprosthetic infection.

Materials and Methods

In this prospective cohort study, 147 patients receiving TXA (96 rTHA, 51 rTKA) were compared to a retrospective cohort of 155 patients without TXA (103 rTHA, 52 rTKA). The TXA regimen consisted of a preoperative bolus of 10 mg/kg bodyweight (BW) TXA plus 1 mg/kgBW/h perioperatively. Given blood products were documented and the perioperative blood loss was calculated. Thromboembolic events were registered until three months postoperatively. In subgroups, the effects of TXA were separately analyzed in 215 aseptic revisions as well as in 87 reimplantations in two-stage revisions for periprosthetic infection.

Results

Both TXA groups showed a significantly reduced mean blood loss compared to the respective control groups. The TXA group of rTHA patients had a mean blood loss of 2916 ml ± 1226 ml versus 3611 ml ± 1474 ml in the control group (p<.001). For the TXA group of rTKA patients, mean calculated blood loss was 2756 ml ± 975 ml compared to 3441 ml ± 1100 ml in the control group (p=.0012). A significantly reduced blood loss was also found in the TXA subgroups for aseptic and septic revision procedures. No thromboembolic events were recorded among the TXA groups.

Conclusions

There is a significant reduction of perioperative blood loss under TXA influence without an increased incidence of adverse events. The standard use of TXA can be recommended in aseptic hip and knee revision arthroplasties as well as in second-stage reimplantations for periprosthetic infection.

Antifibrinolytic Agents in Plastic Surgery: Current Practices and Future Directions

BACKGROUND

Prevention of blood loss is a chief consideration in plastic and reconstructive surgery. The antifibrinolytic drugs tranexamic acid and ε-aminocaproic acid have emerged as promising agents to reduce both perioperative blood loss and transfusion requirements. However, published reports in the plastic surgery literature are lacking. The authors sought to summarize the current knowledge of the use of antifibrinolytics in plastic surgery by reviewing the existing literature for clinical outcomes and recommendations.

METHODS

A systematic review of the PubMed, Cochrane, and Google Scholar databases was conducted for publications examining the use of antifibrinolytics in plastic surgery. Studies were abstracted for procedure type, antifibrinolytic dose, time and mode of administration, blood loss, transfusion requirements, and complications.

RESULTS

Thirty-three studies were deemed eligible for inclusion, comprising a total of 1823 patients undergoing plastic surgical procedures with tranexamic acid (n = 1328) and/or ε-aminocaproic acid (n = 495).

CONCLUSIONS

Tranexamic acid and ε-aminocaproic acid are widely used to reduce blood loss and transfusion requirements in craniofacial and orthognathic surgery, without an increased risk of adverse events. Intravenous administration is most commonly used, although topical formulations show similar efficacy with a reduced systemic distribution. Tranexamic acid has also emerged as a promising agent in aesthetic surgery and burn care, due to its favorable safety profile and role in reducing blood loss, achieving an improved surgical field, and reducing edema and ecchymosis. Further investigation of these agents in the fields of burn care, aesthetic surgery, and microsurgery is warranted to standardize protocols for clinical use.

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.

Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

The effects of tranexamic acid (TXA) in the setting of shoulder arthroplasty are unclear. The objective of this study was to examine the effects of TXA in reducing the need for blood transfusions and blood loss in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective cohort studies (RCS) that compared outcomes of patients who did and did not receive TXA during TSA or RTSA. We searched Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was transfusion rate, and secondary outcomes were changes in hemoglobin, estimated total blood loss (ETBL), blood loss via drainage, operative time, hospital stay, overall complications, and thromboembolic events.

RESULTS

We identified 3 RCTs and 3 RCS including 677 patients with 680 shoulders (343 TXA and 337 non-TXA). The random-effects model meta-analysis showed that TXA group had a lower transfusion rate (risk ratio (RR) 0.34, 95% CI 0.14 to 0.79), less change in hemoglobin (mean difference (MD) -0.64 g/dl, 95% CI -0.81 to - 0.46), and reduced ETBL (MD -249.24 ml, 95% CI -338.74 to - 159.74). In patients with RTSA, the TXA group had a lower transfusion rate (RR 0.28, 95% CI 0.14 to 0.79), less ETBL (MD -249.15 ml, 95% CI -426.60 to - 71.70), less change in hemoglobin (MD - 0.64 g/dl, 95% CI -0.86 to - 0.42), and less blood loss via drainage (MD - 84.56 ml, 95% CI -145.72.14 to - 23.39) than non-TXA group.

CONCLUSIONS

The use of TXA in primary shoulder arthroplasty appears safe, and can reduce transfusion rate, changes in hemoglobin, and perioperative total blood loss, especially in patients with RTSA.

LEVEL OF EVIDENCE

Systematic Review and meta-analysis, III.

EFFICACY OF TRANEXAMIC ACID IN REDUCING BLOOD LOSS IN TOTAL KNEE ARTHROPLASTY

OBJECTIVE

To evaluate the efficacy of tranexamic acid in reducing blood loss in total knee arthroplasty by examining the existing literature.

METHOD

This literature review investigated the use of tranexamic acid in knee arthroplasty. The search was performed in the Pubmed, Science Direct, Google Scholar, and Lilacs databases over a 20-year period using the keywords: "knee arthroplasty, tranexamic acid, and efficacy". Only randomized clinical trials published between 2000 and 2016 in English, Spanish, or Portuguese were accepted, and only trials which scored above 3 on the Jadad scale were selected.

RESULTS

A total of 7 randomized clinical trials met the inclusion criteria, with a sample of 948 patients.

CONCLUSION

The use of tranexamic acid in total knee arthroplasty (unilateral or bilateral) reduces perioperative and postoperative blood loss more than other available antifibrinolytics. With this reduction in total blood loss and the need for blood transfusions without any increase in side effects, the use of tranexamic acid can be considered safe and effective in controlling bleeding after knee arthroplasties. Level of Evidence II; Systematic review.

Periarticular Injection of Tranexamic Acid Reduces Blood Loss and the Necessity for Allogeneic Transfusion After Total Knee Arthroplasty Using Autologous Transfusion: A Retrospective Observational Study

BACKGROUND

This study aimed to examine the influence of a periarticular injection of tranexamic acid (TXA) on blood loss after a total knee arthroplasty (TKA) in patients who received an autologous blood transfusion.

METHODS

We retrospectively reviewed the medical charts of 82 patients (88 consecutive knees) who underwent a primary unilateral TKA with or without a periarticular TXA injection (TXA and control groups, respectively). All patients underwent an autologous blood transfusion. Perioperative parameters related to blood loss were compared between groups.

RESULTS

Compared to the control group, the decrease in hemoglobin was significantly smaller in the TXA group (1.5 ± 1.2 vs 2.5 ± 1.4 g/dL, P < .001), and blood drainage was significantly lower in the TXA group (387.2 ± 215.7 vs 582.3 ± 272.9 mL, P = .002). Moreover, the estimated blood loss, based on either hemoglobin or hematocrit, was significantly lower in the TXA group (509.8 ± 405.2 and 530.7 ± 418.5 mL, respectively) than in the control group (814.2 ± 543.8 and 809.1 ± 469.6 mL, respectively, both P < .001). No severe complications, including a venous thromboembolic event or infection, or local complications, including skin necrosis or delayed wound healing, were observed in either group. A postoperative allogeneic blood transfusion was performed in 2 cases in the control group and none in the TXA group.

CONCLUSION

Periarticular TXA injection is effective in reducing postoperative blood loss and hemoglobin and hematocrit drops without increasing the risk of venous thrombosis or the necessity of an allogeneic blood transfusion.

Influence of single-dose intravenous tranexamic acid on total hip replacement : A study on transfusions, collateral complications, and readmissions

INTRODUCTION

To determine the effects of tranexamic acid (TXA) on transfusions in patients undergoing hip replacement with a hybrid or cementless prosthesis.

METHODS

A group of 172 consecutive patients aged 18 years or older who underwent elective hip replacement with uncemented or hybrid prostheses, undergoing surgery between January 2012 and January 2014 by the same primary surgeon and anesthesiologist, were retrospectively included. TXA (1 g) was administered immediately before incision in the TXA group. Primary variables included number of red blood cell transfusions and the influence of TXA for each type of prosthesis. Secondary variables included hematocrit at discharge, length of hospital stay, thrombosis or pulmonary embolism, seizures, and death.

RESULTS

Average transfusion was 1.53 units/patient in the control group compared to 0.6 units/patient in the TXA group (z = 6.29; U = 1640.5; p < 0.0001). TXA use was significantly correlated with the number of units transfused (p < 0.0001, 95% CI -1.24 to -0.68). Odds risk reduction for transfusion was observed during surgery (OR: 0.14; CI 0.06-0.29; p < 0.0001) and during the rest of hospital stay (OR: 0.11; CI 0.01-0.96; p = 0.046). Both hybrid and cementless prostheses that received TXA were transfused less than control groups (0.57 ± 1 vs. 1.7 ± 1 p < 0.01 and 0.65 ± 1 vs. 1.24 ± 1 p < 0.01). No difference was observed between the groups regarding adverse effects. Hematocrit values at discharge and length of hospital stay were similar between groups. No deaths were observed during hospital stay.

CONCLUSIONS

TXA reduced transfusions without increasing the prevalence of adverse effects. This reduction was observed during surgery and the following days of hospital stay for both for hybrid and cementless prosthesis.

Intravenous versus topical tranexamic acid administration in primary total knee arthroplasty: a meta-analysis

PURPOSE

This meta-analysis was designed to compare the effectiveness and safety of intravenous (IV) versus topical administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty (TKA) by evaluating the need for allogenic blood transfusion, incidence of postoperative complications, volume of postoperative blood loss, and change in haemoglobin levels.

METHODS

Studies were included in this meta-analysis to check whether they assessed the allogenic blood transfusion rate, postoperative complications including pulmonary thromboembolism (PTE) or deep vein thrombosis (DVT), volume of postoperative blood loss via drainage, estimated blood loss, total blood loss, and change in haemoglobin levels before and after surgery in primary TKA with TXA administered through both the IV and topical routes.

RESULTS

Ten studies were included in this meta-analysis. The proportion of patients requiring allogenic blood transfusion (OR 1.34, 95 % CI 0.63-2.81; n.s.) and the proportion of patients who developed postoperative complications including PTE or DVT (OR 0.85, 95 % CI 0.41 to 1.77; n.s.) did not significantly differ between the two groups. There was 52.3 mL less blood loss via drainage (95 % CI -50.74 to 185.66 mL; n.s.), 52.1 mL greater estimated blood loss (95 % CI -155.27 to 51.03 mL; n.s.), and 51.4 mL greater total blood loss (95 % CI -208.16 to 105.31 mL; n.s.) in the topical TXA group as compared to the IV TXA group. The two groups were also similar in terms of the change in haemoglobin levels (0.02 g/dL, 95 % CI -0.36 to 0.39 g/dL; n.s.).

CONCLUSIONS

In primary TKA, there are no significant differences in the transfusion requirement, postoperative complications, blood loss, and change in haemoglobin levels between the IV and topical administration of TXA. In addition, results from subgroup analysis evaluating the effect of the times of TXA administration through the IV route suggested that double IV dose of TXA is more effective than single dose in terms of the transfusion requirements and blood loss via drainage. The current meta-analysis indicates that IV administration of 10 mg/kg of TXA 20 min before inflation of the tourniquet followed by 10 mg/kg of TXA 15 min before deflation of the tourniquet is effective and safe. The topical administration of 2 g of TXA mixed with 100 mL of normal saline after wound closure could be an alternative option in patients at greater risk of thromboembolic complications.

LEVEL OF EVIDENCE

Meta-analysis, Level III.

Factors that influence blood loss and need for transfusion following total knee arthroplasty

Background

Blood loss during total knee arthroplasty (TKA) remains a concern, as many patients require blood transfusions, which increase risks of allergic reactions, disease transmission, and thromboembolisms. The purpose was to determine factors associated with blood loss and need for transfusion in patients receiving routine TKA.

Methods

The authors prospectively analyzed 150 consecutive uncemented TKAs for age, gender, body mass index (BMI), anticoagulant medication, type of anesthesia, tranexamic acid (TXA) administration, tourniquet inflation, drain placement, pre- and post-operative Haemoglobin (Hb) level (g/dL), and whether transfusion was necessary. Univariable and multivariable regression analyses were performed to identify factors associated with Hb loss and need for transfusion with significance level set at P value<0.05.

Results

The cohort comprised 92 women and 58 men, aged 69.5±8.9 years. The mean Hb loss was 3.7±1.3 g/dL. The 20 patients (13%) who had transfusions also had lower preoperative Hb (12.6±1.2 g/dL) compared to the remaining patients (14.3±1.2 g/dL). Hb loss was significantly associated with preoperative Hb, TXA, and gender, but multivariable regression identified gender as a confounder and indicated that TXA reduced Hb loss by 0.92 g/dL. Multivariable regression revealed the need for transfusion was only significantly associated with preoperative Hb and indicated that a decrease of preoperative Hb by 1 g/dL nearly quadrupled the chances of needing transfusion.

Conclusions

Hb loss was significantly associated with preoperative Hb levels and use of TXA, while the need for transfusion was only associated with preoperative Hb levels. These findings could help identify patients at risk for blood transfusions. Level of evidence: level III, prospective case series.

A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement

Background

Studies on the use of tranexamic acid (TXA) to improve clinical outcomes after joint arthroplasty have reported contrasting results between intravenous (IV) TXA alone and combined IV and intraarticular (IA) administration. We compared the effectiveness of the 2 methods in providing higher postoperative hemoglobin (Hb) levels in patients undergoing primary total knee arthroplasty (TKA).

Methods

A total of 100 TKA patients were randomly assigned to receive either IV TXA alone (group 1) or combined IV and topical IA TXA (group 2). Hb and hematocrit levels were measured before and after surgery. The amount of drained blood and transfused blood for the 2 groups was compared.

Results

The Hb level was significantly higher at postoperative day 4, together with a positive, albeit not significant, trend toward less postoperative blood loss in the group that received combined IV and IA TXA. No postoperative infections or deep venous thrombosis events occurred.

Conclusions

This study reinforces evidence that, as compared to IV TXA alone, combined IV and IA administration of TXA has a synergic effect, leading to higher postoperative Hb levels without influencing drug safety in TKA patients.

Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial

PURPOSE

A consistent limb position strategy could be an attractive and easier alternative to reduce blood loss and increase range of motion following total knee arthroplasty. The aim of this study was to understand the proper amount of flexion required to improve functional outcomes with limited patients' discomfort.

METHODS

Eighty-five patients undergoing total knee arthroplasty were randomly assigned to receive mild (30° of knee flexion) or high-flexion protocol (70° of knee flexion), 48 h after surgery. The same daily rehabilitation scheme was followed. Total blood loss, hidden blood loss, haemoglobin and haematocrit levels, fixed flexion deformity, range of motion and limb circumference at the superior patellar pole were evaluated preoperatively and 7 days after surgery.

RESULTS

Demographics, blood parameters and preoperative range of motion did not show any significant difference between the two groups. No complications were recorded in both groups. High-flexion group had greater rate of dropout due to excessive patients' discomfort. A significantly lower Hb at day 1 was found in the high-flexion group. No differences were recorded regarding the remaining parameters.

CONCLUSION

No significant differences were found between the high-flexion and mild-flexion protocols; however, mild-flexion protocol was better tolerated by patients. We therefore recommend a 30° flexion protocol to be routinely used 48 h postoperatively after total knee arthroplasty. This is an easy strategy to improve functional outcomes, which is a fundamental issue considering the steady increase in knee prostheses utilization.

LEVEL OF EVIDENCE

Randomized controlled trial, Level II.

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.

Use of tranexamic acid in total knee arthroplasty

PURPOSE

different strategies have been developed to reduce blood loss in total knee arthroplasty (TKA). The efficacy of both systemic and local tranexamic acid (TXA) administration is demonstrated in the literature. The aim of the present study was to compare the efficacy of systemic, local and combined (systemic + local) administration of TXA in reducing blood loss after TKA.

METHODS

we enrolled all patients submitted to a primary TKA in our department between November 2014 and August 2015. They were divided into three groups corresponding to the method of TXA administration used: intravenous (IV), intra-articular (IA), and a combination of the two. Demographic data, as well as preoperative hemoglobin and platelet levels, were collected. The primary outcome was the maximum hemoglobin loss, while the secondary outcomes were the amount of blood in the drain (cc/hour) and the rate of transfusions; postoperative pain was also assessed. Student's t-test or a χ² test was used to evaluate between-group differences, using p<0.05 as the cut-off for statistically significant differences.

RESULTS

the sample comprised 34 patients: IV, 10 cases; IA, 15 cases, and combined (IV + IA), 9 cases. The average age of the patients was 71.1±6.4 years. No significant differences in the outcome measures were found between the groups, with the exception of a significantly lower maximum hemoglobin loss in the combined versus the IV group (p=0.02). There were no differences between the groups in the amount of blood in the drain or the rate of transfusions.

CONCLUSIONS

the data from this preliminary study, as well as data from the literature, confirm that TXA administration is safe and effective in reducing total blood loss in TKA, and no administration protocol seems to be superior to the others.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

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.

Combined intravenous and topical tranexamic acid versus intravenous use alone in primary total knee and hip arthroplasty: A meta-analysis of randomized controlled trials

OBJECTIVE

The tranexamic acid (TXA) can reduce surgical perioperative blood loss. However, the optimal regimen of tranexamic acid remains controversial. The purpose of this meta-analysis was to compare the efficacy and safety of combined intravenous and topical tranexamic acid versus intravenous use alone in primary total knee and hip arthroplasty.

METHODS

PubMed, EMbase, Cochrane library and OVID were searched. Eligible randomized controlled trials (RCTs) evaluating combined intravenous and topical TXA versus intravenous alone in primary total knee and hip arthroplasty were included. The relative risk (RR) or the mean difference (MD) for dichotomous or continuous data was calculated respectively, and heterogeneity was analyzed by chi-square and I² tests.

RESULTS

A total of five RCTs met the inclusion criteria were included. The meta-analysis indicated that there was statistically significant difference favoring the combined group in total blood loss(MD = -160.90, 95% CI[-201.26, -120.54]), P < 0.00001), hemoglobin drop (MD = -0.41, 95% CI[-0.73,0.08], P = 0.01), transfusion requirements(RR = 0.29, 95% CI[0.12,0.70], P = 0.006) and length of hospital stays (MD = -0.21, 95%CI[-0.40, -0.02], P = 0.03). Both groups showed similar outcomes regarding thromboembolic complications(RR = 0.84, 95% CI[0.26,2.70], P = 0.76).

CONCLUSIONS

Based on our study, Combined use of intravenous and topical TXA is more effective than intravenous TXA alone in primary total knee or hip arthroplasty without increasing the risk of thromboembolic complications. Further high quality studies with more patients are needed in future studies.

Effectiveness and Safety of Fixed-Dose Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Double-Blind Controlled Trial

BACKGROUND

Simultaneous bilateral total knee arthroplasty (TKA) can lead to greater blood loss and higher risk of venous thromboembolism. The effectiveness and safety of tranexamic acid (TXA) in simultaneous bilateral TKAs have not been clearly defined. We presumed that a fixed dose of TXA may be a preferable alternative for ease of administration in patients undergoing simultaneous bilateral TKAs.

METHODS

We prospectively randomized 120 primary simultaneous bilateral TKAs to a fixed dose of TXA or equivalent volume of normal saline intravenously. The primary outcome measure was total blood loss. The secondary outcome measures were blood transfusion rate, transfusion units, intraoperative blood loss, drainage volumes, hidden blood loss, maximum decline of hemoglobin, and postoperative suprapatellar girth increment.

RESULTS

There were statistically significant lower total blood loss, blood transfusion rate, drainage volumes, transfusion units, and maximum decline of hemoglobin in the TXA group than in the control group (P < .05), without increasing incidence of asymptomatic and symptomatic venous thromboembolism. However, TXA did not significantly reduce the hidden blood loss (P = .123). No differences were observed in suprapatellar girth increments between both groups on postoperative day 5 and week 6 (P = .251 and .299).

CONCLUSION

Fixed dose of TXA for patients undergoing simultaneous bilateral TKAs was effective and safe in reducing total blood loss and allogeneic blood transfusion needs without any additional thromboembolic risk. However, TXA administered intravenously did not significantly reduce the hidden blood loss.

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).

Tranexamic Acid in a Multimodal Blood Loss Prevention Protocol to Decrease Blood Loss in Revision Total Knee Arthroplasty: A Cohort Study. Open Orthop J 2016;10:439-447. [PMID: 27708740 PMCID: PMC5039954 DOI: 10.2174/1874325001610010439]

PURPOSE

To clarify if blood loss and transfusion requirements can be decreased in revision knee surgery through a multimodal blood loss approach with tranexamic acid (TXA).

PATIENTS AND METHODS

A retrospective study was designed in 87 knees (79 patients) that received a knee revision between 2007 and 2013. To avoid heterogeneity in the surgical technique, only revisions with one single implant system were included. A treatment series of 44 knees that received TXA and other techniques in a multimodal blood loss protocol was compared to a control series of 43 knees that received neither TXA nor the rest of the multimodal blood loss protocol. No differences in the complexity of surgeries or case severity were detected.

RESULTS

A significant decrease was observed from 58% transfusion rate in the control group to 5% in the treated group. The postoperative haemoglobin drop was also significantly different. Although the use of a blood loss prevention approach including TXA was the most relevant factor in the transfusion risk (OR=15), longer surgical time also associated an increased risk of transfusion (OR=1.15).

CONCLUSION

This study supports the use of a two-dose intravenous TXA under a multimodal blood loss prevention approach in revision knee replacement with significant reduction in the transfusion rate, postoperative blood loss and haemoglobin drop.

The combined effect of administration of intravenous and topical tranexamic acid on blood loss and transfusion rate in total knee arthroplasty: Combined tranexamic acid for TKA

OBJECTIVES

Tranexamic acid (TXA) is an antifibrinolytic agent used as a blood-sparing technique in total knee arthroplasty (TKA), and is routinely administered by intravenous (IV) or intra-articular (IA) injection. Recently, a novel method of TXA administration, the combined IV and IA application of TXA, has been applied in TKA. However, the scientific evidence of combined administration of TXA in TKA is still meagre. This meta-analysis aimed to investigate the efficacy and safety of combined IV and IA TXA in patients undergoing TKA.

MATERIALS AND METHODS

A systematic search was carried out in PubMed, the Cochrane Clinical Trial Register (Issue12 2015), Embase, Web of Science and the Chinese Biomedical Database. Only randomised controlled trials (RCT) evaluating the efficacy and safety of combined use TXA in TKA were identified. Two authors independently identified the eligible studies, extracted data and assessed the methodological quality of included studies. Meta-analysis was conducted using Review Manager 5.3 software.

RESULTS

A total of ten RCTs (1143 patients) were included in this study. All the included studies were randomised and the quality of included studies still needed improvement. The results indicated that, compared with either placebo or the single-dose TXA (IV or IA) group, the combination of IV and IA TXA group had significantly less total blood loss, hidden blood loss, total drain output, a lower transfusion rate and a lower drop in haemoglobin level. There were no statistically significant differences in complications such as wound infection and deep vein thrombosis between the combination group and the placebo or single-dose TXA group.

CONCLUSIONS

Compared with placebo or the single-dose TXA, the combined use of IV and IA TXA provided significantly better results with respect to all outcomes related to post-operative blood loss without increasing the risk of thromboembolic complications in TKA.Cite this article: Z. F. Yuan, H. Yin, W. P. Ma, D. L. Xing. The combined effect of administration of intravenous and topical tranexamic acid on blood loss and transfusion rate in total knee arthroplasty: combined tranexamic acid for TKA. Bone Joint Res 2016;5:353-361. DOI: 10.1302/2046-3758.58.BJR-2016-0001.R2.

A randomized comparative study of topical versus intravenous tranexamic acid administration in enhanced recovery after surgery (ERAS) total knee replacement

BACKGROUND

The aim of this study was to compare the topical to IV tranexamic acid (TXA) administration of the same dose, given at the same time in patients who underwent TKR using an enhanced recovery after surgery (ERAS) regime.

METHODS

Ninety patients were randomized in control group, and IV and topical application groups received 1 g TXA.

RESULTS

Blood loss and transfusion requirements in control group were statistically higher compared to both TXA groups (p < 0.05). Length of stay was the same in all groups.

CONCLUSIONS

TXA reduced significantly the blood loss and the need for transfusion in ERAS primary unilateral TKR.