Efficacy and safety of tranexamic acid in geriatric hip fracture with hemiarthroplasty: a retrospective cohort study

Evaluation of the efficacy of perioperative tranexamic acid in patients with pelvic and acetabular fractures: A systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is commonly used to reduce perioperative bleeding in various surgeries, including acetabular and pelvic fractures treated with open reduction and internal fixation (ORIF). However, research on TXA's effectiveness and safety in this context is conflicting. To address this, we conducted a systematic review and meta-analysis on TXA's efficacy and safety in patients with acetabular and pelvic fractures undergoing ORIF.

METHODS

We systematically searched Cochrane, PubMed, and EMBASE databases until August 30, 2023. Our evaluation of TXA focused on 6 domains: estimated blood loss (EBL), blood transfusion units, transfusion rates, thromboembolic events, other complications, and surgery duration. Data from these studies were analyzed using RevMan Manager 5.4.

RESULTS

This study included 4 randomized controlled trials with 179 patients with acetabular and pelvic fractures treated with TXA. The analysis showed that TXA did not significantly reduce EBL, packed red blood cell transfusion units, blood transfusion rates, or surgery duration. There was no significant difference in thromboembolic events or other postoperative complications, like surgical wound issues, pneumonia, heterotopic ossification, and sciatic nerve injuries, between the TXA and control groups.

CONCLUSION

TXA did not demonstrate a significant benefit in reducing perioperative bleeding or complications in patients treated with ORIF for acetabular and pelvic fractures. The utilization of TXA in such clinical scenarios remains a topic necessitating further rigorous investigation to delineate its role in this clinical setting.

Tranexamic acid efficacy in geriatric hip fractures: impact of nutritional status on blood loss, transfusion rates, and safety

BACKGROUND

Tranexamic acid (TXA) is a widely employed intervention in orthopedic surgeries to minimize blood loss and the need for postoperative transfusions. This study focuses on assessing the efficacy and safety of TXA specifically in undernourished older adults undergoing hip fracture procedures.

METHODS

A total of 216 patients were classified into two groups based on the Geriatric Nutritional Risk Index: undernourished and normal. In total, 82 patients received intravenous TXA at a dosage of 15 mg/kg before incision, with an additional 1 g administered intravenously over a 3-hour period postoperatively. Postoperative hemoglobin (Hb) drop, blood transfusion rate, and the incidence of deep venous thrombosis (DVT) were assessed in each group according to the presence or absence of TXA. Additionally, demographic factors including age, sex, body mass index, and serum albumin were investigated.

RESULTS

51.9% patients were identified as undernourished, experiencing progressive anemia (Hb: 10.9 ± 1.5 g/dL) and hypoalbuminemia (serum albumin: 31.9 ± 8 g/L). In comparison with the normal group, undernourished individuals were more likely to sustain femoral neck fractures (undernutrition vs. normal: 56.2 vs. 42.3%) and less likely to incur trochanteric fractures (undernutrition vs. normal: 43.8 vs. 57.7%) (P = 0.043). TXA administration significantly reduced the transfusion rate (P = 0.014) and Hb drop (P = 0.001) in the normal nutritional group, while its impact on the undernourished group remained less pronounced. There was no significant association between TXA administration and the rate of DVT complications, irrespective of the nutritional status.

CONCLUSIONS

Undernutrition not only diminishes muscle strength and gait function, leading to various types of hip fractures, but it may also hinder the efficacy of TXA in reducing blood transfusion rates and blood loss.

A randomised controlled trial assessing the effect of tranexamic acid on post-operative blood transfusions in patient with intra-capsular hip fractures treated with hemi- or total hip arthroplasty

BACKGROUND

Intravenous tranexamic acid (TA) has proven efficacy in reducing blood loss and incidence of transfusion of blood products in elective total joint arthroplasty. However, evidence of efficacy in the setting of intracapsular hip fractures needing hip hemiarthroplasty (HA) or total hip arthroplasty (THA) are scarce. This study aimed to assess post-operative transfusion incidence in this clinical setting.

METHODS

Over a five-year period 250 patients with intracapsular neck of femur fractures requiring arthroplasty were randomised to two groups. The treatment group received three-dose intravenous TA protocol and the control group received usual treatment without administration of TA. Blood loss was estimated from the change in Hb levels on day 1, 3 and 5 after surgery compared to preoperative levels. Transfusions of blood products were recorded when they were triggered by an a priori protocol. Post-operative complications were recorded during patient hospital admission.

RESULTS

The intervention group showed significantly lower transfusion incidence of packed red blood cells (PRBC) (6 vs. 15, p = 0.04, OR = 0.37, 95%CI OR = 0.14 to 0.99) and in the group of patients who received a blood transfusion, a trend was observed for patients who received TA to have lesser number of units of PRBC (mean = 1.3 vs. 1.6, p = 0.51). A significant difference was noted in post-operative Hb levels of day 1,3 and 5. Backward stepwise multivariable regression analysis showed the use of TA was the most significant factor for reduction in postoperative blood transfusion (p = 0.047, OR = 0.37, 95% CI OR = 0.14 to 0.99). Assessment of the strength of the correlation showed modest correlation (Pearson correlation - 0.13 p = 0.04, 95% CI correlation= -0.25 to -0.01). There was no increase in adverse events in patients who received TA.

CONCLUSION

The use of TA in setting of intracapsular hip fractures requiring arthroplasty reduces blood loss, the need for transfusion of blood products and may reduce surgical site complications without increasing the risk of VTE.

Evaluation of the Early Administration of Tranexamic Acid in Geriatric Hip Fractures in the Emergency Department: A Retrospective Study

Introduction Tranexamic acid (TXA) administration perioperatively has demonstrated efficacy in reducing postoperative drops in hemoglobin levels and the need for transfusions among patients with peritrochanteric hip fractures. This study aims to perform a retrospective analysis to assess the impact on hemoglobin levels by comparing patients with fragility hip fractures who received TXA in the ED, in addition to the standard perioperative TXA dose, with those who did not receive TXA in the ED. Methods This study retrospectively reviewed 64 patient records from May 2020 to May 2021 at a Level II trauma center that were classified into two groups: patients who received one gram (g) of TXA in the ED, within five hours of injury (new protocol), or patients who received no TXA in the ED (old protocol). The primary outcomes of the study were hemoglobin and adverse events. An independent t-test was performed on continuous variables. A chi-square test was used to analyze noncontinuous variables. Statistical Product and Service Solutions (SPSS, version 25; IBM SPSS Statistics for Windows, Armonk, NY) was used for analysis. Statistical significance was set at a p value < 0.05. Results We measured the difference between hemoglobin on the day of surgery or day zero and on arrival in the ED, which was not statistically significant between the two protocols (p value = 0.322). The difference between hemoglobin levels on postoperative day one and on arrival in the ED was also not statistically significant (p = 0.339). Adverse events were lower in the new protocol but not statistically significant between the two protocols (p = 0.178). Conclusion Our study showed improved outcomes in postoperative hemoglobin with early administration of TXA in the ED. This is demonstrated by continuous higher postoperative hemoglobin in the new protocol group without an increase in adverse events. While the data did not achieve statistical significance, we believe there is clinical benefit in the early administration of TXA in the ED, a finding that continues to be explored and supported in the literature.

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.

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.

Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study

INTRODUCTION

Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used.

MATERIALS AND METHODS

2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded.

RESULTS

A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001).

CONCLUSION

In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

Tranexamic acid usage in hip fracture surgery: a meta-analysis and meta-regression analysis of current practice

INTRODUCTION

The use of tranexamic acid (TXA) in hip fracture surgery remains inconclusive. The aim of the present meta-analysis was to assess the role of TXA use in hip fracture surgery, and attempt to disclose possible factors which might influence TXA efficacy and safety.

MATERIALS AND METHODS

A systematic computerized literature search was conducted to retrieve all randomized controlled trials (RCTs) and cohort studies regarding TXA use in hip fracture surgery. Overall efficacy and safety were evaluated. Then, subgroup and meta-regression analyses were conducted to disclose the influence of geographic area, fracture type, administration route, frequency and dosage of TXA, blood transfusion threshold, and follow-up duration on the overall effect.

RESULTS

Thirty-four RCTs and 11 cohort studies were included. Patients receiving TXA had a significant decrease in the need for blood transfusion, reduced total, intra-operative and post-operative blood loss, a decrease in pre- and postoperative hemoglobin difference, without increasing thromboembolic events risk. Subgroup analysis showed that topical TXA had a lower transfusion rate compared with controls, yet the result did not reach statistical significance. Also, TXA had similar efficacy and safety profiles in patients with different frequency and dosage of TXA.

CONCLUSION

Current evidence indicated that intravenous administration of TXA could significantly reduce blood transfusion and blood loss without increasing risk of thromboembolic events. The frequency and dosage of TXA might not alter the beneficial effect. The application of topical TXA should be cautious.

Combination effect of intraoperative and postoperative intravenous tranexamic acid in hip hemiarthroplasty. A propensity score matched analysis

BACKGROUND

Tranexamic acid (TXA) has been proven to reduce perioperative blood loss and the incidence of allogeneic blood transfusion in total joint arthroplasty (TJA). However, there is limited literature on the use of TXA in patients undergoing hip hemiarthroplasty. Furthermore, combination effect of intraoperative and postoperative intravenous TXA has not been investigated extensively. The purpose of this study was to evaluate this combination effect on hip hemiarthroplasty by a propensity score matched analysis (PSMA).

METHODS

This is a retrospective cohort study involving hip hemiarthroplasty for femoral neck fracture. All patients received 1g intraoperative intravenous TXA. One group also received 1g intravenous TXA 6h after surgery, while the other group did not. Perioperative blood loss, the incidence of allogeneic blood transfusion and venous thromboembolism (VTE) were collected and compared.

RESULTS

209 patients who underwent unilateral hip hemiarthroplasty were included. PSMA resulted in 66 matched pairs in each group. There were no significant differences in perioperative blood loss on postoperative day (POD) # 1, 3, 5 (637.2 ± 285.9 versus 653.6 ± 305.5, 726.6 ± 274.2 versus 676.3 ± 313.2, 795.5 ± 291.2 versus 759.9 ± 328.4), the incidence of allogeneic blood transfusion (9.1% versus 12.1%) and VTE (1.5% versus 1.5%) between the two groups (P value> 05) for up to one year.

CONCLUSION

Intraoperative and postoperative intravenous TXA have no combination effect on reducing perioperative blood loss, the incidence of allogeneic blood transfusion and VTE in patients undergoing hip hemiarthroplasty.

Clinical outcomes of tranexamic acid in acute hip hemiarthroplasties in frail geriatric patients

BACKGROUND

Tranexamic acid (TXA) has shown to significantly reduce perioperative blood loss in elective orthopedic joint replacement surgery but is yet not implemented in acute hip fracture surgery for elderly patients who are particularly vulnerable to perioperative blood loss and postoperative anemia. Aim of this study is to answer the following questions: 1. Does TXA reduce bleeding associated complications in elderly patients? 2. Does TXA induce thromboembolic complications in elderly patients?

HYPOTHESIS

TXA reduces perioperative blood loss and associated complications in acute hip fracture surgery in geriatric patients.

PATIENTS AND METHODS

In this observational cohort study with prospectively enrolled patients over 65 years of age who received an acute hip hemiarthroplasty, the primary outcome was blood loss, also described as Δ hemoglobin. Secondary outcomes were bleeding associated complications as hematomas. Also, the occurrence of thromboembolic events and mortality were examined.

RESULTS

In total 864 geriatric patients were included of which 235 received TXA and 629 did not. Multivariable analysis showed reduced Δ hemoglobin loss [-0.24 (-0.39; -0.09), p=0.002] and hematomas (OR 0.44 (0.21; 0.91), p=0.026). Pulmonary embolism were diagnosed more frequently after administration of TXA (2% versus 0.3%, p=0.008), without an association with increased 30-day mortality rate (6% versus 8%, p=0.3).

DISCUSSION

TXA reduced perioperative blood loss and associated complications. However, adverse effects of TXA as pulmonary embolisms were found more frequently without effecting postoperative mortality rates. More research is needed to assess adverse effects of intravenous TXA and topical TXA as an alternative for systemic TXA to prevent systemic adverse effects.

LEVEL OF EVIDENCE

III, Observational cohort study.

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.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

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 and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors: a propensity score matching analysis

Objective

The aim of this study was to investigate the efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors.

Methods

Data were retrospectively collected from 454 consecutive patients with bone and soft tissue tumors who underwent open biopsy, marginal resection, curettage or wide resection between January 2017 and December 2018. We performed propensity score matching of patients who received tranexamic acid with those who did not. The primary outcome variables were intra-operative, peri-operative and estimated blood loss (IBL, PBL and EBL, respectively).

Results

Tranexamic acid (+) and tranexamic acid (−) groups were defined according to whether patients received tranexamic acid or not. Among the 454 patients, open biopsy was performed in 102, marginal resection in 175, curettage in 54 and wide resection in 123. Intra-operative blood loss was significantly lower in the tranexamic acid (+) group than in the tranexamic acid (−) group for both marginal and wide resection (marginal resection: 17.3 vs. 70.3 g, respectively, P = 0.045; wide resection: 128.8 vs. 273.1 g, respectively, P = 0.023). Peri-operative blood loss and estimated blood loss were also significantly lower in the tranexamic acid (+) group for wide resection (peri-operative blood loss: 341.5 vs. 686.5 g, respectively, P = 0.0039; estimated blood loss: 320.7 vs. 550.6 ml, respectively, P = 0.030). No venous thromboembolism occurred in either group.

Conclusion

This study suggests that TXA administration safely and effectively reduces blood loss, in particular for wide resection, with no increase in the rate of adverse events.

The effect of tranexamic acid on the reduction of intraoperative and postoperative blood loss and thromboembolic risk in patients with hip fracture

The aim of this study is to determine whether the use of tranexamic acid (TXA) in patients with hip fracture reduces intraoperative and postoperative blood loss, and on the other hand, whether it increases thromboembolic risk. The study was performed on patients with hip fracture for a period of one year. Patients were divided into two groups (1:1): the first group receiving TXA and the second group receiving placebo. The amount of blood aspiration during the surgery was measured as well as drainage in the postoperative period of 24 h. The occurrence of deep vein thrombosis (DVT) was monitored before and after the surgery by ultrasound of the lower extremities. The amount of total blood loss was two times lower in patients who received TXA (291.8 ± 65.5 mL of blood vs 634.7 ± 150.5 mL of blood). Among the patients who developed DVT, one patient was from the group that did not receive TXA, and two patients were from the group that received TXA. The use of TXA in patients with hip fracture significantly reduces intraoperative and postoperative blood loss, without a significant thromboembolic risk.

Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery

Introduction

The timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients.

Methods

All patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients.

Results

A total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001).

Conclusions

Patients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.

Tranexamic Acid Was Not Associated with Increased Complications in High-Risk Patients with Hip Fracture Undergoing Arthroplasty

BACKGROUND

Tranexamic acid (TXA) is considered safe and efficacious for elective total joint arthroplasty. However, evidence of TXA's safety in high-risk patients with hip fracture requiring nonelective arthroplasty has been lacking. This study aimed to assess whether TXA administration to high-risk patients with a hip fracture requiring arthroplasty increased the risk of thrombotic complications or mortality.

METHODS

All patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) for displaced femoral neck fractures between 2011 and 2019 at 4 sites within 1 hospital system were retrospectively identified. Patients were grouped by risk (high-risk or low-risk) and TXA treatment (with or without TXA). Propensity scores were used for risk adjustment in comparisons between surgery with and without TXA for only the high-risk group (n = 1,066) and the entire population (n = 2,166). Differences in the occurrence of postoperative mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke within 90 days of hip arthroplasty were evaluated.

RESULTS

TXA administration was not associated with an increased risk of thrombotic complications or mortality within 90 days in either high-risk or all-patient groups. Specifically, among 1,066 matched high-risk patients who did not or did receive TXA, there were no significant differences in mortality (14.82% and 10.00%; p = 0.295), deep venous thrombosis (3.56% and 3.04%; p = 0.440), pulmonary embolism (2.44% and 1.96%; p = 0.374), myocardial infarction (3.38% and 2.14%; p = 0.704), or stroke (4.32% and 5.71%; p = 0.225).

CONCLUSIONS

In our review of 1,066 propensity-matched high-risk patients undergoing hip arthroplasty for displaced femoral neck fractures, we found that TXA administration (compared with no TXA administration) was not associated with an increased risk of mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke.

LEVEL OF EVIDENCE

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

Efficacy and Safety of Postoperative Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Study

Objective

To assess the efficacy and safety of postoperative intravenous tranexamic acid (TXA) in patients undergoing total knee arthroplasty (TKA).

Methods

From March 2020 to August 2020, all patients undergoing primary unilateral TKA in our hospital were considered in prospective randomized controlled study. Included patients were randomized into three groups to receive either two doses of 15 mg/kg intravenous TXA postoperatively, at 2 and 24 h after closing the incision (group A), or a single dose of 15 mg/kg intravenous TXA 2 h postoperatively (group B), or placebo (group C). The calculated total blood loss (TBL) and hidden blood loss (HBL), incidence of venous thromboembolism (VTE), and transfusion rate were compared among groups. The levels of prothrombotic state parameters including thrombomodulin (TM), thrombin‐anti‐thrombin complex (TAT), plasmin‐anti‐plasmin complex (PIC), and tissue‐type plasminogen activator‐plasminogen activator inhibitor complex (t‐PAI·C) in plasma were measured during the perioperative period. Patients were compared depending on the Kellgren‐Lawrence classification (K‐L types III and IV).

Results

All patients were followed up for at least 4 weeks. The mean TBL and HBL in group C (1,182.45 ± 160.50; and 965.47 ± 139.61 mL, respectively) were significantly higher than those in groups A (944.34 ± 130.88 mL, P < 0.05; and 712.45 ± 129.82mL, P < 0.05, respectively) or B (995.20 ± 154.00 mL, P < 0.05; and 757.20 ± 134.39 mL, P < 0.05, respectively), but no significant differences were found between groups A and B (P > 0.05 and P > 0.05, respectively). None of the patients of three groups received blood transfusion, so there were no significant differences in blood transfusion rate among groups. Similar results were obtained with subgroups of patients who had the K‐L types III and IV. The DVT frequencies were four, three, and three in groups A, B, and C, respectively, with no significant differences after comparison (P > 0.05). There were no significant differences in the levels of prothrombotic state parameters (TM, TAT, PIC, t‐PAI·C) or incidence of VTE among groups (P > 0.05). Wound leakage was observed in five patients during the hospital stay (two patients in group A, one patient in group B, and two patients in group C), and no statistical difference was found in wound leakage or other complications among groups (P > 0.05).

Conclusions

Short‐term application of postoperative intravenous TXA in TKAs resulted in reduced HBL without a measured increase in the actual incidence of VTE or the potential risk of thrombosis, but administration of TXA after the first 24 h had no significant effect.

Blood loss and transfusion rate compared among different dosing regimens of tranexamic acid administration in patients undergoing hip hemiarthroplasty for femoral neck fracture: A randomized controlled trial

BACKGROUND

Intravenous tranexamic acid (TXA) administration is a proven safe and effective method for reducing both blood loss and transfusion in total joint arthroplasty. However, data specific to its efficacy in hip hemiarthroplasty (HHA) for femoral neck fracture are scarce. Furthermore, no study has investigated the efficacy of an additional dose of TXA administration. Accordingly, this study aimed to assess blood loss and the transfusion rate compared among different regimens of TXA administration in patients undergoing HHA for femoral neck fracture.

METHODS

Between January 2019 to December 2020, 90 HHA patients were randomized into one of three groups (30 patients/group). Control group patients received intravenous normal saline solution (NSS) 20 mL before skin incision, and NSS 20 mL at 3 hours after surgery. one-dose (1D) group patients received 750 mg of intravenous TXA before skin incision, and NSS 20 mL at 3 hours after surgery. Two-dose (2D) group patients received 750 mg of intravenous TXA before skin incision, and 750 mg of TXA at 3 hours after surgery. The primary outcome was blood transfusion rate. Intraoperative blood loss, hemoglobin levels at 24- and 48-hours postoperation, and calculated total blood loss were compared among the three groups.

RESULTS

The mean age of the study population was 79.7 years, and 76.7% of participants were women. The transfusion rate in the control, 1D and 2D groups was 43.3%, 16.7%, and 3.3%, respectively. Total hemoglobin loss; total red blood cell loss; intraoperative blood loss; hemoglobin level at 24- and 48-hours postoperation; change in hemoglobin level between 0 and 24 hours, and between 0 and 48 hours; blood transfusion rate; and, the number of patients who did not require blood transfusion were all significantly improved in the 2D group compared to baseline. No parameters were significantly improved in the 1D group compared to controls.

CONCLUSIONS

The results of this study demonstrate both the efficacy of TXA administration in HHA, and the superiority of two-dose TXA administration over one-dose TXA administration in HHA for femoral neck fracture.

Efficacy and Safety of Tranexamic Acid in Resection and Endoprosthetic Reconstruction of Distal Femoral Osteosarcomas in Children: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the effect of intravenous tranexamic acid (TXA) on blood loss and transfusion rates in children who underwent resection and endoprosthetic reconstruction of distal femoral osteosarcomas.

METHODS

The medical records of 56 patients who underwent resection and endoprosthetic reconstruction for distal femoral osteosarcomas between 2017 and 2019 were retrospectively reviewed. Patients were divided into 2 groups: group 1 consisted of 25 patients (11 male and 14 female, mean age 15.2±3 y) who received preoperative 15 mg/kg intravenous TXA, and group 2 consisted of 31 control patients (18 male and 13 female, mean age 14.3±2.6 y) who did not receive TXA. The groups were compared based on their total blood loss, intraoperative blood loss, hidden blood loss, postoperative drain output, transfusion requirements, preoperative and postoperative hemoglobin (Hb) and hematocrit (Htc) difference, length of hospital stays, operative time, and complications.

RESULTS

The mean total blood loss was lower in intravenous TXA group (1247.5±300.9 mL) when compared with control group (1715.7±857.0 mL) (P=0.018). The mean intraoperative blood loss in intravenous TXA group (386±109 mL) was lower than that in control group (977.4±610.7 mL) (P<0.001). Postoperative drain output at 24 and 48 hours was 198.0±61.8 and 72.4±27.4 mL in intravenous TXA group, respectively, and was low compared with 268.4±118.2 and 117.1±67.8 mL in control group (P=0.028 and 0.006). The rate of patients requiring transfusion was significantly lower in intravenous TXA group (56%) than in control group (83.9%). Preoperative and postoperative 6, 24, and 72 hours Hb and Htc differences were significantly lower in intravenous TXA group [(-1.7±1.8 g/dL P<0.001; -2.0±1.5 g/dL P<0.001; -2.3±1.7 g/dL P<0.001, for Hb) (-5.7±4.6, P<0.001; -6.9±4.0, P<0.001; -9.6±9.1, P<0.001, for Htc)]. Intravenous TXA group had shorter hospital stay time in comparison to control group (P<0.001). The operative time was significantly longer in the control group (P<0.05). No increase in pulmonary embolism or venous thromboembolism rate was observed with intravenous TXA use.

CONCLUSION

We conclude that administration of intravenous TXA reduces intraoperative and postoperative blood loss, transfusion rates, and hospital stay in resection and endoprosthetic reconstruction of the distal femoral osteosarcomas in children.

TYPE OF STUDY

This was a retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture

Objective

This study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF).

Methods

The subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors.

Results

There were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients.

Conclusion

ABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).

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.

Tranexamic acid in non-elective primary total hip arthroplasty

PURPOSE

Blood loss during and following elective total hip arthroplasty (THA) can be substantial and may require allogeneic blood transfusions which carries significant risks and morbidity for patients. Intraoperative use of tranexamic acid (TXA) has been proven to reduce the need for allogeneic blood transfusion in elective THA patients. Data regarding TXA efficacy in reducing blood loss in trauma patients undergoing non-elective primary THA is sparse, and its routine use is not well established.

METHODS

This is a retrospective analysis of a consecutive cohort of patients who underwent non-elective primary THA in a tertiary medical center between January 1st 2011- December 31st 2019. The cohort was divided into two groups; one received perioperative TXA treatment while the other did not. Blood loss, blood product administration, peri and postoperative complications, readmissions and 1-year mortality were compared between groups.

RESULTS

A total of 419 patients (146 males, 273 females) who underwent THA were included in this study. The "TXA" group consisted 315 patients compared to 104 patients in the "no TXA" group. TXA use reduced postoperative bleeding, as indicated by changes in hemoglobin levels before and after surgery (ΔHb= -2.75 gr/dL vs. ΔHb= -3.34 gr/dL, p<0.001) and by administration of allogeneic blood transfusions (7.0% vs. 16.3%, p = 0.004).

CONCLUSION

Similar to the known effect of TXA in elective THA patients, the use of TXA treatment in patients undergoing non-elective THA led to a significant reduction in postoperative blood loss and in the proportion of patients requiring allogeneic blood transfusions.

Single dose of tranexamic acid effectively reduces blood loss and transfusion rates in elderly patients undergoing surgery for hip fracture: a randomized controlled trial

AIMS

The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip.

METHODS

In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day.

RESULTS

Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture.

CONCLUSION

Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442-448.

Variation in prophylactic tranexamic acid administration among anesthesiologists and surgeons in orthopedic surgery: a retrospective cohort study

PURPOSE

Tranexamic acid (TXA) reduces red blood cell transfusion in various orthopedic surgeries, yet the degree of practice variation in its use among anesthesiologists and surgeons has not been described. To target future knowledge transfer and implementation strategies, and to better understand determinants of variability in prophylactic TXA use, our primary objective was to evaluate the influence of surgical team members on the variability of prophylactic TXA administration.

METHODS

This was a retrospective cohort study of all adult patients undergoing primary total hip arthroplasty (THA), hip fracture surgery, and spine fusion ± vertebrectomy at two Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database which we linked to the Ottawa Data Warehouse. We described the percentage of patients that received TXA by individual surgery, the specifics of TXA dosing, and estimated the effect of anesthesiologists and surgeons on prophylactic TXA using multivariable mixed-effects logistic regression analyses.

RESULTS

In the 3,900 patients studied, TXA was most commonly used in primary THA (85%; n = 1,344/1,582), with lower use in hip fracture (23%; n = 342/1,506) and spine fusion surgery (23%; n = 186/812). The median [interquartile range] total TXA dose was 1,000 [1,000-1,000] mg, given as a bolus in 92% of cases. Anesthesiologists and surgeons added significant variability to the odds of receiving TXA in hip fracture surgery and spine fusion, but not primary THA. Most of the variability in TXA use was attributed to patient and other factors.

CONCLUSION

We confirmed the routine use of TXA in primary THA, while observing lower utilization with more variability in hip fracture and spine fusion surgery. Further study is warranted to understand variations in use and the barriers to TXA implementation in a broader population of orthopedic surgical patients at high risk for transfusion.

Use of tranexamic acid is not associated with complications following bipolar hemiarthroplasty for metastatic disease

INTRODUCTION

Advances in the care of cancer patients have resulted in increased survival. The proximal femur is a common site for metastatic disease, often requiring surgical intervention. Tranexamic acid (TXA) has proven to be safe in elective and traumatic femoral hemiarthroplasty; however, its use has not been investigated in oncologic patients.

METHOD

We reviewed 66 patients (37 males) with a mean age of 64 ± 3 years undergoing a hemiarthroplasty for metastatic disease in the femoral neck. A total of 22 (33%) patients received intraoperative TXA. Primary outcomes included postoperative blood loss, intraoperative and postoperative transfusion requirement, and postoperative complications.

RESULTS

There was no difference in the baseline characteristics between the TXA and non-TXA groups. When comparing the TXA and non-TXA groups, there were no differences in 72 h postoperative blood loss between groups (1.21 L vs. 1.33 L, p = 0.61), percentage of patients requiring transfusion (36.4% vs. 36.4%, p = 1.0), or the incidence of postoperative complications including venous thromboembolism (14% vs. 11%, p = 0.70) and pulmonary embolism (0% vs. 5%, p = 1.0).

CONCLUSION

Oncology patients are a high-risk population for thromboembolic events. This initial study supports the safe use of TXA intraoperatively in femoral hemiarthroplasty performed for metastatic disease.

Tranexamic acid in hip hemiarthroplasty

BACKGROUND

Intraoperative use of tranexamic acid (TXA) has been proven to reduce the administration of allogenic blood transfusion in total joint arthroplasty (TJA) patients. Data on TXA efficacy in reducing blood loss in trauma patients undergoing hip hemiarthroplasty are sparse, and its use is not yet well-established. The purpose of this study was to assess the efficacy and safety of intraoperative TXA use in patients undergoing hip hemiarthroplasty as treatment for intracapsular femoral neck fracture.

METHODS

This is a historical cohort of patients who underwent hip hemiarthroplasty in a tertiary medical center between 2011 and 2019, with minimum follow-up of one year. The cohort was divided into one group of patients who received intraoperative TXA treatment and another group that did not. Blood loss, peri‑ and postoperative complications, readmissions, and short- and long-term mortality were compared between groups.

RESULTS

Of the 1722 consecutive patients (601 males and 1121 females) who underwent hip hemiarthroplasty who were included in this study, 504 were in the "TXA" group and 1218 were in the "non-TXA" group. TXA use significantly reduced 30-day mortality (4.6% vs 7.3%, respectively, p < 0.046) and perioperative blood loss, as indicated by changes in hemoglobin levels before and after surgery (Δ-1.38 gr/dL vs Δ-1.76 gr/dL, p < 0.001), and by administration of allogenic blood transfusions (17.5% vs 44.4%, p < 0.001).

CONCLUSIONS

Similar to the known effect of TXA in TJA patients, the use of TXA treatment in patients undergoing hip hemiarthroplasty led to a significant reduction in 30-day mortality, in postoperative blood loss and in the proportion of patients requiring allogenic blood transfusions.

Postoperative outcomes of tranexamic acid use in geriatric trauma patients treated with proximal femoral intramedullary nails: A systematic review and meta-analysis

BACKGROUND

Recently, there has been a series of clinical studies focusing on the perioperative administration of tranexamic acid (TXA) in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery. However, the safety and efficacy of TXA in these patients remains controversial. Therefore, we performed a systematic review to focus on two questions: (1) would TXA reduce perioperative blood loss in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? and (2) would TXA increase the rate of perioperative complications in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery?

PATIENTS AND METHODS

We systematically searched electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) up to April 20, 2019. The perioperative blood loss and complication data were extracted and analysed by RevMan Manager 5.3.

RESULTS

Finally, five randomized controlled studies, involving 539 geriatric intertrochanteric fracture patients undergoing proximal femoral intramedullary nail surgery, were enrolled in this systematic review. Compared with the control group, the TXA group had significantly lower total perioperative blood loss (WMD=-172.84; 95% CI, -241.44 to -104.24; I²=0%), intraoperative blood loss (WMD=-34.20; 95% CI, -46.04 to -22.36; I²=0%), total perioperative hidden blood loss (WMD=-139.05; 95% CI, -213.67 to -64.43; I²=0%), perioperative transfusion rates (RR =-0.16; 95% CI, -0.24 to -0.08; I²=22%), length of hospital stay (WMD=-1.18; 95% CI, -1.91 to -0.46; p=0.001; I2=12%), and postoperative wound haematoma rates (RD=-0.05; 95% CI, -0.09 to 0.00; p=0.03; I²=0%). In addition, there were no significant differences between TXA and control groups in the terms of surgical time, postoperative mortality, total thromboembolic events, wound infections, cerebrovascular accidents, respiratory infections, and renal failure.

DISCUSSION

TXA in geriatric trauma patients undergoing intramedullary nail surgery is effective for perioperative haemostasis without increasing the incidence of postoperative complications.

LEVEL OF EVIDENCE

II, Systematic review and Meta-analysis.