Tranexamic Acid Use in Foot and Ankle Surgery

Tranexamic Acid is Not Associated With a Change in Infection Risk in Trauma Patients

INTRODUCTION

Tranexamic acid (TXA) has been used as an adjunct in traumatic hemorrhage management. Outside of trauma, TXA has been used to limit blood loss across multiple surgical fields. TXA has also been found to have an immune-modulating effect, reducing postoperative infection rates. However, the relationship between TXA and infection rates in trauma patients is unclear.

METHODS

We performed a single-institution retrospective cohort analysis of 364 trauma patients who underwent massive transfusion protocol activation at a level-one trauma level center over a 7-y period. Patients were placed into two groups based on TXA administration (No TXA and TXA). Minors, patients on anticoagulants, pregnant patients, and those who died upon arrival or were hospitalized for less than 1 d were excluded. Univariate and multivariate analysis with propensity score matching were used to evaluate the association between TXA and infection rates.

RESULTS

Sixty-one patients (16.8%) received TXA, and 303 patients (83.2%) did not. TXA was associated with an increased risk of infection on univariate analysis (P = 0.007). However, on multivariate analysis after propensity score matching, TXA was not associated with infection (P = 0.975) while total hospital days and total ventilator days were associated with an increased risk of infection (P = 0.012, P = 0.014).

CONCLUSIONS

Our study found no association between TXA and infection rates among our patient cohort. While TXA remains an important adjunct in trauma resuscitation, we did not find an association between TXA and infection in trauma patients.

The efficacy and safety of different does of intravenous tranexamic acid on blood loss in fresh foot and ankle fractures: a prospective, randomized controlled study

BACKGROUND

There are a few studies on the effectiveness and safety of intravenous administration of tranexamic acid(TXA) in patients who underwent foot and ankle surgery, especially for preoperative hidden blood loss in patients with freshfoot and ankle fractures. Thus, the aim of this study was to investigate whether intravenous administration of different doses of TXA can effectively reduce perioperative blood loss and blood loss before surgery and to determine its safety.

METHODS

A total of 150 patients with fresh closed foot and ankle fractures from July 2021 to July 2023 were randomly divided into a control group (placebo controlled [PC]), standard-dose group (low-dose group [LD], 1 g/24 h; medium-dose group [MD], 2 g/24 h), and high-dose group (HD, 3 g/24 h; ultrahigh-dose group [UD], 4 g/24 h). After admission, all patients completed hematological examinations as soon as possible and at multiple other time points postsurgery.

RESULTS

There was a significant difference in the incidence of hidden blood loss before the operation between the TXA group and the control group, and the effect was greater in the overdose groups than in the standard-dose groups. There were significant differences in surgical blood loss (intraoperative and postoperative), postoperative HGB changes, and hidden blood loss among the groups. The TXA groups showed a significant decrease in blood loss compared to that of the control group, and the overdose groups had a more significant effect than the standard-dose groups. A total of 9 patients in the control group had early wound infection or poor healing, while only 1 patient in the other groups had this complication, and the difference among the groups was significant. No patients in any group suffered from late deep wound infection, cardiovascular or cerebrovascular events or symptomatic VTE.

CONCLUSION

This is the first study on whether TXA can reduce preoperative hidden blood loss in patients with freshfoot and ankle fractures. In our study, on the one hand, intravenous application of TXA after foot and ankle fractures as soon as possible can reduce preoperative blood loss and postoperative blood loss. On the other hand, TXA can also lower wound complications, and over-doses of TXA are more effective than standard doses. Moreover, overdoses of TXA do not increase the incidence of DVT.

The efficacy and safety of tranexamic acid utilization in total ankle arthroplasty: a systematic review and meta-analysis

INTRODUCTION

There is still a lack of information on the role of Tranexamic acid (TXA) in total ankle arthroplasty (TAA). The purpose of this study is to comprehensively review, consolidate, and analyze findings from existing research on the effectiveness and safety of TXA in TAA.

MATERIALS AND METHODS

The comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, Web of Science, and Cochrane databases, for original, English-language studies investigating the efficacy and safety of TXA in TAA, through February 2023. Evaluated data for the meta-analysis included estimated blood loss (EBL), change in perioperative hemoglobin, need for transfusion, and complications including DVT/PE, and wound complications.

RESULTS

A total of nine studies were included in this study. In total, 450 TAA were included, with 244 receiving TXA (54.2%) and 206 not receiving TXA (45.8%). TXA in TAA significantly decreased EBL. A significantly lower rate of wound complications in the TXA group with the relative risk (RR) of 0.51. We classified wound complications into wound infection and delayed wound healing/dehiscence. A significant decrease in the rate of wound infection and a tendency showing a decrease in the rate of delayed wound healing/dehiscence in the TXA group were noted: the RR of 0.29, and 0.63, respectively. TXA did not increase the incidence of DVT/PE following TAA.

CONCLUSIONS

In conclusion, the utilization of TXA during TAA demonstrated a statistically significant reduction in EBL and relative risk for wound complications. However, further RCTs with larger sample sizes will be necessary to establish a more robust conclusion regarding the efficacy and safety of TXA in TAA.

LEVEL OF EVIDENCE

Level III, systematic review and meta-analysis.

Tranexamic Acid Utilization in Foot and Ankle Surgery: A Meta-analysis

BACKGROUND

Tranexamic acid (TXA) has been widely used in various orthopaedic subspecialities to decrease blood loss, transfusions, and wound complications. However, the role of TXA in foot and ankle surgery is not clearly delineated. This meta-analysis aims to report the efficacy and safety of TXA in relation to foot and ankle surgical procedures.

METHODS

Database searches were conducted for eligible studies from data inception through January 2022. Clinical studies on the use of TXA in foot and ankle procedures reporting the desired outcomes were included. Outcomes were estimated blood loss, change in hemoglobin, and overall complications. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale and the Joanna Briggs Institute (JBI) critical appraisal tool.

RESULTS

Nine studies met the inclusion criteria. A total of 752 foot and ankle procedures were included, in which 511 (67.95%) procedures received TXA whereas 241 (32.05%) served as controls and did not receive TXA. The pooled data of change in hemoglobin and overall complications showed no difference between the TXA and control group. Estimated blood loss was significantly lower in the patients who received TXA.

CONCLUSION

In conclusion, TXA use was associated with lower estimated blood loss in foot and ankle surgeries without increased risk of thromboembolic events, wound complications, or changes in hemoglobin.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

Association of Drain Use in Ankle Arthrodesis With Increased Blood Transfusion Risk: A National Observational Study

Background:

Closed wound drainage has been extensively studied in the hip and knee arthroplasty literature with equivocal results on its clinical benefits. Although also used in orthopaedic surgeries like ankle arthrodesis and ankle arthroplasty, large-scale data are currently lacking on utilization patterns and real-world effectiveness. We, therefore, aimed to address this research gap in this distinct surgical cohort using national claims data.

Methods:

Using the Premier Healthcare claims database from 2006 to 2016, ankle arthrodesis (n=10,085) and ankle arthroplasty (n=4,977) procedures were included. The main effect was drain use, defined by detailed billing descriptions. Outcomes included blood transfusion, 90-day readmission, and length and cost of hospitalization. Mixed-effects models measured associations between drain use and outcomes. Odds ratios (OR, or % change), 95% CIs, and P values are reported.

Results:

Overall, drains were used in 11% (n=1,074) and 15% (n=755) of ankle arthrodesis and ankle arthroplasty procedures, respectively. Drain use dramatically decreased over the years in both surgery types: from 14% to 6% and 24% to 7% between 2006 and 2016, for arthrodesis and ankle arthroplasty procedures, respectively. After adjustment for relevant covariates, drain use was associated with increased odds of blood transfusion in ankle arthrodesis surgery (OR 1.4, CI 1.1-1.8, P = .0168), whereas differences that were statistically but not clinically significant were seen in cost and length of stay. In total ankle arthroplasty, no statistically significant associations were observed between drain use and the selected outcomes.

Conclusion:

This is the first national study on drain use in ankle surgery. We found a decrease in use over time. Drain use was associated with higher odds of blood transfusion in ankle arthrodesis patients. Although this negative effect may be mitigated by the rapidly decreasing use of drains, future studies are needed to discern drivers of drain use in this distinct surgical population.

Level of Evidence:

Level III, retrospective cohort study

Plasmin, Immunity, and Surgical Site Infection

SSI are a universal economic burden and increase individual patient morbidity and mortality. While antibiotic prophylaxis is the primary preventative intervention, these agents are not themselves benign and may be less effective in the context of emerging antibiotic resistant organisms. Exploration of novel therapies as an adjunct to antimicrobials is warranted. Plasmin and the plasminogen activating system has a complex role in immune function. The immunothrombotic role of plasmin is densely interwoven with the coagulation system and has a multitude of effects on the immune system constituents, which may not always be beneficial. Tranexamic acid is an antifibrinolytic agent which inhibits the conversion of plasminogen to plasmin. Clinical trials have demonstrated a reduction in surgical site infection in TXA exposed patients, however the mechanism and magnitude of this benefit is incompletely understood. This effect may be through the reduction of local wound haematoma, decreased allogenic blood transfusion or a direct immunomodulatory effect. Large scale randomised clinical trial are currently being undertaken to better explain this association. Importantly, TXA is a safe and widely available pharmacological agent which may have a role in the reduction of SSI.