Combined application versus topical and intravenous application of tranexamic acid following primary total hip arthroplasty: a meta-analysis

Intravenous versus topical tranexamic acid in spinal surgery: a systematic review and meta-analysis

BACKGROUND

The administration of tranexamic acid (TXA) during spinal surgery has been shown to reduce blood loss. However, the efficacy and safety of intravenous TXA (ivTXA) and topical TXA (tTXA) are poorly documented. The present meta-analysis aimed to compare the efficacy and safety of ivTXA and tTXA administration in spinal surgery.

METHODS

Potentially relevant academic articles were identified from PubMed, Ovid, Cochrane Library, CNKI database, and Wanfang Data from the date of inception until March 1, 2024. Randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) were included in our meta-analysis if they compared the efficacy and safety of ivTXA versus tTXA administration during spinal surgery. Secondary sources were identified from the references of the included literature. The meta-analysis was performed in accordance with the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Data were summarized using RevMan 5.3 software from Denmark.

RESULTS

Four RCTs and one non-RCT met our inclusion criteria. The pooled outcomes demonstrated that ivTXA groups compared with tTXA groups had significantly less amount of total blood loss [weighted mean difference (WMD)=-159.55, 95% CI (-181.91,-137.19), P < 0.00001], hidden blood loss [WMD=-132.27, 95% CI (-159.81, -104.72), P < 0.00001], intraoperative blood loss [WMD=-86.22, 95% CI (-99.13, -73.31), P < 0.00001, I2 = 96%], and more high postoperative hemoglobin level [WMD = 8.96, 95% CI (5.18, 12.75), P < 0.00001, I2 = 29%], and less transfusion rate [risk ratio (RR) = 1.11, 95% CI (0.81,1.52), P = 0.50, I2 = 94%]. The pooled results showed no significant difference in thromboembolic events (deep venous thrombosis and pulmonary embolism) between the two groups.

CONCLUSION

Our meta-analysis demonstrated that ivTXA was more effective than tTXA in inducing hemostatic effect during spinal surgery. However, the risk of a thrombotic event was not different between the two administration methods of TXA. More high quality RCTs are needed to further confirm our conclusions.

Efficacy and safety of tranexamic acid in posterior lumbar interbody fusion: a meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) in hemostasis in patients undergoing posterior lumbar interbody fusion (PLIF) by meta-analysis.

METHODS

This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022354812). The databases PubMed, Cochrane Library, Web of Science, and Embase were searched for randomized controlled trial (RCT) papers on the use of TXA in patients with PLIF from database establishment to August 2022. Two researchers screened the literature, extracted data, evaluated the risk of bias of the included studies, recorded the authors, sample size, type of study design, and TXA dose of each study, and extracted the intraoperative blood loss, number of blood transfusions, total blood loss, drainage volume, operation time, and incidence of deep venous thrombosis in each study. Meta-analysis was performed using RevMan 5.4 software provided by Cochrane Library.

RESULTS

A total of 14 RCTs with a total of 1681 patients were included in this study, including 836 patients in the TXA group and 845 patients in the control group. The intraoperative blood loss [mean difference (MD) = - 125.97, 95% confidence interval (CI) (- 138.56, - 113.37), P < 0.0001] and less total blood loss [MD = - 204.28, 95% CI (- 227.38, - 181.18), P < 0.00001] in TXA group were lower than the control group. Statistical significance was also observed in postoperative drainage volume [MD = - 115.03, 95% CI (- 123.89, - 106.17), P < 0.00001], operation time [MD = - 8.10, 95% CI (- 14.49, - 1.71), P = 0.01], and blood transfusion rate [odds ratio (OR) = 0.30, 95% CI (0.23, 0.39), P < 0.00001]. However, there was no statistical difference observed in the incidence of deep venous thrombosis [OR = 0.83, 95% CI (0.56, 1.21), P = 0.33].

CONCLUSION

The application of TXA in PLIF can reduce intraoperative blood loss, total blood loss, drainage volume, the incidence of transfusion events, and operation time without increasing the risk of deep venous thrombosis.

Does tranexamic acid reliably reduce blood loss in proximal femur fracture surgery?

PURPOSE

The aim of our study was to investigate the use of tranexamic acid in patients with proximal femoral fractures and compare the total blood loss, transfusion rates, complications, and the application method.

METHODS

A retrospective single center cohort study (level I trauma center) with 1479 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 was performed. 1 g of tranexamic acid was applied (systemic, topic or combined application). Patient data, surgical procedure, complications, and mortality were assessed. Hemoglobin levels, blood loss and transfusion rates for patients with and without tranexamic acid and the application methods were compared.

RESULTS

667 femoral neck fractures, 701 pertrochanteric and 109 subtrochanteric fractures were included. Mean age was 80.8 years. 274 patients received tranexamic acid. At admission average hemoglobin was 12.2 g/l. Hemoglobin drop postoperatively was less after tranexamic acid (9.72 vs. 9.35 g/dl). Transfusion rates were lowered significantly by 17.1% after tranexamic acid. Blood loss was reduced for all patients after tranexamic acid independent of fracture morphology. The combination of 1 g i.v. and 1 g topical-applied tranexamic acid seems to be more effective. Complication rates did not differ.

CONCLUSION

Tranexamic acid is effective in reducing blood loss and transfusion rates, without increasing the risk of thromboembolic events after proximal femoral fractures. For open reduction and nailing and arthroplasty in fracture setting combined topical and single i.v. application seems most effective and closed reduction with nailing can be treated by single dose i.v. application of 1 g tranexamic acid.

Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations

Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

Tranexamic acid and rosuvastatin in patients at risk of cardiovascular events after noncardiac surgery: a pilot of the POISE-3 randomized controlled trial

Background

Surgical bleeding is associated with postoperative cardiovascular complications. The efficacy and safety of tranexamic acid (TXA) in noncardiac surgery are still uncertain. Statins may prevent perioperative cardiovascular complications. We conducted a pilot to assess the feasibility of a perioperative trial of TXA and rosuvastatin.

Methods

Using a factorial design, we randomized patients at cardiovascular risk undergoing noncardiac surgery to intravenous TXA (1 g at the start and end of surgery) or placebo, and oral rosuvastatin (40 mg before and 20 mg daily for 30 days after surgery) or placebo. Feasibility outcomes included recruitment rates, follow-up, and compliance to interventions. Clinical outcomes were secondarily explored.

Results

After 3 months, we changed the design to a partial factorial due to the difficult recruitment of statin-naive patients. Over 6 months, 100 patients were randomized in the TXA trial (49 TXA, 51 placebo), 34 in the rosuvastatin trial (18 rosuvastatin, 16 placebo). Ninety-two percent (95% CI 80–98) of TXA and 86% (95% CI 74–94) of TXA-placebo patients received the 2 study doses. Thirty-three percent (95% CI 13–59) of rosuvastatin patients and 37% (95% CI 15–65) of rosuvastatin-placebo patients discontinued the study drug. A major cardiovascular complication occurred at 30 days in 1 TXA and 6 TXA-placebo patients, and 1 rosuvastatin and no rosuvastatin-placebo patients.

Conclusions

Our pilot study supports the feasibility of a perioperative TXA trial in noncardiac surgery. Feasibility of a perioperative rosuvastatin trial is uncertain because of a high prevalence of statin use in the target population and concerns about compliance.

Trial registration

ClinicalTrials.govNCT02546648.

Efficacy and safety of tranexamic acid usage in patients undergoing posterior lumbar fusion: a meta-analysis

Background

The purpose of this meta-analysis is to evaluate the efficacy and safety of tranexamic acid (TXA) for patients with degenerative lumbar disc herniation, stenosis or instability undergoing posterior lumbar fusion (PLF) surgery.

Methods

We searched PubMed, Embase, and Cochrane Library until May 1, 2018. Two reviewers selected studies, assessed quality, extracted data, and evaluated the risk of bias independently. Weighted mean difference (WMD) and relative risk (RR) were calculated as the summary statistics for continuous data and dichotomous data, respectively. We chose fixed-effects or random-effects models based on I² statistics. RevMan 5.0 and STATA 14.0 software were used for data analysis.

Results

Nine studies enrolling 713 patients for the study. The pooled outcomes demonstrated that TXA can decrease total blood loss (TBL) in patients underwent PLF surgery [WMD = -250.68, 95% CI (− 325.06, − 176.29), P<0.001], intraoperative blood loss (IBL) [WMD = -72.57, 95% CI (− 103.94, − 41.20), P<0.001], postoperative blood loss (PBL) [WMD = -127.57, 95% CI (− 149.39, − 105.75), P<0.001], and the loss of hemoglobin (Hb) in postoperative 24 h [WMD = -0.31, 95% CI (− 0.44, − 0.18), P<0.001]. However, there is no significant difference between two groups in transfusion rate [RR =0.34, 95% CI (0.09, 1.28), P = 0.11], and none thrombotic event was happened in the two groups.

Conclusion

Our meta-analysis demonstrated that TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability underwent PLF surgery. However, there was no significant difference in blood transfusion rates between the two groups.

[Efficacy and safety of a loading high-dose tranexamic acid followed by postoperative five doses in total hip arthroplasty: A randomized controlled trial]

OBJECTIVE

To evaluate the efficacy and safety of a loading high-dose tranexamic acid (TXA) followed by postoperative 5 doses in total hip arthroplasty (THA) by a randomized controlled trial.

METHODS

Seventy-two patients who underwent primary unilateral THA between December 2017 and March 2018 were randomly divided into two groups (36 patients in each group). A single dose of 20 mg/kg TXA was administered intravenously before 5-10 minutes of operation in group A; and a single dose of 40 mg/kg TXA was administered intravenously in group B at the same time point. All patients received 5 doses of 1 g TXA at 3, 6, 12, 18, and 24 hours after the first dose. There was no significant difference in gender, age, weight, height, body mass index, disease type, and combined medical diseases between the two groups ( P>0.05). Total blood loss (TBL), lowest postoperative hemoglobin (Hb) level, fibrinolysis parameters [fibrin (ogen) degradation products (FDP), D-dimer], inflammatory factors [C-reaction protein (CRP), interleukin-6 (IL-6)], adverse events (thrombosis, pulmonary embolism) were recorded and compared between groups.

RESULTS

The TBL was significantly lower in group B than in group A ( P<0.05). Furthermore, the lowest postoperative Hb level was significantly higher in group B than in group A ( P<0.05). There was no significant difference in FDP and D-dimer before operation between the two groups ( P>0.05). The levels of FDP and D-dimer were significantly lower in group B than in group A at 12 and 36 hours postoperatively ( P<0.05). There was no significant difference in CRP and IL-6 before operation between the two groups ( P>0.05). The levels of CRP and IL-6 were significant lower in group B than in group A at 12, 24, and 36 hours postoperatively ( P<0.05). There was no significant difference at 14 days ( P>0.05). There were 2 patients with intramuscular venous thrombosis in group A and 1 in group B after operation, and there was no significant difference in the incidence of embolic events ( P>0.05). No deep venous thrombosis or pulmonary embolism occurred in all groups.

CONCLUSION

A loading high-dose TXA followed by postoperative 5 doses can further reduce the blood loss, provide additional fibrinolysis and inflammation control in THA, without increasing the risk of embolic events.

A systematic review of tranexamic acid usage in patients undergoing femoral fracture surgery

BACKGROUND

Patients undergoing femoral fracture surgery frequently require blood transfusion. Tranexamic acid (TXA) has been widely used to decrease transfusion rate in joint replacement surgery. Therefore, we conducted a systematic review to evaluate the efficacy and safety of TXA usage in femoral fracture surgery.

MATERIALS AND METHODS

Studies involving TXA usage in femoral fracture surgery were searched through four electronic databases. The end points included total blood loss, postoperative hemoglobin decline, transfusion rate, thromboembolic events, 90-day mortality, and operative time. The present study was performed following Cochrane Reviewers' Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was carried out by using Stata 14.0 software.

RESULTS

Eleven studies concerning intravenous (IV) application of TXA and three studies concerning topical administration of TXA were included. Twelve studies were randomized controlled trials (RCTs), and one was a retrospective cohort study. Regarding IV TXA, our paper indicated that the IV TXA group had less total blood loss (weighted mean difference [WMD] = -319.282, P = 0.000), lower postoperative hemoglobin decline (WMD = -1.14, P = 0.000) and lower transfusion rate (risk difference [RD] = -0.172, P = 0.000). No significant differences were found in thromboembolic events (RD = 0.008, P = 0.507), 90-day mortality (RD = 0.009, P = 0.732) and operative time (WMD = -2.227, P = 0.103). Regarding topical TXA, no significant differences were found in the transfusion rate (RD = -0.098, P = 0.129), postoperative hemoglobin decline (WMD = -1.137, P = 0.231), thromboembolic events (RD = -0.017, P = 0.660) and operative time (WMD = -4.842, P = 0.136).

CONCLUSION

Our meta-analysis demonstrated that both IV and topical application of TXA reduced transfusion rate in femoral fracture surgery. However, still further studies are needed to identify the optimal route of administration, TXA dosage and timing. In addition, high-quality RCTs with a large sample size are required to figure out the safety of TXA application, especially in the elderly, before its wide recommendation.

The effect of tranexamic acid in unilateral and bilateral total knee arthroplasty in the South Asian population: A retrospective cohort study

INTRODUCTION

Together with evidence of higher bleeding tendencies, the vulnerability of the South-Asian population to anemia secondary to a higher prevalence of hemoglobinopathies and micronutrient deficiencies merits further exploration of the effects of tranexamic acid on this population. Additionally, limited access to self-care facilities and certain sociocultural beliefs and practices may not be conducive to a speedy recovery from surgical complications. The aim of this study is to investigate the effects of intraoperative administration of tranexamic acid during total knee arthroplasty when considering the South-Asian population.

METHODOLOGY

Medical record files of 355 patients who underwent total knee arthroplasty (2007-2015) were reviewed to collect data regarding patient characteristics, surgical variables and post-operative complications. Unilateral and Bilateral total knee arthroplasty were studied separately. Analysis was done using t-test, Mann-Whitney U test, chi-square and Fisher's exact square where appropriate. The threshold for significance was p < 0.05.

RESULTS

The study showed that for unilateral surgery, tranexamic acid caused a significant reduction in estimated blood loss (p-value=0.011), total operative time, calculated blood loss, and hemoglobin change (p-value<0.001) whereas in bilateral surgery, tranexamic acid only caused a significant reduction in calculated blood loss (p-value < 0.001) and hemoglobin change (p-value=0.001). Interestingly, in those who received tranexamic acid vs. those who did not, there was a significant increase in length of hospital stay (p<0.001) and special care unit admissions (p-value=0.033) in unilateral and bilateral surgery respectively.

CONCLUSIONS

Although tranexamic acid effectively reduces intraoperative blood loss, it does not have an effect on the need for post-operative blood transfusions. The increased length of stay and special care unit admissions associated with tranexamic acid use should be explored further to reveal the complete safety profile of tranexamic acid administration in the South-Asian population during total knee arthroplasty.

Tranexamic acid in total hip arthroplasty: Mixed treatment comparisons of randomized controlled trials and cohort studies

Background

The present study is a network meta-analysis of various routes of tranexamic acid (TXA) in patients with total hip arthroplasty (THA).

Methods

Randomized controlled trials and cohort studies evaluating TXA in patients with THA were included. Number of patients requiring blood transfusion was the primary outcome.

Results

Pooled estimate for TXA use against placebo for blood transfusion rate was 0.30 [0.23, 0.39] favoring TXA. Maximum reduction in the risk of blood transfusion was observed with topical plus intra-operative intravenous TXA.

Conclusion

Combined topical and intravenous TXA during surgery may perform better than other modes in patients undergoing THA.

Low Rates of Adverse Events Following Ambulatory Outpatient Total Hip Arthroplasty at a Free-Standing Surgery Center

BACKGROUND

We proposed to determine the complication and hospital admission rates for patients with total hip arthroplasty (THA) done by a single surgeon in a stand-alone ambulatory surgical center with same-day discharge. Given the recent emphasis on bundled payments for a 90-day episode of care, this same time frame after surgery was chosen to determine patient outcomes.

METHODS

The records of patients with THAs done through a direct anterior approach by a single surgeon at 2 separate ambulatory surgery centers were reviewed. To analyze the learning curve for outpatient THA, the procedures were arbitrarily divided into 2 groups depending on when they were done: early in our experience or later. Complications were recorded, as were hospital admissions and surgical interventions, length of surgery and blood loss, and time spent at the outpatient facility.

RESULTS

Over a 3-year period, 145 outpatient THAs were done in 125 patients; 73 were considered to be initial procedures, and 72 were considered to be later procedures. Only one of the 145 procedures (0.7%) required transfer from the outpatient facility to the hospital for a blood transfusion. No other direct admissions to the hospital or transfers to the emergency department from the surgery center were necessary. Surgical interventions were required after 3 (2%) of the 145 arthroplasties in the global period (90 days).

CONCLUSION

This study demonstrated that same-day discharge to home following THA can be safely done without increased complications, readmissions, reoperations, or emergency room visits.

The efficacy of combined intra-articular and intravenous tranexamic acid for blood loss in primary total knee arthroplasty: A meta-analysis

BACKGROUND

This meta-analysis aimed to illustrate the efficacy and safety of combined topical and intravenous (IV) tranexamic acid (TXA) for blood loss control in primary total knee arthroplasty (TKA) patients.

METHODS

In April 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google database. Data on patients prepared for TKA surgery in studies that compared combined topical and IV TXA versus placebo, topical, or IV TXA alone were retrieved. The primary endpoint was the need for transfusion, total blood loss, hemoglobin drop, and the occurrence of deep venous thrombosis (DVT), pulmonary embolism (PE), and the infection. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.

RESULTS

Seven clinical studies were ultimately included in the meta-analysis. Compared with IV TXA and control group, combined TXA was associated with less need for transfusion, blood loss, and hemoglobin drop (P < .05). There was no significant difference between the combined TXA and topical TXA in terms of the need for transfusion, total blood loss, and hemoglobin drop (P > .05). There was no significant difference between the complications (DVT, PE, and infection) between the combined TXA, IV TXA, topical TXA, and control group.

CONCLUSIONS

Current meta-analysis suggests that the combined IV and topical TXA was superior than IV TXA or control group. There is still need for more studies to identify whether combined TXA was superior than topical TXA alone.

Tranexamic acid in total hip arthroplasty: A recursive cumulative meta-analysis of randomized controlled trials and assessment of publication bias

INTRODUCTION

TXA has been evaluated in THA in several randomized controlled trials for the past 16 years. We attempted to evaluate the trends in the evidence using recursive cumulative meta-analysis and publication bias using Rosenthal and 'Trim and Fill' methods.

METHODS

Electronic databases were searched for randomized controlled clinical trials comparing TXA with either placebo (or no TXA administration) or TXA, administered through different routes in patients with osteoarthritis or osteonecrosis of the hip who underwent THA. We considered the total number of patients requiring blood transfusion as the clinical outcome for both the analyses and used quality effects model for assessing the changes in the pooled estimates with addition of new clinical trial data. We also assessed the publication bias by plotting individual study estimates with the standard errors using Rosenthal and 'Trim and Fill'methods.

RESULTS

A total of 20 studies were included. The pooled cumulative meta-analysis indicates that from 2014 the addition of estimate from new studies in the following years is only narrowing the confidence interval without any significant change in the point estimate. Rosenthal fail-safe-N for the comparisons of intravenous bolus TXA, intra-operative and post-operative intravenous TXA and topical with control groups were 54, 6 and 16 respectively. Fail-safe-N for the combined intravenous and topical TXA with intravenous TXA alone was 13.

CONCLUSION

Adequate evidence exists supporting the use of intravenous TXA in reducing the need for blood transfusion in THA. There is possible existence of small studies with null effects evaluating the use of TXA in THA.

Is combined topical and intravenous tranexamic acid superior to intravenous tranexamic acid alone for controlling blood loss after total hip arthroplasty?: A meta-analysis

BACKGROUND

We performed a meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of combined intravenous (IV) and topical tranexamic acid (TXA) with IV-TXA alone for controlling blood loss in patients following primary total hip arthroplasty (THA).

METHODS

PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, the Google database, the Chinese Wanfang database, and the China National Knowledge Infrastructure database were searched to identify studies comparing combined IV and topical TXA with IV-TXA alone in patients who were prepared for THA. The weighed mean differences for total blood loss, hemoglobin drop, intraoperative blood loss, and the length of hospital stay were calculated. We calculated risk ratios for the need for transfusion and the occurrence of deep venous thrombosis (DVT) in the combined TXA and IV-TXA alone groups. Relevant data were analyzed using Reviewer Manager 5.3.0.

RESULTS

Eight RCTs with a total of 850 patients (combined TXA: n = 471; IV-TXA: n = 479) were included in this meta-analysis. Pooled results indicated that compared with the IV-TXA alone group, the combined TXA group was associated with a lesser need for transfusion, total blood loss, intraoperative blood loss, and hemoglobin drop (P < .05). There was no significant difference between the 2 groups for the length of hospital stay and the occurrence of DVT (P > .05).

CONCLUSIONS

The current meta-analysis indicated that combined topical and IV-TXA was a relatively effective hemostasis method compared with IV-TXA alone. The number of studies included in this meta-analysis is limited, and more studies are needed to verify the effects of combined IV and topical TXA in THA patients.