Tranexamic acid, given at the end of the operation, does not reduce postoperative blood loss in hip arthroplasty

Role of Tranexamic Acid in Controlling Blood Loss in Hemiarthroplasty of the Hip: A Prospective and Observational Study

INTRODUCTION

Tranexamic acid, an antifibrinolytic drug, is well-established for its efficacy in reducing intraoperative and postoperative blood loss in major orthopedic surgeries, particularly total knee replacement (TKR) and spine surgeries. However, there is limited research on the role of tranexamic acid in hemiarthroplasty of the hip. This study aims to investigate the efficacy of tranexamic acid in controlling blood loss in hemiarthroplasty of the hip.

OBJECTIVES

The primary objective was to analyze the pre- and postoperative changes in hemoglobin levels among patients undergoing hemiarthroplasty of the hip with and without intravenous tranexamic acid administration.

METHODS

A prospective observational study was conducted at the Department of Orthopedics of Government Medical College, Kannur, and St. Joseph's Hospital, Karuvanchal, Kannur. Patients undergoing hemiarthroplasty of the hip with 1 gm of intravenous tranexamic acid were compared with those without tranexamic acid. The sample size was calculated to be 33 in each group. Data were collected using a standardized proforma, entered into an Excel sheet (Redmond, USA), and analyzed using IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.

RESULTS

The study comprised mainly elderly females with a mean age of 74.84 ± 8 years. There was a significant reduction in postoperative hemoglobin drop, requirement for postoperative blood transfusion, and total drain output for the initial three postoperative days among patients who received intravenous tranexamic acid.

CONCLUSION

Preoperative administration of intravenous tranexamic acid significantly reduced postoperative hemoglobin drop and the need for postoperative blood transfusion in patients undergoing hemiarthroplasty of the hip. This highlights the efficacy and safety of tranexamic acid in controlling blood loss in this surgical setting.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis

BACKGROUND

Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care.

OBJECTIVES

To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology.

SEARCH METHODS

We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received.

MAIN RESULTS

We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials).

AUTHORS' CONCLUSIONS

We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.

The optimal regimen, efficacy and safety of tranexamic acid and aminocaproic acid to reduce bleeding for patients after total hip arthroplasty: A systematic review and Bayesian network meta-analysis

OBJECTIVES

We aimed to evaluate the optimal regimen, efficacy and safety of tranexamic acid (TXA) and aminocaproic acid (EACA) for patients after total hip arthroplasty (THA).

METHODS

The network meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. The outcomes were total blood loss, transfusion rates, hemoglobin (HB) drop, and risk for pulmonary embolism (PE) or deep vein thrombosis (DVT). Subgroup analyses were performed among most effective regimens to determine the influences of timing and number of doses.

RESULTS

A total of 56 eligible RCTs with different regimens were assessed. For reducing total blood loss, all high doses of TXA and EACA except high dose of intra-articular (IA) TXA, as well as medium dose of combination of intravenous and intra-articular (combined IV/IA) TXA were most effective. All high doses of TXA, as well as medium dose of combined IV/IA TXA did not show inferiority in reducing transfusion rates and HB drop compared with other regimens. No regimens showed higher risk for PE or DVT compared with placebo, and no statistical differences were seen among most effective regimens in subgroup analyses.

CONCLUSIONS

As effective as high doses of EACA and TXA, medium dose (20-40 mg/kg or 1.5-3.0 g) of combined IV/IA TXA was enough to control bleeding for patients after THA without increasing risk for PE/DVT. TXA was at least 5 times more potent than EACA. Timing and number of doses had few influences on blood conserving efficacy.

LEVEL OF EVIDENCE

Level I.

Can the prophylactic administration of tranexamic acid reduce the blood loss after robotic-assisted radical prostatectomy? Robotic Assisted Radical Prostatectomy with tranEXamic acid (RARPEX): study protocol for a randomized controlled trial

Background

The prophylactic administration of tranexamic acid reduces blood loss during procedures at high risk of perioperative bleeding. Several studies in cardiac surgery and orthopedics confirmed this finding. The aim of this prospective, double-blind, randomized study is to evaluate the effect of tranexamic acid on peri-and postoperative blood loss and on the incidence and severity of complications.

Methods/design

Based on the results of our pilot study, we decided to conduct this prospective, double-blind, randomized trial to confirm the preliminary data. The primary endpoint is to analyze the effect of tranexamic acid on perioperative and postoperative blood loss (decrease in hemoglobin levels) in robotic-assisted radical prostatectomy. The additional endpoint is to analyze the effect of tranexamic acid on postoperative complications and confirm the safety of tranexamic acid in robotic-assisted radical prostatectomy.

Discussion

No study to date has tested the prophylactic administration of tranexamic acid at the beginning of robotic-assisted radical prostatectomy. This study is designed to answer the question of whether the administration of tranexamic acid might lower the blood loss after the procedure or increase the rate and severity of complications.

Trial registration

ClinicalTrials.gov NCT04319614. Registered on 25 March 2020

THE USE OF ANTIFIBRINOLYTICS IN HIP TRAUMA SURGERY IN A PUBLIC HEALTH SYSTEM: A PROSPECTIVE STUDY

Objective:

To evaluate the use of tranexamic acid (TXA) and ε-aminocaproic acid (EACA) in reducing blood loss in hip and proximal femur trauma surgery.

Methods:

Prospective study with 49 patients surgically treated in a trauma hospital between Nov/2015 and Feb/2017. The patients were divided in two groups: TXA (n = 24) and EACA (n = 25). The comparison was made according to gender, age at the time of surgery, ASA, fracture and surgery type, estimated blood loss during surgical approach, hemoglobin and hematocrit levels pre and post-operative, and pharmacological cost. The data was processed using SPSS 22.0 with significance level of p < 0,05.

Results:

No significant difference was found in the variables age, gender, ASA and estimated blood loss during surgical approach. No patient needed blood transfusion. When evaluated post-operatively, the hemoglobin and hematocrit values decrease had no significant difference between the antifibrinolytics (p > 0.05). When analyzing total cost for both pharmacological agents, higher cost was observed in EACA than in TXA (US$ 16.09 - US$ 2.73), resulting in a US$ 13.36 addition per patient.

Conclusion:

Antifibrinolytic use was efficient on lowering the total blood loss, without the need of blood transfusion. Level of evidence II, Prospective Comparative Study.

Tranexamic acid in head and neck procedures: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

We conducted a meta-analysis of all randomized controlled trials (RCTs) that examined the benefits of tranexamic acid (TXA) among cancer patients undergoing head and neck (H&N) procedures.

METHODS

We screened five databases from inception until 20 June 2021 and evaluated the risk of bias of the eligible studies. We pooled continuous outcomes using the weighted mean difference (WMD) with 95% confidence interval (CI).

RESULTS

Five studies, comprising seven RCTs, met the inclusion criteria. This meta-analysis included a total of 540 patients; 265 and 275 patients were assigned to the TXA and control group, respectively. Overall, the included RCTs revealed a low risk of bias. The volume of postoperative bleeding was significantly lower in favor of the TXA group compared with the control group (n = 7 RCTs, WMD = - 51.33 ml, 95% CI [- 101.47 to - 1.2], p = 0.04). However, no significant difference was found between both groups regarding the volume of intraoperative bleeding (n = 6 RCTs, WMD = - 3.48 ml, 95% CI [- 17.11 to 10.15], p = 0.62), postoperative hemoglobin (n = 3 RCTs, WMD = 0.42 mg/dl, 95% CI [- 0.27 to 1.11], p = 0.23), duration of drainage tube removal (n = 4 RCTs, MD = - 0.41 days, 95% CI [- 1.14 to 0.32], p = 0.27), and operation time (n = 6 RCTs, WMD = 1.59 min, 95% CI [- 10.09 to 13.27], p = 0.79). TXA was safe and did not culminate in thromboembolic events or major coagulation derangements.

CONCLUSION

TXA administration is safe and significantly reduces the volume of postoperative bleeding. However, no difference is identified between TXA and control groups regarding the volume of intraoperative bleeding, postoperative hemoglobin level, duration of drainage tube removal, and operation time.

Safety and Efficacy of Using Tranexamic Acid at the Beginning of Robotic-Assisted Radical Prostatectomy in a Double-Blind Prospective Randomized Pilot Study

BACKGROUND

The prophylactic administration of tranexamic acid has been shown to be appropriate for procedures with a high risk of perioperative bleeding in cardiac surgery and orthopaedics. In urology the ambiguous results have been reported. Our goal was to evaluate the effect of tranexamic acid administration in robotic-assisted radical prostatectomy (RARP). A pilot, prospective, double-blind, randomized study was conducted to evaluate this effect.

METHODS

The study included 100 patients who received RARP in the period from April 2017 to January 2018. The patients were randomly assigned to study and control groups of 50 patients each.

RESULTS

The median follow-up was 6 months. Lower haemoglobin level drop weighted for gram of operated prostate was observed in the study group when treating the dorsal vein complex (DVC) at the beginning of the procedure (p = 0.004 after 3 hours and p < 0.001 after 24 hours). There was no evidence of any serious side effect of tranexamic acid.

CONCLUSION

We demonstrated the safety of tranexamic acid at RARP. In addition, we showed that administration of tranexamic acid at the beginning of RARP significantly reduces the decrease in haemoglobin after the procedure when treating the DVC at the beginning of the procedure.

The topical application of tranexamic acid to control bleeding in inguinal hernia surgery candidate patients: A randomized controlled trial

Background and objectives

Inguinal hernia surgery is a common procedure, especially for the elderly, who usually use anticoagulants and antiplatelet drugs. In this study, we evaluated the effectiveness of tranexamic acid (TXA) on the complications of inguinal hernia repair in patients using antiplatelets.

Patients and methods

This study is a randomized controlled trial that was performed during the 2018-2019 years. Forty patients with inguinal hernia and antiplatelet use were enrolled randomly into the two groups. In the intervention group, the patients received two injectable form (500mg/5 mL) of TXA, totally 10 mL as a topical application at the surgical site, and then the patient's surgical site was seen every 8 h for 48 h, and the patient was examined daily for one week.

Results

The mean length of hospitalization, seroma, hematoma and infection in the two groups were not statistically significant (P > 0.05). However, the duration of surgery in the TXA group was significantly shorter than in the control group (54.85 vs. 68.72 min) (P < 0.001). The mean bleeding during surgery was significantly lower in the TXA group than in the control group (P < 0.001).

Conclusion

The findings of present study indicate that topical TXA has a high ability to control bleeding. As a result, TXA is beneficial in terms of reducing bleeding and increasing the surgeon's satisfaction. Therefore, it is recommended that TXA be prescribed for patients requiring inguinal hernia surgery with a high risk of bleeding.

Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression

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.

Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures.

DESIGN

A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates.

RESULTS

A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route.

CONCLUSIONS

There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.

The use of tranexamic acid to reduce blood loss in uncemented total hip arthroplasty for avascular necrosis of femoral head: a prospective blinded randomized controlled study

Background

The purpose of this prospective, double-blinded, randomized controlled study is to assess the efficacy of administration of intravenous tranexamic acid (TXA) for reducing blood loss in uncemented total hip arthroplasty (THA) for the treatment of osteonecrosis of femoral head.

Methods

Between April 2012 and March 2014, 73 patients with avascular necrosis of femoral head were treated in our center. The patients were randomized and allocated to study group (n = 36; treated with TXA) and control group (n = 37). Intra- and postoperative blood loss, blood transfusion, and incidence of deep vein thrombosis were assessed. A p value less than 0.05 was considered statistically significant.

Results

The intraoperative, postoperative, and total (clinical method and Gross’ formula) blood loss were significantly greater in the control group (p < 0.05). On the first, second, and third postoperative days, the levels of hemoglobin and hematocrit were significantly better in the study group (p < 0.05). There was a significantly greater number of patients who required blood transfusion in the control group (p = .027). Deep vein thrombosis was not found in either group.

Conclusions

A single dose of TXA used preoperatively may minimize intraoperative, postoperative, and total blood loss in uncemented THA for the treatment of osteonecrosis of femoral head, and may not increase the risk of prothrombotic complications.

The Effect of Single High-Dose Preoperative Intravenous Tranexamic Acid Administration to Reduce Blood Loss in Patients with Primary Total Knee Replacement

Objectives:

This study aimed to analyze the efficacy of single-dose tranexamic acid (TA) 20 mg/kg preoperatively to reduce blood loss in patients undergoing total knee replacement (TKR).

Methods:

A total of 387 patients (82 males, 305 females) undergoing TKR between January 2014 and December 2018 were included in the study. The T + group was administrated intravenous (iv) TA 20 mg/kg 20 min before the skin incision. We determined perioperative blood loss, the amount of drainage postoperative 24 h, the amount of drainage after postoperative 24–48 h, total volume of drains, total volume of blood loss, postoperative hemoglobin and hematocrit levels, and amount of total blood transfusion.

Results:

In terms of demographic data, no statistically significant difference was observed between the groups. Perioperative blood loss and total volume of blood loss was found statistically higher in T − group compared to T + group. Postoperatively, the mean hemoglobin and hematocrit levels of T − group were statistically significantly lower than T + group.

Conclusion:

A single 20 mg/kg iv TA administration before TKR reduces bleeding during surgery and within 24 h postoperatively.

Use of Intravenous Tranexamic Acid to Reduce Allogeneic Blood Transfusion in Total Hip and Knee Arthroplasty: A Meta-analysis

Total hip or knee arthroplasty is associated with significant blood loss. Techniques such as the use of antifibrinolytics or desmopressin, or normovolaemic haemodilution have been used to reduce the need for allogeneic blood transfusion. Tranexamic acid has been used to reduce blood loss and transfusion requirement for total hip and knee arthroplasty, with variable results. This meta-analysis aims to evaluate whether intravenous tranexamic acid, when compared with placebo, reduces blood loss and transfusion requirement in total hip and knee joint replacement surgery and whether it might increase the risk of thromboembolic complications. The literature search was based on MEDLINE, EMBASE, Cochrane Controlled Trials Register, and information from the pharmaceutical company that produces tranexamic acid (Pharmacia-Upjohn). We identified 15 clinical trials and 12 were considered suitable for detailed data extraction. Tranexamic acid reduces the proportion of patients requiring allogeneic blood transfusion (OR 0.16, 95% CI: 0.09–0.26), total amount of blood loss (WMD 460 ml, 95% CI: 274–626 ml), and the total number of units of allogeneic blood transfused (WMD 0.85 unit, 95% CI: 0.36–1.33). Tranexamic acid does not increase the risk of thromboemobolic complications such as deep vein thrombosis, pulmonary embolism, thrombotic cerebral vascular accident, or myocardial infarction (OR 0.98, 95% CI: 0.45–2.12). Intravenous tranexamic acid appears effective and safe in reducing allogeneic blood transfusion and blood loss in total hip and knee arthroplasty.

Perioperative intravenous tranexamic acid reduces blood transfusion in primary cementless total hip arthroplasty

Background and aim of the work: Blood loss and transfusion requirements are common in total hip arthroplasty. Tranexamic acid is one of the most interesting options to reduce the need for blood transfusions in a variety of surgical settings. The aim of this study was to assess the efficacy of perioperative intravenous traxexamic acid regarding blood transfusion rate and volume of transfused blood without increasing adverse events after primary elective cementless total hip arthroplasty. Methods: A comparative retrospective study was conducted in 86 healthy patients who had undergone primary cementless total hip artrhoplasty for severe joint diseases at a single institution. All surgical procedures were performed through an anterolateral Watson-Jones approach with the patient in supine position. Forty patients (TXA group) received tranexamic acid 1g as an intravenous bolus 10 minutes before skin incision and a further 1 g, diluted in 250 mL of saline solution, in continuous perfusion at 30 mL/h, following commencement of the surgery. Forty-six patients (control group) did not receive TXA. Outcome measures included BT rate, volume of transfused blood, deep vein thrombosis and occurrence of pulmonary embolism. Results: BT rate was significantly less for the TXA group (37.5%) compared with the control group (65%; p=0.011). The mean blood volume transfused was also significantly less for the TXA group (240 mL) compared with the control group (450 mL; p=0.009). No adverse events occurred in any group. Conclusions: Perioperative intravenous tranexamic acid is effective in reducing blood transfusion rate and volume of transfused blood, without increasing the risk of thromboembolic events in patients undergoing primary cementless total hip arthroplasty. (www.actabiomedica.it)

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

Background

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

Methods

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

Results

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

Conclusion

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

Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials.

STUDY DESIGN AND METHODS

A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis.

RESULTS

A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not.

CONCLUSION

Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.

Optimal use of tranexamic acid for total hip arthroplasty: A network meta-analysis

Background

Tranexamic acid (TXA) has been demonstrated to minimize blood loss after total hip arthroplasty. There are three main routes: intravenous (IV), intra-articular (topical), and combined (IV and topical) but little consensus support which is most effective and safe. We performed network meta-analysis.to assess the comparative efficacy and safety of three different administration routes of TXA.

Methods

Twenty-five randomized controlled trials (RCT) were evaluated. Interventions were classified as: combined, IV multiple, IV single, topical and placebo. The primary outcome was effectiveness (transfusion rate, total blood loss, and total drain out). The secondary outcome was safety, based on the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE).

Results

A total of 2227 patients were included in the 5 categories: 564 IV single, 319 IV multiple, 398 topical, 120 combined, and 826 placebo. A network meta-analysis identified the most effective interventions in terms of reducing the need for transfusion as follows: combined = 98.2%, IV single = 54.0%, IV multiple = 78.6%, topical = 66.1%, placebo = 0.0%. Compared with placebo, the IV single, IV multiple, topical, and combined interventions showed no difference in the rate of occurrence of DVT and PE.

Conclusions

A network meta-analysis indicated that combined administration of TXA (IV and topical) was effective in reducing the transfusion rate after hip arthroplasty compared with IV or topical alone. As no high-risk patients were evaluated in the RCTs, it is not known whether the combined method is safer for patients susceptible to DVT or PE.

Is topical or intravenous tranexamic acid preferred in total hip arthroplasty? A randomized, controlled, noninferiority clinical trial

Purpose

The present study aimed to confirm the efficacy and safety of topical and intravenous tranexamic acid (TXA) compared with that of topical placebo and to assess the noninferiority between the two application methods of TXA in patients undergoing unilateral primary total hip arthroplasty.

Methods

Our randomized controlled trial investigated 170 patients with 1:1:1 allocation to two doses of 10-mg/kg intravenous TXA, 3-g topical TXA, and topical placebo of 60-ml physiological saline groups. The primary outcome, total blood loss, was calculated with Nadler and Gross formula. The secondary outcomes included allogeneic blood transfusion requirement, drain blood loss, decreased hemoglobin level. Noninferiority would be established when the upper limit 95% CI is lower than 250 ml of the noninferiority margin for the mean difference of total blood loss between topical and intravenous TXA. Thromboembolic complication incidence was considered as a safety outcome.

Results

The total blood loss of patients administered intravenous (mean±standard deviation, 1125±514 ml) and topical TXA (1211±425 ml) was significantly reduced compared with that of those administered topical placebo (1464±556 ml) (p = 0.0012). Drain blood loss and hemoglobin level reduction in patients administered with TXA were also significantly lower than those in patients administered topical placebo. The mean difference of total blood loss between topical and intravenous TXA is 86 ml (95% CI, −88 to 260 ml). The complications were comparable between patients managed with TXA and patients with topical placebo.

Conclusion

The noninferiority of topical TXA to intravenous TXA can not be concluded. Considering no significant difference was found in all efficacy outcomes between the two administration methods. Any of the two TXA administration methods can be adopted for blood loss prevention in total hip arthroplasty.

The Safety of Tranexamic Acid in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Tranexamic acid (TXA) is effective in reducing blood loss in total joint arthroplasty (TJA), but concerns still remain regarding the drug's safety. The purpose of this direct meta-analysis was to evaluate and establish a basis for the safety recommendations of the combined clinical practice guidelines on the use of TXA in primary TJA.

METHODS

A search was completed for studies published before July 2017 on TXA in primary TJA. We performed qualitative and quantitative homogeneity testing and a direct comparison meta-analysis. We used the American Society of Anesthesiologists (ASA) score of 3 or greater as a proxy for patients at higher risk for complications in general and performed a meta-regression analysis to investigate the influence of comorbidity burden on the risk of arterial thromboembolic event and venous thromboembolic event (VTE).

RESULTS

Topical, intravenous, and oral TXA were not associated with an increased risk of VTE after TJA. In addition, meta-regression demonstrated that TXA use in patients with an ASA status of 3 or greater was not associated with an increased risk of VTE after total knee arthroplasty.

CONCLUSION

Although most studies included in our analysis excluded patients with a history of prior thromboembolic events, our findings support the lack of evidence of harm from TXA administration in patients undergoing TJA. Moderate evidence supports the safety of TXA in patients undergoing total knee arthroplasty with an ASA score of 3 or greater. The benefits of using TXA appear to outweigh the potential risks of thromboembolic events even in patients with a higher comorbidity.

The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used to reduce blood loss in total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy of TXA in primary THA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty.

METHODS

A search was performed using Ovid-MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases to identify all publications before July 2017 on TXA in primary THA. We completed qualitative and quantitative homogeneity testing of all included studies. Direct and indirect comparisons were analyzed using a network meta-analysis followed by consistency testing of the results.

RESULTS

Two thousand one hundred thirteen publications underwent critical appraisal with 34 publications identified as representing the best available evidence for inclusion in the analysis. Topical, intravenous, and oral TXA formulations provided reduced blood loss and risk of transfusion compared to placebo, but no formulation was clearly superior. Use of repeat doses, higher doses, or variation in timing of administration did not significantly reduce blood loss or risk of transfusion.

CONCLUSIONS

Strong evidence supports the use of TXA to reduce blood loss and risk of transfusion after primary THA. No specific routes of administration, dosage, dosing regimen, or time of administration provides clearly superior blood-sparing properties.

Pharmacologic Hemostatic Agents in Total Joint Arthroplasty-A Cost-Effectiveness Analysis

BACKGROUND

Total knee and hip arthroplasties can be associated with substantial blood loss, affecting morbidity and even mortality. Two pharmacological antifibrinolytics, ε-aminocaproic acid (EACA) and tranexamic acid (TXA) have been used to minimize perioperative blood loss, but both have associated morbidity. Given the added cost of these medications and the risks associated with then, a cost-effectiveness analysis was undertaken to ascertain the best strategy.

METHODS

A cost-effectiveness model was constructed using the payoffs of cost (in United States dollars) and effectiveness (quality-adjusted life expectancy, in days). The medical literature was used to ascertain various complications, their probabilities, utility values, and direct medical costs associated with various health states. A time horizon of 10 years and a willingness to pay threshold of $100,000 was used.

RESULTS

The total cost and effectiveness (quality-adjusted life expectancy, in days) was $459.77, $951.22, and $1174.87 and 3411.19, 3248.02, and 3342.69 for TXA, no pharmacologic hemostatic agent, and EACA, respectively. Because TXA is less expensive and more effective than the competing alternatives, it was the favored strategy. One-way sensitivity analyses for probability of transfusion and myocardial infarction for all 3 strategies revealed that TXA remains the dominant strategy across all clinically plausible values.

CONCLUSION

TXA, when compared with no pharmacologic hemostatic agent and with EACA, is the most cost-effective strategy to minimize intraoperative blood loss in hip and knee total joint arthroplasties. These findings are robust to sensitivity analyses using clinically plausible probabilities.

Transfusion rate using intravenous tranexamic acid in hip revision surgery

INTRODUCTION

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

METHODS

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

RESULTS

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

INTERPRETATION

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

The Translational Potential of this Article

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

Tranexamic acid in total hip arthroplasty: Mixed treatment comparisons of randomized controlled trials and cohort studies

Background

The present study is a network meta-analysis of various routes of tranexamic acid (TXA) in patients with total hip arthroplasty (THA).

Methods

Randomized controlled trials and cohort studies evaluating TXA in patients with THA were included. Number of patients requiring blood transfusion was the primary outcome.

Results

Pooled estimate for TXA use against placebo for blood transfusion rate was 0.30 [0.23, 0.39] favoring TXA. Maximum reduction in the risk of blood transfusion was observed with topical plus intra-operative intravenous TXA.

Conclusion

Combined topical and intravenous TXA during surgery may perform better than other modes in patients undergoing THA.

Efficacy and safety of tranexamic acid in total hip replacement: A PRISMA-compliant meta-analysis of 25 randomized controlled trials

BACKGROUND

Hip osteoarthritis is one of the most prevalent musculoskeletal degenerative diseases in elderly. Total hip arthroplasty (THA) is the most effective surgical treatment for end stage hip osteoarthritis. Tranexamic acid (TA) is a potent drug to reduce surgical blood loss in surgery, therefore, as a potential drug for application in THA.

OBJECTIVES

To identify the combined efficacy of TA administration in THA. A meta-analysis including 25 randomized controlled trials was conducted for generating synthesized effects.

METHODS

This meta-analysis followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines for reporting systematic reviews and meta-analysis. A total of 25 Randomized controlled trials (RCTs) were included for meta-analysis.

RESULTS

The pooled results illustrated that total blood loss, intraoperative blood loss, postoperative blood loss, hemoglobin drop, transfusion rate, and average hospital stay were significantly lower than controls (standardized mean difference or odds ratio (OR) (95%CI): -0.87, (-1.13,-0.61), -0.68, (-0.96,-0.39), -1.41, (-2.24,-0.59), -1.11, (-1.63,-0.58), 0.28, (0.20,-0.38), -0.17, (-0.49,0.14), P < .05, respectively). Moreover, TA acts efficiently without increasing risk of thromboembolic events with OR = 1.14, 95%CI = 0.50-2.62, P = .75. Subgroup analysis indicated no statistically significant differences between a higher dose of topical TA (≥2 g or 15 mg/kg) or a lower dose (<2 g or 15 mg/kg).

CONCLUSION

The findings indicated that TA is clinically effective and safe in patients receiving total hip arthroplasty.

Transfusion rate using intravenous tranexamic acid in hip revision surgery

INTRODUCTION

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

METHODS

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

RESULTS

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

INTERPRETATION

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

Effect of Tranexamic Acid on Transfusion: A Randomized Clinical Trial in Acetabular Fracture Surgery

OBJECTIVES

Given the increasing evidence that minimizing blood loss and limiting allogeneic transfusion can improve patient outcome, we are performing a randomized controlled trial of the use of tranexamic acid (TXA) during acetabular fracture surgery.

DESIGN

Prospective, multicenter, and randomized.

SETTING

Two level I trauma centers.

PARTICIPANTS

Eighty-eight patients underwent randomization, with 42 assigned to the TXA group and 46 assigned to the placebo group.

INTERVENTION

The use of TXA during acetabular fracture surgery.

MAIN OUTCOME MEASUREMENTS

The primary outcome was allogeneic blood transfusion. Secondary outcomes consisted of estimate blood loss (EBL) and venous thromboembolism (VTE).

RESULTS

The overall transfusion rate was 40.9% (36 of 88), and the average estimated blood loss was 635 mL. There were no significant differences between groups for transfusion incidence, number of units transfused, EBL, or incidence of VTE. There was no difference in transfusion rate for the TXA group (0.097). Transfusion was significantly more likely in cases with low preoperative hemoglobin levels, higher rates of intraoperative blood loss, and longer surgical times.

CONCLUSIONS

There was no significant difference in transfusion rate, EBL, or VTE for TXA versus placebo. Any potential benefit seems to be overwhelmed by other factors, specifically preoperative anemia and surgical time, which are highly variable in trauma surgery. These findings do not support the routine use of TXA in the setting of open reduction and internal fixation of acetabular fractures.

LEVEL OF EVIDENCE

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

Clinical and instrumental evaluation of two different regimens of tranexamic acid in total hip arthroplasty: a single-centre, prospective, randomized study with 80 patients

PURPOSE

The use of tranexamic acid (TXA) in total hip arthroplasty (THA) can significantly reduce blood losses with many clinical and economical advantages. However, no consensus has been reached regarding the optimal regimen for TXA administration. The aim of this study is to analyse and compare the haemostatic effect of two different intravenous (IV) regimens of TXA.

MATERIALS AND METHODS

We planned a single-centre, prospective, randomized study including 80 patients who underwent primary unilateral minimally invasive THA because of a hip osteoarthritic degeneration. We divided patients into two groups: the G10 group received two IV doses of 10 mg/kg of TXA, and the G20 group received two doses of 20 mg/kg.

RESULTS

No significant differences in mean minimum levels of Hb and HcT stratified by days after surgery were uncovered between the two groups despite the use of two different dosages of TXA. Also the mean blood volume loss was statistically similar between two groups. No differences were also observed regarding the occurrence of adverse effects.

CONCLUSIONS

In two IV bolus regimens of TXA administration, the use of a dose of 10 or 20 mg/kg provides statistically similar results in blood loss sparing. Therefore, the use of two 10 mg/kg doses could be considered more advisable in order to reduce the potential thromboembolic risks related to this drug.

Tranexamic acid in total hip arthroplasty: A recursive cumulative meta-analysis of randomized controlled trials and assessment of publication bias

INTRODUCTION

TXA has been evaluated in THA in several randomized controlled trials for the past 16 years. We attempted to evaluate the trends in the evidence using recursive cumulative meta-analysis and publication bias using Rosenthal and 'Trim and Fill' methods.

METHODS

Electronic databases were searched for randomized controlled clinical trials comparing TXA with either placebo (or no TXA administration) or TXA, administered through different routes in patients with osteoarthritis or osteonecrosis of the hip who underwent THA. We considered the total number of patients requiring blood transfusion as the clinical outcome for both the analyses and used quality effects model for assessing the changes in the pooled estimates with addition of new clinical trial data. We also assessed the publication bias by plotting individual study estimates with the standard errors using Rosenthal and 'Trim and Fill'methods.

RESULTS

A total of 20 studies were included. The pooled cumulative meta-analysis indicates that from 2014 the addition of estimate from new studies in the following years is only narrowing the confidence interval without any significant change in the point estimate. Rosenthal fail-safe-N for the comparisons of intravenous bolus TXA, intra-operative and post-operative intravenous TXA and topical with control groups were 54, 6 and 16 respectively. Fail-safe-N for the combined intravenous and topical TXA with intravenous TXA alone was 13.

CONCLUSION

Adequate evidence exists supporting the use of intravenous TXA in reducing the need for blood transfusion in THA. There is possible existence of small studies with null effects evaluating the use of TXA in THA.

OBTAIN A: Outcome Benefits of Tranexamic Acid in Hip Arthroplasty. A Randomized Double-Blinded Controlled Trial

BACKGROUND

We examined whether the blood conserving effect of tranexamic acid (TXA) in total hip arthroplasty using the direct anterior approach, translates to an effect on functional outcomes in the perioperative period.

METHODS

We conducted a single-center, randomized, double-blinded, placebo-controlled trial. One hundred one patients were randomized to receive either TXA or an equivalent volume of normal saline. The primary outcome measure was thigh swelling. Secondary outcome measures included, visual analogue pain score, timed up and go test, a 10 meter walk test, and length of stay. Blood loss and the incidence of blood transfusions were also recorded.

RESULTS

There were no statistically significant differences between the primary outcome of thigh swelling or the secondary outcome measures of postoperative pain nor mobility. There was a significant reduction in length of stay for those that received TXA 3.58 days (0.84) compared with the control group 4.27 days (0.98) (P < .001). There was significantly less intraoperative blood loss observed in the TXA group (0.460L SD 0.228) compared with the control group (0.687L SD 0.283L) (P < .001). The estimated blood loss was also significantly less in the TXA group (1.084L SD 0.440) compared with the control group (1.394 L SD 0.426).

CONCLUSION

TXA is an effective agent in reducing blood loss in total hip arthroplasty using the anterior approach. The blood conserving effect of TXA was not associated with improved postoperative recovery across the measures of pain and mobility. Administration of TXA may have a positive effect on reducing the duration of inpatient stays.

Chemical Thromboprophylaxis Is Not Necessary to Reduce Risk of Thromboembolism With Tranexamic Acid After Total Hip Arthroplasty

BACKGROUND

The major concern with the use of tranexamic acid is that it may promote a hypercoagulable state and increase the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), particularly when chemical thromboprophylaxis is not used. The objective of this study was to ascertain whether tranexamic acid reduces blood loss and transfusion amounts and increases the prevalence of DVT and PE in the patients undergoing primary cementless total hip arthroplasty (THA) without the use of routine chemical thromboprophylaxis.

METHODS

There were 480 patients (582 hips) in the control group who did not receive tranexamic acid and 487 patients (584 hips) in the study group who received tranexamic acid. Mechanical compression device was applied without any chemical thromboprophylaxis. Transfusion rates and volumes were recorded. DVT was diagnosed using both sonogram and venogram at 7 or 8 days postoperatively. All patients had pre- and postoperative perfusion lung scanning to defect pulmonary embolism (PE).

RESULTS

Intraoperative (614 vs 389 mL) and postoperative blood loss (515 vs 329 mL) and transfusion volumes (3 units vs 1.5 units) were significantly lower (P < .001) in the tranexamic acid group. The prevalence of DVT was 15% (87 of 582 hips) in the control group and 18% (105 of 584 hips) in the tranexamic acid group. No fatal PE occurred in either group.

CONCLUSION

The use of tranexamic acid reduces the volume of blood transfusion and does not increase the prevalence of DVT or PE in the patients who did not receive routine chemical thromboprophylaxis after primary cementless THA.

Safety, Efficacy, and Cost-effectiveness of Tranexamic Acid in Orthopedic Surgery

Perioperative bleeding and postsurgical hemorrhage are common in invasive surgical procedures, including orthopedic surgery. Tranexamic acid (TXA) is a pharmacologic agent that acts through an antifibrinolytic mechanism to stabilize formed clots and reduce active bleeding. It has been used successfully in orthopedics to reduce perioperative blood loss, particularly in total hip and knee arthroplasty and spine surgery. Numerous research studies have reported favorable safety and efficacy in orthopedic cases, although there is no universal standard on its administration and its use has not yet become the standard of practice. Reported administration methods often depend on the surgeon's preference, with both topical and intravenous routes showing efficacy. The type and anatomic site of the surgery seem to influence the decision making but also result in conflicting opinions. Reported complication rates with TXA use are low. The incidence of both arterial and venous thromboembolic events, particularly deep venous thrombosis and pulmonary embolism, has not been found to be significantly different with TXA use for healthy patients. The route of administration and dosage do not appear to affect complication rates either. However, data on patients with higher-risk conditions are deficient. In addition, TXA has shown potential to reduce blood loss, transfusion rates and volumes, perioperative hemoglobin change, and hospital-related costs at various degrees among the published studies. Conservation of blood products, reduced laboratory costs, and shorter hospital stays are likely the major factors driving the cost savings associated with TXA use. This article reviews current data supporting the safety, efficacy, and cost-effectiveness of TXA in orthopedic surgery.

Use of tranexamic acid in dynamic hip screw plate fixation for trochanteric fractures

PURPOSE

To evaluate perioperative blood loss and blood transfusion requirement in patients who underwent dynamic hip screw plate fixation for a stable trochanteric fracture with or without preoperative intravenous tranexamic acid (TXA).

METHODS

49 men and 11 women (mean age, 56.5 years) who underwent open reduction and internal fixation with a dynamic hip screw plate for a stable trochanteric fracture by a single surgeon were equally randomised to receive either a single dose of intravenous TXA (15 mg/kg) 15 minutes prior to surgery or an equal volume of normal saline by slow infusion. Intra- and post-operative blood loss and the need for blood transfusion were assessed, as was any thromboembolic adverse event.

RESULTS

The TXA and control groups were comparable in terms of age, gender, body mass index, blood pressure, pulse rate, time from injury to surgery, operating time, and preoperative haematological data. Blood loss was lower in the TXA than control group intraoperatively (320.3 vs. 403.33 ml, p<0.001), during 0 to 24 hours (61.67 vs. 186.67 ml, p<0.001), and during 24 to 48 hours (27 vs. 86.67 ml, p<0.001), as well as the total volume (408.97 vs. 676.67 ml, p<0.001). Respectively for the TXA and control groups, 27 and 30 required 28 and 41 units of blood intra-operatively (p<0.001), and 6 and 15 required 6 and 15 units of blood postoperatively (p=0.014). No patient had any thromboembolic adverse event.

CONCLUSION

TXA is safe and effective in reducing blood loss in dynamic hip screw plate fixation for stable trochanteric fractures.

A systematic review and meta-analysis of the use of antifibrinolytic agents in total hip arthroplasty

BACKGROUND

Antifibrinolytic agents such as tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and aprotinin are widely used to reduce bleeding and the need for transfusion in cardiac, orthopaedic, and hepatic surgery. We aimed to assess the efficacy and safety of antifibrinolytic agents in total hip arthroplasty (THA).

METHODS

A systematic literature search was performed using MEDLINE, PubMed, EMBASE, and Cochrane databases, as well as the reference lists of relevant articles. Only randomised controlled trials were eligible for this study. The weighted mean difference in blood loss, number of transfusions per patient, and the summary risk ratio of transfusion requirements and deep-vein thrombosis (DVT) were calculated in the antifibrinolytic agents-treated and control groups.

RESULTS

A total of 28 randomised controlled trials involving 2,131 patients were included. Patients receiving antifibrinolytic agents had a reduced total blood loss by a mean of 389.14 ml (95% CI, -483.05 to -295.23), and the number of blood transfusions per patient by 0.65 units (95% CI, -1.19 to -0.12). Antifibrinolytic agents led to a significant reduction in transfusion requirements (RR 0.55; 95% CI, 0.43 to 0.70) and no increase in the risk of DVT (RR 0.85; 95% CI, 0.51 to 1.42).

CONCLUSIONS

Our meta-analysis demonstrated that antifibrinolytic agents significantly reduce blood loss and blood transfusion requirements while not increasing the risk of DVT in patients undergoing total hip arthroplasty.

Meta-analysis of Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty

Previous meta-analyses established that tranexamic acid confers benefits when used during total hip arthroplasty (THA). However, 2 of these meta-analyses included a variety of routes of administration of tranexamic acid in THA (topical, intravenous, oral, and intra-articular), another meta-analysis included a variety of antifibrinolytic drugs (not restricted to a single drug), and the final meta-analysis included nonrandomized controlled trials. This meta-analysis focused on a single medication, tranexamic acid, administered in a specific way, intravenously in patients undergoing primary THA, using data reported only in randomized controlled studies. Outcomes were restricted to blood loss, allogeneic transfusion rates, and complications. Other outcomes, such as return to function or clinical scores, could not be evaluated because of lack of consistent reporting. To better understand the effects of intravenous tranexamic acid in THA on clinical outcomes, such as recovery, return to function, and patient-reported outcome measures, it would be helpful to have more controlled trials examining these measures in a standardized manner. Intravenous tranexamic acid was beneficial for blood loss intraoperatively, blood loss through drains, and total blood loss during hospitalization, in addition to reducing allogeneic transfusion rates. No difference between intravenous tranexamic acid and placebo was found for most complications, except deep venous thrombosis, which showed favorable results with placebo. [Orthopedics.2016; 39(5):e883-e892.].

Single-dose tranexamic acid for reducing bleeding and transfusions in total hip arthroplasty: A double-blind, randomized controlled trial of different doses

BACKGROUND

Tranexamic acid can be effective at decreasing blood loss and transfusion requirements associated with total hip arthroplasty (THA), but few studies have compared the efficacy of different intravenous dosing regimes. This double-blind, randomized controlled trial compared the ability of two doses of intravenous TXA (IV-TXA, 10 or 15mg/kg) to reduce bleeding and transfusions associated with THA.

MATERIALS AND METHODS

A total of 124 patients scheduled for THA were consecutively randomized 1:1:1 into three parallel arms: control (placebo), 10mg/kg IV-TXA and 15mg/kg IV-TXA.

RESULTS

The proportion of patients who experienced bleeding and required transfusions was significantly lower in the 15mg/kg IV-TXA group (1 of 42, 2.4%) than in the 10mg/kg IV-TXA group (8 of 39, 20.5%; P=0.012) and in the control group (10 of 38, 26.3%; P=0.002). In fact, this proportion was similar between the 10mg/kg IV-TXA and control groups (P=0.547). Ultrasound examination on postoperative day 3 revealed only one case of asymptomatic deep vein thrombosis (in the femoral vein) in the 10mg/kg IV-TXA group, which was managed by administering low-molecular-weight heparin. No cases of deep-vein thrombosis were observed in the other two groups. No cases of symptomatic pulmonary embolism were observed.

CONCLUSION

IV-TXA at 10mg/kg significantly reduced blood loss and mitigated the decrease in hemoglobin and hematocrit after THA, but it did not significantly reduce the need for transfusions. In contrast, a dose of 15mg/kg reduced both bleeding and transfusion requirements. Our results argue for a dose of 15mg/kg when using single-dose IV-TXA.

LEVEL OF EVIDENCE

Therapeutic Level I.

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

BACKGROUND

Tranexamic acid has been reported to be safer with topical administration than with intravenous administration in total knee arthroplasty. However, the most effective administration route of tranexamic acid in total hip arthroplasty remains controversial. This study compared the effectiveness of topical tranexamic acid administration with that of intravenous tranexamic acid administration in total hip arthroplasty.

METHODS

We retrospectively examined the medical records of 886 patients with osteoarthritis of the hip joint, who had undergone unilateral primary total hip arthroplasty. The patients were divided into a control group (n = 302; did not receive tranexamic acid), topical group (n = 265; topically administered 2 g tranexamic acid in 30 mL normal saline via drain tubes placed in the joint before wound closure along with posterior soft tissue repair), and intravenous group (n = 319; intravenously administered 1 g tranexamic acid before skin incision along with posterior soft tissue repair). Data on blood loss, hemoglobin levels, transfusion rates, and occurrence of deep vein thrombosis and pulmonary embolization were collected.

RESULTS

The mean operation times were approximately 40 min in all of the groups. The operation time and intra-operative blood loss were significantly lower in the control group than in the topical and intravenous groups. However, the post-operative blood loss, total blood loss, and decrease in the hemoglobin level were significantly higher in the control group than in the topical and intravenous groups. There were no significant differences in terms of blood loss and systemic complications between the tranexamic acid administration methods.

CONCLUSIONS

Tranexamic acid reduces both post-operative and total blood loss in total hip arthroplasty. Moreover, a lower amount of tranexamic acid can be used to reduce blood loss in total hip arthroplasty with intravenous tranexamic acid administration than with topical tranexamic acid administration. Therefore, we suggest that tranexamic acid should be intravenously administered pre-operatively and the posterior soft tissue should be repaired to decrease total hip arthroplasty-related complications.

The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study

Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in elective lower limb arthroplasty surgery. There are potentially even greater physiological benefits in minimising blood loss in hip fracture surgery, however limited evidence exists for TXA use in hemiarthroplasty surgery. This study investigates the effect of TXA use on postoperative transfusion rates and haemoglobin (Hb) levels specifically following hemiarthroplasty surgery for hip fractures. A retrospective cohort study was conducted for consecutive hip hemiarthroplasties for fractures between June 2013 and October 2014 comparing patients with or without prophylactic TXA before incision. During the study, 305 hemiarthroplasties were performed with 271 cases eligible. TXA was given in 84 (31%) cases, and both patient groups were matched for known confounding factors. Patients given TXA had a lower transfusion rate (6% vs. 19%. p=0.005) and less blood loss (Hb drop>20g/L) on day 1 post surgery (26% vs. 42%; p=0.014). One transfusion was prevented with every 8 patients given prophylactic TXA. There were no differences in the 30 and 90-day mortality rates with TXA use. Tranexamic acid is safe, cost-effective and reduces the need for blood transfusion and should be considered in all patients undergoing hip hemiarthroplasty for fractures.

A regime of two intravenous injections of tranexamic acid reduces blood loss in minimally invasive total hip arthroplasty: a prospective randomised double-blind study

Tranexamic acid (TXA), an inhibitor of fibrinolysis, reduces blood loss after total knee arthroplasty. However, its effect on minimally invasive total hip arthroplasty (THA) is not clear. We performed a prospective, randomised double-blind study to evaluate the effect of two intravenous injections of TXA on blood loss in patients undergoing minimally invasive THA. In total, 60 patients (35 women and 25 men with a mean age of 58.1 years; 17 to 84) who underwent unilateral minimally invasive uncemented THA were randomly divided into the study group (30 patients, 20 women and ten men with a mean age of 56.5 years; 17 to 79) that received two intravenous injections 1 g of TXA pre- and post-operatively (TXA group), and a placebo group (30 patients, 15 women and 15 men with a mean age of 59.5 years; 23 to 84). We compared the peri-operative blood loss of the two groups. Actual blood loss was calculated from the maximum reduction in the level of haemoglobin. All patients were followed clinically for the presence of venous thromboembolism. The TXA group had a lower mean intra-operative blood loss of 441 ml (150 to 800) versus 615 ml (50 to 1580) in the placebo (p = 0.044), lower mean post-operative blood loss (285 ml (120 to 570) versus 392 ml (126 to 660) (p = 0.002), lower mean total blood loss (1070 ml (688 to 1478) versus 1337 ml (495 to 2238) (p = 0.004) and lower requirement for transfusion (p = 0.021). No patients in either group had symptoms of venous thromboembolism or wound complications. This prospective, randomised controlled study showed that a regimen of two intravenous injections of 1 g TXA is effective for blood conservation after minimally invasive THA.

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

PURPOSE

Tranexamic acid (TXA) therapy can reduce red blood cell (RBC) transfusion; however, this therapy remains underutilized in many surgical patient populations. We assessed whether implementation of a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty would reduce the incidence of RBC transfusion without increasing adverse clinical outcomes.

METHODS

We implemented a quality of care policy to provide universal administration of intravenous TXA at a dose of 20 mg·kg(-1) iv to all eligible patients undergoing total hip or knee arthroplasty from October 21, 2013 to April 30, 2014. We compared data from an equal number of patients before and after protocol implementation (n = 422 per group). The primary outcome was RBC transfusion with secondary outcomes including postoperative hemoglobin concentration (Hb) and length of hospital stay. Adverse events were identified from the electronic medical records. Data were analyzed by a Chi square test and adjusted logistic and linear regression analysis.

RESULTS

Implementation of the protocol resulted in an increase in TXA utilization from 45.8% to 95.3% [change 49.5%; 95% confidence interval (CI), 44.1 to 54.5; P < 0.001]. This change was associated with a reduction in the rate of RBC transfusion from 8.8% to 5.2%, (change -3.6%; 95% CI, -0.1 to -7.0; P = 0.043). Pre- and post-protocol mean [standard deviation (SD)] Hb values were similar, including the nadir Hb prior to RBC transfusion [72 (8) g·L(-1) vs 70 (8) g·L(-1), respectively; mean difference -1 g·L(-1); 95% CI, -3 to 5; P = 0.569]. Length of stay was not altered, and no increase in adverse events was observed.

CONCLUSIONS

Implementation of a perioperative TXA protocol was associated with both an increase in TXA use and a reduction in RBC transfusion following hip or knee arthroplasty. Adverse events and length of hospital stay were not influenced by the protocol.

Efficiency of tranexamic acid in perioperative blood loss in hip arthroplasty: a systematic literature review and meta-analysis

INTRODUCTION AND OBJECTIVE

Tranexamic acid (TXA) is an antifibrinolytic drug used to reduce bleeding in mortality risk situations such as trauma. Our objective was to conduct a systematic literature review to evaluate the effectiveness and safety of TXA in reducing bleeding in hip arthroplasty.

MATERIAL AND METHODS

A systematic literature review and meta-analysis of primary studies similar to controlled trials was performed. Literature was searched in MEDLINE, Embase, Cochrane, LILACS, SciELO and Google Scholar. The review was proposed and undertaken by 2 reviewers and the inclusion criteria were: a) patients undergoing arthroplasty for primary unilateral hip replacement; b) comparison of a treatment group with TXA to a control group that received a placebo or no treatment at all, and c) outcome measures, total blood loss, number of patients receiving allogeneic transfusion and/or incidence of thromboembolic complications. The search was restricted to studies published from 1966 to June 2013.

RESULTS

A total of 16 studies with 246 patients were retrieved for this review. The total blood loss outcome evidenced a weighted mean difference in favor of TXA vs. controls undergoing hip arthroplasty (-0.45 [P<0.001, 95% CI -0.65 to -0.24]). Weighted relative risk was estimated for the allogeneic transfusion requirement outcome, showing a trend in favor the TXA arm, with fewer patients requiring allogeneic transfusion in hip surgery (0.8 [P<0.02, 95% CI 0.57 to 1.11]); however, this trend was not statistically significant.

LIMITATIONS

There is a noticeable difference in methods for quantifying total blood loss across the studies reviewed. The need for transfusion outcomes are probably not significant taking into account the number of events in the TXA group.

CONCLUSIONS

TXA can be routinely used to reduce intra- and post-operative blood loss in primary hip arthroplasty.

The prophylactic role of tranexamic acid to reduce blood loss during radical surgery: A prospective study

BACKGROUND

The radical surgical procedures are associated with perioperative blood loss. This study was aimed to evaluate the clinical efficacy and safety of tranexamic acid in reducing perioperative blood loss in patients undergoing radical surgery.

MATERIALS AND METHODS

Sixty ASA class I and II adult consented female patients, scheduled for elective radical surgery and met the inclusion criterion, were blindly randomized into two groups to receive either intravenous 1 g tranexamic acid 20 min before skin incision or an equivalent volume of normal saline as placebo (P). All patient's total blood loss was measured and recorded perioperatively at the 12(th)h postoperatively. The preoperative and postoperative hemoglobin, hematocrit values, serum creatinine, activated thromboplastin time, prothombin time, thrombocyte count, fibrinogen, D-dimer, and symptoms of pulmonary embolism were comparatively evaluated.

RESULTS

The tranexamic acid significantly reduced the quantity of total blood loss, 576 ± 53 mL in study group as compared to 823 ± 74 mL in the control group (P<0.01). Postoperatively hematocrit values were higher in the tranexamic acid group. The coagulation profile did not differ between the groups, but D-dimer concentrations were increased in the control group. No complications or adverse effects were reported in the either group.

CONCLUSION

The prophylactic administration of tranexamic acid has effectively reduced theblood loss and transfusion needs during radical surgery without any adverse effects or complication of thrombosis.

Does tranexamic acid alter the risk of thromboembolism after total hip arthroplasty in the absence of routine chemical thromboprophylaxis?

Tranexamic acid (TXA) has been used to reduce blood loss during total hip arthroplasty (THA), but its use could increase the risk of venous thromboembolic disease (VTE). Several studies have reported that TXA does not increase the prevalence of deep vein thrombosis (DVT), but most of those used routine chemical thromboprophylaxis, thereby masking the potential increased risk of TXA on VTE. We wished to ascertain whether TXA increases the prevalence of VTE in patients undergoing THA without routine chemical thromboprophylaxis. We carried out a retrospective case-control study in 254 patients who underwent a primary THA, 127 of whom received TXA (1 g given pre-operatively) and a control group of 127 who did not. All patients had mechanical but no chemical thomboprophylaxis. Each patient was examined for DVT by bilateral ultrasonography pre-operatively and on post-operative days 1 and 7. TXA was found to statistically significantly increase the incidence of total DVT on post-operative day 7 compared with the control group (24 (18.9%) and 12 (9.4%), respectively; p < 0.05) but most cases of DVT were isolated distal DVT, with the exception of one patient with proximal DVT in each group. One patient in the control group developed a non-fatal symptomatic pulmonary embolism (PE). The use of TXA did not appear to affect the prevalence of either proximal DVT or PE.

Cite this article: Bone Joint J 2015; 97-B:458–62.

Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*

The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Blood Management presents an updated report of the Practice Guidelines for Perioperative Blood Management.

Supplemental Digital Content is available in the text.

Tranexamic acid--an old drug still going strong and making a revival

Experience with tranexamic acid, an indirect fibrinolytic inhibitor, started as soon as it was released from Shosuke Okamoto's lab in the early 1960s. It was first prescribed to females with heavy menstrual blood loss and to patients with hereditary bleeding disorders. Soon the indications were widened to elective surgery because of its blood saving effects. Contraindications are few, most important is ongoing venous or arterial thrombosis and allergy to tranexamic acid, and the doses has to be reduced in renal insufficiency. In randomized controlled trials, however, patients with other risk factors are excluded as well (patients with history of cardiovascular disease, thromboembolism, bleeding diathesis, renal failure with creatinine >250μmol/L, pregnancy, and patients on treatment with anticoagulants). Recent meta-analyses of several randomized controlled trials in orthopedic arthroplasty have shown that tranexamic acid reduces peri- and postoperative blood loss, blood transfusion requirements and reoperations caused by bleedings. In general, the preoperative dose was 10-15mg/kg i.v. (or 1g), followed or not, by one or two doses, some as continuous infusion i.v. To validate relationship between dose and effect more data are needed. No evidence was found of increased thromboembolic accidents or other adverse events in the patients on tranexamic acid compared to the control groups. In major cardiac surgery tranexamic acid has been used in a large number of controlled trials with various dosing schemes in which the highest dosages seem to be associated with neurotoxicity; therefore a maximum total dose of 100mg/kg especially in patients over 50years of age is recommended by ISMICS (International Society for Minimally Invasive Cardiothoracic Surgery). Other indications for tranexamic acid are reviewed here as well. In recent years the extensive trial in severe trauma with massive bleedings using tranexamic acid was presented, CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) comprising more than 20,000 patients. It showed that the survival was increased when tranexamic acid was given early after the accident compared to placebo; further studies are taking place is this field to get more information. Of utmost importance is the ongoing WOMAN (World Maternal Antifibrinolytic) a randomized, double-blind, placebo controlled trial among 15,000 with clinical diagnosis of postpartum haemorrhage bearing in mind that each year a large number of women in low and middle income countries, die from causes related to childbirth. In summary, we consider tranexamic acid is a drug of great value to reduce almost any kind of bleeding, it is cheap and convenient to use and has principally few contraindications. It may be added, that tranexamic acid is included in the WHOs list of essential medicines.

The effect of tranexamic acid on artificial joint materials: a biomechanical study (the bioTRANX study)

Background

Tranexamic acid (TXA) has been successfully used to reduce bleeding in joint replacement. Recently local TXA has been advocated to reduce blood loss in total knee or hip replacement; however, this raised concerns about potential adverse effects of TXA upon the artificial joint replacement.

Materials and methods

In this biomechanical study we compared the effects of TXA and saline upon the following biomechanical properties of artificial joint materials—(1) tensile properties (ultimate strength, stiffness and Young’s modulus), (2) the wear rate using a multi-directional pin-on-plate machine, and (3) the surface topography of pins and plates before and after wear rate testing.

Results

There were no significant differences in tensile strength, wear rates or surface topography of either ultra-high-molecular-weight polyethylene pins or cobalt chromium molybdenum metal plates between specimens soaked in TXA and specimens soaked in saline.

Conclusion

Biomechanical testing shows that there are no biomechanical adverse affects on the properties of common artificial joint materials from using topical TXA.

Level of evidence

V