Topical tranexamic acid versus autotransfusion after total knee arthroplasty

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.

Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery

BACKGROUND

Concerns regarding the safety and availability of transfused donor blood have prompted research into a range of techniques to minimise allogeneic transfusion requirements. Cell salvage (CS) describes the recovery of blood from the surgical field, either during or after surgery, for reinfusion back to the patient.

OBJECTIVES

To examine the effectiveness of CS in minimising perioperative allogeneic red blood cell transfusion and on other clinical outcomes in adults undergoing elective or non-urgent surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers for randomised controlled trials (RCTs) and systematic reviews from 2009 (date of previous search) to 19 January 2023, without restrictions on language or publication status.

SELECTION CRITERIA

We included RCTs assessing the use of CS compared to no CS in adults (participants aged 18 or over, or using the study's definition of adult) undergoing elective (non-urgent) surgery only.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 106 RCTs, incorporating data from 14,528 participants, reported in studies conducted in 24 countries. Results were published between 1978 and 2021. We analysed all data according to a single comparison: CS versus no CS. We separated analyses by type of surgery. The certainty of the evidence varied from very low certainty to high certainty. Reasons for downgrading the certainty included imprecision (small sample sizes below the optimal information size required to detect a difference, and wide confidence intervals), inconsistency (high statistical heterogeneity), and risk of bias (high risk from domains including sequence generation, blinding, and baseline imbalances). Aggregate analysis (all surgeries combined: primary outcome only) Very low-certainty evidence means we are uncertain if there is a reduction in the risk of allogeneic transfusion with CS (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.59 to 0.72; 82 RCTs, 12,520 participants). Cancer: 2 RCTs (79 participants) Very low-certainty evidence means we are uncertain whether there is a difference for mortality, blood loss, infection, or deep vein thrombosis (DVT). There were no analysable data reported for the remaining outcomes. Cardiovascular (vascular): 6 RCTs (384 participants) Very low- to low-certainty evidence means we are uncertain whether there is a difference for most outcomes. No data were reported for major adverse cardiovascular events (MACE). Cardiovascular (no bypass): 6 RCTs (372 participants) Moderate-certainty evidence suggests there is probably a reduction in risk of allogeneic transfusion with CS (RR 0.82, 95% CI 0.69 to 0.97; 3 RCTs, 169 participants). Very low- to low-certainty evidence means we are uncertain whether there is a difference for volume transfused, blood loss, mortality, re-operation for bleeding, infection, wound complication, myocardial infarction (MI), stroke, and hospital length of stay (LOS). There were no analysable data reported for thrombosis, DVT, pulmonary embolism (PE), and MACE. Cardiovascular (with bypass): 29 RCTs (2936 participants) Low-certainty evidence suggests there may be a reduction in the risk of allogeneic transfusion with CS, and suggests there may be no difference in risk of infection and hospital LOS. Very low- to moderate-certainty evidence means we are uncertain whether there is a reduction in volume transfused because of CS, or if there is any difference for mortality, blood loss, re-operation for bleeding, wound complication, thrombosis, DVT, PE, MACE, and MI, and probably no difference in risk of stroke. Obstetrics: 1 RCT (1356 participants) High-certainty evidence shows there is no difference between groups for mean volume of allogeneic blood transfused (mean difference (MD) -0.02 units, 95% CI -0.08 to 0.04; 1 RCT, 1349 participants). Low-certainty evidence suggests there may be no difference for risk of allogeneic transfusion. There were no analysable data reported for the remaining outcomes. Orthopaedic (hip only): 17 RCTs (2055 participants) Very low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, or if there is any difference between groups for mortality, blood loss, re-operation for bleeding, infection, wound complication, prosthetic joint infection (PJI), thrombosis, DVT, PE, stroke, and hospital LOS. There were no analysable data reported for MACE and MI. Orthopaedic (knee only): 26 RCTs (2568 participants) Very low- to low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, and whether there is a difference for blood loss, re-operation for bleeding, infection, wound complication, PJI, DVT, PE, MI, MACE, stroke, and hospital LOS. There were no analysable data reported for mortality and thrombosis. Orthopaedic (spine only): 6 RCTs (404 participants) Moderate-certainty evidence suggests there is probably a reduction in the need for allogeneic transfusion with CS (RR 0.44, 95% CI 0.31 to 0.63; 3 RCTs, 194 participants). Very low- to moderate-certainty evidence suggests there may be no difference for volume transfused, blood loss, infection, wound complication, and PE. There were no analysable data reported for mortality, re-operation for bleeding, PJI, thrombosis, DVT, MACE, MI, stroke, and hospital LOS. Orthopaedic (mixed): 14 RCTs (4374 participants) Very low- to low-certainty evidence means we are uncertain if there is a reduction in the need for allogeneic transfusion with CS, or if there is any difference between groups for volume transfused, mortality, blood loss, infection, wound complication, PJI, thrombosis, DVT, MI, and hospital LOS. There were no analysable data reported for re-operation for bleeding, MACE, and stroke.

AUTHORS' CONCLUSIONS

In some types of elective surgery, cell salvage may reduce the need for and volume of allogeneic transfusion, alongside evidence of no difference in adverse events, when compared to no cell salvage. Further research is required to establish why other surgeries show no benefit from CS, through further analysis of the current evidence. More large RCTs in under-reported specialities are needed to expand the evidence base for exploring the impact of CS.

Influencing factors on morbidity and mortality in intertrochanteric fractures

We aimed to evaluate the effect of the patient's clinical and paraclinical condition before and after surgery on short-term mortality and complication and long-term mortality. A retrospective cohort study was conducted and multivariate logistic regression was applied to determine the effect of demographic characteristics (sex, age, AO/OTA classification, height, weight, body mass index), medical history (hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen, Creatinine, Na, and K), surgery-related factors (Anesthesia time and type, implant, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption on short-term mortality and complication and long-term mortality. Three hundred ten patients from November 2016 to September 2020 were diagnosed with an intertrochanteric fracture. 3.23% of patients died in hospital, 14.1% of patients confronted in-hospital complications, and 38.3% died after discharge till the study endpoint. ΔNumber of Neutrophiles is the primary determinant for in-hospital mortality in multivariate analysis. Age and blood transfusion are the main determinants of long-term mortality, and Na before surgery is the primary variable associated with postoperative complications. Among different analytical factors Na before surgery as a biomarker presenting dehydration was the main prognostic factor for in hospital complications. In hospital mortality was mainly because of infection and long-term mortality was associated with blood transfusion.

Effects of Tranexamic Acid on Hemorrhage Control and Deep Venous Thrombosis Rate After Total Knee Arthroplasty: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Background: Total knee arthroplasty (TKA) surgery has a lot of complications, especially hemorrhage, which can be controlled via tranexamic acid (TXA). The guidelines endorse the integration of TXA interventions in the management of TKA-induced complications. However, uncertainty surrounds the effects of different TXA therapies. This frequentist model network meta-analysis (NMA) aims to compare hemorrhage control and deep venous thrombosis (DVT) rate of different TXA therapies in TKA.

Methods: Articles were searched with the PubMed, Embase, Cochrane Library, and Web of Science from 1966 to October 2020. Randomized controlled trials (RCTs) comparing different TXA therapies, or with placebo in patients with TKA were included. Two investigators independently conducted article retrievals and data collection. The outcome was total blood loss and DVT rate. Effect size measures were mean differences (MDs), or odds ratios (ORs) with 95% confidence intervals (CIs). We conducted a random-effects NMA using a frequentist approach to estimate relative effects for all comparisons and rank treatments according to the mean rank and surface under the cumulative ranking curve values. All analyses were performed in Stata software or R software. The study protocol was registered with PROSPERO, number CRD42020202404.

Results: We identified 1 754 citations and included 81 studies with data for 9 987 patients with TKA. Overall, all TXA therapies were superior to placebo for total blood loss in TKA. Of all TXA therapies, M therapy (IV/IV infusion + oral TXA > 3g) was most effective for total blood loss (MD=−688.48, −1084.04–−328.93), followed by F therapy (IV TXA ≥ 15 mg/kg or 1 g three times). TXA therapies in this study are not associated with the increase of DVT risk.

Conclusions: TXA therapies in this study are effective and safe for the treatment of TKA-induced complications. M therapy (IV/IV infusion + oral TXA > 3 g) may be the most effective TXA therapy for hemorrhage control. TXA therapies in this study do not increase DVT risk. Considering hemorrhage control and DVT rate simultaneously, F therapy (IV TXA ≥ 15 mg/kg or 1 g three times) may be suggested to apply for TKA, and this study may provide a crucial clue to future TXA use.

Comparative efficacy and safety of topical hemostatic agents in primary total knee arthroplasty: A network meta-analysis of randomized controlled trials

BACKGROUND

Topical hemostatic agents are commonly used for reducing perioperative blood loss and transfusion requirement in primary total knee arthroplasty (TKA), although the optimal option has yet to be defined. This study aimed to evaluate the efficacy and safety of topical hemostatic agents and rank the best intervention using the network meta-analysis (NMA) method.

METHODS

We searched Web of science, PubMed, and Cochrane Library database up to April 2020, for randomized controlled trials (RCTs) on topical hemostatic agents in primary TKA. The quality of included studies was assessed using the Cochrane "risk of bias" tool. Direct and indirect comparisons were performed for the result of network meta-analysis followed by consistency test.

RESULTS

Thirty seven RCTs with 3792 patients were included in this NMA and the pooled results indicated that tranexamic acid plus diluted epinephrine (TXA+DEP) displayed the highest efficacy in reducing total blood loss, hemoglobin drop and transfusion requirement. None of the included treatments was found to increase risk of thromboembolic events compared to placebo. According to the results of ranking probabilities, TXA+DEP had the highest possibility to be the best topical hemostatic agent with regard to the greatest comparative efficacy and a relatively high safety level.

CONCLUSION

Current evidence supports that administration of TXA+DEP may be the optimal topical hemostatic agent to decrease blood loss and transfusion requirement in primary TKA. More direct studies that focused on the topical application of TXA+DEP versus other treatments are needed in the future.

Allogeneic red blood cell transfusion is an independent risk factor for 1-year mortality in elderly patients undergoing femoral neck fracture surgery: Retrospective study

Allogeneic red blood cell transfusion (ABT) is 1 of the poor prognostic factors for morbidity and mortality in patients with hip fracture, particularly among elderly patients. This study aimed to investigate the risk factors for ABT and 1-year mortality in elderly patients undergoing surgery for femoral neck fracture.A total of 225 elderly patients who underwent femoral neck fracture surgery between May 2013 and November 2015 at a tertiary medical center were retrospectively recruited. Medical records were analyzed.The median patient age was 80 years and 28.4% were men. A total of 113 patients received ABT (50.2%). Multivariate logistic regression analysis showed that female sex (odds ratio [OR] 2.606, 95% confidence interval [CI] 1.283-5.295, P = .008), malignancy (OR 5.098, 95% CI 1.725-15.061, P = .003), chronic kidney disease stage ≥ 3 (OR 3.258, 95% CI 1.603-6.622, P = .001), and anemia (hemoglobin < 12 g/dL) (OR 4.684, 95% CI 2.230-9.837, P < .001) were significantly associated with ABT. The 1-year mortality rate after surgery was 15.1%. Male sex (OR 2.477, 95% CI 1.101-5.575, P = .028), ABT (OR 2.367, 95% CI 1.036-5.410, P = .041), and intensive care unit admission (OR 5.564, 95% CI 1.457-21.249, P = .012) were significantly associated with 1-year mortality.In this study, underlying comorbidities such as chronic kidney disease and malignancy were associated with ABT. Furthermore, ABT was a significant independent risk factor for 1-year mortality. These findings suggest that underlying comorbidities and the need for ABT should be considered in the risk assessment of elderly patients with femoral neck fracture to improve the outcomes after surgery.

Efficacy and Safety of Tranexamic Acid Combined with Rivaroxaban in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Tranexamic acid (TXA) combined with rivaroxaban (RA) has been widely used in total knee replacement (TKA). This meta-analysis explored the clinical effects of TXA combined with RA on reducing bleeding and preventing venous thrombosis in patients with unilateral TKA.

METHODS

Five controlled clinical studies that met the inclusion criteria were collected from PubMed, Embase and Cochrane libraries. Fixed effect model and random effect model were used to compare the TXA + RA group with the RA group in 731 patients.

RESULTS

Decrease of hemoglobin (Hb), total blood loss, transfusion rate and wound complications of the TXA + RA group is lower than the RA group, the difference was statistically significant (p < 0.05). Deep venous thrombosis (DVT) occurs in the TXA + RA group and the RA group showed no statistically significant difference (p > 0.05). There was no obvious difference of two ways of drug given that intra-articular (IA) and intravenous (IV) effect on Hb decrease, total blood loss, transfusion rate, wound complications, DVT (p > 0.05).

CONCLUSION

The application of TXA combined with RA in the TKA can effectively reduce blood loss without increasing the risk of DVT. However, it should be noted that TXA combined with RA after TKA has a potential increased risk of wound complications.

Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials

OBJECTIVE

This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).

DESIGN

This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE).

SETTING

We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration.

PARTICIPANTS

Patients undergoing TKA or THA.

INTERVENTIONS

Intravenous, topical or combined intravenous and topical TXA.

RESULTS

Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles.

CONCLUSIONS

The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.

The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis

BACKGROUND

A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of 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

We searched Ovid MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases for publications before July 2017 on TXA in primary total joint arthroplasty. All included studies underwent qualitative and quantitative homogeneity testing. Direct and indirect comparisons were performed as a network meta-analysis, and results were tested for consistency.

RESULTS

After critical appraisal of the available 2113 publications, 67 articles were identified as representing the best available evidence. Topical, intravenous (IV), and oral TXA formulations were all superior to placebo in terms of decreasing blood loss and risk of transfusion, while no formulation was clearly superior. Use of repeat IV and oral TXA dosing and higher doses of IV and topical TXA did not significantly reduce blood loss or risk of transfusion. Preincision administration of IV TXA had inconsistent findings with a reduced risk of transfusion but no effect on volume of blood loss.

CONCLUSIONS

Strong evidence supports the efficacy of TXA to decrease blood loss and the risk of transfusion after primary TKA. No TXA formulation, dosage, or number of doses provided clearly improved blood-sparing properties for TKA. Moderate evidence supports preincision administration of IV TXA to improve efficacy.

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.