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

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.

Update on the efficacy and safety of intravenous tranexamic acid in hip fracture surgery: a systematic review and meta-analysis

AIM

The aim of this meta-analysis was to assess the safety and efficacy of tranexamic acid (TXA) in the management of hip fracture surgeries in comparison with placebo.

METHODS

A systematic search was conducted from August 6, 2021. Eligible studies included randomized clinical trials and prospective studies comparing the use of intravenous TXA in patients treated for hip fractures, in comparison with placebo. Review Manager was used for the meta-analysis.

RESULTS

Eighteen prospective studies including 14 RCTs met the eligibility criteria. The results favored the TXA group in the quantity of total blood loss (MD =  - 196.91 mL, 95% CI - 247.59, - 146.23, I2 = 92%), intraoperative blood loss (MD = - 26.86 mL, 95% CI - 36.96, - 16.78, I2 = 62%), and rate of blood transfusion (OR 0.35, 95% CI 0.28, 0.42, I2 = 0%). TXA also exhibited higher hemoglobin level at day 1 (MD = 6.77 g/L, 95% CI 4.30, 9.24, I2 = 83%) and day 3 (MD = 7.02 g/L, 95% CI 3.30, 10.74, I2 = 82%) postoperatively. There was no significant difference found in the incidence of thromboembolic events from occurring between the two groups, such as deep vein thrombosis (OR 1.22, 95% CI 0.73, 2.02, I2 = 0%) and pulmonary embolism (OR 0.82, 95% CI 0.33, 2.05, I2 = 0%).

CONCLUSION

Administration of intravenous TXA appears to reduce blood loss, rate of blood transfusions and pose no increased risk of thromboembolic events. Therefore, TXA should be considered by physicians when managing hip fracture patients.

Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures

BACKGROUND

Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications.

OBJECTIVES

To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones.

SEARCH METHODS

We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data.

MAIN RESULTS

We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence).  It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence).  We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect.  Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants).  All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo   Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here.

AUTHORS' CONCLUSIONS

We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration).  We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.

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.

Preoperative Blood Loss of Isolated Acetabular Fractures

OBJECTIVE

To quantify preoperative blood loss in isolated acetabular fractures and identify any fracture or patient characteristics associated with increased blood loss or blood transfusion.

DESIGN

Retrospective cohort study.

SETTING

Two level 1 trauma centers.

PATIENTS/PARTICIPANTS

All patients with operative, isolated acetabular fractures from January 2010 to December 2018.

INTERVENTION

Operative management of an acetabular fracture.

MAIN OUTCOME MEASUREMENTS

Volume of preoperative blood loss and transfusion rates associated with isolated acetabular fracture patterns.

RESULTS

A total of 598 patients were included. The mean preoperative blood loss of all fractures was 1172.6 mL. The 3 fracture patterns with the greatest average preoperative blood loss were associated both column (1454.9 mL), T-type (1374.8 mL), and anterior column posterior hemitransverse fractures (1317.7 mL). The acetabular fracture pattern had a significant association with preoperative blood loss and preoperative transfusion. The timing from injury to surgery and body mass index were significantly associated with preoperative blood loss.

CONCLUSIONS

In conclusion, operatively treated isolated acetabular fractures surprisingly lose an average of greater than 1 liter of blood in the preoperative setting. Surgeons must carefully assess patient's physiology, ensuring they are adequately resuscitated before surgery and remain aware that increasing body mass index is associated with increased preoperative blood loss. However, as patients await surgery, unreduced acetabular fractures continue to contribute to ongoing blood loss beyond the first 24 hours from injury. We believe the best hemostasis after initial resuscitation is provided by surgical reduction and fixation, and we recommend a continued early surgical intervention to prevent continued bleeding from fracture surfaces.

LEVEL OF EVIDENCE

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

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

INTRODUCTION

Open reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial.

MATERIAL AND METHODS

Sixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated.

RESULTS

Both groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups.

CONCLUSION

There is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.

The effect of tranexamic acid in open reduction and internal fixation of pelvic and acetabular fracture: A systematic review and meta-analysis

BACKGROUND

Pelvic bone fractures may cause extensive bleeding; however, the efficacy of tranexamic acid (TXA) usage in pelvic fracture surgery remains unclear. In this systematic review and meta-analysis, we aimed to evaluate the efficacy of TXA in open reduction and internal fixation surgery for pelvic and acetabular fracture.

METHODS

MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 22, 2020, that investigated the effect of TXA in the treatment of pelvic and acetabular fracture with open reduction and internal fixation. A pooled analysis was used to identify the differences between a TXA usage group and a control group in terms of estimated blood loss (EBL), transfusion rates, and postoperative complications.

RESULTS

We included 6 studies involving 764 patients, comprising 293 patients who received TXA (TXA group) and 471 patients who did not (control group). The pooled analysis showed no differences in EBL between the groups (mean difference -64.67, 95% confidence interval [CI] -185.27 to -55.93, P = .29). The study period transfusion rate showed no significant difference between the groups (odds ratio [OR] 0.77, 95% CI 0.19-3.14, P = .71, I2 = 82%), nor in venous thromboembolism incidence (OR 1.53, 95% CI 0.44-5.25, P = .50, I2 = 0%) or postoperative infection rates (OR 1.15, 95% CI 0.13-9.98, P = .90, I2 = 48%).

CONCLUSIONS

Despite several studies having recommended TXA administration in orthopedic surgery, our study did not find TXA usage to be more effective than not using TXA in pelvic and acetabular fracture surgery, especially in terms of EBL reduction, transfusion rates, and the risk of postoperative complications.

The effect of antifibrinolytic agents in periacetabular osteotomy: A systematic review and meta-analysis

BACKGROUND

Periacetabular osteotomy (PAO) is a major hip preservation surgery for developmental dysplasia of the hip. It is inevitably associated with significant blood loss, so it requires frequent transfusions and could be a cause of perioperative morbidity. However, to date, a large number of studies has not evaluated the effect of antifibrinolytic agents in PAO. Therefore we performed a systematic review and meta-analysis to assess if antifibrinolytics would be effective in reducing blood loss and transfusion rate after PAO surgery.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 4, 2020, that investigated the effect of antifibrinolytic agents in PAO. A pooled analysis was designed to identify differences between antifibrinolytic and control groups focusing on blood loss, transfusion, operation time, postoperative venous thromboembolism (VTE), and length of hospital stay.

RESULTS

We included five studies involving 507 patients (antifibrinolytic group: 256; control group: 251). The pooled analysis showed that the control group had a greater total estimated blood loss (EBL) than the antifibrinolytic group (mean difference [MD]=-257.60mL, 95% confidence interval [CI] -389.68 to -125.53, p=0.0001), but there were no statistical differences in intraoperative EBL (MD=-46.46mL, 95% CI: -192.57 to 99.64, p=0.53). The allogenic transfusion rate was higher in the control group than in the antifibrinolytic group (odds ratio [OR] 0.21, 95% CI: 0.10-0.43, p<0.0001), but there was no difference in the autogenic transfusion rate (OR 0.35, 95% CI: 0.09-1.43, p=0.14). The pooled result showed no difference in operation time (MD=9.13min, 95% CI: -8.54 to 26.80, p=0.31). For the VTE rate, a pooled analysis was not conducted due to the lack of data. The length of hospital stay showed no differences (MD=-0.51 days, 95% CI: -1.17 to 0.16, p=0.13).

CONCLUSIONS

Antifibrinolytic use in PAO has positive effects in terms of reduced total EBL and allogenic transfusion rate.

LEVEL OF EVIDENCE

III; meta-analysis.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Efficacy of Tranexamic Acid in Reducing Seroma and Hematoma Formation Following Reduction Mammaplasty

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery.

OBJECTIVES

The aim of this study was to investigate the value and safety profile of both intravenous and topically administered TXA in the setting of bilateral reduction mammaplasty.

METHODS

A retrospective review was performed to identify consecutive patients who underwent bilateral reduction mammaplasty for symptomatic macromastia (January 2016-July 2021). Pertinent preoperative, intraoperative, and postoperative details were collected/reviewed. Primary outcome measures included hematoma requiring surgical evacuation and clinically significant/symptomatic seroma formation mandating percutaneous aspiration. Patients taking anticoagulation/antiplatelet medication or those with a history of thromboembolic diseases were excluded. Patients who had received TXA were compared to a historical control group who did not receive TXA within the same consecutive cohort.

RESULTS

A total of 385 consecutive patients (770 breasts) were included. TXA was used in 514 (66.8%) cases (topical, 318 [61.9%]; intravenous, 170 [33.1%]; intravenous and topical, 26 [5.1%]). Neither seroma nor hematoma were impacted/reduced with TXA (P > 0.05). Increased age (hazards ratio, 1.06 per 1-year increase; 95% CI, 1.004-1.118) significantly increased the risk of hematoma (P = 0.032). The use of drains significantly decreased the risk of seroma (P < 0.0001). Increased BMI increased the risk of seroma (hazards ratio, 1.16 per 1-kg/m2 increase; 95% CI, 1.06-1.26; P = 0.0013). The use of TXA did not impact drain duration.

CONCLUSIONS

This study, the largest to date on the use of IV and topical TXA, did not find any reduction in risk when using TXA in breast reduction surgery.

LEVEL OF EVIDENCE: 3

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.

Effectiveness and Safety of Tranexamic Acid Use in Acute Traumatic Injury in the Prehospital and In-hospital Settings: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives

This systematic review and meta-analysis of randomized controlled trials (RCTs) aims to assess efficacy and safety of tranexamic acid (TXA) use in acute traumatic injuries.

Methods

PubMed and Cochrane libraries were searched for relevant RCTs published between January 2011 and January 3, 2021. Cohen's Q Test for heterogeneous effects was used to determine the appropriateness of fixed versus random effects models.

Results

Twenty-two studies met inclusion criteria. Meta-analysis of relative risk of mortality between treatment and placebo groups in the in-hospital, and perioperative settings was not significant. However, the risk of mortality is significantly lower in the treatment versus placebo group when TXA was given as loading dose only. Ten of the 11 studies evaluating perioperative use of TXA included in systematic review found significantly lower blood loss in the treatment compared with placebo groups, but results of meta-analysis showed no significant difference. Results of meta-analysis indicate that the risk of venous thromboembolism (VTE) in the in-hospital treatment group is greater than that of the placebo. In subset analysis of studies using only a single loading dose, there were no significant differences in VTE.

Conclusions

Systematic review supports TXA benefits are most evident when given shortly after injury and meta-analysis supports TXA reduces mortality as a single loading dose. Systematic review supports perioperative use of TXA when large volume blood loss is anticipated. Meta-results showed no significant difference in risk of thromboembolism in single-dose TXA treatment compared with placebo. These findings suggest that TXA is safe and effective for control of traumatic bleeding.

The Efficacy and Safety of Tranexamic Acid Treatment in Orthopaedic Trauma Surgery

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Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin.

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TXA is a cost-effective treatment for trauma patients across a variety of economic settings.

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Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence.

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TXA has been shown to reduce blood loss in hip fracture surgery.

The Use of Tranexamic Acid in Hip and Pelvic Fracture Surgeries

Tranexamic acid (TXA) use has expanded across many surgical specialties. It has been shown to reduce blood loss, decrease transfusion rates, and, in some cases, improve mortality. Within orthopaedic surgery, its popularity has primarily grown within arthroplasty and spinal surgery. It has only recently gained traction within the field of orthopaedic trauma and fracture care. At this time, most literature focuses on hip fracture and pelvic trauma surgery. For hip fractures, the results are encouraging and generally support the claim that TXA may lower overall blood loss and decrease transfusions. Conversely, less support exists for TXA use in fractures of the acetabulum or pelvic ring. Based on the current fracture-related studies, TXA does not seem to carry an increased risk of thromboembolism or other complications. In addition, few studies have been noted discussing the route of administration, timing, or dosage. This article reviews the most current literature regarding TXA use in fracture care and expands on the need for further research to evaluate the role of TXA in orthopaedic trauma populations who carry a high risk for transfusion.

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.

OBJECTIVES

The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.

METHODS

A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.

RESULTS

Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.

CONCLUSIONS

Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

LEVEL OF EVIDENCE: 4

Efficacy of repeated intravenous tranexamic acid in reducing perioperative bleeding of acetabular fractures

BACKGROUND

Application of tranexamic acid (TXA) in the treatment of acetabular fractures could reduce intraoperative and postoperative blood loss.

OBJECTIVE

To investigate the effect of single and repeated intravenous infusion of TXA on blood loss of acetabular fractures.

METHODS

120 patients with acetabular fractures admitted to our hospital from January 2017 to September 2020 were retrospectively divided into three groups: Patients accepted 1g TXA at preoperative 30 minutes were defined as single TXA group (n = 40); Patients accepted 1g TXA at preoperative 30 minutes and 1g TXA at 3 hours after the start of surgery were defined as repeated TXA group (n = 40); Patients accepted normal saline at preoperative 30 minutes were defined as control group (n = 40).

RESULTS

The total blood loss in single TXA group and repeated TXA group were significantly lower than control group, and the total blood loss in the repeated TXA group was significantly lower than single TXA group (P <  0.05). The hidden blood loss from surgery to postoperative 1 day in repeated TXA group was significantly lower than single TXA group and the control group(P <  0.05). No significant differences were observed in the operative time, postoperative transfusion rate and thrombosis rate among the three groups (P >  0.05).

CONCLUSION

Repeated TXA is more recommended during acetabular fracture surgery since it can reduce the total blood loss without increasing the operative time, postoperative transfusion rate and thrombosis rate compared with single TXA.

The efficiency and safety of intravenous tranexamic acid administration in open reduction and internal fixation of pelvic and acetabular fractures

PURPOSE

This study aimed to investigate the efficiency and safety of tranexamic acid use in open reduction and internal fixation of pelvis and acetabulum fractures.

MATERIALS AND METHODS

73 consecutive patients were included. 1000 mg TXA was administered intravenously to all patients before surgery. The patients were evaluated on the basis of preoperative, postoperative first and third day hemoglobin-hematocrit values, amount of drainage collected, total blood loss, transfusion rates and complications.

RESULTS

Mean operative time was 120.1 min. Average decrease in hematocrit levels between preoperative and postoperative first day was 2.1 g/dL. Average collected blood from the drain was 177 mL. Mean total blood loss was 1137 mL. Transfusion rate of the patients was 21%. Mean transfused units was 0.9 units. Three patients died within 3 weeks after the operation due to myocardial infarction, acute kidney failure and pneumonia. There were no cases of symptomatic venous or pulmonary thromboembolism during the 90 days of follow-up.

CONCLUSION

Use of TXA in pelvic and acetabular fractures was found to be effective in reducing total blood loss, hemoglobin drop and transfusion rates without increasing venous and pulmonary thromboembolism in our series.

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.

Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study

Background

Previous studies have demonstrated the effectiveness and safety of tranexamic acid (TXA) in orthopedic surgery. However, no study has investigated TXA in complex tibial plateau fracture surgery. Therefore, the purpose of this study was to confirm the safety and effectiveness of i.v. (intravenous) TXA and topical TXA.

Material and methods

This was a retrospective analysis of prospectively collected data. The control group received an equal amount of placebo (physiological saline solution); the i.v. group received 1.0 g TXA by intravenous injection before the tourniquet was inflated and before the surgical incision was closed, and the topical group received 3.0 g TXA in 75 mL of physiological saline solution 5 min prior to the final tourniquet release. Perioperative blood loss, vascular events, wound complications, and adverse reactions were compared among the three groups. The pain, knee function, and quality of life (QoL) assessments were based on their corresponding scoring systems.

Results

Baseline data were comparable for all groups. The i.v. group showed the best results for total blood loss (TBL) and hidden blood loss (HBL) (424.5 ± 49.4 mL and 219.3 ± 33.4 mL, respectively, all P values < 0.001). Patients in the i.v. group had lesser real Hb decrease than those in the control group (0.9 vs 1.5, P<0.001) and topical group (0.9 vs 1.2, P = 0.026). The blood coagulation level as measured using fibrinolysis (D-dimer) was lower in the i.v. group than in the control and topical groups on POD1 and POD3; however, this difference was not significant; the fibrin-degradation products also showed a similar trend. Patients in the topical group experienced less pain than those in the control group on POD2, POD4, and PO6W. The VAS pain score was 3.6 vs. 4.4 (POD2, P<0.05), 2.8 vs 3.3 (POD4, P<0.05), and 2.1 vs. 2.6 (PO6W, P<0.001) in the topical group vs control group, respectively. No significant differences were identified in vascular events, wound complications, adverse reactions, knee function, and QoL among the three groups.

Conclusion

To our knowledge, this is the first study that showed both i.v. TXA and topical TXA are safe and effective for complex tibial plateau fractures. The i.v. regimen effectively reduced blood loss during the perioperative period, whereas patients under the topical regimen had less vascular events, wound complications, and a lower incidence of adverse reactions compared to those in the i.v. group.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-1800017754, retrospectively registered from 2018 to 01-01).