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Tan TK, Lee JY, Tay A, Kuster M. Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:709-738. [PMID: 35377071 DOI: 10.1007/s00590-022-03241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
AIM The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | | | - Aaron Tay
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Markus Kuster
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
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MONTEIRO OTÁVIOMONTOVANELLI, PERRONE RODRIGOTURRA, ALMEIDA FABRÍCIONASCIMENTO, MOURA JUNIOR CIDPEREIRADE, OLIVEIRA SAULOGOMESDE, ALMEIDA GUSTAVODALLABERNARDINADE. COMPARISON OF HEMOSTASIS WITH TRANEXAMIC ACID IN TOTAL KNEE ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2021; 29:184-188. [PMID: 34566475 PMCID: PMC8443016 DOI: 10.1590/1413-785220212904235714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/27/2020] [Indexed: 12/04/2022]
Abstract
Objective: To compare the use of intravenous and topical tranexamic acid (TXA) in unilateral primary total knee arthroplasty (TKA) in relation to blood loss and complications inherent to the medication. Method: Three groups with 14 patients each were constituted, and all of them were operated using the same surgical technique. In Group 1, usual measures for bleeding control were performed. Group 2 patients received TXA topically on the joint surface. In Group 3, intravenous TXA was used. Hemoglobin (HB), hematocrit (HTC), platelets (PLAT), prothrombin time, activated partial thromboplastin time and volume of blood drained observed 24 hours after arthroplasty were compared to the values of tests found before surgery. Results: There was a decrease in the concentration of HB, HTC and PLAT in all groups in relation to the preoperative, however without significant difference. Group 3 had a lower mean volume of drained blood than the other groups, with statistical significance. No adverse effects or thromboembolic events were observed in the groups that received TXA. Conclusion: This study showed superiority in the use of intravenous TXA in decreasing the volume of bleeding, without increasing the risk of thromboembolic events. Level of Evidence I, High quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals.
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Taeuber I, Weibel S, Herrmann E, Neef V, Schlesinger T, Kranke P, Messroghli L, Zacharowski K, Choorapoikayil S, Meybohm P. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surg 2021; 156:e210884. [PMID: 33851983 PMCID: PMC8047805 DOI: 10.1001/jamasurg.2021.0884] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use. OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines. DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020. STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded. DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality. RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53). CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.
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Affiliation(s)
- Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Leila Messroghli
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Yang Y, Wang Z, Wang F, Zhao X, Yang K, He J, Jin Y, Yang H, Ding D, Jin Q. Prospective, randomised, controlled study on the efficacy and safety of different strategies of tranexamic acid with total blood loss, blood transfusion rate and thrombogenic biomarkers in total knee arthroplasty: study protocol. BMJ Open 2021; 11:e038399. [PMID: 33637540 PMCID: PMC7919582 DOI: 10.1136/bmjopen-2020-038399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is a common and highly effective orthopaedic procedure for treating end-stage knee osteoarthritis. Tranexamic acid (TXA) has become a routine part of perioperative care in TKAs. The best practices regarding the delivery method of TXA in TKA remain controversial. Plasminogen activator inhibitor-1 (PAI-1), thrombin-antithrombin (TAT) complexes and prothrombin fragment F1+2 (F1+2) have been demonstrated to be elevated in patients with venous thromboembolism (VTE). The aim of this trial was to investigate the most efficacious delivery method of TXA (comparison of intravenous and topical applications and comparison of three topical applications) and to evaluate the safety of TXA strategies by investigating the effect of TXA on the plasma D-dimer, PAI-1, TAT and F1+2 levels. METHODS AND DESIGN This trial is a prospective, randomised, controlled study that will evaluate the efficacy and safety of strategies of TXA. A total of 250 patients undergoing primary TKA will be randomly allocated to five groups for different TXA applications. The primary outcome is total blood loss. The secondary outcomes are blood transfusion rate, drainage volume, plasma D-dimer, PAI-1, TAT and F1+2 levels, maximum haemoglobin drop, wound complications, VTE and length of hospital stay. ETHICS AND DISSEMINATION This study's protocol is in accordance with the declaration of Helsinki. The ethics committee of the General Hospital of Ningxia Medical University approved this study (approval ID: 2020-505). The results of this study will be disseminated in international peer reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2000030624.
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Affiliation(s)
- Yong Yang
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Clinical college, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Zheng Wang
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Clinical college, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Faxuan Wang
- School of Public Health, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Xin Zhao
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Kaijie Yang
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jinlong He
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Yun Jin
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Haibo Yang
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Dong Ding
- Clinical college, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Qunhua Jin
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
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Li J, Liu R, Rai S, Ze R, Tang X, Hong P. Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty. J Orthop Surg Res 2020; 15:581. [PMID: 33267906 PMCID: PMC7709322 DOI: 10.1186/s13018-020-02119-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal dosage and administration approach of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains controversial. In light of recently published 14 randomized controlled trials (RCTs), the study aims to incorporate the newly found evidence and compare the efficacy and safety of intra-articular (IA) vs. intravenous (IV) application of TXA in primary TKA. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for RCTs comparing IA with IV TXA for primary TKA. Primary outcomes included total blood loss (TBL) and drain output. Secondary outcomes included hidden blood loss (HBL), hemoglobin (Hb) fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time. RESULT In all, 34 RCTs involving 3867 patients were included in our meta-analysis. Significant advantages of IA were shown on TBL (MD = 33.38, 95% CI = 19.24 to 47.51, P < 0.001), drain output (MD = 28.44, 95% CI = 2.61 to 54.27, P = 0.03), and postoperative day (POD) 3+ Hb fall (MD = 0.24, 95% CI = 0.09 to 0.39, P = 0.001) compared with IV. There existed no significant difference on HBL, POD1 and POD2 Hb fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time between IA and IV. CONCLUSION Intra-articular administration of TXA is superior to intravenous in primary TKA patients regarding the performance on TBL, drain output, and POD3+ Hb fall, without increased risk of perioperative complications. Therefore, intra-articular administration is the recommended approach in clinical practice for primary TKA.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Renhao Ze
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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KARADUMAN ZO. Decreased blood loss with systemic and intraarticular tranexamic acid administration after total knee arthroplasty. KONURALP TIP DERGISI 2020. [DOI: 10.18521/ktd.650164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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