Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis

Impact of tranexamic acid use in total hip replacement patients: A systematic review and meta-analysis

Purpose

Tranexamic acid (TXA) dose in the context of primary complete hip replacements (THA) is still a hot debate about the best way to administer TXA. The need to select the most efficient and secure TXA dosing regimen, taking into account elements like perioperative bleeding, postoperative complications, and patient outcomes, has been emphasized by numerous studies. Improving clinical procedures and the general efficacy and safety of employing TXA in THA surgeries requires addressing this ongoing debate.

Methods

For this systematic review, We looked at the safety and efficacy of administering TXA intravenously (iTXA) and topically (tTXA) during THA. A thorough search turned up ten randomized controlled trials with 1295 individuals. Parameters evaluated included blood loss, Hb level on the day following surgery, transfusion rates, and drainage volume.

Results

Strategies had comparable impacts on deep vein thrombosis occurrences and wound complications. iTXA produced considerably less intraoperative blood loss (WMD = -12.687), concealed blood loss (WMD = 14.276), and the greatest hemoglobin drop (WMD = -0.400) when compared to tTXA.

Conclusion

Both administration techniques were secure and efficient in primary THA, although iTXA showed superior results in lowering blood loss and Hb decline.

Clearing the Smoke: The Evidence behind Risk of Electrocautery Smoke and Mitigation Strategies

Background

Electrocautery has been a useful, fundamental instrument utilized for surgical procedures since its implementation in the 1920s. However, concerns exist regarding the health hazards of the by-product smoke associated with the use of electrocautery.

Methods

A comprehensive review of articles on the composition, mitigation, and effects of smoke was conducted using the PubMed search engine and excluding articles that did not meet the predetermined inclusion criteria. From January 1963 to December 2021, a total of 264 articles resulted, and a total of 69 articles were included in this narrative review.

Results

Surgical smoke contains volatile organic compounds, polycyclic aromatic compounds, viral particles, and ultrafine particles. There has been some evidence of mutagenicity to bacterial cells during animal in vivo studies, and one human survey study has shown similar mutagenic effects. We also discuss additional hemostatic techniques that can be used, including the use of hemostatic and antithrombolytic agents, epinephrine infiltration, and the use of tourniquet when appropriate.

Conclusions

Further studies should be conducted regarding human effects, but until the data are available, we recommend precautionary measures and actions to protect operating room staff from cautery smoke exposure.

Topical Tranexamic Acid Does Not Reduce Hematoma in Reduction Mammaplasty: A Double-Blind Randomized Controlled Trial

BACKGROUND

Breast reduction mammaplasty is among the most common procedures in plastic surgery, with a 1% to 7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but it remains underused in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following breast reduction mammaplasty.

METHODS

A double-blind randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammaplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000 mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and the patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo breasts.

RESULTS

The overall hematoma rate was 1.5%. There was no significant association between application of TXA and development of a hematoma ( P = 0.56) or other complications. The hematoma rate of patients enrolled in the trial was similar to the overall rate of hematoma during the study period (1.5% versus 2.4%; P = 0.511). In a multivariate model, TXA was not significantly associated with differences in drain output after controlling for resection weight, age, and duration of drain use ( P = 0.799). No adverse effects or thromboembolic events from TXA were observed.

CONCLUSION

Topical application of TXA does not decrease the incidence of hematoma following reduction mammaplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Clinical Use of Tranexamic Acid in High Tibial Osteotomy: A Systematic Review and Meta-analysis

Background

High tibial osteotomy (HTO) can cause postoperative hemorrhage. The use of tranexamic acid to reduce the hemorrhage is still controversial.

Purpose

To investigate the efficacy and safety of tranexamic acid in HTO.

Study Design

Systematic review; Level of evidence, 4.

Methods

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors conducted a comprehensive search of the Embase, Cochrane Library, PubMed, Web of Science, MEDLINE, and Foreign Medical Literature Retrieval Service databases between their inception and January 1, 2023. All clinical studies comparing the use of tranexamic acid versus no tranexamic acid during HTO were collected. The primary outcome measures were hemoglobin decrease, drainage volume, and blood loss, and the secondary outcome measures were wound complications, blood transfusion, and postoperative thrombosis. All indicators were analyzed using meta-analysis software. Results were reported as mean differences or risk ratios with 95% confidence intervals.

Results

Of 152 initial results, 9 studies involving 908 patients were included. The tranexamic acid group had lower indicators for total blood loss, hemoglobin decrease, and total drainage volume (P < .00001 for all). There were no differences between patients with versus without tranexamic acid in wound complications, including hematoma (P = .21) or infection (P = .18), nor were there any group differences in the prevalence of blood transfusion (P = .21) or postoperative thrombosis (P = .36).

Conclusion

Tranexamic acid was able to effectively reduce postoperative hemorrhage in patients undergoing HTO without affecting the rates of wound complications, blood transfusion, or postoperative thrombosis.

Intravenous Versus Locally Injected Tranexamic Acid in a Fragility Hip Fracture Population: A Retrospective Review

OBJECTIVES

Evaluate differences between blood transfusion and complication rates among fragility hip fracture patients treated with locally injected (Local) versus intravenous (IV) tranexamic acid (TXA).

METHODS

Design: Retrospective comparative cohort.

SETTING

Tertiary referral orthopaedic specialty hospital; Level I trauma center.

PATIENT SELECTION CRITERIA

Patients aged 50 years and over who underwent surgical treatment for a proximal femur fragility fracture (Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 31A and 31B). Between March 2018 and April 2022 with or without the use of local TXA during wound closure or IV TXA.

OUTCOME MEASURES AND COMPARISONS

Postoperative blood transfusion, venous thromboembolism, surgical site infections, and 30-day readmissions compared between those who received IV TXA, Local TXA, and controls that did not receive any TXA.

RESULTS

Seven hundred forty-six patients (258 received IV TXA, 252 received Local TXA, and 236 controls that did not receive any TXA) were studied. Both Local and IV TXA groups received fewer blood transfusion versus controls. IV TXA was associated with a transfusion rate reduction of 12% compared with Local TXA ( P < 0.001). Regression analysis indicated that IV TXA reduced the odds of a postoperative blood transfusion by 48% compared with Local TXA ( P = 0.017). There were no differences in complication rates among the groups; however, patients receiving IV TXA had a significantly lower 30-day readmission rate (5%) than the control (13.9%) or Local (13.8%) TXA groups ( P = 0.001).

CONCLUSIONS

IV TXA significantly reduced the risk of postoperative transfusion compared with controls and patients receiving Local TXA. There was no increased risk of complications, and a lower 30-day readmission was observed for the IV TXA group. IV TXA seems to be a safe and effective way to reduce postoperative blood transfusion in patients with fragility hip fractures.

LEVEL OF EVIDENCE

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

[Role of Tranexamic Acid in Plastic Surgery: a Systematic Review]

BACKGROUND

Bleeding events in surgery are a problem and can lead to revision surgery and bleeding anaemia, which sometimes must be treated by blood transfusion. Tranexamic acid is an antifibrinolytic agent and is already known for its role in the prevention and treatment of perioperative bleeding in the fields of orthopaedics, cardiovascular surgery and gynaecology. In plastic surgery, the use of tranexamic acid is increasing in popularity and has already been described in individual studies.

METHODS

A literature search was performed using the database MEDLINE from the United States National Library of Medicine (NLM). The keywords "tranexamic acid in plastic surgery", "intravenous tranexamic acid in plastic surgery", "topical tranexamic acid in plastic surgery" and "subcutaneous tranexamic acid in plastic surgery" were used. The search was limited to the period from 2010 to 2023. The studies were analysed according to the level of evidence, validity and availability and divided into three groups for the topical, intravenous or subcutaneous application of tranexamic acid. Randomised controlled trials and non-randomised prospective and retrospective cohort studies were included in the systematic review. Studies from other disciplines, review articles, technical notes, experimental studies, letters to the editor, comments and case reports were excluded.

RESULTS

The literature search resulted in a total of 135 papers. Of these, 56 papers were assessed as relevant to plastic surgery. After further analysis, 41 papers were excluded using the exclusion criteria described above. Fifteen studies were finally included in the present work and recommendations for possible applications such as intravenous, topical and subcutaneous application of tranexamic acid, including the indications, contraindications and dosage formulas were developed.

DISCUSSION

Although the current study situation on the use of tranexamic acid is limited, the results show more advantages than disadvantages for perioperative use. Establishing the use of tranexamic acid in plastic surgery could facilitate the reduction of perioperative bleeding and lead to more precision in surgery, and it could enable a rapid removal of drains. However, following the analysis of benefit and risk factors, further randomised controlled trials are required for use in plastic surgery.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Effectiveness of Robotic Arm-Assisted Total Knee Arthroplasty on Transfusion Rate in Staged Bilateral Surgery

The transfusion rate in staged bilateral total knee arthroplasty (TKA) remains high despite the application of blood management techniques. The potential of robotic arm-assisted TKA (R-TKA) in reducing the transfusion rate in staged bilateral surgery has not yet been investigated. Therefore, we aimed to evaluate the effectiveness of R-TKA on transfusion reduction compared with conventional TKA (C-TKA) in staged bilateral surgery. This retrospective study involved two groups of patients who underwent 1-week interval staged bilateral TKA-the C-TKA group and the R-TKA group-using MAKO SmartRobotics (Stryker, Kalamazoo, MI, USA). Each group comprised 53 patients after propensity score matching and was compared in terms of nadir hemoglobin (Hb) level and transfusion rate after each stage of surgery. Both groups showed no significant differences in the propensity-matched variables of age, sex, body mass index, American Society of Anesthesiologists physical status score, and preoperative Hb level. The R-TKA group showed a significantly higher nadir Hb level than the C-TKA group after the second TKA (p = 0.002). The transfusion rate was not significantly different between the two groups after the first TKA (p = 0.558). However, the R-TKA group showed a significantly lower transfusion rate in the TKA (p = 0.030) and overall period (p = 0.023) than the C-TKA group. Patients who undergo staged bilateral R-TKA have lower transfusion rate than those who undergo C-TKA. R-TKA may be effective in minimizing unnecessary allogeneic transfusions in staged bilateral surgery.

The Efficacy of Tranexamic Acid for the Treatment of Traumatic Hip Fractures: A Network Meta-Analysis

OBJECTIVES

To compare the efficacy of different dosages of intravenous (IV) tranexamic acid (TXA) in the treatment of traumatic hip fractures against that of the control group of no TXA.

DATA SOURCES

This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to perform a network meta-analysis on the use of TXA for the treatment of hip fractures. The study team used Ovid MEDLINE, Cochrane Reviews, Scopus, Embase, and Web of Science databases to perform the search. Studies that were published in English between the years 2010 and 2020 were selected.

STUDY SELECTION/DATA EXTRACTION

For inclusion in this study, selected articles were required to be randomized controlled trials with at least 1 control group that had no antifibrinolytic intervention to serve as a control, and IV formulations of TXA were used as part of the treatment group. Furthermore, all study participants must have undergone surgical intervention for traumatic hip fractures. Studies that did not immediately meet criteria for inclusion were saved for a review by the full investigating team and were included based on consensus.

DATA SYNTHESIS

All statistical analyses conducted for this study were performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Network meta-analyses were conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R. The frequentist equivalent to surface under the cumulative ranking probabilities, termed " P score," was used to rank different treatments.

CONCLUSION

The use of TXA in the surgical management of traumatic hip fractures reduces the number of transfusions and perioperative blood loss, with minimal to no increased incidence of thrombotic events when compared with those in controls. When comparing formulations, no route of administration is clearly superior in reducing perioperative blood loss.

LEVEL OF EVIDENCE

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

Efficacy and safety of intravenous tranexamic acid in total shoulder arthroplasty: A meta-analysis

BACKGROUND

Total shoulder arthroplasty (TSA) results in a large amount of perioperative blood loss due to severe trauma.

AIM

To investigate the safety and efficacy of intravenous tranexamic acid (TXA) in TSA.

METHODS

We searched the PubMed, Cochrane Library, Embase and Web of Science databases for randomized controlled trials (RCTs) on the use of TXA in TSA. And all the results were checked and assessed by Reference Citation Analysis (https://www.referencecitationanalysis.com/). A meta-analysis was performed with Review Manager 5.3 to calculate the odds ratio (OR) or weighted mean difference (WMD) of related outcome indicators.

RESULTS

A total of 5 RCTs with level 1 evidence were included. There were 369 cases, with 186 in the TXA group and 183 in the placebo group. The meta-analysis showed that TXA can significantly reduce total blood loss during the perioperative period [WMD = -249.56, 95% confidence interval (CI): -347.6 to -151.52, P < 0.0001], and the incidence of adverse reactions was low (OR = 0.36, 95%CI: 0.16-0.83, P = 0.02). Compared with the placebo group, the TXA group had significantly less total haemoglobin loss (WMD = -34.39, 95%CI: -50.56 to -18.22), less haemoglobin fluctuation before and after the operation (WMD = -0.6, 95%CI: -0.93 to -0.27) and less 24-h drain output (WMD = -136.87, 95%CI: -165.87 to -106.49). There were no significant differences in the operation time (P = 0.11) or hospital length of stay (P = 0.30) between the two groups.

CONCLUSION

The application of intravenous TXA in the perioperative period of TSA can significantly reduce the total volume of perioperative blood loss and reduce the incidence of adverse reactions, so TXA is worthy of widespread clinical use.

Tourniquets can further reduce perioperative blood loss in patients on dexamethasone and tranexamic acid during cemented total knee arthritis: a single-center, double-blind, randomized controlled trial

BACKGROUND

Multiple doses of dexamethasone and tranexamic acid can inhibit postoperative inflammation and reduce fibrinolysis and perioperative blood loss in total knee arthroplasty. In this single-center, double-blind, randomized clinical trial, the aim was to investigate whether applying a tourniquet to patients on dexamethasone and tranexamic acid could further reduce perioperative blood loss.

MATERIALS AND METHODS

Patients who underwent cemented total knee arthroplasty at our hospital were randomized to receive a tourniquet (n = 71) or not (n = 70) during the procedure. All patients received multiple doses of dexamethasone and tranexamic acid perioperatively. The primary outcome was perioperative blood loss, while secondary outcomes were surgery duration, postoperative laboratory indices of inflammation and fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, and complications.

RESULTS

Using a tourniquet was associated with significantly lower intraoperative blood loss (P < 0.001) and total blood loss (P = 0.007) as well as significantly shorter surgery duration (P < 0.001). In contrast, the tourniquet did not significantly affect hidden blood loss, postoperative inflammation or fibrinolysis, range of knee motion, VAS pain score, knee circumference, knee swelling rate, homologous transfusion, albumin use, or complications.

CONCLUSIONS

The results of this randomized clinical trial demonstrate that applying a tourniquet during cemented total knee arthroplasty to patients receiving multiple doses of dexamethasone and tranexamic acid can further reduce perioperative blood loss without increasing the risk of inflammation, fibrinolysis, or other complications. Thus, it is advised to use tourniquets combined with dexamethasone and tranexamic acid to reduce perioperative blood loss and avoid tourniquet-related adverse events.

LEVEL OF EVIDENCE

Therapeutic Level I. Trial registration Chinese Clinical Trail Registry, ChiCTR2200060567. Registered 5 June 2022-retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=171291.

The Efficacy of Topical Tranexamic Acid in Femoral Neck Fractured Patients Undergoing Cemented Bipolar Hemiarthroplasty: A Randomized Double Blinded Controlled Trial

Objective  Tranexamic acid (TXA) is an antifibrinolytic that is widely used for decreasing blood loss and blood transfusion rates in total hip arthroplasty. However, there is limited evidence of topical TXA usage in hip hemiarthroplasty for femoral neck fractures. The present study aimed to evaluate the effects of topical TXA on blood loss and on blood transfusions in femoral neck fracture patients who underwent cemented bipolar hemiarthroplasty. Methods  Twenty-six patients with femoral neck fractures who were scheduled for bipolar cemented arthroplasty were randomized into two groups. The first group of 12 patients received topical TXA during their operation, whereas 14 patients in the second group received a placebo. Hematocrit was measured at 6 and 24 hours postoperatively. Blood transfusions and postoperative complications were also recorded. Results  Total blood loss was not different between the TXA group and the control group (TXA group: 459.48 ± 456.32 ml, and control group: 732.98 ± 474.02 ml; p  = 0.14). However, there were no patients within the TXA group who required a blood transfusion, while there were 4 patients in the control group who received allogenic blood transfusions ( p  = 0.044). There were no postoperative complications, such as wound complication, venous thromboembolism, or cardiovascular complications within either group. Conclusion  Topical TXA could not decrease total blood loss but was able to reduce transfusion rates in patients who underwent cemented bipolar hip hemiarthroplasty in femoral neck fractures. Further studies in doses of topical TXA in a larger sample size would be beneficial. Level of Evidence  II.

Benefits of Tranexamic Acid in Total Knee Arthroplasty: A Classification and Regression Tree Analysis in Function of Instrumentation, BMI, and Gender

Tranexamic acid (TXA) is an antifibrinolytic drug that reduces blood loss in patients that undergo Total knee arthroplasty (TKA). Few studies compare its effect on conventional instrumentation (CI) versus patient-specific instrumentation (PSI). The main objective of this study was to understand analytically how TXA usage in both instrumentations influenced blood loss in TKA differently and see if the differences seen could be explained by the patient's body mass index (BMI) and gender. This nonrandomized retrospective study sample consisted of 688 TKA procedures performed on patients who had symptomatic arthrosis resistant to conservative treatment. Descriptive analysis was used to evaluate blood loss using hemoglobin (Hb) mean values and mean variation (%). The Classification and Regression Tree (CRT) method was applied to understand how the independent variables affected the dependent variable. Comparing patients submitted to the same instrumentation, where some received TXA and others did not, patients that received TXA had lower blood loss. Comparing patients who underwent TKA with different instrumentations and without the use of TXA, it was found that patients who underwent TKA with PSI had lower blood loss than those who underwent TKA with CI. However, when these same instruments were compared again, but associated with the use of TXA, the opposite was true with patients undergoing TKA with PSI showing greater blood loss than patients undergoing TKA with CI. TXA usage in TKA is significantly beneficial in minimizing blood loss and regardless of instrumentation. When using TXA, the lowest blood loss was obtained in patients with higher BMI and submitted to TKA with CI. This is most likely explained by the synergistic antifibrotic effect of TXA with adipokines, such as plasminogen activator inhibitor-1 (PAI-1), found in the femoral bone marrow which is perforated using CI. If, however, TXA wasn't used, the lowest blood loss was obtained in patients submitted to TKA with PSI.

Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study

INTRODUCTION

Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used.

MATERIALS AND METHODS

2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded.

RESULTS

A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001).

CONCLUSION

In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

The Use of Tranexamic Acid in Hip Fracture Surgery-A Systematic Review and Meta-analysis

OBJECTIVES

To analyze the effect of intravenous tranexamic acid (TXA) on blood transfusion requirements in adult patients undergoing hip fracture surgery. Secondary aim was to evaluate the safety by assessing thromboembolic events.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Medline, PubMed, and Embase were searched for randomized controlled trials published in English from 2010.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled trials that analyzed the use of intravenous TXA on blood transfusion requirement in hip fracture surgery.

DATA EXTRACTION

Titles and abstracts were screened and assessed for eligibility by 2 independent reviewers. Quality and risk of bias was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach and the Cochrane risk-of-bias tool (RoB2).

DATA SYNTHESIS

Meta-analysis with random and fixed effect models was performed. Risk ratio (RR) was calculated for dichotomous outcomes and estimated with a 95% confidence interval (CI). For continuous data, the risk difference (RD) was estimated with a 95% CI.

RESULTS

A total of 13 trials involving 1194 patients were included. Pooled results showed that patients in the TXA group had significantly lower transfusion requirements (RR 0.50, 95%CI 0.30-0.84, P = 0.009). Similar findings were observed in the subcohort of patients with transfusion threshold of Hb < 8g/dL, (RR 0.42, 95%CI 0.31-0.56, P < 0.0001). This risk reduction was not observed in the subcohort of patients with transfusion threshold of Hb 8.1-10g/dL who received TXA (RR 0.77, 95%CI 0.51-1.18, P = 0.23) and no statistically significant differences were found for total thromboembolic events (RR 0.01, 95%CI -0.02-0.04, P = 0.47).

CONCLUSION

This meta-analysis demonstrated that intravenous TXA reduced blood transfusion rates and did not increase the risk of thromboembolic events.

LEVEL OF EVIDENCE

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

The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial

BACKGROUND

Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair.

METHODS

This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance.

RESULTS

There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery.

CONCLUSION

The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.

Local Infiltration of Tranexamic Acid During Facelift Improves Operating Room Efficiency: A Matched Patient Study

BACKGROUND

Tranexamic acid (TXA) has rapidly gained popularity in aesthetic surgery. Previous reports have suggested that TXA provides a dry surgical field and significantly reduces operating time during facelift surgery.

OBJECTIVES

The aim of this study was to build upon earlier findings by providing a large cohort matched alongside historic controls and more clearly document time saved when performing facelift surgery.

METHODS

A retrospective, single-surgeon case-control study was undertaken between July 2016 and October 2021. All patients underwent facelift surgery alone or in combination with fat transfer and perioral chemical peel. All patients received subcutaneous infiltration of 0.5% lidocaine/1:200,000 epinephrine with or without 1 or 2 mg/mL TXA. Patient demographics, TXA dose, surgical time, and minor and major complications were examined.

RESULTS

In total 145 consecutive patients were identified: 73 in Group 1 (no-TXA) and 72 in Group 2 (TXA). No differences in terms of gender distribution (P = 0.75), age (P = 0.54), BMI (P = 0.18), frequency of secondary rhytidectomy (P = 0.08), rate of ancillary lipografting (P = 0.44), TXA dose (P = 0.238), and minor complication rate (P = 0.56) were observed. However, mean surgical time in the no-TXA group was 21 minutes longer than in the TXA group (P = 0.016). Six patients (8%) in the no-TXA group experienced minor complications vs 8 patients (11%) in the TXA group. No patients experienced major complications.

CONCLUSIONS

Although previous studies have highlighted the potential benefits of TXA in aesthetic surgery, most of the data remain subjective and non-validated. This report adds to the objective body of evidence supporting TXA in facial aesthetic surgery by documenting time saved in the operating room without additional surgical morbidity.

LEVEL OF EVIDENCE: 4

Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials

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.

Total Knee Arthroplasty: Superiority of Intra-Articular Tranexamic Acid Over Intravenous and Cell Salvage as Blood Sparing Strategy – A Retrospective Study

Purpose

Total knee arthroplasty is associated with considerable perioperative hemorrhage. The decrease in hemoglobin concentration and the need for allogenic blood transfusion are related to increased morbidity and mortality. Strategies for minimizing perioperative bleeding are used, such as tranexamic acid and cell salvage. The study aimed to compare intravenous, intra-articular tranexamic acid and cell salvage protocols regarding perioperative hemoglobin variation. Secondary outcomes included blood loss; allogenic transfusions; complications and in-hospital stay.

Patients and Methods

Patients submitted to unilateral total knee arthroplasty between January and December 2018 were retrospectively evaluated. After excluding 62 patients, 204 were subdivided into 3 groups according to the protocol used. Statistical analysis was performed with SPSS version 26.0. One-way ANOVA and Kruskal–Wallis tests were used. Considered a p-value of <0.05 for statistical significance.

Results

Variation of hemoglobin in the intra-articular tranexamic acid group was significantly lower than that of intravenous (p < 0.001) and cell salvage (p = 0.001) groups. Blood loss, variation of hematocrit, need for blood transfusion and in-hospital stay were also statistically significantly lower in the intra-articular tranexamic acid group. The only related complications were in the intravenous tranexamic acid group. No thromboembolic complications were identified which further solidifies the safety of tranexamic acid administration.

Conclusion

This data shows superiority of the intra-articular administration of tranexamic acid over the other techniques in total knee arthroplasty. We propose this protocol as an efficient, low-risk blood-sparing strategy.

Intraoperative and Postoperative Iron Supplementation in Elective Total Joint Arthroplasty: A Systematic Review

INTRODUCTION

Postoperative anemia is associated with substantial morbidity and mortality in total joint arthroplasty (TJA). Our primary objective was to determine whether perioperative iron supplementation improves postoperative hemoglobin levels in TJA. Secondary objectives were to determine the effects of perioperative iron on adverse events, quality of life, and functional measures in TJA.

METHODS

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using six databases. We included English-language, randomized controlled trials investigating intraoperative or postoperative iron supplementation in elective TJA that reported postoperative hemoglobin levels in patients aged 18 years or older. Seven eligible studies were identified, among which substantial heterogeneity was noted. Bias risk was low in four studies, unclear in two studies, and high in one study. Three studies assessed oral iron supplementation, three assessed intravenous iron supplementation, and one compared oral and intravenous iron supplementation. All intravenous iron was administered intraoperatively, except in the oral versus intravenous comparison.

RESULTS

Postoperative oral iron supplementation had no effect on postoperative hemoglobin levels. Intraoperative and postoperative intravenous iron supplementation was associated with higher postoperative hemoglobin levels and greater increases in hemoglobin levels. Two studies reported rates of anemia and found that intraoperative and postoperative intravenous iron supplementation reduced rates of postoperative anemia at postoperative day 30. No adverse events were associated with iron supplementation. One study found that intravenous iron improved quality of life in TJA patients with severe postoperative anemia compared with those treated with oral iron. Perioperative iron had no effects on functional outcomes.

DISCUSSION

We found no evidence that postoperative oral iron supplementation improves hemoglobin levels, quality of life, or functional outcomes in elective TJA patients. However, intraoperative and postoperative intravenous iron supplementation may accelerate recovery of hemoglobin levels in these patients.

LEVEL OF EVIDENCE

Level I, systematic review of randomized controlled trials.

Hidden blood loss in direct anterior total hip arthroplasty: a prospective, double blind, randomized controlled trial on topical versus intravenous tranexamic acid

BACKGROUND

Despite a plethora of literature reporting on the use of tranexamic acid (TXA) in total hip arthroplasty (THA), little is available on its effect on post-operative hidden blood loss and even less on its use in the direct anterior approach (DAA), which is gaining popularity.

MATERIALS AND METHODS

This study was designed as a prospective, double blind, single centre, randomized controlled trial. Sixty patients were allocated to intravenous administration of 1.5 g of TXA just before wound closure while 60 patients were allocated to topical application of 3.0 g of TXA via a subfascial drain at the end of the procedure. Post-operative blood loss was (1) calculated via a well-established formula based on pre- and post-operative Hb levels, patients characteristics and intra-operative blood loss and (2) measured via the amount that collected in the subfascial drain over time.

RESULTS

No statistical significant difference in post-operative blood loss was found, neither when the formula was used (0.55 L [topical] vs 0.67 L [IV]; p = .140) nor when looking at the drain output (0.25 L [topical] vs 0.29 L [IV]; p = .108). No significant difference in secondary outcome measures, such as transfusion of units of packed red blood cells, length of hospital stay or the occurrence of venous thromboembolisms, could be found either.

CONCLUSIONS

This study provides detailed insights into the intra- and post-operative blood loss in DAA THA and shows that topical and IV TXA have similar effects on hidden blood loss. Clinical Trial Number: NCT01940692.

LEVEL OF EVIDENCE I

Level I-Randomized Controlled Trial.

Tranexamic Acid in Patients With Cancer Undergoing Endoprosthetic Reconstruction: A Cost Analysis

INTRODUCTION

Tranexamic acid (TXA) decreases blood loss, perioperative transfusion rates, and cost in total hip and total knee arthroplasty. In a previous study, topical TXA decreased both perioperative blood loss and transfusions in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. The purpose of this study was to explore the cost effectiveness of TXA in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction, assessing transfusion cost, TXA administration cost, postoperative hospitalization cost, posthospital disposition, and 30-day readmissions.

METHODS

This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic resection at a single academic medical center; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. The cost of 1 unit of packed red blood cells, not including administration or complications, was estimated at our institution. The cost of hospitalization was estimated for lodging and basic care. The cost of TXA was $55 per patient. Patients were followed up for 30 days to identify hospital readmissions.

RESULTS

Patients in the TXA cohort experienced a TXA and blood transfusion cost reduction of $155.88 per patient (P = 0.007). Proximal femur replacement patients experienced a $282.05 transfusion cost reduction (P = 0.008), whereas distal femur replacement patients only experienced a transfusion cost reduction of $32.64 (P = 0.43). An average hospital admission cost reduction of $5,072.23 per patient (P < 0.001) was associated with TXA use. Proximal femur replacement patients who received TXA experienced a hospital cost reduction of $5,728.38 (P < 0.001), whereas distal femur replacement patients experienced a reduction of $3,724.90 (P = 0.01). No differences between the cohorts were identified in discharge to home (P = 0.37) or readmissions (P = 0.77).

DISCUSSION

TXA administration is cost effective in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction through reducing both perioperative transfusion rates and postoperative hospitalization.

LEVEL OF EVIDENCE

III-Retrospective Cohort Study.

Tranexamic acid administration and pulmonary embolism in combat casualties with orthopaedic injuries

Objectives:

In combat casualty care, tranexamic acid (TXA) is administered as part of initial resuscitation effort; however, conflicting data exist as to whether TXA contributes to increased risk of venous thromboembolism (VTE). The purpose of this study is to determine what factors increase risk of pulmonary embolism after combat-related orthopaedic trauma and whether administration of TXA is an independent risk factor for major thromboembolic events.

Setting:

United States Military Trauma Centers.

Patients:

Combat casualties with orthopaedic injuries treated at any US military trauma center for traumatic injuries sustained from January 2011 through December 2015. In total, 493 patients were identified.

Intervention:

None.

Main Outcome Measures:

Occurrence of major thromboembolic events, defined as segmental or greater pulmonary embolism or thromboembolism-associated pulseless electrical activity.

Results:

Regression analysis revealed TXA administration, traumatic amputation, acute kidney failure, and hypertension to be associated with the development of a major thromboembolic event for all models. Injury characteristics independently associated with risk of major VTE were Injury Severity Score 23 or greater, traumatic amputation, and vertebral fracture. The best performing model utilized had an area under curve  = 0.84, a sensitivity=0.72, and a specificity=0.84.

Conclusions:

TXA is an independent risk factor for major VTE after combat-related Orthopaedic injury. Injury factors including severe trauma, major extremity amputation, and vertebral fracture should prompt suspicion for increased risk of major thromboembolic events and increased threshold for TXA use if no major hemorrhage is present.

Level of evidence:

III, Prognostic Study

Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations

Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.

The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis

OBJECTIVE

There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy.

METHODS

We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk.

RESULTS

Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373).

CONCLUSIONS

Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

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.

Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty

AIMS

The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA.

METHODS

This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo).

RESULTS

Mean total blood loss (TBL) in groups A (605.0 ml (SD 235.9)), B (790.9 ml (SD 280.7)), and C (844.8 ml (SD 248.1)) were lower than in group D (1,064.9 ml (SD 318.3), p < 0.001). We also found that compared with group D, biomarker level of inflammation, transfusion rate, pain score, and hip range of motion at discharge in groups A, B, and C were significantly improved. There were no differences among the four groups in terms of intraoperative blood loss (IBL), intramuscular venous thrombosis (IMVT), and length of hospital stay (LOS).

CONCLUSION

The combined application of CSS and TXA is more effective than TXA alone in reducing perioperative blood loss and transfusion rates, inflammatory response, and postoperative hip pain, results in better early hip flexion following THA, and did not increase the associated venous thromboembolism (VTE) events. Intravenous combined with topical injection of CSS was superior to intravenous or topical injection of CSS alone in reducing perioperative blood loss. Cite this article: Bone Joint Res 2021;10(6):354-362.

Improving the Female Silhouette and Gluteal Projection: An Anatomy-Based, Safe, and Harmonious Approach Through Liposuction, Suspension Loops, and Moderate Lipofilling

BACKGROUND

Liposuction is the main technique to improve body contour, emphasize appealing curves, and highlight one's muscular definition. The number of procedures in which the harvested fat is utilized for gluteal augmentation has greatly increased.

OBJECTIVES

The authors aim to demonstrate their technique in order to obtain a sculpted harmonious body through a safe procedure, as well as review their 101 consecutive cases between 2014 and 2018.

METHODS

Anatomical guidelines and preoperative markings were provided to guide the 3-step procedure: zones of maximal and mild liposuction, barbed wire suspension, and moderate fat grafting. Novel concepts are introduced as the anterior body diagonal, posterior body diagonal as well as other specific axes the pubic unit, and a vertical ratio for the buttock, which are the basic foundations for sculpting the female body into a pleasing hourglass shape with a well projected buttock. Recommendations for location of sacral diamond, sacral dimples, and the maximally projected point of the buttock are given. The authors explain their philosophy through 4 principles: knowledge of anatomy, the relationship between specific body areas and surrounding zones, a balanced gluteal augmentation is not achieved through large volume fat grafting alone, and grafting in the subcutaneous layer.

RESULTS

A total of 101 patients were treated following the described technique and examples are shown. The complication rate was low. No serious adverse effects were recorded apart from 1 ruptured suspension loop.

CONCLUSIONS

The described anatomy-based approach, including liposuction, suspension loops, and fat grafting, is a novel and safe technique leading to a desirable, long-lasting outcome.

LEVEL OF EVIDENCE: 4

Is there a role of tranexamic acid in rheumatoid arthritis with total knee arthroplasty? Findings from a multicenter prospective cohort study in China

BACKGROUND

Tranexamic acid (TXA) has proven to be effective in reducing the blood loss associated with total knee arthroplasty (TKA) in patients with osteoarthritis. However, there still exists a paucity of evidence regarding the effectiveness of intravenous TXA in patients with rheumatoid arthritis. The aim of this study was to explore the efficacy and safety of intravenous TXA on blood loss after TKA in Chinese patients with rheumatoid arthritis.

MATERIALS AND METHODS

A total of 405 patients with rheumatoid arthritis who had undergone TKA were categorized into two groups based on the protocol of TXA use. TXA group (n = 248): patients received 15 mg/kg TXA prior to operation. Control group (n = 157): patients received no TXA. The outcome measurements such as, total blood loss (TBL), intraoperative blood loss (IBL), hidden blood loss (HBL), transfusion, drainage, the timing of first ambulation, the length of stay (LOS), total hospitalization costs, the results of 12-Item Short Form Survey (SF-12), the incidence of thromboembolic events and other complications were recorded and compared.

RESULTS

The mean TBL, IBL, HBL, volume of transfusion and drainage were significantly lower in TXA group than in Control group. The rate of transfusion was significantly lower in TXA group than in Control group. There was a favorable effect in early ambulation for patients in TXA group, compared with patients in Control group. In addition, TXA group had shorter LOS, lower hospitalization costs and higher postoperative SF-12 score than Control group. The incidence of deep venous thrombosis and other complications did not differ between the two groups.

CONCLUSION

TXA can effectively diminish blood loss, reduce transfusion, shorten LOS and decrease hospitalization costs after TKA in Chinese patients with rheumatoid arthritis, without increasing the risk of complications.

The Combined Effect of Intravenous and Topical Tranexamic Acid in Liposuction: A Randomized Double-Blinded Controlled Trial

Background

Tranexamic acid (TXA) use in surgical procedures due to its hemostatic effects has been gaining an increased interest. In plastic surgery, the effects of TXA have been studied intravenously (IV), and there have been some reports regarding local use.

Objectives

A comparative study examining the combined effect of IV and local TXA was conducted.

Methods

A randomized double-blinded controlled trial was performed for patients undergoing breast reduction treatment with liposuction and resection following the power-assisted liposuction mammaplasty (PALM) technique. All patients received 5 mL IV of 0.5 g/5 mL TXA on induction. Before installation, one researcher prepared two solutions of 1 L normal saline: one with 5 mL of 0.5 g/5 mL TXA associated with epinephrine 1:100,000 and the other with only epinephrine 1:100,000. These were randomly infiltrated in either the left or right breast. Clinical dermal bleeding was assessed for both breasts after deepithelialization. The lipoaspirate from these breasts was then compared with each other. A postoperative evaluation at 24 hours was performed to compare the ecchymosis rate.

Results

Ratios of decanted volume to total lipoaspirate was measured in bottles and compared between breasts. There was a statistical difference (P = 0.0002) in the ratio of decanted to lipoaspirated volume when comparing the control group (ratio: 0.21) with the treatment group (0.13). Video analysis revealed decreased dermal bleeding in the TXA group and postoperative evaluation less ecchymosis.

Conclusions

The combined use of IV and local TXA can help reducing blood loss in liposuction as measured by decantation in separate drain bottles and as assessed clinically preoperatively and postoperatively.

Level of Evidence 2

Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty

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.

The influence of topical use of tranexamic acid in reducing blood loss on early operation for thoracolumbar burst fracture: a randomized double-blinded controlled study

Purpose

To investigate the safety and efficacy of topical use of tranexamic acid (TXA) on early operation for thoracolumbar burst fracture (TBF).

Methods

Patients with acute TBF requiring early decompression were prospectively collected. The enrolled patients were randomly assigned to TXA and control group, in which wound surface was soaked with TXA or the same volume of normal saline for 5 min after wound incision, respectively. The total blood loss (TBL), intraoperative blood loss (IBL), postoperative blood loss (PBL), hemoglobin (HGB) levels on preoperatively (pre-op) and postoperatively, and amount of allogenic blood transfusion were recorded. Furthermore, the general information was also compared between groups.

Results

There were 39 and 37 patients enrolled in TXA and control group for final analysis. The demographics data showed no significant difference between groups (P > 0.05), but operation time and IBL were significantly decreased in TXA group (P < 0.05). Further analysis showed that HGB level was significantly higher in the TXA group at POD1, while the TBL and PBL were significantly less than those in the control group (P < 0.05), but similar to HBL (P > 0.05). The postoperative ambulation time, removal time of drainage tube, length of hospital stay, and blood transfusion rate were also significantly less in TXA group (P < 0.05). At the final follow-up, no neurological deteriorations and no TXA-related complications were observed in both groups.

Conclusion

This RCT first demonstrated that topical TXA usage after wound incision could effectively reduce IBL without increasing risk of complications, beneficial to enhanced recovery after early operation for TBF.

Electronic supplementary material

The online version of this article (10.1007/s00586-020-06626-x) contains supplementary material, which is available to authorized users.

Tranexamic Acid Is Beneficial to Patients Undergoing Open-Wedge High Tibial Osteotomy

The purpose of this study was to investigate the efficacy of tranexamic acid (TXA) in patients undergoing open-wedge high tibial osteotomy (OWHTO). Patients from August 2018 to May 2020 were retrospectively studied. Clinical data were obtained including gender, age, height, weight, body mass index (BMI), smoking, alcohol consumption, hypertension, diabetes, history of aspirin, prepostoperative hematocrit (Hct) and hemoglobin (Hb), thrombotic events, blood transfusion requirement, hospital length of stay, size of osteotomy gap, and wound complications such as wound hematoma and infection. 52 patients were enrolled in the tranexamic acid group (TA group), and 48 patients were enrolled in the nontranexamic acid group (NTA group); there were no significant differences between both groups in terms of gender, age, BMI, preoperative Hb, size of osteotomy gap, incidence of smoking, alcohol consumption, hypertension, diabetes, history of aspirin, thrombotic events, blood transfusion requirement, and wound hematoma and infection. The mean hospital length of stay was 9.4 ± 1.0 days in the TA group and 11.0 ± 1.2 days in the NTA group (P < 0.001), the blood loss was 296.0 ± 128.7 ml in the TA group and 383.3 ± 181.3 ml in the NTA group (P < 0.05), and the postoperative Hb level was 120.8 ± 15.0 g/l in the TA group and 109.5 ± 13.8 g/l in the NTA group (P < 0.001). In conclusion, the administration of TXA is beneficial to patients undergoing OWHTO via decreasing hospital length of stay, reducing blood loss, and maintaining higher postoperative Hb levels.

Combined and intravenous administration of TXA reduces blood loss more than topical administration in primary total knee arthroplasty: A randomized clinical trial

AIM

To determine the most effective administration of tranexamic acid (TXA) in patients with primary total knee arthroplasty (TKA).

MATERIAL AND METHOD

We enrolled a total of 400 patients (154 men and 346 women) in this randomized trial (4 groups, each of 100 patients). The first group (IV1) had a single intravenous dose (15 mg TXA/kg) prior to skin incision. Group 2 (IV2) had TXA in 2 intravenous doses (15 mg TXA/kg): prior to skin incision and 6 hours after the first dose. Group 3 (TOP) had 2 g TXA in 50 mL of saline irrigated topically at the end of the surgery. The fourth group (COMB) combined IV1 and TOP regimens. We monitored the amount of total blood loss (TBL), haemoglobin drop, use of blood transfusions (BTs), and complications in each patient.

RESULTS

The amount of TBL was significantly lower in IV1, IV2 and COMB regimens compared to the TOP (P<0.0001). The lowest decrease in haemoglobin within 12 hours after surgery was observed in intravenous regimens (P=0.045). A significant difference in haemoglobin decrease on day 1 after the surgery was demonstrated in the COMB and intravenous regimens (P=0.011).

CONCLUSION

In primary TKA, it is preferable to administer TXA intravenously in two doses or in a combined regimen. Simple topical administration of TXA was not as effective and is indicated only in cases where systemic administration of TXA is contraindicated. No substantial complications occurred in either group of patients.

Is there a maximal effect of tranexamic acid in patients undergoing total knee arthroplasty? A randomized controlled trial

The optimal dosing regimen of tranexamic acid (TXA) has not been determined in total knee arthroplasty (TKA). In this study, patients were randomized to receive a high initial‐dose (60 mg/kg) TXA before incision, followed by five doses 3, 6, 12, 18, and 24 hours later (A), or three doses 3, 12, and 24 hours later (B), or a single dose 3 hours later (C). The primary outcome was perioperative blood loss. Other outcomes such as, hemoglobin level, transfusion, the levels of fibrin (ogen) degradation products (FDP), D‐dimer, C‐reactive protein (CRP) and interleukin‐6 (IL‐6), coagulation parameters, and adverse events were also compared. The results showed that individuals in Groups A and B had reduced total and hidden blood loss (HBL), lower FDP, D‐dimer, CRP, and IL‐6 levels than in Group C. Such differences were also detected in HBL between Groups A and B. No differences were observed in other outcomes between Groups A and B. No differences were observed in coagulation parameters and adverse events among the three groups. In conclusion, a high initial‐dose (60 mg/kg) TXA before TKA followed by three doses can be sufficient to achieve maximal effects on total blood loss, fibrinolysis, and inflammation.

Additional benefits of multiple-dose tranexamic acid to anti-fibrinolysis and anti-inflammation in total knee arthroplasty: a randomized controlled trial

BACKGROUND

Consensus is lacking regarding the dose and timing of tranexamic acid (TXA). The aim of this study was to determine whether multiple-dose intravenous TXA further reduced blood loss and attenuated inflammation after total knee arthroplasty (TKA).

MATERIALS AND METHODS

We prospectively studied four regimens on TXA: no TXA (A), before incision, 3, 6, and 12 h later (B), before incision, 3, 6, 12, and 18 h later (C) and before incision, 3, 6, 12, 18, and 24 h later (D). The primary outcome was hidden blood loss (HBL). Other outcome measurements such as total blood loss (TBL), intraoperative blood loss (IBL), fibrinolysis parameters [fibrin(-ogen) degradation products, D-dimer], inflammatory factors (C-reactive protein, interleukin-6), visual analog scale (VAS) score, transfusion rate, length of stay (LOS) and complications were also compared.

RESULTS

The mean HBL and TBL were significantly lower in Group D than in Groups C, B and A. The level of inflammatory factors and fibrinolysis parameters were significantly lower in Group D than in Groups C, B and A at 24 and 72 h postoperatively. The VAS score on postoperative days 1 and 3 (POD1 and POD3) was significantly lower in Group D than in Groups C, B and A. There was no significant difference in LOS among groups. No patient underwent blood transfusion. No episodes of deep venous thrombosis or pulmonary embolism occurred in all the groups.

CONCLUSION

The repeated doses of TXA up to 24 h can further diminish HBL, provide additional fibrinolysis and inflammation control and ameliorate postoperative pain following TKA.

LEVEL OF EVIDENCE

I.

Effectiveness of preemptive antifibrinolysis with tranexamic acid in rheumatoid arthritis patients undergoing total knee arthroplasty: a study protocol for a randomized controlled trial

BACKGROUND

Patients with rheumatoid arthritis (RA) who have undergone total knee arthroplasty are at increased risk of requiring a blood transfusion. This study is designed to compare the effects of preemptive antifibrinolysis of single-dose and repeat-dose tranexamic acid (TXA) in in RA patients undergoing total knee arthroplasty (TKA).

METHODS/DESIGN

The study will be a double-blind randomized controlled trial with two parallel groups of RA patients. Group A will be given 100 ml normal saline twice daily starting from 3 days before the operation, Group B will be given TXA 1.5 g twice daily starting from 3 days before the operation. All patients will be given TXA 1.5 g 30 min before the operation. The primary outcomes will be evaluated with total blood loss and hidden blood loss. Other outcome measurements such as, fibrinolysis parameters, inflammatory factors, visual analogue scale for post-operative pain, analgesia usage, coagulation parameters, transfusion, the length of stay (LOS), total hospitalization costs, the incidence of thromboembolic events and other complications will be recorded and compared. Recruitment is scheduled to begin on 1 August 2020, and the study will continue until 31 May 2021.

DISCUSSION

In current literature there is a lack of evidence with regard to the efficacy of TXA in RA patients. The findings of this study, whether positive or negative, will contribute to the formulation of further recommendations on the use of TXA in RA patients undergoing TKA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000029720 . Registered 14 February 2020.

Hidden blood loss and the influential factors after intramedullary nail fixation of extra-articular tibial fractures - a retrospective cohort study

PURPOSE

There were few reports in the literature about the hidden blood loss (HBL) after intramedullary nail (IMN) fixation for extra-articular tibial fractures. Our purpose was to evaluate the amount of hidden blood loss after intramedullary nail fixation for extra-articular tibial fractures, meanwhile, identified the influential factors causing HBL.

METHODS

From January 2015 to December 2017, 122 consecutive extra-articular tibial fracture patients fixed with IMN and 96 met all inclusion criteria for the chosen analysis. Preoperative hematocrit (Hct) levels on admission and postoperative Hct levels on the third day after surgery to calculate the amount of HBL.

RESULTS

The mean HBL was 473.29 ± 102.75 ml after IMN fixation of extra-articular tibial fractures, the multiple regression analysis showed gender, surgical duration, and the diameter of the medullary cavity at the narrowest part of the tibia had an independent influence on HBL.

CONCLUSIONS

A significant amount of postoperative HBL has occurred after IMN fixation of extra-articular tibial fractures. Surgeons should be aware that more HBL can be developed in patients who have male sex, small medullary cavity, and long-time surgical duration. HBL deserves attention to ensure patients' safety in the perioperative period of IMN fixation for extra-articular tibial fractures.

Does Intra-Wound Vancomycin Powder Affect the Action of Intra-Articular Tranexamic Acid in Total Joint Replacement?

The intra-articular use of tranexamic acid (TXA) has contributed to reduced blood loss in total joint arthroplasty (TJA). The purpose of this study is to assess the efficacy of simultaneously topical use of tranexamic acid and vancomycin powder within the TJA space. From 2016 to 2017, 219 consecutive total hip arthroplasties (THAs) and 272 total knee arthroplasties (TKAs) were performed in a tertiary care center, with a group of patients receiving intra-articular TXA and vancomycin, compared to patients receiving only TXA and to a control group that did not receive anything. Haemoglobin and hematocrit were measured preoperatively, on the first and third days. Transfusions and adverse events were recorded. Haemoglobin and hematocrit dropped significantly in all THA and TKA groups till the third day postoperatively, with a major reduction in the control group, compared to the other two treatment groups. Infections and thromboembolic events were similar in either group of the TJAs. In conclusion, the topical use of tranexamic acid mixed with the vancomycin powder within the joint space after the TJAs of the hip and knee did not alter the anti-fibrinolytic effect of TXA.

['Hip-in-a-Day']

BACKGROUND

In 2017, the average length of stay for primary hip replacement patients in Germany was 10.2 days. In our hospital, we have been able to reduce the length of stay in the last 10 years to an average of 3.8 days.

OBJECTIVES

Since September 2015, we offer the 'Hip-in-a-Day' program. This ultra-fast-track pathway consists of a hip arthroplasty procedure with the same day discharge of a well-prepared and explicitly selected patient with maximum intensive interdisciplinary care. The aim is to present the philosophy, treatment principles and daily routine during the pre-, intra- and postoperative phase. The challenges in the German health care system will be discussed.

MATERIAL AND METHODS

From September 2015 to November 2019, we operated on 97 patients (50 F: 47 M, ages: 43-77 years, ⌀ 55 years) who had undergone the Hip-in-a-Day pathway. All 97 patients received general anesthesia. Surgery was performed via the direct anterior approach (DAA) to the hip. Patients stayed in the day clinic less than 24 h after surgery. Of these, 30 patients were discharged on the day of surgery (⌀ 12 h stay), and 67 patients left the clinic the day after the operation (⌀ 20 h stay). Due to integrated health-care contracts with health-care providers, we were eligible to receive bundled reimbursement for this patient population.

RESULTS

All 97 patients completed the Ultra-Fast-Track pathway and were able to meet the discharge criteria within 24 h after surgery. 96 of the 97 (98.9%) patients were able to complete Hip-in-a-Day without readmission. One patient had to undergo revision surgery after 10 days due to cup loosening. All patients (100%) were very satisfied with the routine of the day and the fast discharge from the hospital.

CONCLUSION

The aim of Hip-in-a-Day is to discharge patients within 24 h after surgery. The implementation of the setup at the day clinic is intensive interdisciplinary care of all participating departments, as well as the three cornerstones of anesthesiological management, minimally invasive surgical techniques and patient compliance. In our clinic, ultra-fast-track arthroplasty is routinely feasible and has produced great patient satisfaction. Statutory health-care providers should include short-stay hip arthroplasty into the DRG system, so that this care concept can be reimbursed and practiced nationwide in Germany.

Comparison of Intravenous versus Topical Tranexamic Acid in Nondeformity Spine Surgery: A Meta-Analysis

OBJECTIVE

Tranexamic acid (TXA), an antifibrinolytic agent, interferes with fibrinolysis and has been used for many years to reduce blood loss during spine surgery. The purpose of our meta-analysis was to compare the effect of intravenous versus topical administration of TXA in patients undergoing nondeformity spine surgery.

METHODS

We searched multiple databases, including PubMed, Embase, the Cochrane library, CNKI, WanFang database, and VIP to find studies that met the inclusion criteria. A meta-analysis was performed according to the guidelines of the Cochrane Reviewer's Handbook.

RESULTS

Eight randomized controlled trials (RCTs) were identified, including 660 patients. The surgical methods used in the included studies were nondeformity spine surgery. No significant differences were found in the two groups regarding total blood loss, intraoperative blood loss, hidden blood loss, hematocrit, hemoglobin, fibrinogen, postoperative prothrombin time (PT), postoperative activated partial thromboplastin time (APTT), drainage volume, and blood transfusion rate. There were statistically significant differences in the two groups in terms of preoperative PT (MD = -0.39, 95% CI: [-0.63, -0.15], P=0.002) and preoperative APTT (MD = 1.12, 95% CI: [0.57, 1.68], P=0.002) and preoperative APTT (MD = 1.12, 95% CI: [0.57, 1.68].

CONCLUSION

During nondeformity spine surgery, intravenous administration of TXA did not have a significant effect on the decrease of blood loss and blood transfusion rate compared with the topical group. According to the pooled analysis of PT and APTT, intravenous and topical application of TXA may have different effects on the coagulation pathway. More high-quality RCTs are needed to explore the optimal dosage, method, timing in the future in order to recommend TXA widespread use in spine surgery.

The antifibrinolytic and anti-inflammatory effects of a high initial-dose tranexamic acid in total knee arthroplasty: a randomized controlled trial

PURPOSE

The aim of this study was to evaluate the effects of a high initial-dose (60 mg/kg) intravenous tranexamic acid (IV-TXA) on fibrinolysis and inflammation after total knee arthroplasty (TKA).

METHODS

A total of 132 patients were categorized into two groups based on different TXA regimens: 20 mg/kg before incision (A) or 60 mg/kg before incision (B). All patients received five doses of 1 g TXA at three, six, 12, 18, and 24 hours after the first dose. The primary outcomes were peri-operative blood loss and transfusion rate. Other outcome measurements such as, haemoglobin level, fibrinolysis parameters [fibrin(-ogen) degradation products (FDP), D-dimer], inflammatory factors [C-reactive protein (CRP), interleukin-6 (IL-6)], visual analog scale (VAS) score, consumption of analgesic rescue, coagulation parameters [activated partial thromboplastin time (APTT), prothrombin time (PT), platelet count, thrombelastography (TEG), and anti-factor Xa activity (AFXa)] and complications, were also compared.

RESULTS

There was a favourable effect in reducing peri-operative blood loss and transfusion rate for patients in Group B, compared with patients in Group A. In addition, the levels of FDP, D-dimer, CRP, IL-6, and dynamic pain in Group B were significantly lower than those in Group A on post-operative days one, two and three. There were no statistically significant differences in postoperative coagulation parameters and complications between the two groups.

CONCLUSION

A high initial-dose (60 mg/kg) IV-TXA before surgery followed by five doses can further reduce blood loss, provide additional fibrinolysis and inflammation control, and ameliorate post-operative pain following TKA, without increasing the risk of treatment-related complications.

Minimizing Blood Loss in Spine Surgery

STUDY DESIGN

Broad narrative review.

OBJECTIVE

To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery.

METHODS

A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery.

RESULTS

There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements.

CONCLUSION

As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.

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.

Is intravenous tranexamic acid effective and safe during hip fracture surgery? An updated meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy and safety of intravenous (IV) tranexamic acid (TXA) during hip fracture surgery remain controversial. This meta-analysis aimed to assess the efficacy of IV-TXA administration during hip fracture surgery for reducing the transfusion requirement and blood loss as well as its safety regarding the risk of thrombolysis.

MATERIALS AND METHODS

PubMed, EMBASE, Web of Science, and the Cochrane Library Database were systematically searched for randomized controlled trials (RCTs) that focused on the efficacy and safety of IV-TXA in patients during hip fracture surgery. The primary outcome was the transfusion requirement. Secondary outcomes included total blood loss (TBL), deep vein thrombosis (DVT), and total thromboembolic events (TTEs). Risk ratio (RR), risk difference (RD), and mean difference (MD) for dichotomous and continuous data outcomes were determined from the meta-analysis. Data were analyzed using Rev Man 5.3.

RESULTS

Altogether, 11 RCTs were included (total sample size 892 patients). IV-TXA significantly reduced the transfusion requirement [RR 0.60, 95% confidence interval (CI) 0.38-0.93, P = 0.02] and TBL (MD 326.64 ml, 95% CI - 462.23 to - 191.06, P < 0.00001) vs. cosntrol group. IV-TXA caused no increased risk of DVT (RD 0.02, 95% CI - 0.01 to 0.04, P = 0.13) or TTEs (RD 0.02, 95% CI - 0.01 to 0.05, P = 0.12).

CONCLUSION

Available evidence indicates that IV-TXA efficaciously reduces TBL and transfusion requirements during hip fracture surgery without significantly increasing the risk of TTEs including DVT.

Oral vs intravenous tranexamic acid in total-knee arthroplasty and total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

This study aimed to compare the efficacy and safety of oral tranexamic acid (TXA) with intravenous (IV) TXA in reducing perioperative blood loss in total-knee arthroplasty (TKA) and total-hip arthroplasty (THA).

METHODS

PubMed, Web of Science, Embase, and Cochrane Library were fully searched for relevant studies. Studies comparing the efficacy and safety of oral TXA with IV TXA in TKA and THA were included in this research. Odds ratio (OR) or risk difference (RD) was applied to compare dichotomous variables, while mean difference (MD) was used to compare continues variables.

RESULTS

A total of 7 studies (5 randomized controlled trials and 2 retrospective studies) were included into this study. As for patients undergoing TKA or THA, there were no obvious differences between oral TXA group and IV TXA group in hemoglobin (Hb) drop (MD = 0.06, 95% confidence interval [CI] = -0.01 to 0.13, P = .09), transfusion rate (OR = 0.78, 95% CI = 0.54-1.13, P = .19), total blood loss (MD = 16.31, 95% CI = -69.85 to 102.46, P = .71), total Hb loss (MD = 5.18, 95% CI = -12.65 to 23.02, P = .57), length of hospital stay (MD = -0.06, 95% CI = -0.30 to 0.18, P = .63), drain out (MD = 21.04, 95% CI = -15.81 to 57.88, P = .26), incidence of deep vein deep vein thrombosis (RD = 0.00, 95% CI = -0.01 to 0.01, P = .82) or pulmonary embolism (RD = 0.00, 95% CI = -0.01 to 0.01, P = .91). The sample size of this study was small and several included studies were with relatively low quality.

CONCLUSION

Oral TXA is equivalent to IV TXA in reducing perioperative blood loss and should be recommended in TKA and THA. More high-quality studies are needed to elucidate this issue.

Transfusions and cost-benefit of oral versus intravenous tranexamic acid in primary total hip arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to assess the cost benefit and transfusions of oral and IV tranexamic acid (TXA) in primary total hip arthroplasty (THA).

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) comparing oral and IV TXA in primary THA. Primary outcomes were total blood loss, maximum hemoglobin drop, transfusion requirements, and cost benefit. Secondary outcomes were length of stay, deep venous thrombosis (DVT) and/or pulmonary embolism (PE).

RESULTS

Four independent RCTs were included involving 391 patients. There was no difference in the total blood loss (P = .99), maximum hemoglobin drop (P = .73), and the length of stay (P = .95) between the 2 groups. Transfusion requirements (P = .97) were similar. The total mean cost was the US $75.41 in oral TXA group and the US $580.83 in IV TXA group. The incidence of DVT (P = .3) did not differ significantly between the 2 groups, and no PE was reported in all studies.

CONCLUSION

Oral TXA shows similar efficacy and safety as IV TXA in reducing total blood loss, maximum hemoglobin drop and transfusion requirements in primary THA. However, oral TXA may be more cost-benefit than IV TXA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Finding the Optimal Regimen for Oral Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Previous studies have confirmed that, compared with intravenous and intra-articular formulations, oral tranexamic acid (TXA) provides equivalent reduction in blood loss, at a substantially reduced cost and greater ease of administration. However, the optimal oral dosage regimen to achieve maximum blood-loss reduction remains unclear. The aim of this study was to assess the efficacy of a regimen of multiple doses of oral TXA on blood loss in primary total hip arthroplasty.

METHODS

In this randomized controlled trial, 200 patients were randomized to 1 of 4 interventions. Group A received a single dose of 2.0 g of TXA orally at 2 hours preoperatively. In addition to this same preoperative dose, Group B received 1.0 g of TXA orally at 3 hours postoperatively, Group C received 1.0 g of TXA orally at 3 and 9 hours postoperatively, and Group D received 1.0 g of TXA orally at 3, 9, and 15 hours postoperatively. All patients received a 1.0-g topical dose of TXA. The primary outcome was total blood loss. Secondary outcomes included hemoglobin reduction, transfusion rate, thromboembolic complications, and adverse events.

RESULTS

The mean total blood loss (and standard deviation) was significantly less in Groups B, C, and D (792.2 ± 293.0, 630.8 ± 229.9, and 553.0 ± 186.1 mL, respectively) than in Group A (983.6 ± 286.7 mL) (p < 0.001). Moreover, Groups C and D had a lower mean reduction in hemoglobin than did Groups A and B. However, no differences were identified between Groups C and D for blood loss and hemoglobin reduction. Additionally, no differences were observed among the groups regarding thromboembolic complications and transfusions.

CONCLUSIONS

The multiple postoperative doses of oral TXA further reduced blood loss compared with a single preoperative bolus. The regimen of a preoperative dose and 3 postoperative doses of oral TXA produced maximum effective reduction of blood loss in total hip arthroplasty.

LEVEL OF EVIDENCE

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