Tranexamic acid reduces hidden blood loss in the treatment of intertrochanteric fractures with PFNA: a single-center randomized controlled trial

Hidden blood loss in unilateral open-door cervical laminoplasty for multilevel cervical spondylotic myelopathy

OBJECTIVES

This study aims to evaluate the hidden blood loss (HBL) and its possible risk factors after unilateral open-door cervical laminoplasty (UOCL) in patients with multilevel cervical spondylotic myelopathy (MCSM).

PATIENTS AND METHODS

Between January 2018 and March 2023, a total of 105 patients (55 males, 50 females; median age: 76 years; range, 52 to 93 years) who underwent C3-7 UOCL for MCSM were retrospectively analyzed. Data of the patients were recorded, including age, sex, height, weight, plasma albumin, blood glucose, hematocrit, American Society of Anesthesiologists (ASA) score, surgical time, and intraoperative blood loss. The HBL was calculated according to the Sehat formula, and risk factors were identified.

RESULTS

The median surgical time was 180.7 min. The median total blood loss (TBL) and median HBL were 507.4 mL and 201.7 mL, respectively. Correlation analyses revealed that body mass index and surgical time were correlated with HBL (p<0.05). However, multiple linear regression analysis showed that HBL was positively correlated with surgical time (β=0.293, p<0.05).

CONCLUSION

Our study results showed that surgical time is an independent risk factor for HBL. Therefore, HBL should not be overlooked in patients with MCSM undergoing UOCL, particularly in the patients with expected long surgical time.

Intravenous Versus Locally Injected Tranexamic Acid in a Fragility Hip Fracture Population: A Retrospective Review

OBJECTIVES

Evaluate differences between blood transfusion and complication rates among fragility hip fracture patients treated with locally injected (Local) versus intravenous (IV) tranexamic acid (TXA).

METHODS

Design: Retrospective comparative cohort.

SETTING

Tertiary referral orthopaedic specialty hospital; Level I trauma center.

PATIENT SELECTION CRITERIA

Patients aged 50 years and over who underwent surgical treatment for a proximal femur fragility fracture (Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 31A and 31B). Between March 2018 and April 2022 with or without the use of local TXA during wound closure or IV TXA.

OUTCOME MEASURES AND COMPARISONS

Postoperative blood transfusion, venous thromboembolism, surgical site infections, and 30-day readmissions compared between those who received IV TXA, Local TXA, and controls that did not receive any TXA.

RESULTS

Seven hundred forty-six patients (258 received IV TXA, 252 received Local TXA, and 236 controls that did not receive any TXA) were studied. Both Local and IV TXA groups received fewer blood transfusion versus controls. IV TXA was associated with a transfusion rate reduction of 12% compared with Local TXA ( P < 0.001). Regression analysis indicated that IV TXA reduced the odds of a postoperative blood transfusion by 48% compared with Local TXA ( P = 0.017). There were no differences in complication rates among the groups; however, patients receiving IV TXA had a significantly lower 30-day readmission rate (5%) than the control (13.9%) or Local (13.8%) TXA groups ( P = 0.001).

CONCLUSIONS

IV TXA significantly reduced the risk of postoperative transfusion compared with controls and patients receiving Local TXA. There was no increased risk of complications, and a lower 30-day readmission was observed for the IV TXA group. IV TXA seems to be a safe and effective way to reduce postoperative blood transfusion in patients with fragility hip fractures.

LEVEL OF EVIDENCE

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

Efficacy of preoperative Tranexamic Acid in patients undergoing intertrochanteric hip fracture surgery: A randomized placebo controlled trial

Objective

To determine the efficacy of preoperative Tranexamic Acid (TXA) in reducing perioperative allogenic blood transfusion frequency in patients with intertrochanteric fractures treated with Dynamic Hip Screw (DHS).

Methods

We conducted this placebo controlled double-blinded randomized trial in Orthopaedics & Traumatolgy Division Lady Reading Hospital, Peshawar from 1st January 2020 to 25th December 2022. All patients with intertrochanteric hip fractures fulfilling the inclusion criteria were treated with Dynamic Hip Screw (DHS) and were randomly divided into two equal groups. One group was administered single dose IV Tranexamic Acid (TXA) in a dose of 15mg/kg body weight in 100ml of saline while the other group (Placebo) was given 100 ml normal saline preoperatively. Post-operative Hemoglobin was measured on first, second and third day. The frequency of allogenic blood transfusions in the perioperative period was determined in both groups based upon the transfusion trigger (Hemoglobin 9g/dl). Categorical variables were compared with Chi-square test and mean with Independent sample t-test. P value of <0.05 was considered significant.

Results

The total number of patients in our trial were 200 which were equally but randomly allocated into TXA group and Placebo group each containing 100 patients. The mean age of the patients in TXA group was 48.16±1.75 years and the age of patients in the Placebo group was 48.35±1.60. The baseline demographic and clinical variables of both groups were identical (p< 0.05). The average preoperative hemoglobin was 11.5±4.2 g/dl in TXA group and 11.3±2.4g/dl in the Placebo group (p>0.05). The frequency of allogenic blood transfusion was significantly lower (p<0.05) in TXA group (13%, n=13) than in the Placebo group (41%, n=41).

Conclusion

Tranexamic acid (TXA) significantly reduces the frequency of peri operative allogenic blood transfusion in patients undergoing Dynamic Hip Screw (DHS) for intertrochanteric fractures.

The Efficacy of Tranexamic Acid for Reducing Blood Transfusion Rates in Extracapsular Hip Fractures: A Single-Center Randomized Controlled Trial

Perioperative allogenic blood transfusions for patients with hip fractures are associated with increased costs and complications. This prospective randomized controlled trial evaluated whether tranexamic acid (TXA) reduces blood transfusion rates and blood loss in extracapsular hip fractures, when administered at the time of hospital admission. Patients with closed intertrochanteric or subtrochanteric femur fractures undergoing intramedullary nailing (n=100) were enrolled from October 2015 to January 2019. On arrival to the hospital, patients were randomized to receive either 1 g of intravenous TXA or normal saline. Blood transfusion rates from hospital arrival to postoperative day 5 or discharge, blood loss from hospital arrival to postoperative day 3 or 4, intraoperative blood loss, length of hospital stay, 30-day mortality, and major complications were evaluated. Six patients from the TXA group and five from the placebo group were excluded because of canceled surgery, study drug infusion after incision, multiple fractures, or dropout. Patient characteristics were similar between the groups. Postoperative transfusion rates were 17.5% (7 of 40) in the TXA group and 36.7% (18 of 49) in the placebo group (relative risk, 0.48; 95% CI, 0.22-1.03; P=.046). Total blood loss was significantly less in the TXA group (mean difference, 367 mL; 95% CI, 76-657; P=.01). No significant differences were found for intraoperative blood loss, length of hospital stay, 30-day mortality, or 30-day major complications. TXA administered on hospital arrival decreased the risk of postoperative blood transfusion and mean perioperative blood loss in patients with extracapsular hip fractures. We recommend a single-dose intravenous administration of TXA at the time of hospital admission for patients with extracapsular hip fractures. [Orthopedics. 2023;46(5):e303-e309.].

Early Posttraumatic Antifibrinolysis Reduces Perioperative Hidden Blood Loss in Elderly Patients with an Intertrochanteric Fracture: A Randomized Controlled Trial

BACKGROUND

This study aimed to determine the efficacy and safety of posttraumatic antifibrinolysis with multidose tranexamic acid (TXA) in reducing perioperative hidden blood loss (HBL) in elderly intertrochanteric fracture patients.

METHOD

Ninety-six elderly intertrochanteric fracture patients admitted to our department from June 2021 to September 2022 were randomized into two groups. The control group (Group A) received 100 mL of normal saline, while the experimental group (Group B) received 1.5 g of TXA intravenously q12 h from postadmission Day 1 (PAD1) to the day before surgery, and both groups received 1.5 g of TXA q12 h from postoperative Day 1 (POD1) to POD3. Haemoglobin (Hb), haematocrit (Hct), coagulation parameters, fibrinogen degradation product (FDP), and D-dimer (D-D) were recorded from PAD1 to POD3. HBL was calculated using the gross formula and recorded as the primary outcome.

RESULT

In all-over analyses, the patients in Group B had lower perioperative HBL (on PAD3, POD1, and POD3), preoperative HBL (HBLpre), decline of haemoglobin (ΔHb-on PAD3), allogeneic blood transfusion (ABT) rate, FDP (on PAD3), and D-D (on PAD3) compared with Group A. No significant differences were exhibited in postoperative HBL (HBLpost) between the 2 groups. In subgroup analyses, for patients who received intervention within 24 h, the result is consistent with the whole. For patients who received intervention over 72 h of injury, there were no significant differences in perioperative HBL, ΔHb, ABT rate, FDP, and D-D between the 2 groups. There were no significant differences in APTT, PT, the rate of venous thromboembolism, wound complications, or 90-day mortality between the 2 groups.

CONCLUSION

For elderly intertrochanteric fracture patients, early posttraumatic antifibrinolysis with multidose TXA is effective in reducing perioperative HBL, which mainly manifests as the reduction of preoperative HBL, especially for patients injured within 24 h. Application of TXA beyond 72 h of injury was ineffective.

Intravenous application of tranexamic acid in intramedullary nailing for the treatment of geriatric intertrochanteric fractures: a systematic review and meta-analysis

BACKGROUND

Meta-analyses on the use of tranexamic acid (TXA) in intertrochanteric fractures have shown inconsistent results due to variations in inclusion criteria and clinical heterogeneity. To address these limitations, we conducted a rigorous analysis of recent randomized controlled trials (RCTs) with strict inclusion criteria. The aim of this study was to objectively evaluate the effects and safety of intravenous TXA administration in the treatment of geriatric intertrochanteric femoral fractures with intramedullary nailing.

METHODS

PubMed, Embase, and the Cochrane Library were searched for RCTs published from the database inception to August 2022. The date of total blood loss (TBL), intra-operative blood loss (IBL), hidden blood loss (HBL), transfusion rate, transfusion units, thromboembolic events, and mortality were extracted. Review Manager 5.3 was used for the analysis.

RESULTS

A total of six RCTs involving 689 patients were included. Meta-analyses indicated that TXA can significantly reduce TBL (WMD = -232.82; 95% CI -312.81 to -152.84; p < 0.00001), IBL (WMD = -36.33; 95% CI -51.38 to -21.28; p < 0.00001), HBL (WMD = -189.23; 95% CI -274.92 to -103.54; p < 0.0001), transfusion rate (RR = 0.53; 95% CI 0.33 to 0.85; p = 0.008), and transfusion units (WMD = -0.58; 95% CI -0.75 to -0.41; p < 0.01). No increase in thromboembolic events rate (RR = 0.75; 95% CI 0.38 to 1.50; p = 0.42) and mortality (RR = 1.36; 95% CI 0.61 to 3.04; p = 0.45) was observed.

CONCLUSIONS

Our meta-analysis provides robust evidence supporting the efficacy and safety of intravenous TXA administration in treating geriatric intertrochanteric femoral fractures with intramedullary nailing. TXA significantly reduces blood loss and transfusion requirements without increasing the risk of thromboembolic events or mortality.

Update on the efficacy and safety of intravenous tranexamic acid in hip fracture surgery: a systematic review and meta-analysis

AIM

The aim of this meta-analysis was to assess the safety and efficacy of tranexamic acid (TXA) in the management of hip fracture surgeries in comparison with placebo.

METHODS

A systematic search was conducted from August 6, 2021. Eligible studies included randomized clinical trials and prospective studies comparing the use of intravenous TXA in patients treated for hip fractures, in comparison with placebo. Review Manager was used for the meta-analysis.

RESULTS

Eighteen prospective studies including 14 RCTs met the eligibility criteria. The results favored the TXA group in the quantity of total blood loss (MD =  - 196.91 mL, 95% CI - 247.59, - 146.23, I2 = 92%), intraoperative blood loss (MD = - 26.86 mL, 95% CI - 36.96, - 16.78, I2 = 62%), and rate of blood transfusion (OR 0.35, 95% CI 0.28, 0.42, I2 = 0%). TXA also exhibited higher hemoglobin level at day 1 (MD = 6.77 g/L, 95% CI 4.30, 9.24, I2 = 83%) and day 3 (MD = 7.02 g/L, 95% CI 3.30, 10.74, I2 = 82%) postoperatively. There was no significant difference found in the incidence of thromboembolic events from occurring between the two groups, such as deep vein thrombosis (OR 1.22, 95% CI 0.73, 2.02, I2 = 0%) and pulmonary embolism (OR 0.82, 95% CI 0.33, 2.05, I2 = 0%).

CONCLUSION

Administration of intravenous TXA appears to reduce blood loss, rate of blood transfusions and pose no increased risk of thromboembolic events. Therefore, TXA should be considered by physicians when managing hip fracture patients.

Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews

BACKGROUND

Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT.

OBJECTIVES

To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery.

METHODS

In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality.

MAIN RESULTS

We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL.

AUTHORS' CONCLUSIONS

Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.

Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures

BACKGROUND

Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications.

OBJECTIVES

To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones.

SEARCH METHODS

We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data.

MAIN RESULTS

We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence).  It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence).  We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect.  Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants).  All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo   Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here.

AUTHORS' CONCLUSIONS

We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration).  We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.

A retrospective cohort study of the effect of intravenous tranexamic acid infusion on geriatric hip fractures patients undergoing proximal femoral nail antirotation

Background: Tranexamic acid (TXA) has been used in the management of bleeding. We are conducting a retrospective cohort study to analyse the effect of intravenous TXA infusion on the surgical outcomes of geriatric hip fracture cases which undergoes proximal femoral nail antirotation.  Methods: In this study, 364 patients who had undergone proximal femoral nail antirotation between January 2018 and December 2019 in United Christian Hospital have been recruited. Two-hundred thirteen patients were recruited in controlled group and 151 patients were recruited in TXA group. One gram of TXA acid was injected intravenously on induction of anaesthesia and before surgical incision. Outcomes including length of stay, operation time, intraoperative blood loss, haemoglobin and haematocrit drop and post-operative blood transfusion have been measured. Results: There was a reduction in operative time, intraoperative blood loss, post-operative haemoglobin and haematocrit drop and post-operative blood transfusion in TXA group, with a reduction in the intraoperative blood loss (Controlled group: 97.8 ±  67.7 ml, TXA group: 76.0 ± 71.4, Difference −22.3%, p-value: 0.0036) and post-operative haematocrit drop (Controlled group: 0.04 ± 0.03, TXA group: 0.03 ± 0.03, Difference −25%, p-value: 0.05) being statistically significant. The length of stay is not statistically significant between the two groups. TXA is an antifibrinolytic agent which acts by binding to plasminogen which inhibits plasma formation. It has a potential reduction in blood loss in major operations.  Conclusion: Intravenous TXA infusion helps to reduce blood loss in a patient undergoing proximal femoral nail antirotation. It is safe to use in the geriatric group of patients. We would recommend the usage of TXA infusion to improve the surgical outcome.

Perioperative administration of tranexamic acid in hip fracture surgery (The PATHS study): national audit of current practice

INTRODUCTION

Neck of femur fractures (NOFF) are associated with significant morbidity and mortality, exacerbated by anaemia. Evidence indicates tranexamic acid (TXA) administration in NOFF surgery reduces blood loss and transfusion requirements, without increasing complications. The aim of this study was to establish current TXA administration practice in patients undergoing surgery for NOFF in the UK.

METHODS

We conducted a multicentre prospective study within the UK over a two-week period in March 2019. Pre-, intra- and postoperative data were collected locally and analysed centrally.

RESULTS

Data for 917 patients were submitted from 66 institutions. Of those eligible, 48.0% received TXA perioperatively. Administration rates varied from 0 to 100%. Significantly greater numbers undergoing arthroplasty received TXA (57.6%) compared with internal fixation (38.4%, p<0.01). Some 15.2% of institutions had a protocol for TXA use in NOFF. Patients treated in these units were significantly more likely to receive TXA (86.7%) than those who were not (41.2% p<0.01). Of those receiving TXA, 92.3% were given 1g intravenously (IV) at anaesthetic administration.

CONCLUSIONS

Despite supportive evidence for its use, a wide variation in the administration of TXA between hospitals and procedures has been demonstrated. Administration rates were higher for arthroplasty than for fixation procedures. Most centres do not have a protocol guiding TXA administration. We recommend administration of 1g IV TXA perioperatively for patients undergoing NOFF surgery, where not contraindicated, unless future randomised controlled trials support an alternative regimen. We recommend units include their own locally agreed TXA policy within a written protocol for the care of NOFF patients.

Tranexamic Acid in Hip Hemiarthroplasty Surgery: A Retrospective Analysis of Perioperative Outcome

Introduction: Implantation of a dual-head hip prosthesis to treat medial femoral neck fractures is often associated with significant blood loss. In elective endoprosthetics procedures, it has already been demonstrated that administration of tranexamic acid (TXA) reduces blood loss and need for postoperative transfusions, as well as reducing the frequency of postoperative complications. The aim of this study is to show whether the administration of TXA also leads to a reduction in perioperative blood loss and haemorrhage-associated complications when applied as part of treatment of femoral neck fractures using a dual-head prosthesis. Methods: In a single-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 93 patients who had suffered from femoral neck fractures. This group was compared to a comparison group of 65 patients who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, frequency of transfusion, and frequency of specific complications occurring. Results: The transfusion rate in the TXA group was 6% lower, whereby the volume of blood transfused was 26.7% lower than in the nonTXA group. However, neither result was significant. The calculated perioperative blood loss remained the same. Similarly, the incidence of postoperative renal failure was not significantly lower in the TXA group, at 6.5%, as compared to the nonTXA group (7.7%). A higher rate of complications or deaths as a result of TXA administration was not observed. The tranexamic acid effect seems to be related to the dose. Conclusion: Preoperative administration of TXA during implantation of a dual-head prosthesis for treatment of a femoral neck fracture does not lead to an increased complication rate. The study revealed a trend towards fewer transfusions required, but a significant reduction in blood loss could not be demonstrated. There should be further investigation of other factors influencing blood loss, in particular the dosing regimen followed for perioperative administration of TXA. Level of Evidence: Level 4: retrospective case-control study.

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.

Anticoagulants and fracture morphology have a significant influence on total blood loss after proximal femur fractures

INTRODUCTION

Blood loss after proximal femoral fractures is an important risk factor for postoperative outcome and recovery. The purpose of our study was to investigate the total blood loss depending on fracture type and additional risks, such as anticoagulant use, to be able to recognize vulnerable patients depending on planned surgery and underlying comorbidities.

MATERIALS AND METHODS

A retrospective single center study including 1478 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 at a level I trauma center. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Lab data including hemoglobin and transfusion rates were collected. The Mercuriali formula was implemented to calculate total blood loss. Linear regression was performed to identify influencing factors.

RESULTS

One thousand four hundred seventy-eight mainly female patients were included in the study (mean age: 79.8 years) comprising 667 femoral neck fractures, 704 pertrochanteric- and 107 subtrochanteric fractures. Nearly 50% of the cohort were on anticoagulants or anti- platelet therapy. At time of admission average hemoglobin was 12.1 g/l. Linear regression proved fracture morphology, age, BMI, in-house mortality and anticoagulant use to have crucial influence on postoperative blood loss. Femoral neck fractures had a blood loss of 1227.5 ml (SD 740.4 ml), pertrochanteric fractures lost 1,474.2 ml (SD 830 ml) and subtrochanteric femoral fractures lost 1902.2 ml (SD 1,058 ml).

CONCLUSIONS

Hidden blood loss is underestimated. Anticoagulant use, fracture type, gender and BMI influence the total blood loss. Hemoglobin levels should be monitored closely. Within 48 h there was no increased mortality, so adequate time should be given to reduce anticoagulant levels and safely perform surgery.

The Use of Tranexamic Acid in Hip Fracture Surgery-A Systematic Review and Meta-analysis

OBJECTIVES

To analyze the effect of intravenous tranexamic acid (TXA) on blood transfusion requirements in adult patients undergoing hip fracture surgery. Secondary aim was to evaluate the safety by assessing thromboembolic events.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Medline, PubMed, and Embase were searched for randomized controlled trials published in English from 2010.

STUDY SELECTION

Studies eligible for inclusion were randomized controlled trials that analyzed the use of intravenous TXA on blood transfusion requirement in hip fracture surgery.

DATA EXTRACTION

Titles and abstracts were screened and assessed for eligibility by 2 independent reviewers. Quality and risk of bias was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach and the Cochrane risk-of-bias tool (RoB2).

DATA SYNTHESIS

Meta-analysis with random and fixed effect models was performed. Risk ratio (RR) was calculated for dichotomous outcomes and estimated with a 95% confidence interval (CI). For continuous data, the risk difference (RD) was estimated with a 95% CI.

RESULTS

A total of 13 trials involving 1194 patients were included. Pooled results showed that patients in the TXA group had significantly lower transfusion requirements (RR 0.50, 95%CI 0.30-0.84, P = 0.009). Similar findings were observed in the subcohort of patients with transfusion threshold of Hb < 8g/dL, (RR 0.42, 95%CI 0.31-0.56, P < 0.0001). This risk reduction was not observed in the subcohort of patients with transfusion threshold of Hb 8.1-10g/dL who received TXA (RR 0.77, 95%CI 0.51-1.18, P = 0.23) and no statistically significant differences were found for total thromboembolic events (RR 0.01, 95%CI -0.02-0.04, P = 0.47).

CONCLUSION

This meta-analysis demonstrated that intravenous TXA reduced blood transfusion rates and did not increase the risk of thromboembolic events.

LEVEL OF EVIDENCE

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

Tranexamic acid in pertrochanteric fractures: a retrospective analysis of perioperative outcomes after fixation with a proximal femoral nail

Background

Treatment of pertrochanteric femoral fractures is often associated with significant blood loss. It has already been demonstrated that the administration of tranexamic acid (TXA) for endoprosthetic procedures reduces blood losses and leads to a decreased frequency of postoperative complications. The aim of this study is to demonstrate whether the administration of TXA as part of osteosynthesis treatment for pertrochanteric fractures using a proximal femoral nail reduces perioperative blood losses and haemorrhage-related complications.

Methods

In a two-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 294 patients who had suffered from pertrochanteric femoral fractures. The subjects were compared clinically to a historical control group who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, transfusion requirement, and occurrence of complications.

Results

The TXA group showed evidence of a reduction in blood loss (TXA = 0.97 ± 0.47 l; nonTXA = 1.06 ± 0.47 l; p = 0.004) and a lower frequency of transfusion (TXA = 20%; nonTXA = 31%; p = 0.032) as compared to the nonTXA group. However, evidence of this therapeutic effect could only be demonstrated at one of the centres on subgroup comparison between the two centres. At the second centre, the data did not show a significant difference. A trend could be seen towards a reduction in postoperative renal failure. No complications occurred resulting from the administration of tranexamic acid.

Conclusion

Preoperative administration of TXA does not lead to an increased rate of thromboembolic complications when applied for treatment of pertrochanteric femoral fractures. Evidence of a positive effect could be seen in principle in relation to the reduction in perioperative blood loss and the frequency of transfusion. The difference in effect between the two centres remains to be clarified: for this reason, it is possible to assume that further factors influencing the efficacy of TXA administration are at play which were not taken into account in this study.

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.

Efficacy and safety of tranexamic acid for patients with intertrochanteric fractures treated with intramedullary fixation: A systematic review and meta-analysis of current evidence in randomized controlled trials

Background: Tranexamic acid (TXA) has been widely applied to reduce perioperative bleeding. Recently, several studies focused on the administration of TXA in the treatment for with intertrochanteric fracture patients treated with intramedullary fixation. However, the efficacy and safety of TXA in these studies remain controversial. Therefore, we performed this systematic review and meta-analysis to investigate the efficacy and safety of TXA in intertrochanteric fracture patients treated with intramedullary fixation.

Methods: We systematically searched electronic databases, including Cochrane, PubMed, and EMBASE, up to 16 May 2022. The efficacy and safety of TXA was evaluated in four aspects, which were bleeding-related outcomes, non-bleeding-related outcomes, thromboembolic events, and other complications. The outcomes of these studies were extracted and analyzed by RevMan Manager 5.4.

Results: Finally, nine randomized controlled trials, involving nine hundred and seventy-two intertrochanteric fracture patients treated with TXA, were enrolled in this study. In the bleeding-related outcomes, TXA group was significantly lower than the control group in terms of total blood loss (MD = −219.42; 95% CI, −299.80 to −139.03; p &lt; 0.001), intraoperative blood loss (MD = −36.81; 95% CI, −54.21 to −19.41; p &lt; 0.001), hidden blood loss (MD = −189.23; 95% CI, −274.92 to −103.54; p &lt; 0.001), and transfusion rate (RR = 0.64; 95% CI, 0.49 to 0.85; p = 0.002). Moreover, the postoperative hemoglobin on day 3 of the TXA group was significantly higher than that of the control group (MD = 5.75; 95% CI, 1.26 to 10.23; p = 0.01). In the non-bleeding-related outcomes, the length of hospital stays was significantly shorter in the TXA group (MD = −0.67; 95% CI, −1.12 to −0.23; p = 0.003). In terms of thromboembolic events, there was no significant differences between the TXA group and control group in deep vein thrombosis, pulmonary embolism, myocardial infarction, and ischemic stroke. As for complications and mortality, there was no significant differences between the TXA group and control group in respiratory infection, renal failure, and postoperative mortality within 1 year.

Conclusion: TXA is an effective and safe drug for perioperative bleeding control in intertrochanteric fracture patients treated with intramedullary fixation. However, the long-term efficacy of TXA still needs to be investigated by large-scale multicenter randomized controlled trials.

Level of evidence: II, Systematic review and Meta-analysis.

Systematic Review Registration:https://inplasy.com/, identifier [INPLASY202280027]

Differences between intertrochanteric and femoral neck fractures in resuscitative status and mortality rates

INTRODUCTION

Hip fracture mortality remains a challenge for orthopedic surgeons. The purpose of this study was to compare resuscitative mean arterial pressures (MAPs), intravenous fluid (IVF) administration, and mortality rates between intertrochanteric (IT) and femoral neck (FN) fracture patients.

HYPOTHESIS

We hypothesized that IT fracture patients would receive less aggressive fluid resuscitation than FNF patients given the perceived less invasive nature of intra-medullary nails compared with hemiarthroplasty.

MATERIALS AND METHODS

An institutional database was queried to identify all hip fractures managed surgically over a 2-year period. Preoperative and intraoperative MAPs and IVF administration, as measures of resuscitation, were compared between IT fracture patients treated with open reduction internal fixation and FN fracture patients treated with hemiarthroplasty.

RESULTS

Six hundred and ninety-eight hip fractures, including 531 IT and 167 FN fractures, were analyzed. There were no differences between IT and FN fracture cohorts for age, sex distribution, or Charlson Comorbidity Index scores. IT fracture patients were found to have lower MAP upon admission (103.7±20.1 vs. 107.8±18.4mmHg; p=0.026), and lower average, minimum, and maximum MAP values preoperatively and intraoperatively. Despite lower MAPs, IT fracture patients received less total IVF (581.9±472.5 vs. 832.9±496.5cc; p<0.001) and lower IVF rates intraoperatively (306.5±256.8 vs. 409.8±251.0 cc/h; p<0.001). IT fracture patients experienced higher 30-day (7.9% vs. 3.6%; p=0.040) and 90-day (10.6% vs. 5.4%; p=0.035) mortality rates and trended towards higher inpatient mortality (3.0% vs. 0.6%; p=0.088). Multivariate regression demonstrated IT pattern to be independently predictive of 30-day mortality with 2.459 increased odds relative to FN fracture (p=0.039).

DISCUSSION

IT fracture patterns are associated with decreased perioperative MAP values, yet received lower perioperative IVF rates. IT fracture patients suffered higher 30- and 90-day mortality rates, despite similar age and comorbidities.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Tranexamic Acid Was Not Associated with Increased Complications in High-Risk Patients with Intertrochanteric Fracture

BACKGROUND

For elective total joint arthroplasty, tranexamic acid (TXA) is considered safe and efficacious. However, evidence of TXA's safety in high-risk patients undergoing nonelective surgery for hip fracture is sparse. This study aimed to assess whether TXA administration to high-risk patients with an intertrochanteric (IT) hip fracture increased the risk of thromboembolic complications or mortality.

METHODS

All patients treated surgically for IT hip fracture between 2015 and 2019 across 4 hospitals of a single hospital system were considered. High- versus low-risk patients and those receiving TXA versus no TXA treatment were identified. Propensity scores adjusted for risk differences between patient groups with TXA and no TXA administration were calculated for (1) high-risk patients (n = 141) and (2) the entire population (n = 316). Postoperative mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), and stroke within 90 days of surgery were evaluated.

RESULTS

No association between TXA administration and increased risk of mortality or complications in either group was identified. Specifically, out of 282 matched high-risk patients, no differences in mortality (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.90, 1.05]), DVT (OR, 0.97 [95% CI, 0.93, 1.00]), PE (OR 1.00 [95% CI, 0.95, 1.05]), MI (OR, 1.04 [95% CI, 0.98, 1.10]), or stroke (OR, 1.00 [95% CI, 0.95, 1.05]) were identified.

CONCLUSIONS

In our review of propensity-matched high-risk patients undergoing surgical repair for IT fracture, we found that TXA administration compared with no TXA administration was not associated with an increased risk of mortality, DVT, PE, MI, or stroke within 90 days of surgery.

LEVEL OF EVIDENCE

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

The efficacy and safety of intravenous tranexamic acid on blood loss during total ankle replacement: a retrospective study

Only a few of studies have reported whether Tranexamic acid (TXA) has the same benefits during total ankle replacement as hip and knee replacements. In our study, we hypothesized that TXA was effective in reducing the perioperative blood loss without increasing the risk of symptomatic venous thromboembolism of patients during total ankle replacement. We retrospectively reviewed 71 patients who underwent total ankle replacement at the foot and ankle surgery center of our institution between January 2017 and May 2021. Patients were divided into two groups according to whether they received intravenous tranexamic acid or not. Patients who received intravenous TXA showed significantly lower estimated intraoperative blood loss, hidden blood loss and total blood loss. The early AOFAS score and ROM at the first month follow up of TXA group were better than the NO-TXA group and the incidence of early wound infection and poor healing (< 1 month postoperative) was significant lower than NO-TXA group. Use of TXA was not associated with significant changes in the incidence of postoperative symptomatic venous thromboembolism. We conclude that intravenous TXA can safely and effectively reduce perioperative blood loss and the incidence of early wound infection and poor healing in total ankle replacement, without increasing the risk of symptomatic venous thromboembolism.The application of TXA following total ankle replacement helped improve ankle function and patient quality of life during the early stage.

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.

Oral versus intravenous tranexamic acid in elderly patients with intertrochanteric fracture undergoing proximal femur intramedullary nailing: A prospective cohort study

Objective

Methods

Results

Conclusion

The translational potential of this article

Risk Factors for Perioperative Hidden Blood Loss After Intertrochanteric Fracture Surgery in Chinese Patients: A Meta-Analysis

Study Design

A meta-analysis

Introduction

To perform a meta-analysis to explore the risk factors of perioperative hidden blood loss (HBL) in the treatment of intertrochanteric fracture for Chinese patients.

Significance

An extensive search of the literature was performed in the English databases of PubMed, Embase, and Cochrane Library and the Chinese databases of CNKI and WAN FANG (up to July 2021). We collected factors including demographic data and surgical factors. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

Finally, we collected 7 studies including 1377 patients in the final analysis. In our study, female patients (P <.00001), hypertension (P =.008), time from injury to operation (<2 days, P =.02), operation time (≥60 mins, P =.001), fracture type (A2.2 to A3.3, P <.00001), and without anticoagulation (P <.00001) were found to be associated with perioperative HBL in Chinese patients receiving the treatment of the intertrochanteric fracture. However, anesthesia, ASA classification, and body mass index were not associated with perioperative HBL.

Conclusions

In our study, female patients, hypertension, time from injury to operation (<2 days), operation time (≥60 mins), fracture type (A2.2 to A3.3), and without anticoagulation were related to increased risks of perioperative HBL in Chinese patients receiving the treatment for the intertrochanteric fracture. We hope this article can guide for surgeons to reduce perioperative HBL as far as possible in the treatment of intertrochanteric fracture.

Efficacy and Safety of Locally Injected Tranexamic Acid in Hip Fracture Patients: A Retrospective Review

OBJECTIVE

To determine whether locally injected tranexamic acid (TXA) used in the surgical treatment of fragility hip fractures can lower transfusion rates without increasing the risk of complications.

DESIGN

Retrospective comparative cohort.

SETTING

Tertiary referral orthopaedic specialty hospital, Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 490 patients (252 patients received TXA) 50 years of age and older who underwent surgery for a low-energy fragility fracture of the proximal femur between March 2018 and February 2020 were included in this study.

INTERVENTION

Use of locally injected TXA at the time of wound closure.

MAIN OUTCOME

The main outcomes of this study were the number of patients requiring postoperative blood transfusions, incidences of venous thromboembolism, and surgical site infections.

RESULTS

A statistically significant difference was noted in the frequency of transfusion between patients who received TXA compared with those who did not receive TXA (33% vs. 43%, respectively) (P = 0.034). There were no significant differences in venous thromboembolism incidence (0.4% vs. 0.8% TXA vs. No TXA) (P = 0.526) or infections (0.4% vs. 0.4% TXA vs. No TXA) (P = 0.965). Regression analysis indicated that the use of TXA reduced the need for postoperative blood transfusion by 31% (odds ratio: 0.688, 95% CI: 0.477-0.993, P = 0.045).

CONCLUSION

Locally injected TXA significantly reduced the need for postoperative transfusion in the surgical treatment of fragility hip fractures. In addition, there was no increased risk of complications in those receiving TXA versus those who did not. Locally injected TXA seems to be both a safe and effective way to reduce postoperative blood transfusions in patients with fragility hip fractures.

LEVEL OF EVIDENCE

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

Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials

AIM

The objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages.

METHODS

A systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri‑operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events' incidence. A subgroup analysis was performed with respect to TXA dosage.

RESULTS

Out of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between "single" and "multiple doses" studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg.

CONCLUSIONS

This meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes.

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.

A Single Dose Versus Two Doses of Tranexamic Acid for Extracapsular Hip Fractures

Objective In this study, we aimed to compare the effectiveness of one dose of tranexamic acid (TXA) at the time of hospital admission versus two doses of TXA (one at the time of hospital admission and another dose intraoperatively) in reducing perioperative total blood loss in patients with extracapsular hip fractures. Methods This retrospective cohort study included 80 patients from a single institution who underwent surgical fixation for extracapsular hip fractures. Forty patients received a single dose of 1 gram of TXA at the time of hospital admission (per standardized protocol of an ongoing research study at the time), and 40 patients received the same dose of TXA on hospital admission as well as a second dose of 1 gram of TXA intraoperatively at the time of incision (per standard practice change following the completion of the research study). The primary study outcome of interest was total blood loss, which was calculated by estimating blood volume via Nadler's formula followed by calculating the total blood loss with the hemoglobin dilution method. Secondary outcomes included blood transfusion rates, hospital length of stay (LOS), and 30-day mortality. Results Patient gender, age, the American Society of Anesthesiologists (ASA) score, procedure length, fracture type, hardware type, and hemoglobin on hospital arrival were similar across the study groups (all p>0.05), though the twice-dosed group had a higher average BMI (26.4 kg/m2 vs. 24 kg/m2, p=0.04). When adjusting for BMI, the twice-dosed group was estimated to have a slightly larger but non-significant difference in total blood loss (115-ml difference, 95% CI: 158.2-389.3, p=0.40) compared to the single-dose TXA group. More patients in the twice-dosed group required blood transfusion compared to the single-dose TXA group, though this was not statistically significant (30.0% vs. 17.5%, adjusted OR=1.64, 95% CI: 0.55-5.12, p=0.38). The distribution of hospital LOS and 30-day mortality rates were similar across the groups (p=0.13 and p>0.99). Conclusion In the setting of surgically treated extracapsular hip fractures, patients who received one dose of TXA at the time of hospital admission and a second intraoperative dose of TXA did not demonstrate significant differences in total blood loss or a need for blood transfusion compared to patients who only received a single dose of TXA at the time of hospital admission.

Study protocol: haemostatic efficacy and safety of preemptive antifibrinolysis with multidose intravenous tranexamic acid in elderly hip fracture patients: design of a prospective randomised controlled trial

INTRODUCTION

Hip fracture surgery is often associated with substantial blood loss and a high allogeneic blood transfusion (ABT) rate. Preoperative hidden blood loss (HBL) has been observed clinically but there is little evidence for the efficacy of tranexamic acid (TXA) in controlling preoperative HBL. We designed a randomised controlled trial to evaluate the efficacy of preemptive antifibrinolysis with multidose intravenous TXA (IV-TXA) in reducing preoperative HBL in elderly patients with hip fractures.

METHODS AND ANALYSIS

This is a prospective, randomised, placebo-controlled clinical trial. Patients older than 65 years diagnosed with primary unilateral femoral neck fracture or intertrochanteric fracture will be randomly assigned to group A (receiving 100 mL of intravenous normal saline every 12 hours preoperatively and 1.5 g of IV-TXA every 12 hours postoperatively for 3 days) or group B (receiving 1.5 g of IV-TXA every 12 hours preoperatively and 1.5 g of IV-TXA every 12 hours postoperatively for 3 days). The primary outcomes will be the hidden blood loss, haemoglobin decrease and ABT rate. The secondary outcomes include the levels of inflammatory factors (such as C reactive protein) and coagulation and fibrinolysis parameters (such as D-dimer). Other outcomes such as injury time, length of stay and hospitalisation expenses will also be compared between groups.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University. The findings of the study will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100045960.

Effectiveness and Safety of Tranexamic Acid Use in Acute Traumatic Injury in the Prehospital and In-hospital Settings: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives

This systematic review and meta-analysis of randomized controlled trials (RCTs) aims to assess efficacy and safety of tranexamic acid (TXA) use in acute traumatic injuries.

Methods

PubMed and Cochrane libraries were searched for relevant RCTs published between January 2011 and January 3, 2021. Cohen's Q Test for heterogeneous effects was used to determine the appropriateness of fixed versus random effects models.

Results

Twenty-two studies met inclusion criteria. Meta-analysis of relative risk of mortality between treatment and placebo groups in the in-hospital, and perioperative settings was not significant. However, the risk of mortality is significantly lower in the treatment versus placebo group when TXA was given as loading dose only. Ten of the 11 studies evaluating perioperative use of TXA included in systematic review found significantly lower blood loss in the treatment compared with placebo groups, but results of meta-analysis showed no significant difference. Results of meta-analysis indicate that the risk of venous thromboembolism (VTE) in the in-hospital treatment group is greater than that of the placebo. In subset analysis of studies using only a single loading dose, there were no significant differences in VTE.

Conclusions

Systematic review supports TXA benefits are most evident when given shortly after injury and meta-analysis supports TXA reduces mortality as a single loading dose. Systematic review supports perioperative use of TXA when large volume blood loss is anticipated. Meta-results showed no significant difference in risk of thromboembolism in single-dose TXA treatment compared with placebo. These findings suggest that TXA is safe and effective for control of traumatic bleeding.

Dose tranexamic acid reduce blood loss associated with simultaneous bilateral distal tibial tubercle-high tibial osteotomy?

Background

Simultaneous bilateral distal tibial tubercle high tibial osteotomy (SBDTT-HTO) can result in increased blood loss. The aim of this study is to evaluate the actual hemostatic effect of different tranexamic acid (TXA) treatment regimen in SBDTT-HTO.

Methods

We conducted a retrospective case–control study including 54 patients who underwent SBDTT-HTO. The single-dose group (n = 18) received 1 g of intravenous TXA 15–30 min before surgery, the two-dose group (n = 18) received an additional 1 g of intravenous TXA 6 h after surgery, and the multiple-dose group (n = 18) received an additional 1 g intravenous TXA per-day until discharge. Blood loss, hemoglobin levels, occurrence of any adverse events,functional analysis, quality of life, and pain assessmentswere compared among the three groups.

Results

The total blood loss, hidden blood loss, drainage volumes, and haemoglobin level in the multiple-dose group all occupy a significant advantage.(p < 0.05). In addition, better quality of life were observed in patients belonging to the multiple-dose group then single-dose group.(p < 0.05).

Conclusions

Based on our results, for patients undergoing SBDTT-HTO, sequential intravenous TXA administration can effectively and safely reduce blood loss,maintain postoperative Hb levels,and with the advantage of accelerating recovery.

Transfusion in orthopaedic surgery : a retrospective multicentre cohort study

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

Methods

We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma.

Results

Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon.

Conclusion

Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies.

Cite this article: Bone Jt Open 2021;2(10):850–857.

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 efficacy and safety of tranexamic acid in the treatment of intertrochanteric fracture: an updated meta-analysis of 11 randomized controlled trials

This meta-analysis was performed to investigate the efficacy and safety of tranexamic acid (TXA) in the elderly patients undergoing intertrochanteric fracture surgery from the current literatures. The electronic literature database of PubMed, Embase and Cochrane library were searched in October 2019. The intraoperative blood loss, hidden blood loss, postoperative drainage and total blood loss, postoperative hemoglobin, length of stay, transfusion rate, mortality rate, thromboembolic events and wound complications were extracted. Stata 14.0 software was used for our meta-analysis. A total of 11 RCTs (3 new RCTs in 2019) with 1202 patients met our inclusion criteria. This meta-analysis showed that administration of TXA can reduce intraoperative blood loss (P = 0.009), hidden blood loss (P = 0.000), total blood loss (P = 0.000), length of stay (P = 0.003), transfusion rate (P = 0.000) and the occurrence of wound complications (P = 0.006). Furthermore, administration of TXA was associated with an increase in the postoperative Hb level at day 1, 2 and 3 (P = 0.000, P = 0.000 and P = 0.000, respectively) after surgery. However, no significant difference was found between the TXA group and control group regarding the occurrence of thromboembolic events (P = 0.978, including deep vein thrombosis, P = 0.850; pulmonary embolism, P = 0.788; cerebrovascular accident, P = 0.549; myocardial infarction, P = 0.395) and mortality rate (P = 0. 338). Our meta-analysis suggested that administration of TXA is effective in reducing intraoperative blood loss, hidden blood loss, total blood loss, length of stay, transfusion rate, wound complications and enhancing postoperative Hb without increasing the risk of thromboembolic events and mortality rate in intertrochanteric fracture surgery. More large multi-center and high-quality RCTs are required for further research.

The factors that affect blood loss in intertrochanteric fractures treated with proximal femoral nail in the elderly

PURPOSE

Intertrochanteric femur fractures (IFF) is one of the biggest health problems in elderly population and mostly treated by proximal femoral nails. Although it is done in less invasive technique this method can cause higher blood loss than expected and subsequent allogenic blood transfusions. In this study, we aimed to investigate the factors that were related to the blood loss in proximal femoral nail fixation of IFF including patients' ongoing anticoagulant treatments.

METHODS

231 consecutive patients with IFF who treated with proximal femoral nail anti-rotation between January 2017 and December 2019 were included the study. The factors that can affect the blood loss determined as patients demographics, time from injury to operation, duration of operation, the American Society of Anesthesiologists (ASA) scores, preoperative anticoagulant medications. Hematocrit and hemoglobin were obtained on admission day, postoperative day one and postoperative day 3. Total blood loss and allogenic blood transfusions assessed.

RESULTS

Higher BMI is found related to higher blood loss. The patients who were operated in the first two days after admission had lower blood loss levels independent from anticoagulant use (p = 0.027). Preoperative Hct was higher in patients who did not need RBCs in the perioperative period (p = 0.039). According to the AO classification, A2.1 fractures had lower blood loss levels.

CONCLUSION

This study demonstrated that ongoing anticoagulant treatments of intertrochanteric fracture patients did not increase the perioperative blood loss. The factors affecting blood loss in the proximal femoral nail fixation were BMI, the time to surgery, and fracture type in the elderly.

Efficacy and Safety of Long-Term Intravenous Tranexamic Acid Administration for Blood Management in Revision Surgery for Femoral Shaft Nonunion: A Retrospective Case-Control Study

Femoral shaft nonunion is a complication that seriously affects physiological functions. We aimed to assess the effectiveness and safety of short- and long-term intravenous tranexamic acid (TXA) administration in the perioperative period of revision surgery for femoral shaft nonunion. In this retrospective study, 53 patients undergoing double-locking plates with channel bone grafting technology for the treatment of femoral shaft nonunion were divided into 3 groups: the patients in group A without use TXA during hospitalization, the patients in group B received intravenous (IV) 1-g TXA at 30 min before the surgery and deep soaked 1-g TXA for 5 min before closing the incision, and then 1-g TXA IV again 6 h after surgery, and the patients in group C received 1-g TXA IV before the operation, 1-g TXA topically during the operation, and subsequent long-term 1-g TXA IV until discharged. The primary outcomes were total blood loss (TBL) and hidden blood loss (HBL). The secondary outcomes included actual hemoglobin (Hb) loss values, transfusion requirement, number of units transfused, postoperative laboratory values (Hb, hematocrit, fibrinogen, and D-dimer), visual analogue scale (VAS) scores, and hospitalization time. The mean TBL was lower in group C than in group A (1168 mL vs. 2714 mL, P < 0.001) and group B (1168 mL vs. 1557 mL, P = 0.008). The differences in HBL volumes were also significant between groups A and C (P < 0.001) and between groups A and B (P < 0.01). The actual Hb loss in the 3 groups showed a consistent trend with TBL, but no significant differences between groups B and C (P = 0.23). On postoperative day (POD) 3, the Hb level was higher in group C than in group A (111.1 g/L vs. 94.6 g/L, P = 0.02). No significant differences were found in VAS, hospital stay, thromboembolic complications, incision-related complications, and TXA adverse reactions among groups. Long-term intravenous TXA during hospitalization can effectively reduce perioperative blood loss, Hb drop, and postoperative hyperfibrinolysis, but is associated with an increased incidence of adverse reactions.

Early intravenous tranexamic acid intervention reduces post-traumatic hidden blood loss in elderly patients with intertrochanteric fracture: a randomized controlled trial

PURPOSE

Elderly patients with intertrochanteric fractures exhibit post-traumatic hidden blood loss (HBL). This study aimed to evaluate the efficacy and safety of reducing post-traumatic HBL via early intravenous (IV) tranexamic acid (TXA) intervention in elderly patients with intertrochanteric fracture.

METHODS

A prospective randomized controlled study was conducted with 125 patients (age ≥ 65 years, injury time ≤ 6 h) who presented with intertrochanteric fracture from September 2018 and September 2019. Patients in the TXA group (n = 63) received 1 g of IV TXA at admission, whereas those in the normal saline (NS) group (n = 62) received an equal volume of saline. Hemoglobin (Hgb) and hematocrit (Hct) were recorded at post-traumatic admission (PTA) and on post-traumatic days (PTDs) 1-3. HBL was calculated using the Gross formula. Lower extremity venous ultrasound was performed to detect venous thrombosis.

RESULTS

Hgb on PTDs 2 and 3 was statistically higher in the TXA group than in the NS group. Hct and HBL on PTDs 1-3 were significantly less in the TXA group compared to the NS group. Preoperative transfusion rate was significantly lower in the TXA group compared with the NS group. There was no difference between the two groups with regard to the rates of complications.

CONCLUSION

Early IV TXA intervention could reduce post-traumatic HBL and pre-operative transfusion rate in elderly patients with intertrochanteric fractures without increasing the risk of venous thrombosis.

Tranexamic acid in hip fracture surgery: A systematic review and meta-analysis

AIMS

The primary objective of this review was to determine whether tranexamic acid (TXA) reduces transfusion rates in patients undergoing surgery for hip fractures. The secondary objective was to assess the effects of TXA on mortality and thromboembolic events in the same cohort.

METHODS

A systematic review of electronic databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials comparing perioperative TXA in patients treated surgically for hip/proximal femoral fractures against placebo. The primary outcome was the proportion of patients requiring blood transfusion. Secondary outcomes were blood loss, mortality, and complications. Meta-analysis was performed using inverse variance and random effects model.

RESULTS

The pooled data from 10 studies involving 842 patients showed that the proportion of patients requiring blood transfusion was significantly less in the TXA group (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.59-0.88). There was no difference between TXA and control groups when comparing mortality (RR 1.17, 95% CI 0.65-2.10), deep venous thrombosis (RR 1.14, 95% CI 0.43-3.06), pulmonary embolism (RR 0.53, CI 0.09-3.02), acute coronary syndrome (RR 1.52, CI 0.18-12.98), cerebrovascular events (RR 0.78, CI 0.16-3.68), or wound complications (RR 1.61, CI 0.51-5.13).

CONCLUSION

There is evidence that TXA reduces the proportion of patients requiring blood transfusions when undergoing hip fracture surgery. However, the small sample size and low event rates for adverse effects preclude any definitive conclusions from being established regarding adverse effects. Future trials should be powered to further assess potential complications and determine the ideal dosage and regime.

Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study

Background

Previous studies have demonstrated the effectiveness and safety of tranexamic acid (TXA) in orthopedic surgery. However, no study has investigated TXA in complex tibial plateau fracture surgery. Therefore, the purpose of this study was to confirm the safety and effectiveness of i.v. (intravenous) TXA and topical TXA.

Material and methods

This was a retrospective analysis of prospectively collected data. The control group received an equal amount of placebo (physiological saline solution); the i.v. group received 1.0 g TXA by intravenous injection before the tourniquet was inflated and before the surgical incision was closed, and the topical group received 3.0 g TXA in 75 mL of physiological saline solution 5 min prior to the final tourniquet release. Perioperative blood loss, vascular events, wound complications, and adverse reactions were compared among the three groups. The pain, knee function, and quality of life (QoL) assessments were based on their corresponding scoring systems.

Results

Baseline data were comparable for all groups. The i.v. group showed the best results for total blood loss (TBL) and hidden blood loss (HBL) (424.5 ± 49.4 mL and 219.3 ± 33.4 mL, respectively, all P values < 0.001). Patients in the i.v. group had lesser real Hb decrease than those in the control group (0.9 vs 1.5, P<0.001) and topical group (0.9 vs 1.2, P = 0.026). The blood coagulation level as measured using fibrinolysis (D-dimer) was lower in the i.v. group than in the control and topical groups on POD1 and POD3; however, this difference was not significant; the fibrin-degradation products also showed a similar trend. Patients in the topical group experienced less pain than those in the control group on POD2, POD4, and PO6W. The VAS pain score was 3.6 vs. 4.4 (POD2, P<0.05), 2.8 vs 3.3 (POD4, P<0.05), and 2.1 vs. 2.6 (PO6W, P<0.001) in the topical group vs control group, respectively. No significant differences were identified in vascular events, wound complications, adverse reactions, knee function, and QoL among the three groups.

Conclusion

To our knowledge, this is the first study that showed both i.v. TXA and topical TXA are safe and effective for complex tibial plateau fractures. The i.v. regimen effectively reduced blood loss during the perioperative period, whereas patients under the topical regimen had less vascular events, wound complications, and a lower incidence of adverse reactions compared to those in the i.v. group.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-1800017754, retrospectively registered from 2018 to 01-01).

Quantification and influencing factors of perioperative hidden blood loss during intramedullary fixation for intertrochanteric fractures in the elderly

INTRODUCTION

We aimed to quantify perioperative hidden blood loss (HBL) and investigate its influencing factors in elderly patients with intertrochanteric fractures (IFs) undergoing intramedullary fixation surgery.

MATERIALS AND METHODS

We prospectively collected the clinical data of 200 elderly patients with IFs treated with intramedullary fixation surgery in our hospital between December 1, 2014 and August 31, 2018. The intraoperative visible blood loss, blood transfusion rate, and pre- and postoperative hemoglobin (Hb) levels as well as the general characteristics of the enrolled patients were recorded. A multiple linear regression analysis model (stepwise) was used to identify independent factors affecting perioperative HBL.

RESULTS

The mean perioperative HBL was 614.72 ± 368.14 mL, which accounted for 84.05% of the mean total perioperative blood loss (731.37 ± 391.50 mL). The mean preoperative HBL was 368.33 ± 325.57 mL, which accounted for 50.36% of the mean total perioperative blood loss. Patients with fracture types AO/OTA 31-A2.2 to A3.3 had more severe preoperative HBL (median 580.10 mL), and most of them developed mild-to-moderate anemia before the operation, and 27.63% of them received preoperative blood transfusion. Compared with patients operated within 5 days after injury, patients operated over 5 days had lower Hb value at admission (101.56 ± 19.49 vs. 107.28 ± 16.53; P = 0.026) and higher preoperative transfusion rate (25.84% vs. 9.01%; P = 0.001). Multiple linear regression analysis revealed that fracture types AO/OTA 31-A2.2 to A3.3, male sex, right-sided injury, and operation time > 60 min were independently associated with increased perioperative HBL. Tranexamic acid treatment was negatively correlated with perioperative HBL.

CONCLUSION

IFs in elderly patients undergoing intramedullary fixation surgery were associated with significant perioperative HBL and anemia. Persistent HBL occurred before the operation and on the first few postoperative days. Surgeons should pay more attention to preoperative HBL in patients with fracture types AO/OTA 31-A2.2 to A3.3 and regularly measure Hb levels preoperatively to avoid anemia. Shortening preoperative time may helps to reduce preoperative blood loss.

Tranexamic acid safely reduces hidden blood loss in patients undergoing intertrochanteric fracture surgery: a randomized controlled trial

PURPOSE

To investigate the efficacy and safety of intravenous tranexamic acid (IV-TXA) in patients undergoing intertrochanteric fracture surgery.

METHODS

A total of 122 patients were included in this double-blinded trial and equally randomized to receive 1 g of IV-TXA or normal saline 10 min before incision and 3 h later. The primary efficacy outcome was calculated hidden blood loss (HBL). The secondary efficacy outcome was allogeneic erythrocyte transfusion rate during hospitalization. Safety outcome was a composite of thromboembolic events including deep venous thrombosis (DVT) up to 90 days. A meta-analysis combining this study with previous randomized controlled trials in hip fracture surgery (total sample size: 1112 patients) was also conducted.

RESULTS

The mean HBL in TXA group (640.96 ± 421.63 ml) was significantly lower than that in placebo group (1010.11 ± 398.96 ml, P < 0.001). The rate of erythrocyte transfusions was 29.5% in TXA group and 60.7% in placebo group (P = 0.001). The incidence of thromboembolic events at 90 days was 4.9% in TXA group and 1.6% in placebo group (P = 0.619). The updated meta-analysis showed that IV-TXA significantly reduced erythrocyte transfusion in hip fracture surgery (risk ratio 0.60, 95% confidence intervals 0.53-0.68), and IV-TXA caused no increased risk of thromboembolic events (risk difference 0.01, 95% confidence intervals - 0.02-0.04).

CONCLUSION

IV-TXA could effectively reduce the HBL and allogeneic erythrocyte transfusion requirements in patients undergoing intertrochanteric fracture surgery without an increase of thromboembolic events including DVT.

TRIAL REGISTRATION

Clinical trials: safety and efficiency of tranexamic acid in hip fracture patients. Date of registration: August 31, 2018.

TRIAL REGISTRATION NUMBER

ChiCTR1800018110.

[Application of intravenous injection of tranexamic acid combined with local use of tranexamic acid cocktail in intertrochanteric fracture fixation]

Objective

To explore the efficacy and safety of intravenous injection of tranexamic acid (TXA) combined with local use of TXA cocktail in intertrochanteric fracture fixation with proximal femoral nail antirotation (PFNA).

Methods

Patients with intertrochanteric fractures who underwent close reduction and internal fixation with PFNA between February 2018 and March 2019 were enrolled in the study. Among them, 45 patients who met the selection criteria were included in the study and randomly allocated into 3 groups ( n=15). The patients in group A were not received TXA during perioperative period. The patients were intravenously injected of 1.0 g TXA before operation in group B and combined with local use of TXA cocktail during operation in group C. There was no significant difference in the age, gender, body mass index, fracture classification, disease duration, and complications between groups ( P>0.05). The perioperative blood loss and blood transfusion rate, the visual analogue scale (VAS) score before operation and at 12, 24, and 48 hours after operation, the levels of prostaglandin E2 (PGE2) and bradykinin (BK) before operation and at 1 and 3 days after operation, postoperative complications, and the maximum amplitude (MA) of thromboelastogram were recorded and compared between groups.

Results

The total blood loss, hidden blood loss, and visible blood loss were significantly lower in groups B and C than those in group A ( P<0.05), and the total blood loss and hidden blood loss were significantly lower in group C than those in group B ( P<0.05). There was no significant difference in the blood transfusion rate, preoperative VAS scores and the levels of PGE2 and BK between groups ( P>0.05). The postoperative VAS scores and the levels of PGE2 and BK were significantly lower in group C than in groups A and B ( P<0.05). There was no significant difference in pre- and post-operative MA of thromboelastogram between groups ( P>0.05). The incidences of postoperative complications were 33.33% (5/15), 20.00% (3/15), and 13.33% (2/15) in groups A, B, and C, respectively, with no significant difference between groups ( χ ²=1.721, P=0.550).

Conclusion

For intertrochanteric fractures, application of intravenous injection of TXA combined with local use of TXA cocktail in PFNA fixation can reduce perioperative blood loss, relieve pain after operation, and do not increase the risk of complications.

The effect of topical and systemic tranexamic acid on fracture healing in rats

OBJECTIVE

The aim of the present study was to determine the effect of topical and systemic tranexamic acid (TXA) on fracture healing in a rat surgical model.

METHODS

We created standard, right-sided, open, diaphyseal femoral fractures with intramedullary Kirschner wire fixation in 48 male rats and divided them into three groups: a topical TXA (10 mg/kg) group, a systemic TXA (10 mg/kg) group, and a control group. Fracture healing was evaluated radiographically and histologically after early (week 2) and late (week 4) postoperative sacrifice.

RESULTS

The radiological scores differed significantly among the all groups (p=0.001), as did the week 2 and 4 scores (p=0.003 and p=0.010, respectively). Radiologically, the topical TXA group exhibited better bone healing at both 2 (p=0.001) and 4 (p=0.007) weeks than the control group, and the systemic group showed better healing at both 2 (p=0.027) and 4 (p=0.023) weeks than the control TXA group. Moreover, bone healing was better in the group treated with topical rather than systemic TXA on radiological examinations performed at 2 (p=0.001) and 4 (p=0.007) weeks postoperatively (p=0.001 and p=0.007, respectively). Histologically, the groups differed significantly (p=0.001). The histological scores differed significantly among the all groups (p=0.001). At 2 weeks, the topical TXA group exhibited significantly better bone healing than the control group (p=0.001).

CONCLUSION

Our results suggested that topical application of TXA in fracture patients may accelerate healing, whereas systemic administration may adversely affect healing.

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.

Efficacy and safety of tranexamic acid for reducing blood loss in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery: A meta-analysis of randomized controlled trials

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of tranexamic acid (TXA) in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery.

METHODS

We searched MEDLINE, the Cochrane Library and EMBASE for published randomized clinical trials relevant to use of TXA in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery. Meta-analysis was performed according to the guidelines of the Cochrane Reviewer's Hand book.

RESULTS

Five trials assessing 540 patients were included for meta-analysis. The pooled results showed that the mean total blood loss in TXA group was significant lower than that in the control group (mean difference - 172.83, 95% CI -241.43 to -104.23; p<0.00001, fixed-effect model). The intra- and postoperative transfusion rate for the TXA group was 34.4% (91/264) and for the control group was 49.27% (136/276), and the relative risk was 0.71 (95% CI 0.52 to 0.97; p<0.03, random-effect model) with substantial heterogeneity (I2=63%, p=0.03). The overall incidence of thrombotic events was 6.43% (17/264) in the intravenous TXA group, 7.63% (21/275) in the control group, with no significant difference (relative risk 0.84, 95% CI 0.46 to 1.54; p=0.57, fixed-effect model).

CONCLUSION

The present evidence shows that TXA can significantly reduce total and hidden blood loss, transfusion rate, and do not increase the risk of thrombotic events in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. However, the impact of TXA on thrombotic events needs to be researched in more high-quality, large-sample randomized clinical trials.

LEVEL OF EVIDENCE

Level I Therapeutic Study.

Femoral trochanteric fracture: PFNA spiral blade placement with the aid of an angler

Objective

To investigate the effect of angler-assisted proximal femoral nail antirotation (PFNA) spiral blade fixation in treating femoral trochanteric fractures.

Methods

Patients who underwent angler-assisted PFNA screw blade fixation (angler-assisted group), or conventional internal fixation-intramedullary nailing (traditional surgery group) were included. Intraoperative indicators and treatment effects data were retrospectively analysed.

Results

Statistically significant differences were observed between the angler-assisted group (n = 27) and traditional surgery group (n = 28) regarding surgery duration (71.24 ± 8.01 min versus 81.50 ± 11.56 min), number of intraoperative fluoroscopy images (7.28 ± 0.91 versus 12.83 ± 1.55), and surgical bleeding volume (88.80 ± 7.98 ml versus 121.11 ± 27.21 ml). Rates of one-time intramedullary pin puncture for internal fixation in the angler-assisted and traditional surgery groups were 92.59% (25/27) and 32.14% (9/28), respectively. At 1 year following surgery, fractures in both groups had healed without internal fixation failure or fracture displacement failure. Harris hip function scores were 90.68 ± 4.23 (angler-assisted group) versus 81.69 ± 5.85 (traditional surgery group).

Conclusions

Angler-assisted intramedullary nailing with PFNA spiral blade provides good spiral blade positioning, low internal fixation failure rate, low fluoroscopy, short surgery time, and low bleeding volume. Hip function was well restored.

[Research progress on tranexamic acid in traumatic orthopedic surgery]

OBJECTIVE

To summarize the research progress on the application of tranexamic acid (TXA) in traumatic orthopedic surgery in recent years.

METHODS

The domestic and foreign literature in recent years was reviewed, and the efficacy and safety of TXA in traumatic orthopedic surgeries with different regimen, dose and route of administration were comprehensively summarized and compared.

RESULTS

The application of TXA in traumatic orthopedic surgeries increased gradually in recent years. Intravenous or topical administration of TXA efficaciously reduced blood loss and transfusion requirements during hip fracture surgery without significantly increasing the risk of thromboembolic events. However, the efficacy was not clear in other traumatic orthopedic surgeries such as pelvic and acetabular fractures.

CONCLUSION

More studies are needed to confirm the efficacy and safety of TXA in traumatic orthopedic surgeries.

The efficacy and safety of intravenous tranexamic acid in hip fracture surgery: A systematic review and meta-analysis

OBJECTIVE

The present meta-analysis was conducted to compare the efficacy and safety of intravenous application of tranexamic acid (TXA) with placebo in patients with hip fracture undergoing hip surgeries.

METHODS

PubMed, EMBASE and Cochrane Library were searched from inception until March 2018. A combined searching strategy of subject words and random words was adopted. Only randomized clinical trials were included. The comparisons regarding transfusion rate, total blood loss, intraoperative blood loss, postoperative blood loss, postoperative haemoglobin and postoperative thromboembolic complications were conducted. The meta-analysis was performed using Review Manager 5.3, and the bias evaluation was based on the Cochrane Handbook 5.1.0.

RESULTS

Ten randomized controlled trials published from 2007 to 2018 were included in the meta-analysis. The results showed that there were significant differences in the two groups concerning transfusion rate of allogeneic blood [risk ratio (RR) = 0.66, 95% confidence interval (CI): 0.56 to 0.78, P = 0.003], total blood loss [mean difference (MD) = -273.00, 95% CI: -353.15 to -192.84, P < 0.00001], intraoperative blood loss (MD = -76.63, 95% CI: -139.55 to -13.71, P = 0.02), postoperative blood loss (MD = -125.29, 95% CI: -221.96 to -28.62, P = 0.01) and postoperative haemoglobin (MD = 0.80, 95% CI: 0.38 to 1.22, P = 0.0002). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 1.38, 95% CI: 0.74 to 2.55, P = 0.31).

CONCLUSIONS

This meta-analysis of the available evidence implies that the intravenous route of TXA shows an ability to reduce transfusion requirements and total blood loss, not increasing the incidence of thromboembolic events in patients undergoing hip surgeries.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

The result of this meta-analysis shows that the utilization of intravenous TXA in patients with hip fracture undergoing hip surgeries possesses great potential in reducing blood loss and allogeneic blood transfusion safely.