Tranexamic Acid Reduces Blood Transfusions in Revision Total Hip Arthroplasty

Drainage in primary and revision hip and knee arthroplasty

Drainage after total hip or knee arthroplasty (THA, TKA) used to be systematic to prevent complications and notably hematoma and infection. However, improvement in practices, the introduction of blood-sparing protocols and above all the conclusions reported in many studies have cast doubt on this dogma. There is abundant literature on the pros and cons of drainage after primary THA and TKA. The main endpoints were transfusion rates and volumes, total blood loss and variations in hemoglobin levels. Clinical endpoints comprised pain, edema, postoperative hematoma and, more rarely, short-to-medium-term function. Except for a few studies reporting greater pain and edema without drainage, there is agreement that drainage not only provides no benefit but actually aggravates postoperative bleeding. There are fewer studies of drainage in revision procedures for the hip and very few for the knee. The interest of drainage has not been demonstrated and again postoperative bleeding is aggravated. Whether in primary or revision arthroplasty, tranexamic acid is recommended when not contraindicated, whatever the administration protocol. However, it should not be seen as the sole and determining reason for abandoning drainage. LEVEL OF EVIDENCE: V, expert opinion.

The Efficacy and Safety of Tranexamic Acid in Total Hip and Knee Arthroplasty: A Literature Review

Historically, total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been associated with significant perioperative blood loss and a relatively high rate of allogeneic blood transfusions. However, in recent years, tranexamic acid (TXA), a competitive inhibitor of tissue plasminogen activator, inhibiting fibrinolysis of existing thrombi, has substantially decreased the need for blood transfusion in THA and TKA. Various administration strategies have been studied, but there remains a lack of consensus on an optimal route and dosing regimen, with intravenous and topical regimens being widely used. A growing body of literature has demonstrated the safety and efficacy of TXA in primary and revision THA and TKA to reduce blood loss, allogeneic transfusions, and complications; it is associated with lowered lengths of stay, costs, and readmission rates.

Risk Factors for Prolonged Hospital Stay After Femoral Neck Fracture

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64-98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211-217.].

Independent Risk Factors for Transfusion in Contemporary Revision Total Hip Arthroplasty

BACKGROUND

The incidence of transfusion in contemporary revision total hip arthroplasty (THA) remains high despite recent advances in blood management, including the use of tranexamic acid. The purpose of this prospective investigation was to determine independent risk factors for transfusion in revision THA.

METHODS

Six centers prospectively collected data on 175 revision THAs. A multivariable logistic analysis was performed to determine independent risk factors for transfusion. Revisions were categorized into subgroups for analysis, including femur-only, acetabulum-only, both-component, explantation with spacer, and second-stage reimplantation. Patients undergoing an isolated modular exchange were excluded.

RESULTS

Twenty-nine patients required at least one unit of blood (16.6%). In the logistic model, significant risk factors for transfusion were lower preoperative hemoglobin, higher preoperative international normalized ratio (INR), and longer operative time (P < .01, P = .04, P = .05, respectively). For each preoperative 1g/dL decrease in hemoglobin, the chance of transfusion increased by 79%. For each 0.1-unit increase in the preoperative INR, transfusion chance increased by 158%. For each additional operative hour, the chance of transfusion increased by 74%. There were no differences in transfusion rates among categories of revision hip surgery (P = .23). No differences in demographic or surgical variables were found between revision types.

CONCLUSION

Despite the use of tranexamic acid, transfusions are commonly required in revision THA. Preoperative hemoglobin and INR optimization are recommended when medically feasible. Efforts should also be made to decrease operative time when technically possible.

Intraoperative blood loss as indicated by haemoglobin trend is a predictor for the development of postoperative spinal implant infection-a matched-pair analysis

Background

With a reported rate of 0.7–20%, postoperative spinal implant infection (PSII) is one of the most common complications after spine surgery. While in arthroplasty both haematoma formation and perioperative blood loss have been identified as risk factors for developing periprosthetic joint infections and preoperative anaemia has been associated with increased complication rates, literature on the aetiology of PSII remains limited.

Methods

We performed a matched-pair analysis of perioperative haemoglobin (Hb) and haematocrit (Hct) levels in aseptic and septic spine revision surgeries. 317 patients were included, 94 of which were classified as septic according to previously defined criteria. Patients were matched according to age, body mass index, diabetes, American Society of Anesthesiologists score and smoking habits. Descriptive summaries for septic and aseptic groups were analysed using Pearson chi-squared for categorical or Student t test for continuous variables.

Results

Fifty patients were matched and did not differ significantly in their reason for revision, mean length of hospital stay, blood transfusion, operating time, or number of levels operated on. While there was no significant difference in preoperative Hb or Hct levels, the mean difference between pre- and postoperative Hb was higher in the septic group (3.45 ± 1.25 vs. 2.82 ± 1.48 g/dL, p = 0.034).

Conclusions

We therefore show that the intraoperative Hb-trend is a predictor for the development of PSII independent of the amount of blood transfusions, operation time, number of spinal levels operated on and hospital length of stay, which is why strategies to reduce intraoperative blood loss in spine surgery need to be further studied.

Efficacy of intravenous tranexamic acid administration in revision hip arthroplasty

BACKGROUND

This study aimed to evaluate the efficiency of constant dose intravenous administration of tranexamic acid (TXA) in reducing postoperative blood loss, hemoglobin (Hb) concentration, and the number of transfusions in revision hip arthroplasty (RHA).

METHODS

The study included 145 consecutive patients who had undergone RHA: a TXA group (75 patients) who received two doses of TXA (1.0 g 15 min before skin incision and 1.0 g during wound closure) and a no-TXA group (70 patients). Percentage blood loss and quantitative blood loss were calculated.

RESULTS

The percentage blood loss (23.82 ± 10.6% vs. 39.17 ± 15.1%; P < 0.001), Hb drop (2.9 ± 1.14 g/dL vs. 4.22 ± 1.4 g/dL; P < 0.001), and total blood loss (1030 ± 477 mL vs. 1736 ± 761 mL; P < 0.001) were significantly lower in the TXA group than in the no-TXA group on postoperative day 1. Percentage blood loss (37.5 ± 10.4% vs. 43.1 ± 12.5%; P < 0.01), Hb drop (4.64 ± 1.5 g/dL vs. 5.22 ± 1.6 g/dL; P < 0.01) and total blood loss (1639 ± 543 mL vs. 1908 ± 681 mL; P = 0.02) were significantly lower in the TXA group than in the no-TXA group on the 5th postoperative day. The blood transfusion requirements were lower in the TXA group than those in the no-TXA group (30.7% vs. 71.4% of patients; P < 0.001), with a lower transfusion per patient ratio of 0.55 in the TXA group and 1.4 in the no-TXA group. No postoperative complications were associated with TXA administration, including deep-vein thrombosis and pulmonary embolism.

CONCLUSION

Administration of TXA is an effective method to reduce perioperative blood loss, Hb drop and the number of transfusions in RHA.

Tranexamic acid lowers transfusion requirements and hospital length of stay following revision total hip or knee arthroplasty

Backgroud

Intravenous tranexamic acid (TXA) has been shown to reduce blood loss in patients undergoing total joint arthroplasty without systemic complications. There is limited evidence of its effectiveness in revision procedures. This study evaluated intravenous TXA effect on blood loss, transfusion rates, and length of hospital stay in revision joint replacement.

Methods

One-hundred revision total joint arthroplasty patients were retrospectively reviewed [44 revision total hip arthroplasty (THA) and 54 revision total knee arthroplasty (TKA)] who underwent surgery from 2013 to 2016. Fifty-four revision joint patients (23 THA and 31 TKA) received intravenous TXA intra-operatively, while 46 revision joint patients (23 THA/TKA) did not. Primary outcome measures were blood loss, transfusion rates, and length of hospital stay.

Results

The mean blood loss difference between revision THA patients who received TXA vs. not receiving TXA was 180ml in revision THA patients (p < .005). Mean length of hospital stay was 6 days in non-TXA vs. 3 days in TXA patients (p < .001). Eighteen patients received transfusions in the non-TXA revision TKA group compared to nine patients in the TXA revision TKA group (p < .001). Average length of hospital stay was 5 days in the non-TXA revision TKA group compared to 3 days in the TXA revision TKA group (p < .003). There was no increased risk of thromboembolic complications in TXA groups for either procedure.

Conclusions

Intravenous TXA reduced length of hospital stay in both revision cohorts, decreased blood loss in revision THA and decreased the rate of transfusion in revision TKA without an increase in thromboembolic complications.

Level of Evidence

Level III (Case-control study)

Factors Associated With Perioperative Transfusion in Lower Extremity Revision Arthroplasty Under a Restrictive Blood Management Protocol

INTRODUCTION

Approximately 37% of patients undergoing lower extremity revision total joint arthroplasty (TJA) receive allogeneic blood transfusions (ABTs), which are associated with increased risk of morbidity and death. It is important to identify patient factors associated with needing ABT because the health of higher-risk patients can be optimized preoperatively and their need for ABT can be minimized. Our goal was to identify the patient and surgical factors independently associated with perioperative ABT in revision TJA.

METHODS

We included all 251 lower extremity revision TJA cases performed at our academic tertiary care center from January 1, 2016, to December 31, 2018. We assessed the following factors for associations with perioperative ABT: patient age, sex, race, body mass index, preoperative hemoglobin level, and infection status (ie, infection as indication for revision TJA); use of vasopressors, tranexamic acid (TXA), surgical drains, tourniquets, and intraoperative cell salvage; and procedure type (hip versus knee), procedure complexity (according to the number of components revised), and surgical time. Multivariable regression was used to identify factors independently associated with perioperative ABT.

RESULTS

The following characteristics were independently associated with greater odds of perioperative ABT: preoperative hemoglobin level (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5 to 2.2), infectious indication for revision (OR, 3.6; 95% CI, 1.3 to 9.7), and procedure complexity. TXA use was a negative predictor of ABT (OR, 0.47; 95% CI, 0.23 to 0.98). Compared with polyethylene liner exchanges, single-component revisions (OR, 14; 95% CI, 3.6 to 56) and dual-component revisions (OR, 7.8; 95% CI, 2.3 to 26) were associated with greater odds of ABT.

DISCUSSION

Patients with preoperative anemia, those undergoing revision TJA because of infection, those who did not receive TXA, and those undergoing more complex TJA procedures may have greater odds of requiring ABT. We recommend preoperative optimization of the health of these patients to reduce the need for ABT.

LEVEL OF EVIDENCE

Level III, prognostic study.

Intravenous tranexamic acid is associated with safe reduced blood loss and transfusion rate in one-stage exchange for infected hip arthroplasty

Objectives

This study aims to investigate if the use of intravenous (IV) tranexamic acid (TXA) during one-stage exchange for periprosthetic joint infection (PJI) of the hip that necessitates an extensive debridement is associated with decreased blood loss, if the rate of blood transfusion that may lead to side effects can be lowered with IV TXA, and if there is any difference regarding the occurrence of postoperative venous thromboembolism (VTE).

Patients and methods

We retrospectively reviewed patients who underwent one-stage exchange for PJI of the hip with perioperative IV administration of TXA (n=163; 90 males, 73 females; mean age 68±10.3; range, 25 to 90 years) between January 2015 and December 2016 and compared them to another group (n=190; 106 males, 84 females; mean age 71±10.1; range, 39 to 92 years) who underwent one-stage exchange for PJI of the hip without perioperative IV administration of TXA between January 2006 and December 2012. Blood loss, transfusion rates, amount of transfused blood, and occurrence of VTE complications were observed.

Results

Mean blood loss of the TXA group was significantly lower than that of the non-TXA group (2.4 L and 4.5 L, respectively; p<0.001). Patients in non-TXA group experienced significantly higher rate of blood transfusion (71.1% and 58.3%, respectively; p=0.014) and higher quantity of transfused packed red blood cells (3.2 and 1.9 units, respectively; p<0.001). There was one patient with VTE complication in each group.

Conclusion

Even in the presence of infection, usage of IV TXA during one-stage exchange for PJI of the hip is associated with significantly lower blood loss and transfusion rates showing no higher risk of VTE events.

Use of Topical Tranexamic Acid Reduces Direct and Indirect Blood Loss and Transfusion Rates in Revision Total Hip Arthroplasty

BACKGROUND

In primary total hip arthroplasty (THA), evidence supports the use of tranexamic acid (TXA) as an effective strategy for reducing blood loss, but scant evidence supports its use in revision THA.

QUESTIONS/PURPOSES

We aimed to evaluate whether the use of topical TXA in revision THA is associated with less blood loss and lower transfusion rates and to assess its safety, specifically as it relates to thromboembolic complications.

METHODS

In this retrospective comparative study, two groups who underwent revision THA between 2005 and 2017 were defined: 98 patients who received 3 g of topical TXA (study group) and 475 patients who did not receive TXA (control group). Subjects were divided into subgroups according to the type of revision. Hemoglobin and hematocrit levels, blood loss, and transfusions were recorded. The follow-up period was 6 weeks.

RESULTS

Median estimated blood loss, hidden blood loss, hemoglobin drop, and transfusion rates were significantly lower in the study group. The rates of post-operative thromboembolism were similar in the two groups. According to subgroup analysis, patients with revision of the femoral component, both components, and staged exchange revisions showed significantly lower rates of transfusion.

CONCLUSION

Topical TXA administration during revision THA effectively reduced direct and indirect blood loss, including hidden losses, without increasing the rates of thromboembolic events. This effect appeared to be enhanced when the femoral component was revised.

The Optimal Dosing Regimen for Tranexamic Acid in Revision Total Hip Arthroplasty: A Multicenter Randomized Clinical Trial

BACKGROUND

The purpose of this multicenter, randomized trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss in revision total hip arthroplasty.

METHODS

Six centers prospectively randomized 175 patients to 1 of 4 regimens: (1) 1-g intravenous (IV) TXA prior to incision (the single-dose IV group), (2) 1-g IV TXA prior to incision followed by 1-g IV TXA after arthrotomy wound closure (the double-dose IV group), (3) a combination of 1-g IV TXA prior to incision and 1-g intraoperative topical TXA (the combined IV and topical group), or (4) 3 doses totaling 1,950-mg oral TXA (the multidose oral group). Randomization was based on revision subgroups to ensure equivalent group distribution. An a priori power analysis (α = 0.05; β = 0.80) determined that 40 patients per group were required to identify a >1-g/dL difference in postoperative hemoglobin reduction between groups. Per-protocol analysis involved an analysis of variance, Fisher exact tests, and two 1-sided t tests for equivalence. Demographic and surgical variables were equivalent between groups.

RESULTS

No significant differences were found between TXA regimens when evaluating reduction in hemoglobin (3.4 g/dL for the single-dose IV group, 3.6 g/dL for the double-dose IV group, 3.5 g/dL for the combined IV and topical group, and 3.4 g/dL for the multidose oral group; p = 0.95), calculated blood loss (p = 0.90), or transfusion rates (14% for the single-dose IV group, 18% for the double-dose IV group, 17% for the combined group, and 17% for the multidose oral group; p = 0.96). Equivalence testing revealed that all possible pairings were statistically equivalent, assuming a >1-g/dL difference in hemoglobin reduction as clinically relevant. There was 1 venous thromboembolism, with no differences found between groups (p = 1.00).

CONCLUSIONS

All 4 TXA groups tested had equivalent blood-sparing properties in the setting of revision total hip arthroplasty, with a single venous thromboembolism reported in this high-risk population. Based on the equivalence between groups, surgeons should utilize whichever of the 4 investigated regimens is best suited for their practice and hospital setting. Given the transfusion rate in revision total hip arthroplasty despite TXA utilization, further work is required in this area.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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.

Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty

BACKGROUND

Revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. Tranexamic acid (TXA) is gaining popularity in revision TJA to minimize blood loss and the need for transfusion; however, its effect on PJI reduction has yet to be investigated. The hypothesis of this study was that the administration of TXA during revision arthroplasty is protective against subsequent PJI.

METHODS

A prospectively maintained institutional database was used to identify patients who underwent revision TJA for aseptic failure from 2009 to 2018 and had a minimum follow-up of 90 days. Patients who developed PJI following revision arthroplasty were identified. All patients with PJI met Musculoskeletal Infection Society (MSIS) criteria. A multivariate analysis was performed to identify variables independently associated with PJI after aseptic revision TJA.

RESULTS

Overall, 1,731 patients who underwent aseptic revision were identified; of these patients, 83 (4.8%) developed PJI. Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%. After controlling for relevant confounding variables, TXA remained a significant independent factor that protected against PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030). Female sex was also identified as a significant independent factor that protected against PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016). However, preoperative anemia was independently associated with an increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003).

CONCLUSIONS

Based on this study conducted at a single institution, the use of TXA during aseptic revision arthroplasty was independently associated with a reduced risk of subsequent acute PJI after adjusting for multiple patient characteristics and surgical factors.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Administration of Tranexamic Acid in Proximal Humeral Fractures

INTRODUCTION

This study aimed to analyze the efficacy of intravenous administration of tranexamic acid in complex proximal humeral fractures.

MATERIALS AND METHODS

Sixty-seven patients with displaced 3 and 4 part proximal humerus fractures were randomized into the control (n = 33) and TXA (n = 34) groups. Fifteen minutes before the skin incision, 15 mg/kg body weight of 0.9% sodium chloride solution or TXA was injected intravenously. Open reduction and internal fixation was conducted through a deltoid-pectoral approach with fixed angle locked plating (PHILOS) for all the patients. The patients were followed up 2 months after surgery. Total blood loss, blood test results, blood transfusion rate, and wound complications were analyzed between the two groups.

RESULTS

Significant differences were observed in intraoperative blood loss and postoperative blood loss during the first 24 h between the two groups. There were no significant differences in postoperative blood loss during the second 24 h, wound complication rates, blood transfusion rate and adverse side effects. And thromboembolic events related with the application of TXA were not noted in the TXA group.

CONCLUSION

Preoperative administration of tranexamic acid could reduce intraoperative and postoperative blood loss in patients with complex proximal humeral fractures.

LEVEL OF EVIDENCE

II, prospective comparative study.

Prolonged operative time increases risk of blood loss and transfusion requirements in revision hip surgery

INTRODUCTION

Revision hip surgery is well documented to have a high association with substantial blood loss and the associated need for a blood transfusion. This exposes the patient to increased risk of transfusion reaction and blood borne infection. There are many strategies to minimize allogeneic transfusion rates in revision surgery such as pre-operative autologous donation, peri-operative tranexamic acid, thrombin sealants, normovolaemic haemodilution, intra-operative blood salvage and the use of post-operative autologous drains.

PATIENTS AND METHODS

We prospectively looked at 177 consecutive cases performed at one centre by a single surgical and anaesthetic team to identify which patient and operative factors were most significant in minimizing the requirement for an allogeneic blood transfusion.

RESULTS

Our results identified the duration of surgery as being the only significant variable affecting the level of blood loss. We noted a 3% increase in the probability of massive blood loss (> 2000 mls) for every minute of increased surgical time in our series.

CONCLUSIONS

We conclude that measures to minimize the duration of surgery would be beneficial in reducing blood loss and the risks of requiring blood transfusions in revision hip surgery.

Intravenous Tranexamic Acid for Reducing Perioperative Blood Loss During Revision Surgery for Vancouver Type B Periprosthetic Femoral Fractures After Total Hip Arthroplasty: A Retrospective Study

Objective

To explore the efficacy and safety of intravenous tranexamic acid for reducing perioperative blood loss and allogeneic blood transfusions in revision surgery for Vancouver type B periprosthetic femoral fractures after total hip arthroplasty (THA).

Methods

We retrospectively reviewed 129 patients who underwent revision surgeries because of Vancouver type B periprosthetic femoral fractures from January 2008 to September 2018. Patients were divided into two groups according to whether they received intravenous tranexamic acid (n = 72) or not (n = 57). The two groups were compared in terms of estimated intraoperative blood loss, visible blood loss, hidden blood loss, the volume of allogeneic blood transfusion and the incidence of symptomatic venous thromboembolism (VTE). Patients were also compared depending on the Vancouver classification (Vancouver type B1, B2, and B3).

Results

Regardless of the subtype of Vancouver classification, patients who received tranexamic acid showed significantly lower estimated intraoperative blood loss, visible blood loss, hidden blood loss, and allogeneic blood transfusion volume. Use of tranexamic acid was not associated with significant changes in the incidence of postoperative symptomatic VTE. Similar results were obtained with subgroups of patients who had the Vancouver type B1, B2, or B3 periprosthetic femoral fractures.

Conclusions

The administration of intravenous tranexamic acid can safely and effectively reduce perioperative blood loss and allogeneic blood transfusions in revision surgery for Vancouver type B periprosthetic femoral fractures, without increasing the risk of symptomatic VTE.

Intravenous tranexamic acid reduces blood transfusions in revision total hip arthroplasty: a meta-analysis

Aim: We performed a meta-analysis to systematically assess the efficacy and safety of intravenous tranexamic acid in revision total hip arthroplasty. Method: Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect and other databases. The time range we retrieved from was that from the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data. Results: A total of eight articles were involved in our study. The overall participants of tranexamic acid (TXA) group were 3533, whereas it was 11,007 in the control group. Our meta-analysis showed that TXA is preferable for revision total hip arthroplasty because of its lower value of hemoglobin reduction (weighted mean difference = -1.277-1.405; 95% CI: -1.996 to -0.559; p < 0.001), the rate of blood transfusion (odds ratio: 0.233; 95% CI: 0.129-0.422; p < 0.001) and the number of red blood cell units transfused (weighted mean difference = -0.978; 95% CI = -1.631 to -0.324; p = 0.003). However, there was no difference in calculated blood loss (p = 0.075), operation duration (p = 0.569) and venous thromboembolism complications (p = 0.338). Conclusion: Based on available evidence, use of intravenous TXA for patients undergoing revision arthroplasty may reduce hemoglobin reduction, number of red blood cell units transfused and blood transfusion rate without increasing the risk of venous thromboembolism and length of operation duration. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.

Intravenous tranexamic acid safely and effectively reduces transfusion rates in revision total hip arthroplasty

AIMS

Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA.

PATIENTS AND METHODS

We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery.

RESULTS

Tranexamic acid significantly and substantially reduced the rate of blood transfusions after revision THA overall from 54% to 26% (p < 0.001; adjusted relative risk (RR) 1.6; 95% confidence interval (CI) 1.3 to 1.9), with a significant reduction in both aseptic (49% to 18%; p < 0.001) and septic (73% to 53%; p = 0.04) revisions. The rate of VTE was minimal overall, with three events (0.3%) in the TXA group and four events (0.2%) in the non-TXA group. There were no significant differences in VTE rates based on TXA use or aetiology of revision.

CONCLUSION

Intravenous TXA significantly reduced transfusion rates during all-cause revision THAs, including a subgroup analysis of both aseptic and septic cohorts. Adjusted risk using propensity modelling showed no statistical difference in rates of VTEs between either group. Cite this article: Bone Joint J 2019;100-B(6 Supple B):104-109.

Comparative efficacy and safety of different hemostatic methods in total hip arthroplasty: a network meta-analysis

Background

It is unclear which kind of interventional therapy is the best when reducing blood loss in patients prepared for total hip arthroplasty (THA). We performed this network meta-analysis to rank the best intervention arm for blood loss control in THA patients.

Methods

We searched electronic databases about randomized controlled trials (RCTs) to compare three treatments (topical tranexamic acid (TXA), intravenous TXA, and topical fibrin sealant (FS)) versus placebo for the people prepared for THA. Traditional and network meta-analyses were performed. The quality assessment was conducted using Cochrane Collaboration’s tool. The network meta-analysis was conducted using Stata 13.0 software.

Results

Finally, a total of 32 RCTs were included in this network meta-analysis. Topical TXA, intravenous TXA, and topical FS significantly decreased the need for transfusion and total blood loss when compared with placebo. And intravenous TXA ranks the first hemostasis agent for reducing the need for transfusion and total blood loss. There was no significant difference between these three treatments (intravenous TXA, topical TXA, and topical FS) in the occurrence of deep venous thrombosis (DVT).

Conclusion

Intravenous TXA may be the best way to reduce the need for transfusion and total blood loss. More direct studies that focused on topical TXA versus FS are needed in the future.

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.

Intravenous tranexamic acid use in revision total joint arthroplasty: a meta-analysis

Purpose

Massive perioperative blood loss in complex revision total joint arthroplasty (TJA) often requires blood transfusions. Tranexamic acid (TXA) has been used in elective primary TJA to minimize blood loss and transfusions. The purpose of this meta-analysis was to evaluate the safety and efficacy of intravenous TXA in revision TJA.

Methods

A literature search of PubMed, Scopus, and the Cochrane Controlled Trials Register was performed to identify studies published between January 2000 and May 2017. All randomized controlled trials (RCTs) and retrospective cohort observational studies evaluating the efficacy of intravenous TXA during revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) were included. The mean differences (MDs) of blood loss, hemoglobin (Hb) change, and red blood cell (RBC) units transfused were compiled, and ORs of transfusion and venous thromboembolism (VTE) events in TXA and control groups were calculated.

Results

Seven studies involving 930 patients were included (501 TXA vs 429 control). Intravenous TXA use had a significantly less blood transfusion (OR=0.20, 95% CI=0.11–0.34, P<0.001), lower Hb drop (MD=−0.88, 95% CI=−1.31 to −0.44, P<0.001), and less number of RBC units transfused (MD=−0.44, 95% CI=−0.65 to −0.24, P<0.001) compared to control in the postoperative period. No significant difference was seen in blood loss (MD=−245, 95% CI=−556 to 66, P=0.12) and VTE events (OR=0.57, 95% CI=0.13–2.42, P=0.45) between groups.

Conclusion

Our meta-analysis suggests that intravenous administration of TXA can significantly reduce blood transfusion requirements following revision TJA, without increasing the risk of VTE. However, due to the variation in included studies, larger RCTs are required to draw firm conclusions.

The Effect of Preoperative Administration of Intravenous Tranexamic Acid During Revision Hip Arthroplasty: A Retrospective Study

BACKGROUND

Revision hip arthroplasty poses several challenges, including the management of perioperative blood loss. Recent studies have validated the use of tranexamic acid in primary total hip arthroplasty, showing reduced blood loss and decreased number of allogenic blood transfusions. The effectiveness of tranexamic acid has not been well studied in the revision hip arthroplasty setting.

METHODS

We performed a retrospective review of 1,072 patients who underwent revision hip arthroplasty at our institution from 2008 to 2016. A total of 634 patients met the inclusion criteria, and comparisons were made between 232 consecutive patients without the use of tranexamic acid and 402 consecutive patients with the use of tranexamic acid. Patients were subdivided into 4 groups based on the complexity of revision surgical procedures: (1) major revision, (2) isolated femoral component revision, (3) isolated acetabular component revision, and (4) isolated femoral head and acetabular liner exchange. Within these groups, we compared the demographic data, estimated intraoperative blood loss, perioperative blood units transfused, postoperative hemoglobin drop, and thromboembolic complications between patients receiving either tranexamic acid or no antifibrinolytic therapy.

RESULTS

The primary outcomes of our study (estimated intraoperative blood loss, postoperative hemoglobin drop, and perioperative blood transfusion) were all reduced in patients who received tranexamic acid compared with patients who received no antifibrinolytic therapy. When analyzed on the basis of the complexity of surgical revision, there was a decrease in estimated intraoperative blood loss following tranexamic acid administration in the major revision group (845 compared with 1,095 mL; p < 0.001). The postoperative drop in hemoglobin was lower in the major revision group with tranexamic acid administration (by 8.9 g/L; p < 0.01) and the isolated acetabular component revision group with tranexamic acid administration (by 11.9 g/L; p < 0.001). The need for perioperative blood transfusion was reduced across all revisions treated with tranexamic acid (major revision group, 1.79 compared with 3.33 units, p < 0.001; femoral revision only, 0.97 compared with 2.25 units, p < 0.01; acetabular revision only, 0.73 compared with 1.72 units, p < 0.001; and head and liner exchange, 0.15 compared with 0.89 unit, p < 0.05).

CONCLUSIONS

Based on this study, preoperative administration of intravenous tranexamic acid in revision hip arthroplasty reduces allogenic blood transfusions and perioperative blood loss.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transfusion rate using intravenous tranexamic acid in hip revision surgery

INTRODUCTION

Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery.

METHODS

We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications.

RESULTS

Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups.

INTERPRETATION

The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.

Transfusion rate using intravenous tranexamic acid in hip revision surgery

INTRODUCTION

Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery.

METHODS

We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications.

RESULTS

Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups.

INTERPRETATION

The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.

High Concentrations of Tranexamic Acid Inhibit Ionotropic Glutamate Receptors

BACKGROUND

The antifibrinolytic drug tranexamic acid is structurally similar to the amino acid glycine and may cause seizures and myoclonus by acting as a competitive antagonist of glycine receptors. Glycine is an obligatory co-agonist of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptors. Thus, it is plausible that tranexamic acid inhibits NMDA receptors by acting as a competitive antagonist at the glycine binding site. The aim of this study was to determine whether tranexamic acid inhibits NMDA receptors, as well as α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid and kainate subtypes of ionotropic glutamate receptors.

METHODS

Tranexamic acid modulation of NMDA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, and kainate receptors was studied using whole cell voltage-clamp recordings of current from cultured mouse hippocampal neurons.

RESULTS

Tranexamic acid rapidly and reversibly inhibited NMDA receptors (half maximal inhibitory concentration = 241 ± 45 mM, mean ± SD; 95% CI, 200 to 281; n = 5) and shifted the glycine concentration-response curve for NMDA-evoked current to the right. Tranexamic acid also inhibited α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (half maximal inhibitory concentration = 231 ± 91 mM; 95% CI, 148 to 314; n = 5 to 6) and kainate receptors (half maximal inhibitory concentration = 90 ± 24 mM; 95% CI, 68 to 112; n = 5).

CONCLUSIONS

Tranexamic acid inhibits NMDA receptors likely by reducing the binding of the co-agonist glycine and also inhibits α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid and kainate receptors. Receptor blockade occurs at high millimolar concentrations of tranexamic acid, similar to the concentrations that occur after topical application to peripheral tissues. Glutamate receptors in tissues including bone, heart, and nerves play various physiologic roles, and tranexamic acid inhibition of these receptors may contribute to adverse drug effects.