Effects of topical tranexamic acid during open reduction and internal fixation of acetabular fractures: A retrospective study

Intravenous Injection of Tranexamic Acid in Patients with Pelvic Fractures: A Prospective Randomized Trial

Purpose

The purpose of the study is to examine the efficacy of intravenous injections of tranexamic acid (TXA) in reducing perioperative blood loss in patients scheduled for open reduction and internal fixation for pelvic fractures (Tile B and C). A study population with greater homogeneity was selected to minimize confounding variables related to fracture and fixation methods that may reflect an accurate result.

Materials and Methods

A prospective randomized controlled trial including 100 patients who received either 15 mg/kg of TXA added to 40 mL saline twice separated by 3 hours interval or a similar volume of normal saline (~50 mL twice in same manner) intravenously. Measurement of hemoglobin was performed preoperatively and postoperatively. Blood loss in drain, blood units transfused, and complications were recorded.

Results

The mean decrease in hematocrit levels (preoperatively and postoperatively) was 3.2% in the trial group versus 3.7% in the control group (P>0.05). Mean total blood loss was 1,106 and 1,340 mL (trial vs. control group [P<0.05]). The mean operative time was 122.5 and 130.3 minutes (trial vs. control group [P>0.05]). Mean collected blood from the drain was 155 and 170 mL (trial vs. control group [P>0.05]). The transfusion rate was 28% and 76% while the mean for transfused units was 0.72 and 1.1 units (trial vs. control group [P<0.05]). There were no venous thromboembolic events.

Conclusion

Intravenous injection of TXA in pelvic fractures was effective in reducing blood loss and the rates of blood transfusion. There were no associated thromboembolic complications.

Increased risk of adverse events following the treatment of associated versus elementary acetabular fractures: a matched analysis of short-term complications

PURPOSE

This retrospective cohort study aims to compare short-term complication rates between patients receiving open reduction and internal fixation (ORIF) for associated versus elementary acetabular fractures, with a secondary objective of identifying independent risk factors for adverse outcomes.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) codes to identify patients that underwent ORIF for associated acetabular (CPT 27228) or elementary acetabular fractures (CPT 27226, 27227) from 2010 to 2021. Propensity score matching was employed to account for baseline differences and the short-term complication rates were compared between the cohorts.

RESULTS

We identified 1,330 patients who underwent ORIF for an acetabular fracture between 2010 and 2021, including 868 patients with elementary fractures and 462 with associated fractures. After matching, there were 462 patients in each cohort. The matched associated acetabular fracture group experienced higher rates of any adverse event (AAE, p = 0.029), transfusion (p = 0.010), and reoperation (p = 0.049). Increased age, increased operative time, higher body mass index (BMI), and prolonged hospital length of stay (LOS) augmented the risk of any complication.

CONCLUSION

The findings of this study identify areas of greater risk of postoperative complications after ORIF in individuals with associated versus elementary acetabular fractures. Discussion of these heightened risks is critical to appropriate patient care. Understanding these risks plays an important role in the clinical decision-making process and may identify areas to monitor patients postoperatively.

A prophylactic TXA administration effectively reduces the risk of intraoperative bleeding during open management of pelvic and acetabular fractures

This study aimed to evaluate the efficacy of perioperative intravenous TXA in reducing blood loss in pelvic and acetabular fracture patients managed surgically. The study included 306 consecutive patients, divided as: group I, 157 patients who did not receive perioperative infusion of TXA and group II, 149 patients who received perioperative TXA. The perioperative blood test results and complication rates were compared between the two groups. The average perioperative hematocrit was higher during the preoperative period than during the first, second and third postoperative day in both groups. In the estimated blood loss between the two groups, there was a significant difference of 1391 (± 167.49) ml in group I and 725 (± 403.31) ml in group II respectively (p = 0.02). No significant difference was seen in the total of intraoperative transfusion units as well as in the total units of blood transfused. There was a reduced level of postoperative hemoglobin (9.28 ± 17.88 g/dl in group I and 10.06 ± 27.57 g/dl in group II compared to the values obtained in preoperative investigations (10.4 ± 2.37 g/dl in group I and 11.4 ± 2.08 g/dl in group II); with a significant difference in postoperative transfusion rates (p = 0.03). Therefore, the use of TXA effectively reduces the risk of intraoperative bleeding during open management of pelvic and acetabular fractures.

Tranexamic Acid: When is It Indicated in Orthopaedic Surgery?

Tranexamic acid (TXA) has been studied extensively during the last 5-8 years. It inhibits clot dissolution during surgery and can therefore reduce blood loss. However, there has been concern that this could result in more frequent complications, specifically in terms of thromboembolic events. The indications for TXA are widespread, and this review covers the literature on orthopaedic indications such as joint replacement, fracture surgery, and arthroscopic procedures. In general, TXA is safe and can be used in a wide variety of orthopaedic procedures, lowering blood loss without increasing the risk of complications.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

INTRODUCTION

Open reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial.

MATERIAL AND METHODS

Sixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated.

RESULTS

Both groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups.

CONCLUSION

There is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.

The effect of tranexamic acid in open reduction and internal fixation of pelvic and acetabular fracture: A systematic review and meta-analysis

BACKGROUND

Pelvic bone fractures may cause extensive bleeding; however, the efficacy of tranexamic acid (TXA) usage in pelvic fracture surgery remains unclear. In this systematic review and meta-analysis, we aimed to evaluate the efficacy of TXA in open reduction and internal fixation surgery for pelvic and acetabular fracture.

METHODS

MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 22, 2020, that investigated the effect of TXA in the treatment of pelvic and acetabular fracture with open reduction and internal fixation. A pooled analysis was used to identify the differences between a TXA usage group and a control group in terms of estimated blood loss (EBL), transfusion rates, and postoperative complications.

RESULTS

We included 6 studies involving 764 patients, comprising 293 patients who received TXA (TXA group) and 471 patients who did not (control group). The pooled analysis showed no differences in EBL between the groups (mean difference -64.67, 95% confidence interval [CI] -185.27 to -55.93, P = .29). The study period transfusion rate showed no significant difference between the groups (odds ratio [OR] 0.77, 95% CI 0.19-3.14, P = .71, I2 = 82%), nor in venous thromboembolism incidence (OR 1.53, 95% CI 0.44-5.25, P = .50, I2 = 0%) or postoperative infection rates (OR 1.15, 95% CI 0.13-9.98, P = .90, I2 = 48%).

CONCLUSIONS

Despite several studies having recommended TXA administration in orthopedic surgery, our study did not find TXA usage to be more effective than not using TXA in pelvic and acetabular fracture surgery, especially in terms of EBL reduction, transfusion rates, and the risk of postoperative complications.

The effect of antifibrinolytic agents in periacetabular osteotomy: A systematic review and meta-analysis

BACKGROUND

Periacetabular osteotomy (PAO) is a major hip preservation surgery for developmental dysplasia of the hip. It is inevitably associated with significant blood loss, so it requires frequent transfusions and could be a cause of perioperative morbidity. However, to date, a large number of studies has not evaluated the effect of antifibrinolytic agents in PAO. Therefore we performed a systematic review and meta-analysis to assess if antifibrinolytics would be effective in reducing blood loss and transfusion rate after PAO surgery.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 4, 2020, that investigated the effect of antifibrinolytic agents in PAO. A pooled analysis was designed to identify differences between antifibrinolytic and control groups focusing on blood loss, transfusion, operation time, postoperative venous thromboembolism (VTE), and length of hospital stay.

RESULTS

We included five studies involving 507 patients (antifibrinolytic group: 256; control group: 251). The pooled analysis showed that the control group had a greater total estimated blood loss (EBL) than the antifibrinolytic group (mean difference [MD]=-257.60mL, 95% confidence interval [CI] -389.68 to -125.53, p=0.0001), but there were no statistical differences in intraoperative EBL (MD=-46.46mL, 95% CI: -192.57 to 99.64, p=0.53). The allogenic transfusion rate was higher in the control group than in the antifibrinolytic group (odds ratio [OR] 0.21, 95% CI: 0.10-0.43, p<0.0001), but there was no difference in the autogenic transfusion rate (OR 0.35, 95% CI: 0.09-1.43, p=0.14). The pooled result showed no difference in operation time (MD=9.13min, 95% CI: -8.54 to 26.80, p=0.31). For the VTE rate, a pooled analysis was not conducted due to the lack of data. The length of hospital stay showed no differences (MD=-0.51 days, 95% CI: -1.17 to 0.16, p=0.13).

CONCLUSIONS

Antifibrinolytic use in PAO has positive effects in terms of reduced total EBL and allogenic transfusion rate.

LEVEL OF EVIDENCE

III; meta-analysis.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Is intravenous tranexamic acid effective in reduction of blood loss during pelvic and acetabular surgery?

PURPOSE

Pelvic and acetabular surgery is associated with one of the highest amounts of blood loss. Tranexamic acid is a good choice to reduce blood loss during this type of surgery. However, being antifibrinolytic drug, the chance to have coagulation complications including DVT is a risk that should be considered particularly in such major trauma patients with the body's response to trauma and with possible prolonged bed stay. The aim of this study is to evaluate the effectiveness of intravenous tranexamic acid injection during pelvic and acetabular surgery for reduction of blood loss during surgery and after surgery and to evaluate any possible complications for its use.

METHODS

This prospective randomized clinical trial includes 97 patients divided between two groups; group 1 (G1) which received TXA, while the second group (G2) is the control group. The primary outcome measures were total blood loss (TBL), allogenic blood units transfused, and the blood lost intra-operatively (IBL). The TBL was calculated by the haemoglobin balance method while the intra-operative blood loss was measured by the gravimetric method. Any complications related to the drug were evaluated particularly DVT.

RESULTS

The study showed significantly less TBL (G1 = 829.7 ± 219.2, G2 = 1036.9 ± 314.9) and blood transfusion (G1 = 52.4 ± 40 g, G2 = 89.4 ± 60.6 g) in G1 compared to the G2.

CONCLUSION

This study proved the possible reduction of TBL and the need of blood transfusion by the use of TXA in pelvic and acetabular injuries.

Tranexamic acid use in pelvic and/or acetabular fracture surgery: A systematic review and meta-analysis

Purpose

The purpose of this study is to determine whether tranexamic acid (TXA) use was associated with lower rates of blood transfusion in patients undergoing pelvic and/or acetabular fracture surgery.

Methods

Four studies were included, 3 of which were included in the pooled data analysis for a total of 308 patients.

Results

The transfusion rate was significantly lower in the TXA group (44%) compared with the non-TXA group (57%) (P = 0.02).

Conclusion

TXA use was associated with a significantly lower transfusion rate in patients who underwent pelvic and/or acetabular fracture surgery.

Level of evidence

Level 3. Systematic review of retrospective cohort studies and prospective randomized controlled trials.

Efficacy and Safety of Tranexamic Acid in Resection and Endoprosthetic Reconstruction of Distal Femoral Osteosarcomas in Children: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the effect of intravenous tranexamic acid (TXA) on blood loss and transfusion rates in children who underwent resection and endoprosthetic reconstruction of distal femoral osteosarcomas.

METHODS

The medical records of 56 patients who underwent resection and endoprosthetic reconstruction for distal femoral osteosarcomas between 2017 and 2019 were retrospectively reviewed. Patients were divided into 2 groups: group 1 consisted of 25 patients (11 male and 14 female, mean age 15.2±3 y) who received preoperative 15 mg/kg intravenous TXA, and group 2 consisted of 31 control patients (18 male and 13 female, mean age 14.3±2.6 y) who did not receive TXA. The groups were compared based on their total blood loss, intraoperative blood loss, hidden blood loss, postoperative drain output, transfusion requirements, preoperative and postoperative hemoglobin (Hb) and hematocrit (Htc) difference, length of hospital stays, operative time, and complications.

RESULTS

The mean total blood loss was lower in intravenous TXA group (1247.5±300.9 mL) when compared with control group (1715.7±857.0 mL) (P=0.018). The mean intraoperative blood loss in intravenous TXA group (386±109 mL) was lower than that in control group (977.4±610.7 mL) (P<0.001). Postoperative drain output at 24 and 48 hours was 198.0±61.8 and 72.4±27.4 mL in intravenous TXA group, respectively, and was low compared with 268.4±118.2 and 117.1±67.8 mL in control group (P=0.028 and 0.006). The rate of patients requiring transfusion was significantly lower in intravenous TXA group (56%) than in control group (83.9%). Preoperative and postoperative 6, 24, and 72 hours Hb and Htc differences were significantly lower in intravenous TXA group [(-1.7±1.8 g/dL P<0.001; -2.0±1.5 g/dL P<0.001; -2.3±1.7 g/dL P<0.001, for Hb) (-5.7±4.6, P<0.001; -6.9±4.0, P<0.001; -9.6±9.1, P<0.001, for Htc)]. Intravenous TXA group had shorter hospital stay time in comparison to control group (P<0.001). The operative time was significantly longer in the control group (P<0.05). No increase in pulmonary embolism or venous thromboembolism rate was observed with intravenous TXA use.

CONCLUSION

We conclude that administration of intravenous TXA reduces intraoperative and postoperative blood loss, transfusion rates, and hospital stay in resection and endoprosthetic reconstruction of the distal femoral osteosarcomas in children.

TYPE OF STUDY

This was a retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Effect and safety of topical application of tranexamic acid to reduce perioperative blood loss in elderly patients with intertrochanteric fracture undergoing PFNA

The specific method and dose of tranexamic acid (TXA) topically applied for intertrochanteric fractures have not been well established. The aim of this study is to investigate the efficacy and safety of TXA topically administered via our protocol for perioperative bleeding management in elderly patients with intertrochanteric fractures who underwent proximal femoral nail anti-rotation (PFNA).A retrospective comparative analysis was performed. The TXA group was composed of 82 patients with topical use of TXA, and the control group was composed of 82 patients without TXA use during the PFNA procedure. Intraoperative, total and hidden amounts of blood loss, drainage volumes, postoperative blood transfusion volumes and complications were compared between the 2 groups.The intraoperative, total and hidden amounts of blood loss and the drainage volumes were significantly lower in the TXA group than in the control group (P = .012, P < .01, P < .01, P = .014, respectively). The volume and rate of blood transfusion in the TXA group were significantly lower than those in the control group (P < .01). There were no significant differences in complications between the 2 groups (P > .05).Topical application of TXA offers an effective and safe option for reducing perioperative blood loss and transfusion in elderly patients with intertrochanteric fractures undergoing PFNA.

The Efficacy and Safety of Tranexamic Acid Treatment in Orthopaedic Trauma Surgery

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Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin.

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TXA is a cost-effective treatment for trauma patients across a variety of economic settings.

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Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence.

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TXA has been shown to reduce blood loss in hip fracture surgery.

Efficacy of repeated intravenous tranexamic acid in reducing perioperative bleeding of acetabular fractures

BACKGROUND

Application of tranexamic acid (TXA) in the treatment of acetabular fractures could reduce intraoperative and postoperative blood loss.

OBJECTIVE

To investigate the effect of single and repeated intravenous infusion of TXA on blood loss of acetabular fractures.

METHODS

120 patients with acetabular fractures admitted to our hospital from January 2017 to September 2020 were retrospectively divided into three groups: Patients accepted 1g TXA at preoperative 30 minutes were defined as single TXA group (n = 40); Patients accepted 1g TXA at preoperative 30 minutes and 1g TXA at 3 hours after the start of surgery were defined as repeated TXA group (n = 40); Patients accepted normal saline at preoperative 30 minutes were defined as control group (n = 40).

RESULTS

The total blood loss in single TXA group and repeated TXA group were significantly lower than control group, and the total blood loss in the repeated TXA group was significantly lower than single TXA group (P <  0.05). The hidden blood loss from surgery to postoperative 1 day in repeated TXA group was significantly lower than single TXA group and the control group(P <  0.05). No significant differences were observed in the operative time, postoperative transfusion rate and thrombosis rate among the three groups (P >  0.05).

CONCLUSION

Repeated TXA is more recommended during acetabular fracture surgery since it can reduce the total blood loss without increasing the operative time, postoperative transfusion rate and thrombosis rate compared with single TXA.

The efficiency and safety of intravenous tranexamic acid administration in open reduction and internal fixation of pelvic and acetabular fractures

PURPOSE

This study aimed to investigate the efficiency and safety of tranexamic acid use in open reduction and internal fixation of pelvis and acetabulum fractures.

MATERIALS AND METHODS

73 consecutive patients were included. 1000 mg TXA was administered intravenously to all patients before surgery. The patients were evaluated on the basis of preoperative, postoperative first and third day hemoglobin-hematocrit values, amount of drainage collected, total blood loss, transfusion rates and complications.

RESULTS

Mean operative time was 120.1 min. Average decrease in hematocrit levels between preoperative and postoperative first day was 2.1 g/dL. Average collected blood from the drain was 177 mL. Mean total blood loss was 1137 mL. Transfusion rate of the patients was 21%. Mean transfused units was 0.9 units. Three patients died within 3 weeks after the operation due to myocardial infarction, acute kidney failure and pneumonia. There were no cases of symptomatic venous or pulmonary thromboembolism during the 90 days of follow-up.

CONCLUSION

Use of TXA in pelvic and acetabular fractures was found to be effective in reducing total blood loss, hemoglobin drop and transfusion rates without increasing venous and pulmonary thromboembolism in our series.

As an unusual traumatic presentation, acetabular fracture and concomitant ipsilateral intertrochanteric femur fracture: a retrospective case series of 18 patients

BACKGROUND

Acetabular fracture and concomitant ipsilateral intertrochanteric femur fracture has been suggested as an unusual traumatic presentation and rarely reported in the literature. The aims of this study were (1) to identify the etiological characteristics, (2) to summarize the treatment strategy, and (3) to present the mid- to long-term results of patients with this rare traumatic presentation.

METHODS

In this retrospective study, 18 patients (15 males, 3 females; mean age = 42.77 ± 17.74 years, range = 16 to 87 years) who were diagnosed and treated for simultaneous acetabular fracture and ipsilateral intertrochanteric fracture were included. Injury mechanisms, fracture classifications, and treatment strategies were noted. To assess functional status, the Harris score was used. To evaluate pain intensity, visual analogous scale (VAS) was used. The reduction quality of acetabular fractures was examined as per Matta's standard. Postoperative complications were also recorded.

RESULTS

The mean follow-up was 10.04 ± 3.38 (range = 6.2 to 16 years). The most common injury mechanism was traffic accident, followed by falling from a tall height. As per the Evans classification, intertrochanteric fractures were defined as type 3 in 13 patients, type 2 in one patient, and type 4 in 4 patients. In acetabular fracture site, the most common fractures were posterior wall fractures, followed by anterior column fractures. All patients received internal fixation for their intertrochanteric fractures. Ten out of 18 patients also received internal fixation for their acetabular fracture. However, for the remaining patients, acetabular fractures were treated conservatively or with fracture fragment resection. Bony healing was achieved in all but one patient who died postoperatively. Twelve patients achieved excellent and good results (Harris score ≥ 80 points) whereas five patients achieved fair and poor results (Harris score < 80 points). The proportion of patients who achieved an excellent-good Harris score was 70.6%. Dislocation of the hip was found to be an independent risk factor (HR = 9.194, 95% CI = 1.024-82.515) for the poor patient outcome.

CONCLUSION

To sum up, high-impact trauma is the main cause of acetabular fracture and concomitant ipsilateral intertrochanteric femur fracture. For patients who have undergone surgical treatment, fracture healing is usually achieved. However, the occurrence of complications, especially avascular necrosis, is the major cause of a poor prognosis. Dislocation of the hip joint at the time of injury is considered to be an important risk factor for a poor prognosis.

Intravenous tranexamic acid for reducing perioperative blood loss during revision hip arthroplasty: A retrospective study

OBJECTIVE

This study aimed to explore the efficacy and safety of intravenous tranexamic acid (TXA) for reducing perioperative blood loss and allogeneic blood transfusions in revision hip arthroplasty.

METHODS

TXA was routinely administered as an intravenous preoperative dose in all the revision hip arthroplasty cases in our institution from December 2012. We retrospectively reviewed 803 patients who underwent revision hip arthroplasty from January 2008 to September 2018. These patients were divided into 2 groups based on whether they received intravenous TXA (n=482; 231 men and 251 women; mean age: 63.27±11.73 years) or not (n=321; 159 men and 162 women; mean age: 63.91±11.69 years). The 2 groups were compared in terms of estimated intraoperative blood loss, visible blood loss, hidden blood loss, the rate and volume of allogeneic blood transfusions, and the incidence of symptomatic venous thromboembolism. The patients were also compared depending on whether they underwent total hip revision, isolated acetabular revision, or isolated femoral revision.

RESULTS

Regardless of the type of revision involved, the patients who received TXA showed significantly lower estimated intraoperative blood loss, visible blood loss, hidden blood loss, and allogeneic blood transfusion rate and volume (all p values were less than 0.001). Use of TXA was not associated with significant changes in the incidence of postoperative symptomatic venous thromboembolism (p=0.911). Similar results were obtained with subgroups of patients who underwent different types of revision surgeries, except hidden blood loss (p=0.994) of patients in the isolated femoral revision subgroup.

CONCLUSION

The administration of intravenous TXA can safely and effectively reduce the perioperative blood loss and allogeneic blood transfusions in revision hip arthroplasty.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

A retrospective comparison of the conventional versus three-dimensional printed model-assisted surgery in the treatment of acetabular fractures

OBJECTIVE

The aim of this study was to compare the clinical and radiological outcomes of the conventional versus individualized three-dimensional (3D) printing model-assisted pre-contoured plate fixation in the treatment of patients with acetabular fractures.

METHODS

The data from 18 consecutive patients who underwent surgery for the acetabular fractures were retrospectively analyzed. The patients were divided into two groups (9 in each): conventional and 3D printed model-assisted. The groups were then compared in terms of the duration of surgery, time of instrumentation, time of intraoperative fluoroscopy, and volume of blood loss. The quality of the fracture reduction was also evaluated postoperatively by radiography and computed tomography in both the groups. The quality of the fracture reduction was defined as good (<2 mm) or fair (>2 mm) based on the amount of displacement in the acetabulum.

RESULTS

The conventional group included 9 patients (9 males; mean age=41.7 years; age range=16-70) with a mean follow-up of 11.9 months (range=8-15); the 3D printed model-assisted group consisted of 9 patients (9 males; mean age=46.2 years; age range=30-66) with a mean follow-up of 10.33 months (range=7-17). The average duration of surgery, mean time of instrumentation, time of intraoperative fluoroscopy, and mean volume of blood loss were 180.5±9 minutes, 36.2±3.6 minutes, 6±1 times, and 403.3±52.7 mL in the 3D printed model-assisted group, and 220±15.6 minutes, 57.4±10.65 minutes, 10.4±2.2 times, and 606.6±52.7 mL in the conventional group, respectively. Procedurally, the average duration of surgery, mean time of instrumentation, and mean time of fluoroscopy were significantly shorter, and the mean volume of blood loss was significantly lower in the 3D printed model-assisted group (p<0.05). The quality of the fracture reduction was good in 7 patients (78%) in the conventional group and 8 patients (89%) in the 3D printed model-assisted group.

CONCLUSION

As compared with the conventional surgery, the 3D printing model-assisted pre-contoured plate fixation technique can improve the clinical and radiological outcomes of the acetabular fractures, with shorter surgery, instrumentation, intraoperative fluoroscopy times, and blood loss.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Safety and efficacy of tranexamic acid with epinephrine for prevention of blood loss following surgery for trochanteric femoral fractures

OBJECTIVE

This study aimed to determine whether the local administration of tranexamic acid (TXA) combined with diluted epinephrine (DEP) reduces blood loss and the need for transfusions compared with the administration of TXA alone following surgery for trochanteric femoral fractures.

METHODS

Hundred patients were enrolled in this study. In the target group (TXA/DEP group: n=50; 19 men and 31 women, mean age 72.5±11.1 years), the surgical sites were injected with 35 mL normal saline mixed with 3 g of TXA with 0.2 mg of DEP at a 1:200,000 dilution (TXA/DEP) immediately after musculoaponeurotic closure. In the control group (TXA group: n=50; 22 men and 28 women; mean age: 70.5±12.2 years), the surgical site was injected with 35 mL normal saline containing 3 g of TXA alone. The main outcome measures were postoperative hemoglobin (Hb) levels, hematocrit, drainage volume, and total blood loss (TBL); the secondary measures included transfusion requirements and perioperative complications.

RESULTS

The mean Hb levels among patients in theTXA/DEP group were significantly lower than among those in the TXA group, measured on postoperative day 1 at 101.0±14.1 g/L vs. 106.9±10.5 g/L and day 3 as 104.2±8.2 g/L vs. 108.5±9.1 g/L, respectively (p<0.05). Drainage volume from the surgical site and TBL measured on postoperative day 2 were also significantly reduced in the TXA/DEP group vs. the TXA group, measured at 71.4±26.0 mL vs. 82.5±24.6 mL and 343.6±148.0 mL vs. 419.6±165.4 mL, respectively (p<0.05). Furthermore, 11 patients (22%) from the TXA group and 15 (30%) from the TXA/DEP group received blood transfusions; the mean number of transfusion events (1.2±0.4 vs. 1.9±0.7) and the amount of blood transfused (1.7±0.5 Units vs. 2.9±1.0 Units) was also markedly reduced in the TXA/DEP group (p<0.05). Two cases in the TXA/DEP group and three in the TXA group were diagnosed with deep vein thrombosis, a difference that did not reach statistical significance (p>0.05).

CONCLUSION

Local administration of TXA with DEP reduced blood loss and limited the need for blood transfusions after surgery for trochanteric femoral fracture without increasing the risk of perioperative complications. Our study indicates that the local administration of TXA/DEP is safe and more effective than the administration of TXA alone in treating trochanteric femoral fractures.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

The effect of topical and systemic tranexamic acid on fracture healing in rats

OBJECTIVE

The aim of the present study was to determine the effect of topical and systemic tranexamic acid (TXA) on fracture healing in a rat surgical model.

METHODS

We created standard, right-sided, open, diaphyseal femoral fractures with intramedullary Kirschner wire fixation in 48 male rats and divided them into three groups: a topical TXA (10 mg/kg) group, a systemic TXA (10 mg/kg) group, and a control group. Fracture healing was evaluated radiographically and histologically after early (week 2) and late (week 4) postoperative sacrifice.

RESULTS

The radiological scores differed significantly among the all groups (p=0.001), as did the week 2 and 4 scores (p=0.003 and p=0.010, respectively). Radiologically, the topical TXA group exhibited better bone healing at both 2 (p=0.001) and 4 (p=0.007) weeks than the control group, and the systemic group showed better healing at both 2 (p=0.027) and 4 (p=0.023) weeks than the control TXA group. Moreover, bone healing was better in the group treated with topical rather than systemic TXA on radiological examinations performed at 2 (p=0.001) and 4 (p=0.007) weeks postoperatively (p=0.001 and p=0.007, respectively). Histologically, the groups differed significantly (p=0.001). The histological scores differed significantly among the all groups (p=0.001). At 2 weeks, the topical TXA group exhibited significantly better bone healing than the control group (p=0.001).

CONCLUSION

Our results suggested that topical application of TXA in fracture patients may accelerate healing, whereas systemic administration may adversely affect healing.

Postoperative outcomes of tranexamic acid use in geriatric trauma patients treated with proximal femoral intramedullary nails: A systematic review and meta-analysis

BACKGROUND

Recently, there has been a series of clinical studies focusing on the perioperative administration of tranexamic acid (TXA) in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery. However, the safety and efficacy of TXA in these patients remains controversial. Therefore, we performed a systematic review to focus on two questions: (1) would TXA reduce perioperative blood loss in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? and (2) would TXA increase the rate of perioperative complications in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery?

PATIENTS AND METHODS

We systematically searched electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) up to April 20, 2019. The perioperative blood loss and complication data were extracted and analysed by RevMan Manager 5.3.

RESULTS

Finally, five randomized controlled studies, involving 539 geriatric intertrochanteric fracture patients undergoing proximal femoral intramedullary nail surgery, were enrolled in this systematic review. Compared with the control group, the TXA group had significantly lower total perioperative blood loss (WMD=-172.84; 95% CI, -241.44 to -104.24; I²=0%), intraoperative blood loss (WMD=-34.20; 95% CI, -46.04 to -22.36; I²=0%), total perioperative hidden blood loss (WMD=-139.05; 95% CI, -213.67 to -64.43; I²=0%), perioperative transfusion rates (RR =-0.16; 95% CI, -0.24 to -0.08; I²=22%), length of hospital stay (WMD=-1.18; 95% CI, -1.91 to -0.46; p=0.001; I2=12%), and postoperative wound haematoma rates (RD=-0.05; 95% CI, -0.09 to 0.00; p=0.03; I²=0%). In addition, there were no significant differences between TXA and control groups in the terms of surgical time, postoperative mortality, total thromboembolic events, wound infections, cerebrovascular accidents, respiratory infections, and renal failure.

DISCUSSION

TXA in geriatric trauma patients undergoing intramedullary nail surgery is effective for perioperative haemostasis without increasing the incidence of postoperative complications.

LEVEL OF EVIDENCE

II, Systematic review and Meta-analysis.