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Blumenthal SR, Fryhofer GW, Stein MK, Zhang SE, Looby S, Mehta S. Variable Efficacy of Tranexamic Acid in Geriatric Hip Fractures Treated With Arthroplasty Versus Cephalomedullary Nails. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202408000-00006. [PMID: 39121795 PMCID: PMC11319306 DOI: 10.5435/jaaosglobal-d-24-00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Geriatric hip fractures are associated with high rates of disability and mortality. Many of these patients require perioperative and postoperative allogeneic blood transfusions, which carry several noteworthy risks. A growing body of literature supports the efficacy of tranexamic acid (TXA) in geriatric hip fractures, without sufficient data examining which subgroups are likely to benefit the most. METHODS In this study, we sought to evaluate whether TXA was associated with reduced blood loss and transfusions in a geriatric population undergoing hip fracture fixation at our institution during a 2-year period. The first year's data were collected in a retrospective fashion before the introduction of a quality control initiative encouraging TXA administration for all geriatric hip fractures. The second year's data were collected prospectively. A subgroup analysis was conducted for patients who underwent arthroplasties. RESULTS Among the pooled cohort of patients undergoing surgery, TXA showed no benefit over control subjects for reducing blood loss or transfusion requirements. However, the subgroup of patients undergoing arthroplasty procedures showed a notable decrease in total blood loss and total units transfused during hospitalization. DISCUSSION These results suggest that TXA may be most beneficial when targeted to arthroplasties performed for geriatric hip fractures.
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Affiliation(s)
- Sarah R. Blumenthal
- From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Stein, Dr. Zhang, Mr. Looby, Dr. Mehta), and the Department of Orthopaedic Surgery, Keck Medicine of University of Southern California, Los Angeles, CA (Dr. Blumenthal)
| | - George W. Fryhofer
- From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Stein, Dr. Zhang, Mr. Looby, Dr. Mehta), and the Department of Orthopaedic Surgery, Keck Medicine of University of Southern California, Los Angeles, CA (Dr. Blumenthal)
| | - Matthew K. Stein
- From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Stein, Dr. Zhang, Mr. Looby, Dr. Mehta), and the Department of Orthopaedic Surgery, Keck Medicine of University of Southern California, Los Angeles, CA (Dr. Blumenthal)
| | - Steven E. Zhang
- From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Stein, Dr. Zhang, Mr. Looby, Dr. Mehta), and the Department of Orthopaedic Surgery, Keck Medicine of University of Southern California, Los Angeles, CA (Dr. Blumenthal)
| | - Sean Looby
- From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Stein, Dr. Zhang, Mr. Looby, Dr. Mehta), and the Department of Orthopaedic Surgery, Keck Medicine of University of Southern California, Los Angeles, CA (Dr. Blumenthal)
| | - Samir Mehta
- From the Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Stein, Dr. Zhang, Mr. Looby, Dr. Mehta), and the Department of Orthopaedic Surgery, Keck Medicine of University of Southern California, Los Angeles, CA (Dr. Blumenthal)
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Zhao Y, Zhang C, Zhang Y, Li R, Xie T, Bai L, Chen H, Rui Y. Efficacy and Safety of Orally and Intravenously Administration of Tranexamic Acid in Patients with Elderly Femoral Neck Fracture. Orthop Surg 2024; 16:1581-1591. [PMID: 38766813 PMCID: PMC11216831 DOI: 10.1111/os.14089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE For elderly femoral neck fracture patients, anemia is one of the most common complications, increasing the risk of postoperative adverse events. Tranexamic acid (TXA) has been widely applied to the perioperative blood management. However, the optimal route of TXA administration in elderly femoral neck fracture remains unclear. The aim of this study is to evaluate the efficacy and safety of oral and intravenous (IV) application of TXA in elderly patients with femoral neck fracture undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA). METHODS All elderly patients aged over 65 years old diagnosed with femoral neck fracture admitted to the trauma orthopedics from August 1, 2020 to February 28, 2022 were enrolled in this prospective cohort study. Participants were divided into three groups: oral group: TXA 2g orally 2 h before incision; IV group: intravenous infusion of TXA 1g 15 min before incision; and control group: usual hemostatic method. The primary outcomes were total blood loss, allogeneic transfusion rate, and postoperative thromboembolic events. SPSS 23.0 (IBM, Armonk, NY, USA) was used for statistical analysis, and p ≤ 0.05 was considered statistically significant. RESULTS A total of 100 patients were enrolled, including 32 cases in the oral group, 34 cases in the IV group and 34 cases in the control group. Compared with the control group, the total perioperative blood loss in the oral and IV groups was significantly decreased (763.92 ± 358.64 mL vs 744.62 ± 306.88 mL vs 1250.60 ± 563.37 mL, p = 0.048). No significant difference was identified between the oral and IV groups (p = 0.970). The rate of allogeneic transfusion was lower in the oral and IV groups than in the control group, but the difference had no statistical significant (6 vs 5 vs 12, p = 0.108), However, subgroup analysis showed that the IV and oral groups in patients who underwent THA have significant lower transfusion rate compared with the control group (1 vs 3 vs 7, p = 0.02). During 6 months follow-up, no thromboembolic events were identified. Two patients (one from the oral group and one from the control group) died of respiratory failure. The cost of blood management from the oral group was significantly lower than IV (p < 0.001) and control groups (p = 0.009). CONCLUSION Elderly patients with femoral neck fracture undergoing THA can benefit from both IV and oral administration of tranexamic acid. The results of these two administration routes are similar in safety and effectiveness. A similar tendency was observed in patients undergoing HA. Oral TXA is more cost-benefit compared with intravenous applications.
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Affiliation(s)
- Ya‐kuan Zhao
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- The Fourth Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Cheng Zhang
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Yuan‐wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Ru‐ya Li
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Li‐yong Bai
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Handan First HospitalHandanChina
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
| | - Yun‐feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
- Orthopaedic Trauma Institute (OTI)Southeast UniversityNanjingChina
- Multidisciplinary Team (MDT) for elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of MedicineSoutheast UniversityNanjingChina
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Xie W, Donat A, Jiang S, Baranowsky A, Keller J. The emerging role of tranexamic acid and its principal target, plasminogen, in skeletal health. Acta Pharm Sin B 2024; 14:2869-2884. [PMID: 39027253 PMCID: PMC11252461 DOI: 10.1016/j.apsb.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 07/20/2024] Open
Abstract
The worldwide burden of skeletal diseases such as osteoporosis, degenerative joint disease and impaired fracture healing is steadily increasing. Tranexamic acid (TXA), a plasminogen inhibitor and anti-fibrinolytic agent, is used to reduce bleeding with high effectiveness and safety in major surgical procedures. With its widespread clinical application, the effects of TXA beyond anti-fibrinolysis have been noticed and prompted renewed interest in its use. Some clinical trials have characterized the effects of TXA on reducing postoperative infection rates and regulating immune responses in patients undergoing surgery. Also, several animal studies suggest potential therapeutic effects of TXA on skeletal diseases such as osteoporosis and fracture healing. Although a direct effect of TXA on the differentiation and function of bone cells in vitro was shown, few mechanisms of action have been reported. Here, we summarize recent findings of the effects of TXA on skeletal diseases and discuss the underlying plasminogen-dependent and -independent mechanisms related to bone metabolism and the immune response. We furthermore discuss potential novel indications for TXA application as a treatment strategy for skeletal diseases.
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Affiliation(s)
- Weixin Xie
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Antonia Donat
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Shan Jiang
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Anke Baranowsky
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Johannes Keller
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
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Zhao YK, Zhang C, Zhang YW, Li RY, Xie T, Bai LY, Chen H, Rui YF. Efficacy and safety of tranexamic acid in elderly patients with femoral neck fracture treated with hip arthroplasty: A systematic review and meta-analysis. J Orthop Sci 2024; 29:542-551. [PMID: 36797125 DOI: 10.1016/j.jos.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Elderly patients with femoral neck fracture have high perioperative blood loss according to the trauma and hip arthroplasty surgery. Tranexamic acid is a fibrinolytic inhibitor and has been widely used in hip fracture patients to against perioperative anemia. The aim of the present meta-analysis was to evaluate the efficacy and safety of Tranexamic acid (TXA) in elderly patients with femoral neck fracture undergoing hip arthroplasty. METHODS We performed search using Pubmed, EMBASE, Cochrane Reviews, and Web of Science databases to identify all relevant research studies published from inception to June 2022. Randomized controlled studies and high-quality cohort studies that reported the perioperative use of TXA in patients with femoral neck fractures treated with arthroplasty, and made a comparison with the control group were included. Meta-analysis was performed using Review Manager 5.3 to assess the efficacy and safety of TXA. Subgroup analysis was conducted to further investigate the impact caused by surgery types and administration routes on the efficacy and safety outcomes. RESULTS Five randomized controlled trials (RCTs) and eight cohort studies published from January 2015 to June 2022 were included in this meta-analysis. The results showed significant reductions in the rate of allogeneic blood transfusion, total blood loss (TBL) and postoperative hemoglobin (Hb) drop in the TXA group compared with the control group, while no significant difference was found in the intraoperative blood loss, postoperative drainage, hospital length of stay (LOS), re-admission rate, and wound complications between the two groups. The incidence of thromboembolic events and mortality showed no significant difference. Subgroup analysis indicated that surgery types and administration routes did not change the overall tendency. CONCLUSION The current evidence shows that both intravascular administration (IV) and topical administration of TXA can significantly decrease the perioperative transfusion rate and TBL without increasing the risk of thromboembolic complications in elderly patients with femoral neck fracture.
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Affiliation(s)
- Ya-Kuan Zhao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China; The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210000, PR China
| | - Cheng Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Ru-Ya Li
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Li-Yong Bai
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Multidisciplinary Team (MDT) for Elderly Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China; School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China.
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Li S, Liu M, Yang J, Yan X, Wu Y, Zhang L, Zeng M, Zhou D, Peng Y, Sessler DI. Intravenous tranexamic acid for intracerebral meningioma resections: A randomized, parallel-group, non-inferiority trial. J Clin Anesth 2024; 92:111285. [PMID: 37857168 DOI: 10.1016/j.jclinane.2023.111285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
STUDY OBJECTIVES Tranexamic acid (TXA) is an antifibrinolytic that is widely used to reduce surgical bleeding. However, TXA occasionally causes seizures and the risk might be especially great after neurosurgery. We therefore tested the hypothesis that TXA does not meaningfully increase the risk of postoperative seizures within 7 days after intracranial tumor resections. DESIGN Randomized, double-blind, placebo-controlled, non-inferiority trial. SETTING Beijing Tiantan Hospital, Capital Medical University. PATIENTS 600 patients undergoing supratentorial meningioma resection were included from October 2020 to August 2022. INTERVENTIONS Patients were randomly assigned to a single dose of 20 mg/kg of TXA after induction (n = 300) or to the same volume of normal saline (n = 300). MEASUREMENT The primary outcome was postoperative seizures occurring within 7 days after surgery, analyzed in both the intention-to-treat and per-protocol populations. Non-inferiority was defined by an upper limit of the 95% confidence interval for the absolute difference being <5.5%. Secondary outcomes included incidence of non-epileptic complication within 7 days, changes in hemoglobin concentration, estimated intraoperative blood loss. Post hoc analyses included the types and timing of seizures, oozing assessment, and a sensitivity analysis for the primary outcome in patients with pathologic diagnosis of meningioma. MAIN RESULTS All 600 enrolled patients adhered to the protocol and completed the follow-up for the primary outcome. Postoperative seizures occurred in 11 of 300 (3.7%) of patients randomized to normal saline and 13 of 300 (4.3%) patients assigned to tranexamic acid (mean risk difference, 0.7%; 1-sided 97.5% CI, -∞ to 4.3%; P = 0.001 for noninferiority). No significant differences were observed in any secondary outcome. Post hoc analysis indicated similar amounts of oozing, calculated blood loss, recurrent seizures, and timing of seizures. CONCLUSION Among patients having supratentorial meningioma resection, a single intraoperative dose of TXA did not significantly reduce bleeding and was non-inferior with respect to postoperative seizures after surgery. REGISTRY INFORMATION This trial was registered at clinicaltrials.gov (NCT04595786) on October 22, 2020, by Dr.Yuming Peng.
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Affiliation(s)
- Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jingchao Yang
- Department of Anesthesiology, Cancer Hospital, Chinses Academy of Medical Sciences, Beijing, PR China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Dabiao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; Outcome Research Consortium, Cleveland, OH, USA.
| | - Daniel I Sessler
- Outcome Research Consortium, Cleveland, OH, USA; Department of Outcome Research, Cleveland Clinic, Cleveland, OH, USA.
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de Haan E, Roukema GR, van Rijckevorsel VAJIM, Kuijper TM, Jong LD. Risk factors for prosthetic joint infections after hemiarthroplasty of the hip following a femoral neck fracture. Injury 2024; 55:111195. [PMID: 38039635 DOI: 10.1016/j.injury.2023.111195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/24/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE The primary aim of this study was to identify risk factors and validate earlier reported risk factors for Prosthetic Joint Infection (PJI) after hemiarthroplasty. The secondary aim was to assess peri‑operative clinical outcomes, adverse events and mortality rates in PJI patients after hemiarthroplasty. METHODS A prospective hip fracture database was used to obtain data for this observational cohort study. Patients who underwent hemiarthroplasty between 2011 and 2021 were included. A PJI was diagnosed by the Musculoskeletal Infection Society criteria. Univariable and multivariable analyses were performed to identify factors highly associated with a PJI. RESULTS In total, 2044 patients were analysed of which 72 patients (3.5 %) developed PJI. The multivariable analysis showed that Body Mass Index (BMI) >30 (OR2.84, P = 0.020), operating time of <45 min (OR=2.80, P = 0.002), occurrence of haematoma (OR=6.24, P<0.001), decreasing level of hemoglobin (OR=1.62, P = 0.001) and re-operation for luxation (OR=9.25, P<0.001) were significant independent prognostic risk factors for development of PJI after hemiarthroplasty. Diabetes Mellitus (OR=0.34, P = 0.018) and >20 hemiarthroplasties performed by the surgeon in the previous year (OR=0.33, P = 0.019) were prognostic protective factors. In patients with PJI, 40 % (n = 29) died within one year after surgery, compared with 27 % (n = 538) in patients without PJI (OR=1.80, P = 0.017). CONCLUSION Independent significant prognostic factors highly associated with PJI after hemiarthroplasty were BMI >30, operating time of <45, decreasing level of hemoglobin, occurrence of haematoma and re-operation for luxation. Diabetes Mellitus and >20 hemiarthroplasties performed by the surgeon in the previous year were prognostic protective factors for the development of PJI. PJI was associated with significantly higher 1-year all-cause mortality.
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Affiliation(s)
- Eveline de Haan
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands; Surgery Department, Franciscus Gasthuis en Vlietland, 3045 PM Rotterdam, the Netherlands.
| | - Gert R Roukema
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands
| | | | - T Martijn Kuijper
- Maasstad Academy, Maasstad Hospital, 3079 DZ Rotterdam, the Netherlands
| | - Louis de Jong
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands
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Luo XP, Peng J, Zhou L, Liao H, Jiang XC, Tang X, Tang D, Liu C, Liu JH. Intramedullary administration of tranexamic acid reduces bleeding in proximal femoral nail antirotation surgery for intertrochanteric fractures in elderly individuals: A randomized controlled trial. Chin J Traumatol 2024:S1008-1275(24)00006-3. [PMID: 38429175 DOI: 10.1016/j.cjtee.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE Intertrochanteric fractures undergoing proximal femoral nail antirotation (PFNA) surgery are associated with significant hidden blood loss. This study aimed to explore whether intramedullary administration of tranexamic acid (TXA) can reduce bleeding in PFNA surgery for intertrochanteric fractures in elderly individuals. METHODS A randomized controlled trial was conducted from January 2019 to December 2022. Patients aged over 60 years with intertrochanteric fractures who underwent intramedullary fixation surgery with PFNA were eligible for inclusion and grouped according to random numbers. A total of 249 patients were initially enrolled, of which 83 were randomly allocated to the TXA group and 82 were allocated to the saline group. The TXA group received intramedullary perfusion of TXA after the bone marrow was reamed. The primary outcomes were total peri-operative blood loss and post-operative transfusion rate. The occurrence of adverse events was also recorded. Continuous data was analyzed by unpaired t-test or Mann-Whitney U test, and categorical data was analyzed by Pearson Chi-square test. RESULTS The total peri-operative blood loss (mL) in the TXA group was significantly lower than that in the saline group (577.23 ± 358.02 vs. 716.89 ± 420.30, p = 0.031). The post-operative transfusion rate was 30.67 % in the TXA group and 47.95 % in the saline group (p = 0.031). The extent of post-operative deep venous thrombosis and the 3-month mortality rate were similar between the 2 groups. CONCLUSION We observed that intramedullary administration of TXA in PFNA surgery for intertrochanteric fractures in elderly individuals resulted in less peri-operative blood loss and decreased transfusion rate, without any adverse effects, and is, thus, recommended.
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Affiliation(s)
- Xiang-Ping Luo
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China.
| | - Jian Peng
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Ling Zhou
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Hao Liao
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Xiao-Chun Jiang
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Xiong Tang
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Dun Tang
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Chao Liu
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
| | - Jian-Hui Liu
- Department of Orthopaedic, Hengyang Central Hospital, Hengyang, 421001, Hunan province, China
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8
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Poston JN, Kruse-Jarres R. How I treat von Willebrand disorders in older adults. Blood 2024; 143:197-204. [PMID: 37672774 DOI: 10.1182/blood.2022018534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/09/2023] [Accepted: 07/10/2023] [Indexed: 09/08/2023] Open
Abstract
ABSTRACT von Willebrand disease (VWD) is the most common bleeding disorder and especially milder type 1 VWD might not be cared for in specialty clinics. VW factor levels rise with age, but the rise of these levels does not necessarily correlate with bleeding risk. A recent bleeding history combined with recent labs are important for hemostatic management decision during surgical interventions. Antifibrinolytics appear safe in the population of older adults, whereas desmopressin (DDAVP) should be used cautiously. Where needed, factor concentrates present a great treatment option. Acquired von Willebrand syndrome is vastly underrecognized, but likely to surface in the aging, especially in the setting of comorbidities, such as plasma-cell dyscrasias. Intravenous immunoglobulin can be an effective treatment in this scenario, but potentially increases thrombotic risk.
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Affiliation(s)
- Jacqueline N Poston
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
- Division of Clinical Pathology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
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9
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Youssef Y, Dietrich AKIM, Hättich A. Anticoagulation management in elderly patients with proximal femur fractures - overview of current concepts. Innov Surg Sci 2023; 8:209-214. [PMID: 38510368 PMCID: PMC10949210 DOI: 10.1515/iss-2023-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/02/2023] [Indexed: 03/22/2024] Open
Abstract
Objectives Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial. Content This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF. Summary and Outlook Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.
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Affiliation(s)
- Yasmin Youssef
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Leipzig, 04103Leipzig, Germany
| | | | - Annika Hättich
- Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
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10
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Su S, Zhang Y, Wang R, Zhou R, Chen Z, Zhou F. Early surgery within 48 h was associated with reduced perioperative blood loss and red blood cell transfusion requirements in older patients with hip fracture: a retrospective study. Eur Geriatr Med 2023; 14:1241-1248. [PMID: 37436688 DOI: 10.1007/s41999-023-00834-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE The aim of this study was to analyze the relationship between the timing of surgery and perioperative blood loss, red blood cell (RBC) transfusion rate, and RBC transfusion volume in older patients with hip fracture. METHODS From January 2020 to August 2022, this retrospective study enrolled older patients with hip fracture who underwent surgery in our hospital. The demographics, fracture type, type of surgery, time from injury to hospital, timing of surgery, medical history (hypertension, diabetes), duration of surgery, intraoperative blood loss, laboratory tests, and preoperative, postoperative and perioperative RBC transfusion requirements were recorded and analyzed. According to the surgical treatment within 48 h or after 48 h after admission, the patients were divided into early surgery group (ES) and delayed surgery group (DS). RESULTS A total of 243 older patients with hip fracture were finally included in the study. Among these, 96 patients (39.51%) underwent surgery within 48 h of admission and 147 (60.49%) underwent surgery after this time. Total blood loss (TBL) in the ES group was lower than that in the DS group (576.03 ± 265.57 ml vs 699.26 ± 380.58 ml, P = 0.003). Preoperative RBC transfusion rate, and preoperative and perioperative RBC transfusion volume in the ES group were significantly lower than those in the DS group (15.63% vs 26.53%, P = 0.046; 50.00 ± 128.15 ml vs 117.01 ± 225.85 ml, P = 0.004; 80.21 ± 196.63 ml vs 144.90 ± 253.52 ml, P = 0.027). CONCLUSION Timing of surgery within 48 h of admission for older patients with hip fracture was associated with reduced the total blood loss and RBC transfusion requirements during the perioperative period.
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Affiliation(s)
- Shilong Su
- Department of Orthopedics, Peking University Third Hospital, No.49 North Garden Road, Haidian, 100191, Beijing, China
| | - Yunqing Zhang
- Department of Orthopedics, The First Hospital of Changsha, No.311 Yingpan Road, Changsha, 410005, Hunan Province, China
| | - Ruideng Wang
- Department of Orthopedics, Peking University Third Hospital, No.49 North Garden Road, Haidian, 100191, Beijing, China
| | - Rubing Zhou
- Department of Orthopedics, Peking University Third Hospital, No.49 North Garden Road, Haidian, 100191, Beijing, China
| | - Zhengyang Chen
- Department of Orthopedics, Peking University Third Hospital, No.49 North Garden Road, Haidian, 100191, Beijing, China
| | - Fang Zhou
- Department of Orthopedics, Peking University Third Hospital, No.49 North Garden Road, Haidian, 100191, Beijing, China.
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11
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Haddad FS. Looking ahead to autumn. Bone Joint J 2023; 105-B:943-945. [PMID: 37652451 DOI: 10.1302/0301-620x.105b9.bjj-2023-0780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Fares S Haddad
- Princess Grace Hospital, London, UK
- University College London Hospitals and The NIHR Biomedical Research Centre at UCLH, London, UK
- The Bone & Joint Journal , London, UK
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12
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Yu H, Liu M, Zhang X, Ma T, Yang J, Wu Y, Wang J, Li M, Wang J, Zeng M, Zhang L, Jin H, Liu X, Li S, Peng Y. The effect of tranexamic acid on intraoperative blood loss in patients undergoing brain meningioma resections: Study protocol for a randomized controlled trial. PLoS One 2023; 18:e0290725. [PMID: 37651373 PMCID: PMC10470952 DOI: 10.1371/journal.pone.0290725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/18/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) has been proven to prevent thrombolysis and reduce bleeding and blood transfusion requirements in various surgical settings. However, the optimal dose of TXA that effectively reduce intraoperative bleeding and blood product infusion in patients undergoing neurosurgical resection of meningioma with a diameter ≥ 5 cm remains unclear. METHODS This is a single-center, randomized, double-blinded, paralleled-group controlled trial. Patients scheduled to receive elective tumor resection with meningioma diameter ≥ 5 cm will be randomly assigned the high-dose TXA group, the low-dose group, and the placebo. Patients in the high-dose TXA group will be administered with a loading dose of 20 mg/kg TXA followed by continuous infusion TXA at a rate of 5 mg/kg/h. In the low-dose group, patients will receive the same loading dose of TXA followed by a continuous infusion of normal saline. In the control group, patients will receive an identical volume of normal saline. The primary outcome is the estimated intraoperative blood loss calculated using the following formula: collected blood volume in the suction canister (mL)-the volume of flushing (mL) + the volume from the gauze tampon (mL). Secondary outcomes include calculated intraoperative blood loss, intraoperative coagulation function assessed using thromboelastogram (TEG), intraoperative cell salvage use, blood product infusion, and other safety outcomes. DISCUSSION Preclinical studies suggest that TXA could reduce intraoperative blood loss, yet the optimal dose was controversial. This study is one of the early studies to evaluate the impact of intraoperative different doses infusion of TXA on reducing blood loss in neurological meningioma patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT05230381. Registered on February 8, 2022.
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Affiliation(s)
- Haojie Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingchao Yang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hailong Jin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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13
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Miangul S, Oluwaremi T, El Haddad J, Adra M, Pinnawala N, Nakanishi H, Matar RH, Than CA, Stewart TM. Update on the efficacy and safety of intravenous tranexamic acid in hip fracture surgery: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2179-2190. [PMID: 36156738 PMCID: PMC10275812 DOI: 10.1007/s00590-022-03387-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/02/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Shahid Miangul
- St George's University of London, London, SW17 0RE, UK.
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus.
| | - Timothy Oluwaremi
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Joe El Haddad
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Maamoun Adra
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Nathan Pinnawala
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Hayato Nakanishi
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
| | - Reem H Matar
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Christian A Than
- St George's University of London, London, SW17 0RE, UK
- University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, 4072, Australia
| | - Thomas M Stewart
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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15
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Gibbs VN, Geneen LJ, Champaneria R, Raval P, Dorée C, Brunskill SJ, Novak A, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures. Cochrane Database Syst Rev 2023; 6:CD013499. [PMID: 37272509 PMCID: PMC10241722 DOI: 10.1002/14651858.cd013499.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Parag Raval
- Trauma and Orthopaedic Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Zuelzer DA, Weaver D, Zuelzer AP, Hessel EA. Current Strategies in Medical Management of the Geriatric Hip Fracture Patient. J Am Acad Orthop Surg 2023:00124635-990000000-00694. [PMID: 37184459 DOI: 10.5435/jaaos-d-22-00815] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/01/2023] [Indexed: 05/16/2023] Open
Abstract
Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.
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Affiliation(s)
- David A Zuelzer
- From the Department of Orthopaedic and Sports Medicine (Zuelzer), Department of Internal Medicine (Weaver), Department of Anesthesiology (Zuelzer and Hessel), University of Kentucky, Lexington, KY
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17
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Haddad FS. Stronger every year. Bone Joint J 2023; 105-B:1-2. [PMID: 36587254 DOI: 10.1302/0301-620x.105b1.bjj-2022-1272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal, London, UK
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18
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Tripathy SK, Varghese P, Kumarasamy AKN, Mishra NP, Neradi D, Jain M, Sarkar S, Sen RK. Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:33-43. [PMID: 36660490 PMCID: PMC9789237 DOI: 10.1007/s43465-022-00779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/09/2022] [Indexed: 11/28/2022]
Abstract
Purpose Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients. Methods Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality). Results There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03). Conclusions Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients. Level of evidence III.
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Affiliation(s)
- Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Paulson Varghese
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | | | - Narayan Prasad Mishra
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Deepak Neradi
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Mantu Jain
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar, 751019 India
| | - Soumya Sarkar
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, India
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Augustinus S, Mulders MAM, Gardenbroek TJ, Goslings JC. Tranexamic acid in hip hemiarthroplasty surgery: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 49:1247-1258. [DOI: 10.1007/s00068-022-02180-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
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20
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Farrow L, Brasnic L, Martin C, Ward K, Adam K, Hall AJ, Clement ND, MacLullich AMJ. A nationwide study of blood transfusion in hip fracture patients. Bone Joint J 2022; 104-B:1266-1272. [DOI: 10.1302/0301-620x.104b11.bjj-2022-0450.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. Conclusion Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272.
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Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
- Grampian Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Lorena Brasnic
- Institute of Applied Health Sciences, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Caroline Martin
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Kirsty Ward
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Karen Adam
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
| | - Andrew J. Hall
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK
| | - Nick D. Clement
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alasdair M. J. MacLullich
- Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
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21
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Lin GX, Chen CM, Zhu MT, Zheng L. The Safety and Effectiveness of Tranexamic Acid in Lumbar Interbody Fusion Surgery: An Updated Meta-analysis of Randomized Controlled Trials. World Neurosurg 2022; 166:198-211. [PMID: 36084620 DOI: 10.1016/j.wneu.2022.07.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Several previous meta-analyses have been published, followed by additional randomized clinical trials investigating the effects of tranexamic acid (TXA) in patients undergoing posterior lumbar interbody fusion (PLIF) surgery. As a result, the purpose of this research is to present an updated quantitative analysis of the existing literature and to further explicate its effectiveness. METHODS PubMed, Embase, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing the application of TXA and placebo in patients undergoing PLIF surgery from their establishment to December 31, 2021. Data on clinical outcomes, perioperative outcomes, and complications were collected. The summary statistics for continuous and dichotomous variables were derived as weighted mean difference (WMD) and relative risk (RR), respectively. RESULTS A total of 12 studies enrolling 1088 participants were included in this meta-analysis. The combined results revealed that TXA can decrease intraoperative blood loss (WMD: -84.83, P < 0.0001), total blood loss (WMD: -189.93, P < 0.00001), hidden blood loss (WMD: -134.69, P = 0.002), postoperative drainage (WMD: -100.71, P < 0.00001), postoperative hemoglobin loss (WMD: 6.21, P < 0.00001), operative time (WMD: -3.80, P = 0.007), hospital stay (WMD: -1.86, P = 0.001), and transfusion rates (RR: 0.41, P < 0.00001) in PLIF without increasing the risk of thromboembolic events (RR: 0.80, P = 0.43). CONCLUSIONS TXA can considerably decrease surgical blood loss, postoperative drainage, reduce operative times, hospital stays, and transfusion rates. Furthermore, the TXA group had lower postoperative hemoglobin drop values than the placebo group.
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Affiliation(s)
- Guang-Xun Lin
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China; The Third Clinical Medical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Tao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Linfei Zheng
- Department of Neurosurgery, Fuzhou Second Hospital of Xiamen University, School of Medicine, Xiamen University, Fuzhou, China; Fuzhou Second Hospital, Fuzhou, China; Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopaedic Trauma (2020Y2014), Fuzhou, China.
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22
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van Rijckevorsel VAJIM, Roukema GR, Kuijper TM, de Jong L. Clinical outcomes of tranexamic acid in acute hip hemiarthroplasties in frail geriatric patients. Orthop Traumatol Surg Res 2022; 108:103219. [PMID: 35093562 DOI: 10.1016/j.otsr.2022.103219] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 12/13/2021] [Accepted: 01/04/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) has shown to significantly reduce perioperative blood loss in elective orthopedic joint replacement surgery but is yet not implemented in acute hip fracture surgery for elderly patients who are particularly vulnerable to perioperative blood loss and postoperative anemia. Aim of this study is to answer the following questions: 1. Does TXA reduce bleeding associated complications in elderly patients? 2. Does TXA induce thromboembolic complications in elderly patients? HYPOTHESIS TXA reduces perioperative blood loss and associated complications in acute hip fracture surgery in geriatric patients. PATIENTS AND METHODS In this observational cohort study with prospectively enrolled patients over 65 years of age who received an acute hip hemiarthroplasty, the primary outcome was blood loss, also described as Δ hemoglobin. Secondary outcomes were bleeding associated complications as hematomas. Also, the occurrence of thromboembolic events and mortality were examined. RESULTS In total 864 geriatric patients were included of which 235 received TXA and 629 did not. Multivariable analysis showed reduced Δ hemoglobin loss [-0.24 (-0.39; -0.09), p=0.002] and hematomas (OR 0.44 (0.21; 0.91), p=0.026). Pulmonary embolism were diagnosed more frequently after administration of TXA (2% versus 0.3%, p=0.008), without an association with increased 30-day mortality rate (6% versus 8%, p=0.3). DISCUSSION TXA reduced perioperative blood loss and associated complications. However, adverse effects of TXA as pulmonary embolisms were found more frequently without effecting postoperative mortality rates. More research is needed to assess adverse effects of intravenous TXA and topical TXA as an alternative for systemic TXA to prevent systemic adverse effects. LEVEL OF EVIDENCE III, Observational cohort study.
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Affiliation(s)
| | - Gert R Roukema
- Surgery Department, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands
| | - Tjallingius M Kuijper
- Maasstad Academy, statistician, Maasstad Hospital, 3007 AC Rotterdam, the Netherlands
| | - Louis de Jong
- Surgery Department, Franciscus Hospital, 3045 PM Rotterdam, the Netherlands
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23
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The Efficacy and Safety of Intravenous Iron in Geriatric Hip Fracture Surgeries: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:2595-2606. [PMID: 35947180 DOI: 10.1007/s00268-022-06690-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND With the increasing evidence provided by recent high-quality studies, the intravenous iron appears to be a reliable therapy for blood administration in geriatric patients with hip fractures. Here, this systematic review and meta-analysis were aimed to assess the effectiveness and safety of intravenous iron in geriatric patients sustaining hip fractures. METHODS Potential pertinent literatures evaluating the effects of intravenous iron in the geriatric patients undergoing hip fractures were identified from Web of Science, PubMed, Embase, and Scopus. We performed a pairwise meta-analysis using fixed- and random-effects models, and the pooling of data was carried out by using RevMan 5.1. RESULTS Four randomized controlled trials and four observational studies conform to inclusion criteria. The results of meta-analysis showed that intravenous iron reduced transfusion rates compared to the control group, yet the result did not reach statistical significance. The intravenous iron was related to lower transfusion volumes, shorter length of stay, and a reduced risk of nosocomial infections. And there was no significant difference in terms of the mortality and other complications between the treatment group and the control group. CONCLUSION Current evidence suggests that intravenous iron reduces the transfusion volume, length of hospital stay, and risk of nosocomial infections. It takes about 7 days for intravenous iron to elevate hemoglobin by 1 g/dl and about 1 month for 2 g/dl. The safety profile of intravenous iron is also reassuring, and additional high-quality studies are needed.
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24
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Karayiannis PN, Agus A, Bryce L, Hill JC, Beverland D. Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial. Bone Jt Open 2022; 3:536-542. [PMID: 35816170 PMCID: PMC9350706 DOI: 10.1302/2633-1462.37.bjo-2021-0213.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536–542.
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Affiliation(s)
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Leanne Bryce
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - J. C. Hill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
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Li S, Yan X, Li R, Zhang X, Ma T, Zeng M, Dong J, Wang J, Liu X, Peng Y. Safety of intravenous tranexamic acid in patients undergoing supratentorial meningiomas resection: protocol for a randomised, parallel-group, placebo control, non-inferiority trial. BMJ Open 2022; 12:e052095. [PMID: 35110315 PMCID: PMC8811564 DOI: 10.1136/bmjopen-2021-052095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Growing evidence recommends antifibrinolytic agent tranexamic acid (TXA) to reduce blood loss and transfusions rate in various surgical settings. However, postoperative seizure, as one of the major adverse effects of TXA infusion, has been a concern that restricts its utility in neurosurgery. METHODS AND ANALYSIS This is a randomised, placebo-controlled, non-inferiority trial. Patients with supratentorial meningiomas and deemed suitable for surgical resection will be recruited in the trial. Patients will be randomised to receive either a single administration of 20 mg/kg TXA or a placebo of the same volume with a 1:1 allocation ratio after anaesthesia induction. The primary endpoint is the cumulative incidence of early postoperative seizures within 7 days after craniotomy. Secondary outcomes include the incidence of non-seizure complications, changes of haemoglobin level from baseline, intraoperative blood loss, erythrocyte transfusion volume, Karnofsky Performance Status, all-cause mortality, and length of stay, and total hospitalisation cost. ETHICS AND DISSEMINATION This trial is registered at ClinicalTrial.gov and approved by the Chinese Ethics Committee of Registering Clinical Trials (ChiECRCT20200224). The findings will be disseminated in peer-reviewed journals and presented at national or international conferences relevant to subject fields. TRIAL REGISTRATION NUMBER NCT04595786.
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Affiliation(s)
- Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ruowen Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Dong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Masouros P, Antoniou G, Nikolaou VS. Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials. Injury 2022; 53:294-300. [PMID: 34689986 DOI: 10.1016/j.injury.2021.09.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/19/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Georgia Antoniou
- Evangelismos General Hospital, Orthopaedic Department, Athens, Greece
| | - Vasileios S Nikolaou
- Konstandopoulio General Hospital, 2nd Academic Department of Orthopaedics, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.
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Moran J, Kahan JB, Morris J, Joo PY, O’Connor MI. Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery. Geriatr Orthop Surg Rehabil 2022; 13:21514593221124414. [PMID: 36081840 PMCID: PMC9445454 DOI: 10.1177/21514593221124414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph B. Kahan
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Jensa Morris
- Center for Musculoskeletal Care and Yale New Haven Health, Yale School of Medicine, New Haven, CT, USA
- Hospitalist Service, Yale New Haven Hospital, New Haven, CT, USA
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Mary I. O’Connor
- Department of Orthopaedic Surgery, Vori Health, San Francisco Bay Area, CA, USA
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Wang Z, Chen X, Chen Y, Yang L, Wang H, Jiang W, Liu S, Liu Y. Low serum calcium is associated with perioperative blood loss and transfusion rate in elderly patients with hip fracture: a retrospective study. BMC Musculoskelet Disord 2021; 22:1025. [PMID: 34876077 PMCID: PMC8653606 DOI: 10.1186/s12891-021-04914-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/26/2021] [Indexed: 01/04/2023] Open
Abstract
Background To investigate whether hypocalcemia influenced total blood loss and transfusion rate in elderly patients with hip fracture. Methods From our hip fracture database, patients were consecutively included between January 2014 and December 2020. Serum calcium level was corrected for albumin concentration, and hypocalcaemia was defined as corrected calcium < 2.11 mmol/L. Hemoglobin and hematocrit were obtained on admission day and postoperative day, and blood transfusions were collected. According to the combination formulas of Nadler and Gross, the total blood loss of each patient was calculated. Risk factors were further analyzed by multivariate linear regression. Results A total of 583 consecutive elderly hip fracture patients were finally included (mean age 79.32 ± 8.18 years, 68.61% female). On admission, the mean serum corrected calcium level was 2.17 ± 0.14 mmol/L, and the prevalence of hypocalcemia was 33.11% (95% CI: 29.42–37.02). When comparing patients with normal calcium, hypocalcemia patients exhibited a higher blood transfusion rate (7.69% vs 16.06%, P < 0.05), and significantly larger total blood loss (607.86 ± 497.07 ml vs 719.18 ± 569.98 ml, P < 0.05). Multivariate linear regression analysis showed that male, anemia on admission, time from injury to hospital, intertrochanteric fracture, blood transfusion and hypocalcemia were independently associated with increased total blood loss (P < 0.05). Conclusion Hypocalcemia is common in elderly patients with hip fracture, and significantly associated with more total blood loss and blood transfusion. The other risk factors for increased total blood loss are male, anemia on admission, time from injury to hospital, intertrochanteric fracture, and blood transfusion. Level of evidence Level III, retrospective study.
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Affiliation(s)
- Zhicong Wang
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China
| | - Xi Chen
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China
| | - Yan Chen
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China
| | - Ling Yang
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China
| | - Hong Wang
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China
| | - Wei Jiang
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China
| | - Shuping Liu
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China.
| | - Yuehong Liu
- Department of Orthopedic Surgery, Deyang People's Hospital, Orthopaedic Center of Deyang City, Deyang, 618000, Sichuan, China.
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Porter SB, Spaulding AC, Duncan CM, Wilke BK, Pagnano MW, Abdel MP. Tranexamic Acid Was Not Associated with Increased Complications in High-Risk Patients with Hip Fracture Undergoing Arthroplasty. J Bone Joint Surg Am 2021; 103:1880-1889. [PMID: 34449443 DOI: 10.2106/jbjs.21.00172] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is considered safe and efficacious for elective total joint arthroplasty. However, evidence of TXA's safety in high-risk patients with hip fracture requiring nonelective arthroplasty has been lacking. This study aimed to assess whether TXA administration to high-risk patients with a hip fracture requiring arthroplasty increased the risk of thrombotic complications or mortality. METHODS All patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) for displaced femoral neck fractures between 2011 and 2019 at 4 sites within 1 hospital system were retrospectively identified. Patients were grouped by risk (high-risk or low-risk) and TXA treatment (with or without TXA). Propensity scores were used for risk adjustment in comparisons between surgery with and without TXA for only the high-risk group (n = 1,066) and the entire population (n = 2,166). Differences in the occurrence of postoperative mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke within 90 days of hip arthroplasty were evaluated. RESULTS TXA administration was not associated with an increased risk of thrombotic complications or mortality within 90 days in either high-risk or all-patient groups. Specifically, among 1,066 matched high-risk patients who did not or did receive TXA, there were no significant differences in mortality (14.82% and 10.00%; p = 0.295), deep venous thrombosis (3.56% and 3.04%; p = 0.440), pulmonary embolism (2.44% and 1.96%; p = 0.374), myocardial infarction (3.38% and 2.14%; p = 0.704), or stroke (4.32% and 5.71%; p = 0.225). CONCLUSIONS In our review of 1,066 propensity-matched high-risk patients undergoing hip arthroplasty for displaced femoral neck fractures, we found that TXA administration (compared with no TXA administration) was not associated with an increased risk of mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Aaron C Spaulding
- Division of Health Care Delivery Research, Mayo Clinic, Jacksonville, Florida
| | - Christopher M Duncan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Benjamin K Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Wei H, Xiao Q, He J, Huang T, Xu W, Xian S, Xia M. Effect and safety of topical application of tranexamic acid to reduce perioperative blood loss in elderly patients with intertrochanteric fracture undergoing PFNA. Medicine (Baltimore) 2021; 100:e27123. [PMID: 34449517 PMCID: PMC8389971 DOI: 10.1097/md.0000000000027123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 08/16/2021] [Indexed: 01/04/2023] Open
Abstract
The specific method and dose of tranexamic acid (TXA) topically applied for intertrochanteric fractures have not been well established. The aim of this study is to investigate the efficacy and safety of TXA topically administered via our protocol for perioperative bleeding management in elderly patients with intertrochanteric fractures who underwent proximal femoral nail anti-rotation (PFNA).A retrospective comparative analysis was performed. The TXA group was composed of 82 patients with topical use of TXA, and the control group was composed of 82 patients without TXA use during the PFNA procedure. Intraoperative, total and hidden amounts of blood loss, drainage volumes, postoperative blood transfusion volumes and complications were compared between the 2 groups.The intraoperative, total and hidden amounts of blood loss and the drainage volumes were significantly lower in the TXA group than in the control group (P = .012, P < .01, P < .01, P = .014, respectively). The volume and rate of blood transfusion in the TXA group were significantly lower than those in the control group (P < .01). There were no significant differences in complications between the 2 groups (P > .05).Topical application of TXA offers an effective and safe option for reducing perioperative blood loss and transfusion in elderly patients with intertrochanteric fractures undergoing PFNA.
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Affiliation(s)
- Huiping Wei
- Department of Orthopaedics, Nanchuan People's Hospital of Chongqing Medical University, Chongqing, China
| | - Qiuping Xiao
- Department of Orthopaedics, Nanchuan People's Hospital of Chongqing Medical University, Chongqing, China
| | - Jianfeng He
- Department of Orthopaedics, Nanchuan People's Hospital of Chongqing Medical University, Chongqing, China
| | - Tianji Huang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wantang Xu
- Department of Orthopaedics, Nanchuan People's Hospital of Chongqing Medical University, Chongqing, China
| | - Siping Xian
- Department of Orthopaedics, Nanchuan People's Hospital of Chongqing Medical University, Chongqing, China
| | - Menghong Xia
- Department of Orthopaedics, Nanchuan People's Hospital of Chongqing Medical University, Chongqing, China
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Bian FC, Cheng XK, An YS. Preoperative risk factors for postoperative blood transfusion after hip fracture surgery: establishment of a nomogram. J Orthop Surg Res 2021; 16:406. [PMID: 34162408 PMCID: PMC8220667 DOI: 10.1186/s13018-021-02557-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to explore the preoperative risk factors related to blood transfusion after hip fracture operations and to establish a nomogram prediction model. The application of this model will likely reduce unnecessary transfusions and avoid wasting blood products. Methods This was a retrospective analysis of all patients undergoing hip fracture surgery from January 2013 to January 2020. Univariate and multivariate logistic regression analyses were used to evaluate the association between preoperative risk factors and blood transfusion after hip fracture operations. Finally, the risk factors obtained from the multivariate regression analysis were used to establish the nomogram model. The validation of the nomogram was assessed by the concordance index (C-index), the receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and calibration curves. Results A total of 820 patients were included in the present study for evaluation. Multivariate logistic regression analysis demonstrated that low preoperative hemoglobin (Hb), general anesthesia (GA), non-use of tranexamic acid (TXA), and older age were independent risk factors for blood transfusion after hip fracture operation. The C-index of this model was 0.86 (95% CI, 0.83–0.89). Internal validation proved the nomogram model’s adequacy and accuracy, and the results showed that the predicted value agreed well with the actual values. Conclusions A nomogram model was developed based on independent risk factors for blood transfusion after hip fracture surgery. Preoperative intervention can effectively reduce the incidence of blood transfusion after hip fracture operations.
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Affiliation(s)
- Fu Cheng Bian
- Chengde Medical University, Chengde, 067000, Hebei, China.,Department of Minimally Invasive Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei, China
| | - Xiao Kang Cheng
- Chengde Medical University, Chengde, 067000, Hebei, China.,Department of Minimally Invasive Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei, China
| | - Yong Sheng An
- Department of Minimally Invasive Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei, China.
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Rebai L, Mahfoudhi N, Fitouhi N, Daghmouri MA, Bahri K. Intraoperative tranexamic acid use in patients undergoing excision of intracranial meningioma: Randomized, placebo-controlled trial. Surg Neurol Int 2021; 12:289. [PMID: 34221620 PMCID: PMC8247750 DOI: 10.25259/sni_177_2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/01/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Intracranial meningioma resection is associated with substantial intraoperative bleeding. Intraoperative tranexamic acid (TXA) use can reduce bleeding in a variety of surgical procedures. The objective of this study was to evaluate the effects of TXA treatment on blood loss and transfusion requirements in patient undergoing resection of intracranial meningioma. Methods: We conducted a prospective, randomized double-blind clinical study. The patient scheduled to undergo excision of intracranial meningioma were randomly assigned to receive intraoperatively either intravenous TXA or placebo. Patients in the TXA group received intravenous bolus of 20 mg/kg over 20 min followed by an infusion of 1 mg/kg/h up to surgical wound closure. Efficacy was evaluated based on total blood loss and transfusion requirements. Postoperatively, thrombotic complications, convulsive seizure, and hematoma formation were noted. Results: Ninety-one patients were enrolled and randomized: 45 received TXA (TXA group) and 46 received placebo (group placebo). Total blood loss was significantly decreased in TXA group compared to placebo (283 ml vs. 576 ml; P < 0.001). Transfusion requirements were comparable in the two groups (P = 0.95). The incidence of thrombotic complications, convulsive seizure, and hematoma formation was similar in the two groups. Conclusion: TXA significantly reduces intraoperative blood loss, but did not significantly reduced transfusion requirements in adults undergoing resection of intracranial meningioma.
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Affiliation(s)
- Lotfi Rebai
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Nahed Mahfoudhi
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Nizar Fitouhi
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Mohamed Aziz Daghmouri
- Department of Anesthesiology and Critical Care Ben Arous, University of Tunis El Manar, Tunisia
| | - Kamel Bahri
- Department of Neurosurgery, Traumatology and Severe Burns Center, Ben Arous, University of Tunis El Manar, Tunisia
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