Comparison between topical and intravenous administration of tranexamic acid in primary total hip arthroplasty

Intravenous tranexamic acid is associated with an increased risk of pulmonary embolism following sarcoma resection

INTRODUCTION

Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer-associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA.

METHODS

A retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90-day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality.

RESULTS

TXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23-50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use.

CONCLUSION

Our results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.

Comparison of the Effect of Different Local Analgesia Administration Techniques in Total Hip Arthroplasty: A Retrospective Comparative Cohort Study

Objective

To improve postoperative pain management, several authors have described the use of periarticular injection (PAI) or intra-articular injection (IAI) following total hip arthroplasty (THA). However, no comparative studies examining the results between PAI and IAI following THA have been published. This study aimed to evaluate the analgesic and anti-inflammatory effects of PAI and IAI following THA.

Methods

This single-center, retrospective cohort study enrolled patients who underwent unilateral primary THA. A total of 278 patients (281 hips) were included in the final analyses, with 112 patients (113 hips) in the control group, 85 patients (87 hips) in the PAI group, and 81 patients (81 hips) in the IAI group. Numeric rating scale (NRS) scores and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7.

Results

NRS scores, creatine phosphokinase, and C-reactive protein levels in the PAI and IAI groups were significantly lower than those in the control group on POD 1 and 7. D-dimer levels were significantly lower in the PAI and IAI groups than in the control group on POD 7. The white blood cell count was significantly higher in the PAI and IAI groups than in the control group on POD 1 and 7. Aspartate transaminase, alanine aminotransferase, blood urea nitrogen, and creatinine levels were within the reference ranges in all three groups at all time points. NRS scores and laboratory data showed no significant differences between the PAI and IAI groups at all time points.

Conclusion

PAI and IAI have equivalent analgesic and anti-inflammatory effects. Considering the technical challenges of PAI, IAI may be preferable because of its simplicity in the case of using a closed suction drain.

Reduction of Blood Loss by Tranexamic Acid Following Total Hip and Knee Arthroplasty: A Meta-Analysis

BACKGROUND

This study involved a meta-analysis of 36 published studies to examine the efficacy of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss, drain output, thromboembolic complications, and hospital stay following total hip and total knee arthroplasty. This study also evaluated whether treatment with a combination of both IA and IV TXA has an effect on these outcomes. Lastly, this study attempted to analyze the method and technique of TXA administration in order to establish a best practice for its use in reducing overall blood loss in arthroplasty procedures.

METHODS

MEDLINE, Embase, and the Cochrane Library database were screened. Studies comparing IV TXA with IA TXA or with combined IV and IA TXA were included. Data including total blood loss, drain output, thromboembolic complications, and hospital stay, where available, were analyzed using meta-analysis with fixed effects. Results are presented as the standardized mean difference (SMD), and meta-regression was employed to explore plausible demographic contributions to heterogeneity.

RESULTS

Twenty-eight randomized controlled trials, 3 prospective cohort studies, and 5 retrospective cohort studies with 5,499 patients were included in this review. IA administration during total knee arthroplasty showed a significant advantage in terms of total blood loss (SMD = -0.14, 95% confidence interval [CI] = -0.027 to -0.02, I = 78.2%) and drain output (SMD = -0.30, 95% CI = -0.43 to -0.18). There was no significant difference between IV and IA administration in total hip arthroplasty. Combined IA plus IV TXA was associated with a significant reduction in blood loss versus IV TXA alone in both total knee arthroplasty and total hip arthroplasty. IV TXA dosing varied, as 14 (39%) of the studies used a weight-based approach while 22 (61%) used a standard dose. Twenty-seven (96%) of 28 studies of IA administration used standard dosing while 1 study followed a weight-based protocol. There was no difference in symptomatic thromboembolic complications, with overall rates in total knee arthroplasty and total hip arthroplasty of 1.0% and 1.0% for IV administration and 1.1% and 0.3% for IA administration, respectively. There was no difference in length of hospital stay for IV versus IA TXA administration.

CONCLUSIONS

IA TXA, either alone or in conjunction with IV TXA, reduces total blood loss and/or drain output in total knee arthroplasty and total hip arthroplasty. Optimal methodology remains to be clarified; however, there are substantial economic benefits of utilizing either IV or IA TXA, with greater cost benefits when using IA TXA.

LEVEL OF EVIDENCE

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

Use of topical tranexamic acid in primary total hip arthroplasty. Efficiency and safety. Our experience

BACKGROUND AND AIM

Intravenous tranexamic acid has been shown to reduce bleeding and the need for transfusions in total hip arthroplasty, although it has a theoretical risk of producing thromboembolic phenomena. Recently some papers have been published using the topical application of tranexamic acid, but the ideal administration protocol has not yet been clearly defined. The aim of this paper was to demonstrate that our protocol of topical tranexamic acid is effective and safe.

MATERIALS AND METHODS

Prospective data collection from a case series of 80 primary hip arthroplasties, in which the following topical tranexamic acid protocol is used: 1.5 grams diluted to a total volume of 60ml were administered, applying 20ml in the acetabular bed, 20ml in the femoral canal and 20ml through the Redon drain, keeping it closed for 20minutes.

RESULTS

Eighty patients were operated. Preoperative haemoglobin 14.26g / dL; preoperative haematocrit 42.39%. An average loss of 2.74g / dL of haemoglobin and 8% of haematocrit was obtained. Eleven percent of the patients required transfusion, of whom 67% had known previous anaemia; only 3 patients without prior anaemia required transfusion (4%). There were no thromboembolic complications in our series.

CONCLUSIONS

The use of topical tranexamic acid was safe and effective in primary total hip arthroplasty, reducing the need for blood transfusion compared to that described in the literature in untreated patients.

The efficiency and safety of oral tranexamic acid in total hip arthroplasty: A meta-analysis

BACKGROUND

Intravenous (IV), topical and combination of both application of tranexamic acid (TXA) can reduce blood loss, hemoglobin drop, and transfusion rate in patients following total hip arthroplasty (THA). Lately, published articles reported that oral TXA had as similar blood-saving as IV and topical TXA in THA. The purpose of this meta-analysis is to investigate the efficiency and safety of oral TXA in THA.

METHODS

We systematically searched articles about oral administration of TXA in THA from PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Chinese Wanfang database.

STUDY ELIGIBILITY CRITERIA

The outcomes were collected and analyzed by the Review Manager 5.3.

RESULTS

Nine RCTs and 1 CCT, containing 1305 patients, were ultimately included according to the inclusion criteria and exclusion criteria in the meta-analysis. The effectiveness of oral TXA was as similar as the IV or topical TXA in regard to hemoglobin drop (SMD = -0.14; 95% CI, [-0.28, 0.01]; P = .06), total blood loss (SMD = 0.01; 95% CI, [-0.13, 0.16]; P = .84), transfusion rate (OR = 0.76; 95% CI, [0.38, 1.55]; P = .37). Compared with single oral TXA or blank group, multiple oral TXA effectively reduced hemoglobin drop (SMD = -1.06; 95% CI, [-1.36, -0.77]; P < .05), total blood loss (SMD = -1.30; 95% CI, [-1.66, -0.94]; P < .05), transfusion rate (OR = 0.53; 95% CI, [0.29, 0.95]; P = .03). There were no significant difference in terms of length of stay and complication among all of enrolled studies.

CONCLUSION

Oral TXA has favorable effect of blood-saving and do not increase risk of complication in patients following THA. Oral TXA may have no effect in the length of stay. More high quality RCTs are necessary.

Disminución de transfusiones con uso de Ácido Tranexámico en artroplastias de cadera y rodilla

Introducción: se ha demostrado que el uso de Ácido Tranexámico (AT) en diferentes procedimientos quirúrgicos puede disminuir la necesidad de transfusiones sanguíneas. Objetivo: Determinar si disminuye la necesidad de transfusiones sanguíneas con el uso de AT  en artroplastias de cadera y rodilla. Métodos: Estudio descriptivo y retrospectivo desarrollado con información de 230 pacientes operados en los hospitales Herrera Llerandi y Multimédica en los períodos de 2015, 2016 y 2017. Resultados: Utilizando la distribución binomial para dos poblaciones se obtuvo que existe una disminución de la necesidad de transfusiones sanguíneas del 97.7% al utilizar AT. Los pacientes que no reciben AT tienen una probabilidad de 83.4% de necesitar una transfusión sanguínea. Conclusión: Se logró determinar que con la utilización de Ácido Tranexámico disminuye la necesidad de transfusiones sanguíneas en artroplastias de cadera y rodilla en un 97.7% con el 95% de confianza.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

The Translational Potential of this Article

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

A systematic review and meta-analysis comparing combined intravenous and topical tranexamic acid with intravenous administration alone in THA

PURPOSE

To compare the effectiveness and safety of combined intravenous and topical tranexamic acid with intravenous use alone in THA.

METHODS

The electronic databases MEDLINE, EMBASE, BIOSIS, Cochrane central, and further adapted for Google and Google Scholar internet, last updated on Dec 30, 2016, were searched. Evaluated outcomes included total blood loss, transfusion rate, maximum postoperative Hb drop, and incidence of thromboembolic complications. The standard mean difference (SMD) or the relative risk (RR) was calculated for continuous or dichotomous data respectively. The quality of the trial was assessed, and meta-analyses were performed with the Cochrane Collaboration's RevMan 5.0 software.

RESULTS

Five RCTs with 457 patients were included. Combined TXA administration reduced blood loss (SMD, 1.39; 95%CI, 0.55 to 2.23; P<0.00001, I2 = 94%), hemoglobin decline (SMD, 0.84; 95%CI, 0.13 to 1.54; P = 0.01, I2 = 83%) and the need for transfusion (RR, 2.58; 95%CI, 1.59 to 4.18; P = 0.65, I2 = 0%) without increasing the rate of thromboembolic complications significantly (RR, 0.83; 95%CI, 0.27 to 2.54; P = 0.81, I2 = 0%).

CONCLUSION

The present study has emphasized that combined TXA administration can effectively reduce blood loss, hemoglobin decline and the need for transfusion without increasing the rate of thromboembolic complications.

Effect of tranexamic acid administration on bleeding in primary total hip arthroplasty

OBJECTIVE

To study the efficacy of tranexamic acid to decrease perioperative bleeding in patients who have undergone a total hip arthroplasty operation and to evaluate drug safety.

MATERIAL AND METHODS

Observational, prospective, controlled and randomized study on the efficacy of tranexamic acid as a method to reduce bleeding in primary hip replacement surgery. We included 134 patients operated during 2014 in our centre, who were divided into 2 groups according to whether or not they had received tranexamic acid. The main study variables were haemoglobin and haematocrit levels, the amount of blood collected from the post-operative drain in the first 12, 24 and 48hours and transfusion requirements.

RESULTS

Post-operative haemoglobin and haematocrit levels were statistically higher (P<.001) in the group with treatment. During the first 48hours bleeding values from the group that did not receive TAX were higher compared to patients treated with tranexamic acid. Statistically significant differences (P=.001) were found as to the need for transfusion according to group, more transfusions were performed in the cohort that had not received tranexamic acid: 25.37% compared to 4.48% for the group with tranexamic acid. No adverse events related to administration of tranexamic acid were recorded.

CONCLUSIONS

Administration of tranexamic acid has proved to be an effective and safe method to reduce peri-operative bleeding in patients who underwent total hip arthroplasty and avoids allogenic blood transfusion. Therefore, tranexamic acid treatment could entail a financial saving for the healthcare system and expose the patient to less risk.

Efficacy and safety of intravenous tranexamic acid administration in patients undergoing hip fracture surgery for hemostasis: A meta-analysis

BACKGROUND

Patients undergoing hip fracture surgery frequently require blood transfusion. Tranexamic acid (TXA) has been widely used to decrease blood loss and transfusion rates in joint replacement surgery. Therefore, we conducted a meta-analysis to evaluate efficacy and safety of intravenous TXA administration in patients suffering from hip fractures.

METHODS

Electronic databases were searched before December 2016 by 2 independent reviewers, including Cochrane Library, EMBASE, PubMed, Web of Science, the Chinese Biomedical Literature database, and the China National Knowledge Infrastructure databases. Randomized controlled trials (RCTs) involving the efficacy and safety of intravenous (IV) TXA in patients who underwent hip surgery were included in our meta-analysis. The endpoints included total blood loss, hidden blood loss, postoperative hemoglobin decline, transfusion rates, the rate of thrombotic events, and operative time. Current meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. The pooling of data was carried out using STATA V.12.0 software.

RESULT

Eight RCTs were included, involving 598 participants. Current meta-analysis indicated that the IV TXA group had less total blood loss (weighted mean difference [WMD] = -277, 95%CI: -335 to -220, P = .000), less hidden blood loss (WMD = -246, 95%CI: -252 to -241, P = .000), lower postoperative hemoglobin decline (WMD = -1.36, 95% CI: -1.84 to -0.88, P = .000), and lower transfusion rates (risk difference [RD] = -0.19, 95% CI: -0.27 to -0.11, P = .000) compared to the control group. No significant differences were found regarding the rate of thrombotic events (RD = 0.02, 95% CI: = -0.01 to 0.05, P = .262) and operative time (WMD = -0.7, 95% CI: -3.3 to 1.9, P = .6).

CONCLUSION

It was well established that systemic administration of TXA could reduce blood loss and transfusion rates in hip fracture surgery. But the optimal regimen, dosage, and timing still need a further research. In addition, more large and high-quality randomized controlled studies are needed to focus on the safety of IV TXA application before its wide recommendation for use in hip fracture surgery.

Combined application versus topical and intravenous application of tranexamic acid following primary total hip arthroplasty: a meta-analysis

Background

The use of intravenous (IV) or topical tranexamic acid (TXA) in total hip arthroplasty has been proven to be effective and safe in total hip arthroplasty. However, which of these two administration routes is better has not been determined. The combined administration of TXA has been used in total knee arthroplasty with satisfactory results. We hypothesized that combined application of TXA may be the most effective way without increased rate of thrombotic events such as deep vein thrombosis (DVT) and pulmonary embolisms (PE) in patients subjected to primary total hip replacement (THA). A meta-analysis was conducted to compare the efficacy and safety of the combined use of tranexamic acid (TXA) relative to topical or intravenous (IV) use alone for treatment of primary THA. The outcomes included total blood loss, postoperative hemoglobin decline, transfusion rates, and the incidence rates of deep vein thrombosis (DVT) and pulmonary embolisms (PE).

Methods

We searched electronic databases including PubMed, EMBASE, the Cochrane Library, Web of Science, the Chinese Biomedical Literature database, the CNKI database, and Wanfang Data until September 2016. The references of the included articles were also checked for additional potentially relevant studies. There were no language restrictions for the search. The data of the included studies were analyzed using RevMan 5.3 software.

Results

Seven studies met the inclusion criteria, encompassing a total of 1762 patients. Our meta-analysis demonstrated that total blood loss, postoperative hemoglobin decline, and transfusion rates were significantly lower for patients that received the combined treatment compared to patients that received either topical or intravenous administration of TXA. No statistical differences were found in the incidence of deep venous thrombosis (DVT) or pulmonary embolism (PE).

Conclusion

The group that received the combined treatment had lower total blood loss, postoperative hemoglobin decline, and transfusion rates without an increased rate of thrombotic events (DVT or PE). The topical or intravenous use of TXA in primary THA is generally considered to be safe and effective. This meta-analysis demonstrated that combined TXA application may be superior to topical or intravenous application of TXA alone. However, larger, high-quality randomized control trials are required for greater confidence in this finding.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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