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

Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery

PURPOSE

While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery.

METHODS

We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression.

RESULTS

Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p = 0.463; 15.4% vs. 28%, p = 0.181). Median units transfused did not differ between groups (2 ± 1 vs. 2 ± 1, p = 0.515; 2 ± 1 vs. 2 ± 0, p = 0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions.

CONCLUSION

Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.

Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion

OBJECTIVE

The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss.

METHODS

DESIGN

Retrospective review.

SETTING

Three level 1 trauma centers at 2 academic institutions.

PATIENT SELECTION CRITERIA

Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures).

OUTCOME MEASURES AND COMPARISONS

Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery.

RESULTS

195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277-733] mL early versus 364 [IQR 160-661] delayed by Gross method, P = 0.017; 165 [IQR 99-249] g of Hgb early versus 143 [IQR 55-238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05).

CONCLUSION

There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant.

LEVEL OF EVIDENCE

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

A prophylactic TXA administration effectively reduces the risk of intraoperative bleeding during open management of pelvic and acetabular fractures

This study aimed to evaluate the efficacy of perioperative intravenous TXA in reducing blood loss in pelvic and acetabular fracture patients managed surgically. The study included 306 consecutive patients, divided as: group I, 157 patients who did not receive perioperative infusion of TXA and group II, 149 patients who received perioperative TXA. The perioperative blood test results and complication rates were compared between the two groups. The average perioperative hematocrit was higher during the preoperative period than during the first, second and third postoperative day in both groups. In the estimated blood loss between the two groups, there was a significant difference of 1391 (± 167.49) ml in group I and 725 (± 403.31) ml in group II respectively (p = 0.02). No significant difference was seen in the total of intraoperative transfusion units as well as in the total units of blood transfused. There was a reduced level of postoperative hemoglobin (9.28 ± 17.88 g/dl in group I and 10.06 ± 27.57 g/dl in group II compared to the values obtained in preoperative investigations (10.4 ± 2.37 g/dl in group I and 11.4 ± 2.08 g/dl in group II); with a significant difference in postoperative transfusion rates (p = 0.03). Therefore, the use of TXA effectively reduces the risk of intraoperative bleeding during open management of pelvic and acetabular fractures.

To Assess the Outcomes Associated With the Use of Tranexamic Acid in the Open Fixation of Pelvic and Acetabular Fractures

There is a growing knowledge base for the use of antifibrinolytic therapy in trauma and orthopaedic surgery. The mechanism of action of tranexamic acid (TXA) is through the inhibition of fibrinolysis. The role of TXA in hip fractures has been researched extensively. However, the research has been limited to the cases of pelvic and acetabular fractures. This systematic review aimed to examine the effect of TXA on patients undergoing open pelvic and acetabular fracture surgery. The primary goal of the study was to examine the estimated blood loss (EBL) and blood transfusion rates in patients who received TXA versus those who did not receive TXA. The secondary goal was to examine the rates of deep venous thrombosis (DVT). A literature search was carried out using PubMed, Medline and the Cochrane database. The selection criteria for the systematic review were studies investigating intravenous TXA in the form of randomised controlled trials (RCTs), as well as cohort studies. Five studies were included in the systematic review with 625 total patients. The EBL between the two groups was noted to be 661 mL in the control group and 850 mL in the TXA (p=0.49). There was a marginally lower number of units transfused in the control group vs the TXA group (1.9 vs 2.2) (p=0.27). The rates of transfusion in the TXA group were 29% TXA whilst, in the control group, it was 31% (p=0.13). The overall incidence of DVT was 2.8% in the TXA group and 1.7% in the control group (p=0.097).

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Topical use of tranexamic acid: Are there concerns for cytotoxicity?

Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.

Is intravenous tranexamic acid effective in reduction of blood loss during pelvic and acetabular surgery?

PURPOSE

Pelvic and acetabular surgery is associated with one of the highest amounts of blood loss. Tranexamic acid is a good choice to reduce blood loss during this type of surgery. However, being antifibrinolytic drug, the chance to have coagulation complications including DVT is a risk that should be considered particularly in such major trauma patients with the body's response to trauma and with possible prolonged bed stay. The aim of this study is to evaluate the effectiveness of intravenous tranexamic acid injection during pelvic and acetabular surgery for reduction of blood loss during surgery and after surgery and to evaluate any possible complications for its use.

METHODS

This prospective randomized clinical trial includes 97 patients divided between two groups; group 1 (G1) which received TXA, while the second group (G2) is the control group. The primary outcome measures were total blood loss (TBL), allogenic blood units transfused, and the blood lost intra-operatively (IBL). The TBL was calculated by the haemoglobin balance method while the intra-operative blood loss was measured by the gravimetric method. Any complications related to the drug were evaluated particularly DVT.

RESULTS

The study showed significantly less TBL (G1 = 829.7 ± 219.2, G2 = 1036.9 ± 314.9) and blood transfusion (G1 = 52.4 ± 40 g, G2 = 89.4 ± 60.6 g) in G1 compared to the G2.

CONCLUSION

This study proved the possible reduction of TBL and the need of blood transfusion by the use of TXA in pelvic and acetabular injuries.

Tranexamic acid use in pelvic and/or acetabular fracture surgery: A systematic review and meta-analysis

Purpose

The purpose of this study is to determine whether tranexamic acid (TXA) use was associated with lower rates of blood transfusion in patients undergoing pelvic and/or acetabular fracture surgery.

Methods

Four studies were included, 3 of which were included in the pooled data analysis for a total of 308 patients.

Results

The transfusion rate was significantly lower in the TXA group (44%) compared with the non-TXA group (57%) (P = 0.02).

Conclusion

TXA use was associated with a significantly lower transfusion rate in patients who underwent pelvic and/or acetabular fracture surgery.

Level of evidence

Level 3. Systematic review of retrospective cohort studies and prospective randomized controlled trials.

Tranexamic Acid: When is It Indicated in Orthopaedic Surgery?

Tranexamic acid (TXA) has been studied extensively during the last 5-8 years. It inhibits clot dissolution during surgery and can therefore reduce blood loss. However, there has been concern that this could result in more frequent complications, specifically in terms of thromboembolic events. The indications for TXA are widespread, and this review covers the literature on orthopaedic indications such as joint replacement, fracture surgery, and arthroscopic procedures. In general, TXA is safe and can be used in a wide variety of orthopaedic procedures, lowering blood loss without increasing the risk of complications.

Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery

PURPOSE

Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration.

METHODS

We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion.

RESULTS

Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p < 0.01) and intraoperative IV fluids (p < 0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70 years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion.

CONCLUSION

In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.

Use of tranexamic acid is not associated with complications following bipolar hemiarthroplasty for metastatic disease

INTRODUCTION

Advances in the care of cancer patients have resulted in increased survival. The proximal femur is a common site for metastatic disease, often requiring surgical intervention. Tranexamic acid (TXA) has proven to be safe in elective and traumatic femoral hemiarthroplasty; however, its use has not been investigated in oncologic patients.

METHOD

We reviewed 66 patients (37 males) with a mean age of 64 ± 3 years undergoing a hemiarthroplasty for metastatic disease in the femoral neck. A total of 22 (33%) patients received intraoperative TXA. Primary outcomes included postoperative blood loss, intraoperative and postoperative transfusion requirement, and postoperative complications.

RESULTS

There was no difference in the baseline characteristics between the TXA and non-TXA groups. When comparing the TXA and non-TXA groups, there were no differences in 72 h postoperative blood loss between groups (1.21 L vs. 1.33 L, p = 0.61), percentage of patients requiring transfusion (36.4% vs. 36.4%, p = 1.0), or the incidence of postoperative complications including venous thromboembolism (14% vs. 11%, p = 0.70) and pulmonary embolism (0% vs. 5%, p = 1.0).

CONCLUSION

Oncology patients are a high-risk population for thromboembolic events. This initial study supports the safe use of TXA intraoperatively in femoral hemiarthroplasty performed for metastatic disease.

The effect of topical and systemic tranexamic acid on fracture healing in rats

OBJECTIVE

The aim of the present study was to determine the effect of topical and systemic tranexamic acid (TXA) on fracture healing in a rat surgical model.

METHODS

We created standard, right-sided, open, diaphyseal femoral fractures with intramedullary Kirschner wire fixation in 48 male rats and divided them into three groups: a topical TXA (10 mg/kg) group, a systemic TXA (10 mg/kg) group, and a control group. Fracture healing was evaluated radiographically and histologically after early (week 2) and late (week 4) postoperative sacrifice.

RESULTS

The radiological scores differed significantly among the all groups (p=0.001), as did the week 2 and 4 scores (p=0.003 and p=0.010, respectively). Radiologically, the topical TXA group exhibited better bone healing at both 2 (p=0.001) and 4 (p=0.007) weeks than the control group, and the systemic group showed better healing at both 2 (p=0.027) and 4 (p=0.023) weeks than the control TXA group. Moreover, bone healing was better in the group treated with topical rather than systemic TXA on radiological examinations performed at 2 (p=0.001) and 4 (p=0.007) weeks postoperatively (p=0.001 and p=0.007, respectively). Histologically, the groups differed significantly (p=0.001). The histological scores differed significantly among the all groups (p=0.001). At 2 weeks, the topical TXA group exhibited significantly better bone healing than the control group (p=0.001).

CONCLUSION

Our results suggested that topical application of TXA in fracture patients may accelerate healing, whereas systemic administration may adversely affect healing.

Efficacy and Safety of Tranexamic Acid in Reducing Blood Loss of Lower Extremity Osteotomy in Peri-acetabulum and High Tibia: A Systematic Review and Meta-analysis

Objective

To assess the efficacy of tranexamic acid (TXA) in reducing total blood loss and transfusion, and the risk of thromboembolic events in patients undergoing periacetabular osteotomy (PAO) and high tibial osteotomy (HTO).

Methods

A systematic literature search was performed using PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), Medline (Ovid), and Web of Science. ClinicalTrials.gov, American Academy of Orthopaedic Surgeons (AAOS), and Orthopaedic Trauma Association (OTA) conference proceedings were also searched to gain more eligible studies. The primary outcome measure was total blood loss and the blood transfusion rate of the TXA group versus control. The meta‐analysis was conducted using the RevMan 5.3 and Stata 14.0 software.

Results

A total of six studies were included involving 665 patients. Three studies were PAO, and the other three were HTO. The total blood loss in PAO (WMD, −330.49; 95% CI, −390.16 to −270.83; P < 0.001) and HTO (WMD, −252.50; 95% CI, −356.81 to −148.18; P < 0.001) and hemoglobin decline (WMD, −0.74; 95% CI, −1.09 to −0.38; P < 0.001) were significantly less in the TXA group than in the control group. TXA could reduce transfusion rates in PAO (RR, 0.26; 95% CI, 0.09 to 0.75; P = 0.01) but had no effect on HTO (RR, 0.20; 95% CI, 0.01 to 4.10; P = 0.30). The wound complications (RR, 0.62; 95% CI, 0.13 to 2.94; P = 0.54) had no significant difference between TXA and control groups.

Conclusions

This meta‐analysis demonstrated that TXA reduces total blood loss and hemoglobin decline in patients undergoing PAO and is safe, but it has little benefit in regard to reducing transfusion rates or wound complications in HTO, so TXA might be unwarranted for routine use for HTO.

[Research progress on tranexamic acid in traumatic orthopedic surgery]

OBJECTIVE

To summarize the research progress on the application of tranexamic acid (TXA) in traumatic orthopedic surgery in recent years.

METHODS

The domestic and foreign literature in recent years was reviewed, and the efficacy and safety of TXA in traumatic orthopedic surgeries with different regimen, dose and route of administration were comprehensively summarized and compared.

RESULTS

The application of TXA in traumatic orthopedic surgeries increased gradually in recent years. Intravenous or topical administration of TXA efficaciously reduced blood loss and transfusion requirements during hip fracture surgery without significantly increasing the risk of thromboembolic events. However, the efficacy was not clear in other traumatic orthopedic surgeries such as pelvic and acetabular fractures.

CONCLUSION

More studies are needed to confirm the efficacy and safety of TXA in traumatic orthopedic surgeries.

Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial

OBJECTIVE

To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur.

DESIGN

Prospective, randomized controlled trial.

SETTING

Single Level 1 trauma center.

PATIENTS

Forty-seven patients were randomized to the study group, and 46 patients comprised the control group.

INTERVENTION

The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose.

MAIN OUTCOME MEASUREMENTS

Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)].

RESULTS

TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57).

CONCLUSION

The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures.

LEVEL OF EVIDENCE

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

A novel approach using 3-D printing in the Irish National Centre for pelvic and acetabular surgery

BACKGROUND

Complex pelvic fractures present the orthopaedic surgeon with many challenges. 3-D printed models may provide assistance in pre-operative planning, may lead to improvements in intra-operative (i) decision making and (ii) efficiencies (time reduction, blood loss reduction, screening reduction) and may result in improvements in post-operative outcomes (fracture reduction & quality of life). The models also provide hands-on opportunities for orthopaedic trainees and patients. This may result in improvements in (i) education/training regarding the management of pelvic and acetabular fractures for orthopaedic trainees and (ii) improvements in patient consenting and overall patient satisfaction.

DESIGN

Single-centre, two orthopaedic surgeons (pelvic and acetabular fellowship trained), prospective observational study. Twenty patients with acute displaced pelvic/acetabular fracture(s); ten 3-D-printed pelvis and ten non-printed cases for comparison. The comparison cohorts were matched for fracture classification, sex and age.

OUTCOME MEASURES

Classification assistance, intra-operative time, estimated blood loss, screening amount, post-operative reduction and infection, EQ-5D-5L, teaching/educational assistance and pre-operative counselling.

RESULTS

The models provided more information regarding fracture pattern, however, this did not result in change of CT-planned approach/procedure or patient outcomes. The models scored highly on surgeon's questionnaire. The models were found to have a positive impact on trainee education and patient consenting/counselling. With regard to objective comparisons, there was no significant improvements in time-to-surgery, intra-operative time, estimated blood loss, screening amount, fracture reduction or infection rate. There was no significant difference in quality of life questionnaire ~ 12 months post-surgery (statistical tests used; Cohen's effect size and Fisher's exact test).

CONCLUSIONS

Whilst the authors recognize the positive subjective findings with respect to the use of 3-D printing in pelvic and acetabular trauma in our National Centre, objective findings were lacking.

Effects of topical tranexamic acid during open reduction and internal fixation of acetabular fractures: A retrospective study

Objective

The aim of this study was to assess the effect of topical tranexamic acid on blood loss and transfusion rates in acetabular fracture surgery.

Methods

The medical records of 61 patients who underwent open reduction and internal fixation for acetabular fracture between 2012 and 2015 were retrospectively reviewed. The patients were divided into two groups: Group I consisted of 31 patients (19 men and 12 women, mean age: 52 ± 19 years) who received intraoperatively a topical tranexamic acid solution of 3 g and Group 2 consisted of 30 control patients (17 men and 13 women, mean age: 48 ± 24 years) who received only 0.9% saline solution. The groups were compared based on their intraoperative blood loss, Postoperative drain output at 24 and 48 h, and postoperative hemoglobin levels, and transfusion rates.

Results

The mean intraoperative blood loss was 410 ± 100 ml in Group 1, compared to 570 ml ± 160 ml of the control group (p < 0.05). The postoperative drain output after 24 h was 210 ± 70 ml in Group 1 compared to 330 ± 90 ml of the control group (p < 0.05). The drain output at 48 h was (50 ± 20 ml) in group 1 compared to 90 ± 40 ml of the control group (p < 0.05). The transfusion rate was significantly low group 1 (42%) than the control group (97%). Hemoglobin drop was again significantly less in tranexamic acid group (2.1 ± 1.1) than the control group (3.2 ± 1.3). The nadir postoperative hemoglobin was higher in the Group 1 (10.4 ± 1.5) than the control group (9.2 ± 1.3).

Conclusion

Topical administration of tranexamic acid reduces intraoperative and postoperative blood loss in acetabular fracture surgery, decreasing transfusion rates.

Level of Evidence

Level III, Therapeutic Study.