Optimal route for administering tranexamic acid in primary unilateral total hip arthroplasty: Results from a multicenter cohort study

Tranexamic acid administration for the prevention of periprosthetic joint infection and surgical site infection: a systematic review and meta-analysis

INTRODUCTION

Tranexamic acid (TXA) has been widely utilized to reduce blood loss and allogeneic transfusions in patients who undergo lower limb arthroplasty. In recent years, there have been several articles reporting the incidence of periprosthetic joint infection (PJI) as a primary outcome of TXA administration, but no meta-analysis has been conducted to date. The present systematic review and meta-analysis evaluated the efficacy of TXA administration in preventing PJI and surgical site infection (SSI).

MATERIALS AND METHODS

Pubmed, CINAHL, and the Cochrane Library bibliographic databases were searched for studies published by May 24, 2022, that evaluated the effects of TXA on PJI and SSI. Two researchers screened the identified studies based on the PRISMA flow diagram. The quality of each randomized clinical trial was assessed using Version 2 of the Cochrane risk-of-bias tool for randomized trials (ROB2.0), and the quality of cohort and case-control studies was assessed by risk of bias for nonrandomized studies (ROBANS-I).

RESULTS

Of the 2259 articles identified from the database search, 31 were screened and selected. Treatment with TXA significantly reduced the incidence of overall infection, including PJI, SSI, and other infections (OR 0.55; 95% CI 0.49-0.62) (P < 0.00001), and that of PJI alone (OR 0.53; 95% CI 0.47-0.59) (P < 0.00001). TXA reduced the incidence of overall infection in patients who underwent total hip arthroplasty (THA; OR 0.51; 95% CI: 0.35-0.75) (P = 0.0005) and total knee arthroplasty (TKA; OR 0.55; 95% CI: 0.43-0.71) (P < 0.00001). Intravenous administration of TXA reduced the incidence of overall infection (OR 0.59; 95% CI 0.47-0.75) (P < 0.0001), whereas topical administration did not.

CONCLUSIONS

Intravenous administration of TXA reduces the incidence of overall infection in patients undergoing both THA and TKA.

LEVEL OF EVIDENCE

Level III.

Incidence and risk factors associated with human albumin administration following total joint arthroplasty: a multicenter retrospective study

Background

Enhanced recovery after surgery (ERAS) program advocates implementation of perioperative goal-directed fluid therapy and reduced application of colloidal fluids. It should be used reasonably selectively in high-risk patients despite the clear efficacy of human albumin (HA). Therefore, it is vital to identify the risk factors for the use of HA. This study aims to determine the incidence and risk factors of HA administration in patients undergoing total hip or knee arthroplasty (THA, TKA).

Methods

We identified patients undergoing THA or TKA in multiple institutions from 2014 to 2016 and collected patient demographics and perioperative variables. The criterion of HA administration was defined as a postoperative albumin level < 32 g/L or 32 to 35 g/L for at-risk patients. We compared 14 variables between patients who received HA administration and those who did not after stratification by the preoperative albumin (pre-ALB) level. Multivariable regressions identified the independent risk factors associated with HA administration.

Results

In total, 958 (20.3%) of 4713 patients undergoing THA and 410 (9.7%) of 4248 patients undergoing TKA received HA administration. In addition to pre-ALB < 35 g/L, preoperative anemia (odds ratio [OR] 2.12, P = 0.001; OR 1.39, P < 0.001) and drain use (OR 3.33, P = 0.001; OR 4.25, P < 0.001) were also independent risk factors for HA administration after THA regardless pre-ALB < 35 g/L or not, and patients undergoing TKA diagnosed of rheumatoid arthritis or ankylosing spondylitis tended to receive HA administration regardless pre-ALB < 35 g/L or not (OR 3.67, P = 0.002; OR 2.06, P < 0.001).

Conclusions

The incidence of HA administration was high in patients undergoing THA or TKA, and several variables were risk factors for HA administration. This finding may aid surgeons in preoperatively identifying patients requiring HA administration and optimizing perioperative managements.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02642-9.

Low blood transfusion rate after implementation of tranexamic acid for fast- track hip- and knee arthroplasty. An observational study of 5205 patients

The purpose of this study was to retrospectively evaluate the efficacy of a tranexamic acid (TXA) perioperative protocol for primary hip- and knee arthroplasty, in terms of allogenic blood transfusion rates. A retrospective cohort study was conducted and included all primary hip and knee arthroplasty procedures in the period of 2014-2019. Patients who underwent surgery due to trauma or revision were excluded. A total amount of 5205 patients were eligible for inclusion. Two equal and weight depending doses of TXA were given, preoperative as an oral dose and intravenously at wound closure. The primary outcome was blood transfusion rate. Further analysis on patient characteristics (e.g. age, gender), blood loss, perioperative haemoglobin (Hb) levels and complication/readmission rate was performed. A total of 49 (0.9%) patients received perioperative allogenic blood transfusions. Mean age, distribution of gender, body-mass index, American Society of Anaesthesiologists score, duration of surgery, type of arthroplasty, estimated blood loss, perioperative Hb levels and length of stay were statistically significant different between transfused and not-transfused patients. The incidence of thromboembolic adverse events (e.g. deep vein thrombosis/lung embolism) was 0.5%. Low blood transfusion rate was found after implementation of a standardized perioperative TXA protocol for primary hip and knee arthroplasty.

Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies

PURPOSE

To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder.

METHODS

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores).

RESULTS

Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05).

CONCLUSION

Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients.

LEVEL OF EVIDENCE

II, systematic review of level I and II studies.

Effectiveness of different doses and routes of administration of tranexamic acid for total hip replacement

PURPOSE

The aim of the study is to show the therapeutic efficacy, safety, and cost-benefit of using tranexamic acid (TXA), as well as the superiority of the route of administration and amount of dose in primary cementless total hip replacement (THR).

METHODS

In this prospective, randomized, double-blind study, we divided 200 patients into five groups of 40 patients each. The placebo group did not receive TXA. Three groups received 2 g TXA each (intravenous, topical, and combined intravenous + topical), while the fifth, combined + group, received 4 g TXA. Total blood loss was calculated, number of transfusions and thromboembolic vascular incidents were monitored, and a cost-benefit analysis of the use of TXA was performed.

RESULTS

Regardless of the route of administration, TXA statistically significantly reduced total blood loss (p = 0.000) and the need for transfusion (p = 0.000) compared with placebo. Total blood loss and the need for allogenic blood transfusion were statistically significantly reduced in the combined + group compared with placebo, and also compared with all other groups. Post-operative thromboembolic vascular incidents were not reported. The cost-benefit of using TXA in THR is associated with reduction of transfusion costs.

CONCLUSIONS

None of the TXA administration routes are superior to others, but multiple doses could statistically significantly reduce blood loss and transfusion requirements, which should be the subject of future researches.

On the relevance of preoperative haemoglobin optimisation within a Patient Blood Management programme for elective hip arthroplasty surgery

BACKGROUND

Preoperative anaemia is highly prevalent among patients scheduled for total hip arthroplasty (THA), and is the main risk factor for perioperative red blood cell transfusion (RBCT). This retrospective cohort study aimed at assessing whether preoperative haemoglobin (Hb) optimisation reduced RBCT rates and improved outcome in this patient population.

MATERIALS AND METHODS

All patients entered a Patient Blood Management (PBM) programme consisting of in-hospital erythropoiesis stimulation, tranexamic acid administration, and a restrictive RBCT policy. Data from preoperatively anaemic patients (Hb <13 g/dL) who underwent THA, before (2015-2016, control group, n=75) or after (2017-2018, study group, n=70) the incorporation of a preoperative Hb optimisation protocol (Ferric carboxymaltose IV, 1,000 mg ± epoetin-α, 40,000 IU; administered 4 weeks prior to surgery) to the PBM programme underwent a comparative analysis.

RESULTS

Haemoglobin concentrations at preoperative assessment were similar (12.1±0.7 g/dL vs 12.2±0.7 g/dL, for study and control groups, respectively; p=0.129). At hospital admission, significantly higher Hb were observed in the study group (13.4±0.8 g/dL vs 12.2±0.7 g/dL, respectively; p=0.001), with anaemia being corrected in 79% of cases. Compared to the control group, reduced perioperative RBCT rate (4% vs 24%, respectively; p=0.001), shorter length of hospital stay (6 [range 5-7] days vs 7 [5-8 days], respectively; p=0.002), and increased proportion of patients being discharged directly to their home (74% vs 47%, respectively; p=0.01) were observed in the study group. No treatment-related side-effects were witnessed.

DISCUSSION

Within a PBM programme for THA, preoperative Hb optimisation was efficacious at correcting anaemia and minimising RBCT requirements, thus contributing to an improvement in postoperative outcomes.

Optimal route for administering tranexamic acid in primary unilateral total hip arthroplasty: Results from a multicenter cohort study

AIM

This study aimed to compare the efficacy and safety of different tranexamic acid (TXA) routes following primary total hip arthroplasty (THA).

METHODS

We collected data from the National Health Database on patients registered from January 2013 to September 2017. The patients were divided based on TXA administration route into a control group (without TXA), intravenous group, topical group and combined group. The primary outcome was transfusion; secondary outcomes were total blood loss, haemoglobin level, decrease in haemoglobin on postoperative day 3, and incidence of complications.

RESULTS

Data were collected on 7667 primary THA, 4662 with TXA and 3005 without TXA. The transfusion rate was 28.7% in the control group, 12.7% in the topical group, 8.9% in the intravenous group, and 6.1% in the combined group, and the inter-group differences were significant (P < .01). The combined group showed significantly smaller total blood loss (1.23 ± 0.52 L), smaller reduction in haemoglobin level (26.5 ± 11.1 g/L) and higher haemoglobin level on postoperative day 3 (107.0 ± 15.5 g/L) than the other three groups (P < .05). The three TXA groups showed significantly lower incidence of deep vein thrombosis than the control group (0.08% vs 0.47%, P = .001) as well as a lower rate of other complications (0.34% vs 0.67%, P = .044).

CONCLUSION

TXA is effective and safe to decrease blood loss and transfusion following primary THA, regardless of whether it is administered intravenously, topically or both. Intravenous or combined routes may produce better haemostatic effects, so they may be suggested in the absence of contraindications.