Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty

Tranexamic Acid Is Safe in Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty

BACKGROUND

Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not.

METHODS

Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders.

RESULTS

The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001).

CONCLUSIONS

TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients.

LEVEL OF EVIDENCE

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

A comparison of accuracy and safety between stem-first and cup-first total hip arthroplasty: a prospective randomised controlled trial

BACKGROUND

The combined anteversion theory to prevent impingement in total hip arthroplasty (THA) has been proposed. However, because stem-anteversion is influenced by the native femoral anteversion and the stem flexion/extension angle, it is often difficult to adjust stem anteversion during surgery. Therefore, the stem-first (combined anteversion) technique may be useful to adjust and achieve appropriate cup anteversion during surgery with respect to the implanted stem anteversion angle. However, the technique may adversely affect cup or stem angle accuracy and result in intra-operative bleeding, post-operative adverse events, and prolonged operative time. It is inconclusive whether either the stem-first or cup-first technique is safe or accurate. Therefore, this study assessed the accuracy and safety of stem-first THA compared to those of cup-first THA.

MATERIALS AND METHODS

This prospective randomised controlled trial analysed 114 patients who were randomly divided into 2 groups (stem-first group: n = 57, cup-first group (control group): n = 57). Primary outcomes included cup and stem angle, the discrepancies from the targeted angle and combined anteversion (evaluated via CT at 3 months postoperatively). Secondary outcomes included intraoperative blood loss, operative time, WOMAC, and adverse events.

RESULTS

There were no significant differences in age, gender, BMI or in the primary and secondary outcomes between the 2 groups.

CONCLUSIONS

Performing stem-first in THA did not adversely affect cup and stem angle accuracy, or result in intraoperative bleeding, prolongation of operative time, or postoperative adverse events. Thus, performing stem-first may be advantageous for achieving combined anteversion theory.

TRIAL REGISTRATION

University Hospital Medical Information Network (UMIN) registration number UMIN000025189.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Is Tranexamic Acid Safe and Efficacious in Hip Surgeries?

Background

The incidence of hip fractures is increasing in the current population. It is estimated by the year 2050 around 6.3 million hip fractures may occur per year. Management of hip fractures and replacement surgeries might be associated with substantial blood loss which leads to perioperative anemia. Tranexamic acid is an antifibrinolytic agent that has evidence of reducing blood loss during arthroplasty surgeries. This study aims to evaluate the efficacy and safety of tranexamic acid in patients undergoing hip surgeries.

Materials and methods

This is a cross-sectional study of the patients during the period of May 2020 to April 2021. Forty-eight patients who underwent hip surgery during this period were taken up for the study. Patients were divided into the following groups: group T (n=24) and group P (n=24). Group T received tranexamic acid 10 mg/kg intravenously, as a bolus slowly, 30 minutes prior to skin incision and 1 mg/kg/h intravenous infusion till the closure of skin incision. Group P received normal saline 0.1 ml/kg intravenously, as a bolus slowly, 30 minutes prior to skin incision, and then 1 ml/kg/h intravenous infusion till the skin closure. The primary outcome measured was the total blood loss using Gross and Nadel formulaand the secondary outcomes measured were packed red blood cell (PRBC) transfusion requirement, length of hospital stay, drop-in hematocrit value, ambulation time, and incidence of any other adverse event between the two groups.

Results

The total blood loss in group T patients was 474.12 (± 90.35) ml and in group P was 647.41 (± 114.58) ml, the p-value was <0.001 which was statistically significant. The overall PRBC transfusion rate was 75% (18 patients) in group P and 37.5% (nine patients) in group T with a p-value of 0.020. Nine (37.5%) patients included in group T began to ambulate within 24 hours of surgery while six patients in group P were ambulated within 24 hours with a p-value of <0.001.

Conclusion

Preoperative infusion of tranexamic acid is effective in reducing intraoperative blood loss and blood transfusion requirement rates. It is also safe and efficacious in patients undergoing hip surgeries.

Paget's Disease in Primary Total Hip Arthroplasty Is Associated With Greater In-Hospital Lengths of Stay, Costs, and Complications

BACKGROUND

There are few well-powered studies investigating the association of Paget's disease of bone on patients undergoing primary total hip arthroplasty (THA). This study utilized a nationwide database to determine whether Paget's patients undergoing primary THA are associated with higher rates of (1) lengths of stay (LOS); (2) costs; and (3) complications (medical/surgical and implant-related).

METHODS

Using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes, Paget's patients undergoing primary THA were identified and matched to non-Paget's patients in a 1:5 ratio by age, sex, and comorbidities utilizing the PearlDiver database. This resulted in 21,714 patients in Paget's (n = 3619) and non-Paget's (n = 18,095) cohorts. Outcomes assessed included LOS, episode-of-care costs, medical/surgical complications, and implant-related complications. A P value less than .003 was considered statistically significant.

RESULTS

Compared to the matched cohort, Paget's patients undergoing primary THA had significantly longer LOS (P < .0001), higher 90-day total global episode-of-care costs (P < .0001), higher 90-day medical and surgical complications (P < .0001), and higher implant-related complications (P < .0001).

CONCLUSION

We found that Paget's was associated with higher rates of LOS, costs, and complications. Although there was an association found, the risk appears reasonably low compared to the matched cohort. The study can be utilized by orthopedic professionals to counsel and educate these patients of potential complications which may occur following their procedure.

Changes in patient-perceived leg length discrepancy following total hip arthroplasty

PURPOSE

Leg length discrepancy (LLD) after total hip arthroplasty (THA) prevents functional recovery and reduces patient satisfaction. We investigated impact of changes in patient-perceived LLD on patient satisfaction and walking ability.

METHODS

one hundred and forty-nine patients with unilateral hip osteoarthritis undergoing THA from 2014 to 2017, (125 women, 24 men; average age, 68.5 years) with an objective LLD < 1 cm were included. Outcome measures included the patient-perceived LLD, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, 10-m walking speed, and affected leg loading rate, assessed preoperatively and at 3 weeks, 3 months, and 1 year postoperatively.

RESULTS

The absolute patient-perceived LLD (mean ± SD) (the number of patients with perceived LLD > 5 mm) were 6.4 ± 9.6 mm [88 patients (59%)] preoperatively; and 2.2 ± 4.0 mm [48 (32%); p < 0.001], 0.7 ± 2.3 mm [17 (11%); p < 0.001], and 0.4 ± 1.6 mm [10 (7%); p = 0.095] at 3 weeks, 3 months, and 1 year postoperatively, respectively. All outcome measures improved over time. One year postoperatively, a weak positive correlation between the patient-perceived LLD and WOMAC or 10-m walking speed (r = 0.24, 0.23, respectively) was found. The risk of patient-perceived LLD persisting > 1 year postoperatively was 5.5-fold higher in patients who exhibited it at 3 months and those with a WOMAC score > 10 at 3 months postoperatively, using multivariate logistic regression.

CONCLUSION

Achieving a post-THA objective LLD < 1 cm significantly reduced the patient-perceived LLD up to 3 months postoperatively. The residual patient-perceived LLD at 1 year postoperatively was predicted from the WOMAC score or the presence of patient-perceived LLD at 3 months after THA.

LEVEL OF EVIDENCE

Therapeutic level IV.

Intravenous tranexamic acid is associated with safe reduced blood loss and transfusion rate in one-stage exchange for infected hip arthroplasty

Objectives

This study aims to investigate if the use of intravenous (IV) tranexamic acid (TXA) during one-stage exchange for periprosthetic joint infection (PJI) of the hip that necessitates an extensive debridement is associated with decreased blood loss, if the rate of blood transfusion that may lead to side effects can be lowered with IV TXA, and if there is any difference regarding the occurrence of postoperative venous thromboembolism (VTE).

Patients and methods

We retrospectively reviewed patients who underwent one-stage exchange for PJI of the hip with perioperative IV administration of TXA (n=163; 90 males, 73 females; mean age 68±10.3; range, 25 to 90 years) between January 2015 and December 2016 and compared them to another group (n=190; 106 males, 84 females; mean age 71±10.1; range, 39 to 92 years) who underwent one-stage exchange for PJI of the hip without perioperative IV administration of TXA between January 2006 and December 2012. Blood loss, transfusion rates, amount of transfused blood, and occurrence of VTE complications were observed.

Results

Mean blood loss of the TXA group was significantly lower than that of the non-TXA group (2.4 L and 4.5 L, respectively; p<0.001). Patients in non-TXA group experienced significantly higher rate of blood transfusion (71.1% and 58.3%, respectively; p=0.014) and higher quantity of transfused packed red blood cells (3.2 and 1.9 units, respectively; p<0.001). There was one patient with VTE complication in each group.

Conclusion

Even in the presence of infection, usage of IV TXA during one-stage exchange for PJI of the hip is associated with significantly lower blood loss and transfusion rates showing no higher risk of VTE events.

Effectiveness of tranexamic acid in reducing blood loss in cervical laminoplasty: A retrospective observational study

Background:

Tranexamic acid (TXA) has been proved effective in reducing perioperative blood loss in patients undergoing orthopedic operations. However, given the heterogeneity in the diagnoses and spinal operations, there are only limited studies comparing patients with uniform diagnoses and procedures performed.

Methods:

A comparative observational control study was performed on 62 patients with cervical myelopathy. They were divided into control (32) and TXA (30) groups according to whether they had received TXA before and during surgery. Cervical laminoplasty from C3 to C6/7 was performed for all patients using a consistent procedure. Preoperative and postoperative hematological data and perioperative blood loss were compared.

Results:

There were no statistically significant differences between the two groups in terms of age, gender, body mass index, and operating time. The TXA group had significantly less intraoperative (310 ± 215 ml vs. 144 ± 90 ml, p < 0.05) and postoperative blood loss than the control group (150 ± 50 ml vs. 249 ± 94 ml, p < 0.01). The drop of hemoglobin (Hb) level in the TXA group was also significantly lower (0.5 ± 0.42 g/dl vs. 2.1 ± 1.03 g/dl, p < 0.01). No thromboembolic complications found.

Conclusion:

TXA significantly reduced perioperative blood loss and reduced drop of postoperative Hb level in cervical laminoplasty.

Factors associated with blood loss in ankylosing spondylitis patients with hip involvement undergoing primary total hip arthroplasty: a cross-sectional retrospective study of 243 patients

Background

Total hip arthroplasty (THA) can cause considerable blood loss and perioperative transfusion in ankylosing spondylitis (AS) patients. This study aimed to identify the factors related to blood loss in AS patients with hip involvement undergoing THA.

Methods

We analyzed 243 AS patients with advanced hip involvement undergoing primary THA from 2012 to 2017. Bilateral THA was performed by a one-stage operation during one general anesthesia session. The patients were divided into three groups according to the grade of blood loss, as determined by the Advanced Trauma Life Support hypovolemic shock classification system. Ordinal logistic regression was used to identify factors associated with blood loss in the patients.

Results

The proportion of patients who were male, underwent bilateral THA, had a hip range of motion (ROM) = 0°, had a BASRI-hip score of 4, underwent iliopsoas and adductor release, and underwent autologous or allogenic transfusion increased significantly with the grade of blood loss, while that of the patients who received tranexamic acid (TXA) decreased significantly (P < 0.05). The preoperative hemoglobin (Hb) level, hematocrit level, and operating time also increased significantly with the grade of blood loss (P < 0.05). The ordinal logistic regression results identified the factors related to blood loss during THA in AS patients with hip involvement to be the male sex (odds ratio [OR] = 3.287; 95% confidence interval [CI] 1.022, 10.567), bilateral THA (OR = 13.896; 95% CI 4.950, 39.011), hip ROM = 0° (OR = 2.513; 95% CI 1.277, 4.946), an elevated erythrocyte sedimentation rate (ESR) level (OR = 3.042; 95% CI 1.320, 7.014), an elevated preoperative Hb level (OR = 1.043; 95% CI 1.017, 1.070), a long operating time (OR = 1.009; 95% CI 1.003, 1.016), and the administration of TXA (OR = 0.252; 95% CI 0.134, 0.472).

Conclusions

The male sex, bilateral THA, a hip ROM = 0°, an elevated ESR level, a high preoperative Hb level, and a long operating time are risk factors associated with blood loss in AS patients with hip involvement undergoing THA, while the administration of TXA is a protective factor. These results might help determine the risk of bleeding in the perioperative assessment and develop more efficient blood management strategies for THA in AS patients with hip involvement.

Transfusion rates with intravenous tranexamic acid in total hip arthroplasty performed using the direct anterior approach

INTRODUCTION

Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing total hip arthroplasty (THA). Most studies have focused on TXA in THA performed using a posterior approach (PA) or lateral approach. The aim of this study was to analyse the efficacy of TXA in patients undergoing THA using the direct anterior approach (DAA).

PATIENTS AND METHODS

Using our institutional database, a retrospective analysis was conducted on consecutive primary THA performed for osteoarthritis to determine transfusion rates in patients undergoing THA with the DAA with and without TXA.

RESULTS

146 consecutive THA were performed using DAA: 83 (56.8%) patients had TXA and 63 (43.2%) did not have TXA. Among patients who had TXA, 1 patient required a blood transfusion compared to 7 patients among those who did not have TXA (1.2% vs. 11.12%, p = 0.02). The relative risk of 0.11 (95% confidence interval 0.01-0.86) indicates an 89% reduction in the risk of requiring blood transfusion with TXA administration compared to no TXA.

CONCLUSION

TXA is effective in reducing blood transfusion requirements for patients undergoing DAA THA.

Intravenous tranexamic acid safely and effectively reduces transfusion rates in revision total hip arthroplasty

AIMS

Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA.

PATIENTS AND METHODS

We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery.

RESULTS

Tranexamic acid significantly and substantially reduced the rate of blood transfusions after revision THA overall from 54% to 26% (p < 0.001; adjusted relative risk (RR) 1.6; 95% confidence interval (CI) 1.3 to 1.9), with a significant reduction in both aseptic (49% to 18%; p < 0.001) and septic (73% to 53%; p = 0.04) revisions. The rate of VTE was minimal overall, with three events (0.3%) in the TXA group and four events (0.2%) in the non-TXA group. There were no significant differences in VTE rates based on TXA use or aetiology of revision.

CONCLUSION

Intravenous TXA significantly reduced transfusion rates during all-cause revision THAs, including a subgroup analysis of both aseptic and septic cohorts. Adjusted risk using propensity modelling showed no statistical difference in rates of VTEs between either group. Cite this article: Bone Joint J 2019;100-B(6 Supple B):104-109.

Short-term safety of tranexamic acid use in posterior cervical decompression and fusion surgery

Posterior cervical decompression and fusion (PCDF) can result in substantial blood loss, leading to blood transfusions and associated complications, such as infections, hypotension and organ damage. The antifibrinolytic tranexamic acid (TXA), an inhibitor of the activation of plasminogen, has been shown to be beneficial in multiple surgical procedures without any apparent increase in postoperative complications. However, there are only few studies reporting TXA utilization in cervical spine surgery and there is currently no literature detailing the short-term safety of its use in this setting. The purpose of our study is to determine the safety profile of TXA in posterior cervical decompression and fusion. From January 2015 to April 2018, 47 patients were identified to have undergone PCDF, 19 with the utilization of a TXA protocol at our institution. The incidence of adverse events was evaluated in the perioperative period and at 1 month follow-up. Of 39 patients, Nineteen (49%) received TXA as per our instructional protocol and 20 (51%) did not. Post-operative blood was significantly reduced (453 ml vs 701 ml; p = 0.03) in the group that received TXA. There was also a significant reduction in duration of surgery associated with TXA use (269 min vs 328 min; p = 0.05). There were no complications on the first 30 days after surgical intervention on the TXA group. TXA use during PCDF is a safe, effective method to reduce postoperative blood loss. Considering the limited number of patients in this study, these results should be validated on a larger group of patients.

Effect of periarticular morphine injection for total hip arthroplasty: a randomised, double-blind trial

BACKGROUND

The periarticular multimodal cocktail injection is currently commonly used to treat postoperative pain after total hip arthroplasty (THA). Despite its analgesic effect, it is frequently reported to cause nausea and vomiting, which are adverse effects of opioids. This study aimed to assess the efficacy of morphine as a component of a multimodal cocktail injection for providing postoperative analgesia and alleviating swelling in patients who underwent THA.

MATERIALS AND METHODS

This was a prospective, single-centre, randomised controlled trial involving 100 patients scheduled for unilateral THA. A mixture of steroids, local anaesthetics, NSAIDs, and epinephrine with or without morphine (0.1 mg/kg), was injected into randomly assigned patients. Postoperative assessment was performed with all attending personnel and patients blind to group assignment. Visual analogue scale (VAS) of pain, range of motion (ROM), nausea numerical rating scale (NRS), the total dose of antiemetic drugs used and thigh swelling were compared between groups on postoperative days.

RESULTS

Pain VAS scores both at rest and on motion did not differ between the 2 groups at any postoperative time-point. The nausea NRS scores during the postoperative period from 0 minutes to 1 hour and the total dose of antiemetic drugs administered were significantly higher in the morphine group. The thigh girth showed no difference between groups on any of the postoperative days.

CONCLUSIONS

The results of this study suggested that addition of morphine to the multimodal cocktail injection after THA is not effective for relieving postoperative pain, alleviating swelling, or improving ROM, and results in nausea and vomiting. Randomised controlled trial registration number UMIN000022668.

Perioperative intravenous tranexamic acid reduces blood transfusion in primary cementless total hip arthroplasty

Background and aim of the work: Blood loss and transfusion requirements are common in total hip arthroplasty. Tranexamic acid is one of the most interesting options to reduce the need for blood transfusions in a variety of surgical settings. The aim of this study was to assess the efficacy of perioperative intravenous traxexamic acid regarding blood transfusion rate and volume of transfused blood without increasing adverse events after primary elective cementless total hip arthroplasty. Methods: A comparative retrospective study was conducted in 86 healthy patients who had undergone primary cementless total hip artrhoplasty for severe joint diseases at a single institution. All surgical procedures were performed through an anterolateral Watson-Jones approach with the patient in supine position. Forty patients (TXA group) received tranexamic acid 1g as an intravenous bolus 10 minutes before skin incision and a further 1 g, diluted in 250 mL of saline solution, in continuous perfusion at 30 mL/h, following commencement of the surgery. Forty-six patients (control group) did not receive TXA. Outcome measures included BT rate, volume of transfused blood, deep vein thrombosis and occurrence of pulmonary embolism. Results: BT rate was significantly less for the TXA group (37.5%) compared with the control group (65%; p=0.011). The mean blood volume transfused was also significantly less for the TXA group (240 mL) compared with the control group (450 mL; p=0.009). No adverse events occurred in any group. Conclusions: Perioperative intravenous tranexamic acid is effective in reducing blood transfusion rate and volume of transfused blood, without increasing the risk of thromboembolic events in patients undergoing primary cementless total hip arthroplasty. (www.actabiomedica.it)

Tranexamic Acid Prophylaxis in Hip and Knee Joint Replacement

BACKGROUND

The antifibrinolytic agent tranexamic acid (TXA) is widely used for the prevention and treatment of hyperfibrinolytic states, such as in severe polytrauma. It can also be used for the systemic prevention of hemorrhage in elective orthopedic procedures. In this review, we assess the efficacy and risks of the prophylactic administration of tranexamic acid before major endoprosthetic surgery of the hip and knee.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in the PubMed and Cochrane Library databases.

RESULTS

Endoprosthetic surgery of the hip and knee is often associated with perioperative blood losses exceeding 500 mL. The prophylactic administration of tranexamic acid immediately before such procedures has been shown in randomized, controlled trials to lessen the quantity of intra- and postoperative bleeding and to reduce the likelihood of blood transfusion (number needed to treat [NNT] 3.7-5.7 for knee replacement and 4.1-8.2 for hip replacement). The rate of thromboembolic events did not differ significantly from the rate in the placebo groups. No reliable data are available on the frequency of epileptic seizures as a complication of TXA use in knee and hip endoprosthetic surgery. On the basis of data from other types of surgery, one may reasonably conclude that the doses of TXA used for knee and hip endoprosthetic procedures are unlikely to cause this problem.

CONCLUSION

The prophylactic intravenous administration of tranexamic acid lessens the amount of bleeding in endoprosthetic knee and hip procedures and reduces the likelihood of blood transfusion. According to the current state of the evidence, complications are rare. Nonetheless, consideration of the risks and benefits implies that tranexamic acid should not be given for this purpose to patients who have recently had urogenital bleeding, pulmonary embolism, or a myocardial infarction, who have recently undergone percutaneous transluminal coronary angioplasty or stenting, or who are known to have epilepsy.

When Should Complete Blood Count Tests Be Performed in Primary Total Hip Arthroplasty Patients?

BACKGROUND

Routine laboratory studies are often obtained following total hip arthroplasty (THA). Moreover, laboratory studies are often continued daily until the patient is discharged regardless of medical management. The purpose of this study was to investigate the use of routine complete blood count (CBC) tests following THA. Secondarily, the purpose was to identify patient factors associated with abnormal postoperative lab values.

METHODS

This retrospective review identified 352 patients who underwent primary THA at a single institution from 2012 to 2014. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were used to identify factors associated with an abnormal postoperative lab and risk of transfusion.

RESULTS

Of the 352 patients, 54 patients were transfused (15.3%). Patients who underwent transfusion had a significantly lower preoperative hemoglobin (Hb; 12.0 g/dL) compared to patients who did not undergo transfusion (13.5 g/dL; P < .001). Patients who did not receive TXA were 3.7 times more likely to receive a transfusion. No patients received medical intervention based on the outcome of postoperative platelet or white blood counts. A Hb value below 11.94 g/dL for patients who are anemic preoperative or did not receive TXA predicted transfusion after postoperative day 1.

CONCLUSION

Under value-based care models, cost containment while maintaining high-quality patient care is critical. Routine postoperative CBC tests in patients with a normal preoperative Hb who receive TXA do not contribute to actionable information. Patients who are anemic before THA or do not receive TXA should at minimum obtain a CBC on postoperative day 1.

Assessment of the effect of addition of 24 hours of oral tranexamic acid post-operatively to a single intraoperative intravenous dose of tranexamic acid on calculated blood loss following primary hip and knee arthroplasty (TRAC-24): a study protocol for a randomised controlled trial

BACKGROUND

While it is has been proven that tranexamic acid (TXA) reduces blood loss in primary total hip and knee arthroplasty (THA and TKA), there is little published evidence on the use of TXA beyond 3 h post-operatively. Most blood loss occurs after wound closure and the primary aim of this study is to determine if the use of oral TXA post-operatively for up to 24 h will reduce calculated blood loss at 48 h beyond an intra-operative intravenous bolus alone following primary THA and TKA. To date, most TXA studies have excluded patients with a history of thromboembolic disease.

METHODS/DESIGN

This is a phase IV, single-centred, open-label, parallel-group, randomised controlled trial. Participants are randomised to one of three groups: group 1, an intravenous (IV) bolus of TXA peri-operatively plus oral TXA post-operatively for 24 h; group 2, an IV bolus of TXA peri-operatively or group 3, standard care (no TXA). Eligible participants, including those with a history of thromboembolic disease, are allocated to these groups with a 2:2:1 allocation ratio. The primary outcome is the indirectly calculated blood loss 48 h after surgery. Researchers and patients are not blinded to the treatment; however, staff processing blood samples are. Originally 1166 participants were required to complete this study, 583 THA and 583 TKA. However, following an interim analysis after 100 THA and 100 TKA participants had been recruited to the study, the data monitoring ethics committee recommended stopping group 3 (standard care).

DISCUSSION

TRAC-24 will help to determine whether an extended TXA dosing regimen can further reduce blood loss following primary THA and TKA. By including patients with a history of thromboembolic disease, this study will add to our understanding of the safety profile of TXA in this clinical situation.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN58790500 . Registered on 3 June 2016, EudraCT: 2015-002661-36.

One Dose of Intravenous Tranexamic Acid Is Equivalent to Two Doses in Total Hip and Knee Arthroplasty

BACKGROUND

Tranexamic acid (TXA) helps to prevent excessive blood loss during total hip arthroplasty (THA) and total knee arthroplasty (TKA), but the most efficacious dosing protocol has not been ascertained. The purpose of this study was to identify whether 1 dose of intravenous TXA is equivalent to 2 doses for reducing blood loss and transfusion rates following THA and TKA without an increase in complications.

METHODS

We identified 1,736 patients who underwent THA (592 who did not receive TXA, 454 who received 1 dose of TXA, and 690 who received 2 doses) and 2,042 patients who underwent TKA (744 who did not receive TXA, 499 who received 1 dose, and 799 who received 2 doses) from 2012 to 2016. The differences among groups with regard to the change in hemoglobin levels, rate of allogeneic blood transfusions, and rate of complications were assessed.

RESULTS

Patients who underwent THA and received 1 dose or 2 doses of TXA had similar drops in the mean hemoglobin levels postoperatively (2.9 g/dL and 3.1 g/dL, respectively; p = 0.197) and both had a smaller drop than the control group (3.6 g/dL; p < 0.001 compared with the 1 and 2-dose groups). These findings were confirmed by a multivariate analysis that controlled for age, sex, and preoperative hemoglobin level. Transfusion was required for 12.5% of the patients who underwent THA without receiving TXA, no patient who received 1 dose, and 0.7% of the patients who received 2 doses. The patients who underwent TKA and received 1 dose or 2 doses of TXA had similar mean drops in the hemoglobin level postoperatively (2.4 g/dL and 2.4 g/dL, respectively; p = 0.891), and both had less of a drop than the control group (2.9 g/dL; p < 0.001 compared with the 1 and 2-dose groups). These findings were also confirmed by a multivariate analysis that controlled for age, sex, and preoperative hemoglobin level. Transfusion was required for 4.3% of the patients who underwent TKA without receiving TXA, 0.4% of those who received 1 dose, and 0.3% of those who received 2 doses. Similar rates of perioperative complications occurred among all groups.

CONCLUSIONS

One dose of TXA was as effective as 2 doses for decreasing blood loss and transfusion rates after THA and TKA without an increase in complications.

LEVEL OF EVIDENCE

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

The effect of tranexamic acid on hidden bleeding in older intertrochanteric fracture patients treated with PFNA

OBJECTIVE

To investigate the effect of tranexamic acid (TXA) on hidden bleeding in older intertrochanteric fracture patients treated with intramedullary nails.

METHOD

Between January 2016 and January 2017, 100 cases of intertrochanteric fractures eligible for the study were treated with proximal femoral nail antirotation (PFNA) in our hospital. All patients were divided into two groups of 50 patients each: the TXA group and a blank control group. In the TXA group, all patients received TXA at a dose of 10 mg/kg^-1 intravenously, 10 min preoperatively and 5 h postoperatively. The control group did not receive TXA. We recorded the volume of intraoperative blood loss and postoperative drainage, and the need for postoperative blood transfusion and transfusion volume for all patients. Blood routine examination was performed on the day of surgery and 2 days postoperatively. We calculated the total blood loss and hidden blood loss in the two groups separately according to the Gross equation. All patients underwent deep vein ultrasound of the lower limbs preoperatively and 1 week postoperatively to detect thrombosis.

RESULTS

Compared with controls, patients in the TXA group had lower: overt bleeding (50.59 ml; p = .012), total blood loss (181.58 ml; p = .005), hidden blood loss (130.64 ml; p = .037), volume of blood transfusion (110.0 ml; p = .019), and 20% lower transfusion rate compared with the control group. Patients receiving short-nail fixation had significantly lower hidden blood loss compared with patients receiving long-nail fixation (p < .05). However, we found no statistically significant difference in the incidence of deep vein thrombosis in the lower limbs between the two groups (p = .938).

CONCLUSION

TXA significantly reduced hidden blood loss in older intertrochanteric fracture patients treated with intramedullary nails without an increased risk of thrombosis in lower limb deep veins.

Effect of knee flexion position and combined application of tranexamic acid on blood loss following primary total knee arthroplasty: a prospective randomized controlled trial

PURPOSE

The aim of this study was to demonstrate the association between tranexamic acid (TXA)-combined application and knee flexion in the first 24 hour post-operatively that could reduce total blood loss and transfusion need in patients undergoing total knee arthroplasty (TKA), without sacrificing safety.

METHODS

Ninety TKA patients were divided into three groups randomly: the flexion group: the knee was in 90° flexion position for the first 12 hour post-surgery and kept at 60°for the next 12 hour, combined with 1 g TXA topical and 1 g TXA intravenous application. The extension group: the knee was in fully extension position post-operatively, combined with topical and intravenous TXA application. The controlled group: the knee was in fully extension position post-operatively combined with single intravenous TXA application. The primary outcomes included blood loss variables and transfusion values. The secondary outcomes included post-operative hospital stay, knee flexion degree, complication rate, and hospital charge.

RESULTS

The total blood loss and transfusion needs in the flexion group were significantly reduced in comparison with that in the extension group and controlled group. The post-operative knee flexion motion was significant higher in the flexion group than the other two groups. There was no difference among the three groups with regard to the rates of complications.

CONCLUSIONS

Keeping the knee in flexion position combined with topical and intravenous TXA application in patients undergoing primary unilateral TKA significantly reduced post-operative bleeding and the transfusion rate compared with what was found after treatment with extension knee position or single intravenous TXA application.

LEVEL OF EVIDENCE

Therapeutic Level I.

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

Background

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

Methods

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

Results

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

Conclusion

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

Influence of single-dose intravenous tranexamic acid on total hip replacement : A study on transfusions, collateral complications, and readmissions

INTRODUCTION

To determine the effects of tranexamic acid (TXA) on transfusions in patients undergoing hip replacement with a hybrid or cementless prosthesis.

METHODS

A group of 172 consecutive patients aged 18 years or older who underwent elective hip replacement with uncemented or hybrid prostheses, undergoing surgery between January 2012 and January 2014 by the same primary surgeon and anesthesiologist, were retrospectively included. TXA (1 g) was administered immediately before incision in the TXA group. Primary variables included number of red blood cell transfusions and the influence of TXA for each type of prosthesis. Secondary variables included hematocrit at discharge, length of hospital stay, thrombosis or pulmonary embolism, seizures, and death.

RESULTS

Average transfusion was 1.53 units/patient in the control group compared to 0.6 units/patient in the TXA group (z = 6.29; U = 1640.5; p < 0.0001). TXA use was significantly correlated with the number of units transfused (p < 0.0001, 95% CI -1.24 to -0.68). Odds risk reduction for transfusion was observed during surgery (OR: 0.14; CI 0.06-0.29; p < 0.0001) and during the rest of hospital stay (OR: 0.11; CI 0.01-0.96; p = 0.046). Both hybrid and cementless prostheses that received TXA were transfused less than control groups (0.57 ± 1 vs. 1.7 ± 1 p < 0.01 and 0.65 ± 1 vs. 1.24 ± 1 p < 0.01). No difference was observed between the groups regarding adverse effects. Hematocrit values at discharge and length of hospital stay were similar between groups. No deaths were observed during hospital stay.

CONCLUSIONS

TXA reduced transfusions without increasing the prevalence of adverse effects. This reduction was observed during surgery and the following days of hospital stay for both for hybrid and cementless prosthesis.

Oral and Intravenous Tranexamic Acid Are Equivalent at Reducing Blood Loss Following Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss and the need for transfusions when administered intravenously in total hip arthroplasty. Oral formulations of the drug are available at a fraction of the cost of the intravenous preparation. The purpose of this randomized controlled trial was to determine if oral and intravenous formulations of tranexamic acid have equivalent blood-sparing properties.

METHODS

In this double-blinded trial, 89 patients undergoing primary total hip arthroplasty were randomized to receive 1.95 g of tranexamic acid orally 2 hours preoperatively or a 1-g tranexamic acid intravenous bolus in the operating room prior to incision; 6 patients were eventually excluded for protocol deviations, leaving 83 patients available for study. The primary outcome was the reduction of hemoglobin concentration. Power analysis determined that 28 patients were required in each group with a ±1.0 g/dL hemoglobin equivalence margin between groups with an alpha of 5% and a power of 80%. Equivalence analysis was performed with a two one-sided test (TOST) in which a p value of <0.05 indicated equivalence between treatments.

RESULTS

Forty-three patients received intravenous tranexamic acid, and 40 patients received oral tranexamic acid. Patient demographic characteristics were similar between groups, suggesting successful randomization. The mean reduction of hemoglobin was similar between oral and intravenous groups (3.67 g/dL compared with 3.53 g/dL; p = 0.0008, equivalence). Similarly, the mean total blood loss was equivalent between oral and intravenous administration (1,339 mL compared with 1,301 mL; p = 0.034, equivalence). Three patients (7.5%) in the oral group and one patient (2.3%) in the intravenous group were transfused, but the difference was not significant (p = 0.35). None of the patients in either group experienced a thromboembolic event.

CONCLUSIONS

Oral tranexamic acid provides equivalent reductions in blood loss in the setting of primary total hip arthroplasty, at a greatly reduced cost, compared with the intravenous formulation.

LEVEL OF EVIDENCE

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

Intravenous Combined with Topical Administration of Tranexamic Acid in Primary Total Hip Arthroplasty: A Randomized Controlled Trial

OBJECTIVE

Although there are still some controversies, large previous studies have confirmed that intravenous (i.v.) tranexamic acid (TXA) can effectively reduce blood loss and transfusions in total hip arthroplasty (THA) without increasing the risk of deep venous thrombosis. However, few studies have investigated the combination of i.v. and topical application of TXA in primary THA. The purpose of our current study is to examine whether i.v. combined with topical administration of TXA decreases postoperative blood loss and transfusion rates after THA.

METHODS

From December 2013 to May 2014, all adult patients undergoing primary THA at our arthroplasty center were considered for inclusion in the present study. Included patients were randomly assigned to two groups by computer-generated list number: a TXA group and a placebo group. Patients in the TXA group received i.v. (15 mg/kg) combined with topical administration (1.0 g) of TXA during the THA procedure, and patients in the other group received the same dosage of normal saline both i.v. and topically. Our primary outcome measures were total blood loss (calculated using Gross's equation), hemoglobin, hematocrit and platelet concentration changes on the third postoperative day, the amount of drainage, the amount of intraoperative blood loss, the frequency of transfusion, and the number of blood units transfused. Secondary outcome measures were the length of postoperative stay, range of hip motion (measured by goniometer), Harris hip scores (HHS), and any perioperative complications or events such as infection, DVT or PE. Range of motion and HHS were measured at 3 week follow-up and compared with preoperative values.

RESULTS

This trial included 100 patients (50 in each group). Patients in the TXA group had significantly higher postoperative hemoglobin (103 vs 87.7 g/dL, P < 0.01), lower hemoglobin changes (32.2 vs 44.9 g/dL, P < 0.01), higher postoperative hematocrit (0.32 vs 0.27 L/L, P < 0.01), lower hematocrit changes (0.1 vs 0.14 L/L, P < 0.01), lower total blood loss (822 vs 1100 mL, P = 0.004), lower drainage (117.8 vs 242.4 mL, P < 0.01), lower intraoperative blood loss (193.8 vs 288.2 mL, P < 0.01), and lower transfusion rate (2% vs 34%, P < 0.01) compared with those in the placebo group. No statistical difference was found in postoperative platelets between the two groups. There were no differences in perioperative complications or venous thromboembolism (VTE) events.

CONCLUSIONS

The combined administration of i.v. and topical TXA resulted in a clinically relevant reduction in blood loss, compared with placebo group. No thromboembolic complications were observed. This randomized controlled trial supports the combined i.v. and topical administration of TXA in primary THA.

Safety, Efficacy, and Cost-effectiveness of Tranexamic Acid in Orthopedic Surgery

Perioperative bleeding and postsurgical hemorrhage are common in invasive surgical procedures, including orthopedic surgery. Tranexamic acid (TXA) is a pharmacologic agent that acts through an antifibrinolytic mechanism to stabilize formed clots and reduce active bleeding. It has been used successfully in orthopedics to reduce perioperative blood loss, particularly in total hip and knee arthroplasty and spine surgery. Numerous research studies have reported favorable safety and efficacy in orthopedic cases, although there is no universal standard on its administration and its use has not yet become the standard of practice. Reported administration methods often depend on the surgeon's preference, with both topical and intravenous routes showing efficacy. The type and anatomic site of the surgery seem to influence the decision making but also result in conflicting opinions. Reported complication rates with TXA use are low. The incidence of both arterial and venous thromboembolic events, particularly deep venous thrombosis and pulmonary embolism, has not been found to be significantly different with TXA use for healthy patients. The route of administration and dosage do not appear to affect complication rates either. However, data on patients with higher-risk conditions are deficient. In addition, TXA has shown potential to reduce blood loss, transfusion rates and volumes, perioperative hemoglobin change, and hospital-related costs at various degrees among the published studies. Conservation of blood products, reduced laboratory costs, and shorter hospital stays are likely the major factors driving the cost savings associated with TXA use. This article reviews current data supporting the safety, efficacy, and cost-effectiveness of TXA in orthopedic surgery.

Meta-analysis of Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty

Previous meta-analyses established that tranexamic acid confers benefits when used during total hip arthroplasty (THA). However, 2 of these meta-analyses included a variety of routes of administration of tranexamic acid in THA (topical, intravenous, oral, and intra-articular), another meta-analysis included a variety of antifibrinolytic drugs (not restricted to a single drug), and the final meta-analysis included nonrandomized controlled trials. This meta-analysis focused on a single medication, tranexamic acid, administered in a specific way, intravenously in patients undergoing primary THA, using data reported only in randomized controlled studies. Outcomes were restricted to blood loss, allogeneic transfusion rates, and complications. Other outcomes, such as return to function or clinical scores, could not be evaluated because of lack of consistent reporting. To better understand the effects of intravenous tranexamic acid in THA on clinical outcomes, such as recovery, return to function, and patient-reported outcome measures, it would be helpful to have more controlled trials examining these measures in a standardized manner. Intravenous tranexamic acid was beneficial for blood loss intraoperatively, blood loss through drains, and total blood loss during hospitalization, in addition to reducing allogeneic transfusion rates. No difference between intravenous tranexamic acid and placebo was found for most complications, except deep venous thrombosis, which showed favorable results with placebo. [Orthopedics.2016; 39(5):e883-e892.].

Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial of Intravenous Combined with Topical Versus Single-Dose Intravenous Administration

BACKGROUND

The use of tranexamic acid (TXA) in primary total hip arthroplasty is well documented. However, considering the potential side effects, including deep vein thrombosis and pulmonary embolism, the ideal method of providing TXA to patients undergoing total hip arthroplasty remains controversial. The objective of this trial was to assess the efficacy and safety of intravenous (IV) administration combined with topical administration of TXA regarding postoperative blood loss and transfusion rates in patients treated with primary unilateral total hip arthroplasty.

METHODS

In this prospective, randomized controlled trial, 150 patients were divided into three groups: the combined group (IV administration of 15 mg/kg of TXA combined with topical administration of 1 g/100 mL of TXA), the single IV group (IV administration of 15 mg/kg of TXA), and the placebo group. The primary outcomes included blood-loss variables (total, intraoperative, and drainage blood loss; changes in hemoglobin, hematocrit, and platelet concentration; and amount of IV transfusion fluid) and transfusion values (frequency of transfusion and number of transfused blood units). The secondary outcomes included the length of the hospital stay, range of hip motion, Harris hip score, and prevalences of deep vein thrombosis and pulmonary embolism.

RESULTS

The total blood loss in the combined group (mean and standard deviation, 835.49 ± 343.50 mL) was significantly reduced (p < 0.05) in comparison with that in the single IV group (1002.62 ± 366.85 mL) and placebo group (1221.11 ± 386.25 mL). The combined group also had fewer transfusions in comparison with the single IV and placebo groups (1, 8, and 19, respectively; p < 0.05). There was no difference among the 3 groups with regard to the rates of deep vein thrombosis or pulmonary embolism.

CONCLUSIONS

Intravenous combined with topical administration of TXA in patients undergoing a primary unilateral total hip arthroplasty significantly reduced postoperative bleeding and the transfusion rate. Studies with more patients and longer follow-up are needed to confirm whether this promising combined strategy is safe with regard to thromboembolic complications.

LEVEL OF EVIDENCE

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

Does Surgical Approach Affect Patient-reported Function After Primary THA?

BACKGROUND

Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach.

QUESTIONS/PURPOSES

We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA?

METHODS

Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques.

RESULTS

After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events.

CONCLUSIONS

With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Single-dose tranexamic acid for reducing bleeding and transfusions in total hip arthroplasty: A double-blind, randomized controlled trial of different doses

BACKGROUND

Tranexamic acid can be effective at decreasing blood loss and transfusion requirements associated with total hip arthroplasty (THA), but few studies have compared the efficacy of different intravenous dosing regimes. This double-blind, randomized controlled trial compared the ability of two doses of intravenous TXA (IV-TXA, 10 or 15mg/kg) to reduce bleeding and transfusions associated with THA.

MATERIALS AND METHODS

A total of 124 patients scheduled for THA were consecutively randomized 1:1:1 into three parallel arms: control (placebo), 10mg/kg IV-TXA and 15mg/kg IV-TXA.

RESULTS

The proportion of patients who experienced bleeding and required transfusions was significantly lower in the 15mg/kg IV-TXA group (1 of 42, 2.4%) than in the 10mg/kg IV-TXA group (8 of 39, 20.5%; P=0.012) and in the control group (10 of 38, 26.3%; P=0.002). In fact, this proportion was similar between the 10mg/kg IV-TXA and control groups (P=0.547). Ultrasound examination on postoperative day 3 revealed only one case of asymptomatic deep vein thrombosis (in the femoral vein) in the 10mg/kg IV-TXA group, which was managed by administering low-molecular-weight heparin. No cases of deep-vein thrombosis were observed in the other two groups. No cases of symptomatic pulmonary embolism were observed.

CONCLUSION

IV-TXA at 10mg/kg significantly reduced blood loss and mitigated the decrease in hemoglobin and hematocrit after THA, but it did not significantly reduce the need for transfusions. In contrast, a dose of 15mg/kg reduced both bleeding and transfusion requirements. Our results argue for a dose of 15mg/kg when using single-dose IV-TXA.

LEVEL OF EVIDENCE

Therapeutic Level I.

Tranexamic acid

Aims

This study investigated whether the use of tranexamic acid (TXA) decreased blood loss and transfusion related cost following surface replacement arthroplasty (SRA).

Methods

A retrospective review of patients treated with TXA during a SRA, who did not receive autologous blood (TXA group) was performed. Two comparison groups were established; the first group comprised of patients who donated their own blood pre-operatively (auto group) and the second of patients who did not donate blood pre-operatively (control). Outcomes included transfusions, post-operative haemoglobin (Hgb), complications, and length of post-operative stay.

Results

Between 2009 and 2013, 150 patients undergoing SRA were identified for inclusion: 51 in the auto, 49 in the control, and 50 in the TXA group. There were no differences in the pre-operative Hgb concentrations between groups. The mean post-operative Hgb was 11.3 g/dL (9.1 to 13.6) in the auto and TXA groups, and 10.6 g/dL (8.1 to 12.1)in the control group (p = 0.001). Accounting for cost of transfusions, administration of TXA, and length of stay, the cost per patient was $1731, $339, and $185 for the auto, control and TXA groups, respectively.

Discussion

TXA use demonstrated higher post-operative Hgb concentrations when compared with controls and decreased peri-operative costs. Take home message: Tranexamic acid safely limits allogeneic transfusion, maintains post-operative haemoglobin, and decreases direct and indirect transfusion related costs in surface replacement arthroplasty. Cite this article: Bone Joint J 2016;98-B:173–8.

Tranexamic Acid Benefits Total Joint Arthroplasty Patients Regardless of Preoperative Hemoglobin Value

While tranexamic acid (TXA) reduces transfusion in total joint arthroplasty (TJA), it remains unclear whether there is a preoperative hemoglobin (Hgb) threshold above which it is no longer beneficial. 2100 primary TJA patients were retrospectively categorized by preoperative Hgb; 1161 (55%) received TXA. Transfusion rates decreased with TXA in all groups; with Hgb>15 the transfusion rate was 0.5% with TXA and 4.5% without (P=0.0086); with Hgb>11 the transfusion rate was 4.7% with TXA and 18.7% without (P<0.0001). Patients receiving TXA had a shorter LOS by 0.51 days (P<0.0001). Patients receiving a postoperative transfusion had a longer LOS by 0.69 days (P<0.0001). TXA should be considered in all TJA patients independent of preoperative Hgb level.

Tranexamic Acid in Hip and Knee Arthroplasty

Perioperative blood loss is a significant concern for patients undergoing total joint arthroplasty. A growing body of evidence has shown tranexamic acid (TXA) to be effective in decreasing perioperative blood loss and transfusion requirements in both primary and revision hip and knee arthroplasty. TXA is a synthetic drug that limits blood loss through inhibition of fibrinolysis and clot degradation. Both topical and intravenous administration of TXA, in a variety of dosing regimens, has proven effective. Further investigation is required to determine the optimal dose and dosing regimens; however, evidence exists to recommend an initial intravenous dose be given before beginning the procedure, with at least one additional intravenous dose administered postoperatively. Additionally, topical TXA doses >2 g appear to be more efficacious than lower doses. Finally, relatively few adverse reactions have been reported in arthroplasty patients, and no study to date has demonstrated an increased risk of symptomatic venous thromboembolic events in this patient population.

Topical tranexamic Acid does not affect electrophysiologic or neurovascular sciatic nerve markers in an animal model

BACKGROUND

Tranexamic acid is a safe and effective antifibrinolytic agent used systemically and topically to reduce blood loss and transfusion rate in patients having TKA or THA. As the hip does not have a defined capsule, topical application of tranexamic acid may entirely envelop the sciatic nerve during THA. Accidental application of tranexamic acid onto the spinal cord in spinal anesthesia has been shown to produce seizures; therefore, we sought to investigate if topical application of tranexamic acid on the sciatic nerve has a deleterious effect.

QUESTIONS/PURPOSES

We explored whether there were any short- or long-term alterations in (1) electrophysiologic measures, (2) macrophage recruitment, or (3) blood-nerve barrier permeability. Our hypothesis was that local application of tranexamic acid would have a transient effect or no effect on histologic features and function of the sciatic nerve.

METHODS

We used a rat protocol to model sciatic nerve exposure in THA to determine the effects of tranexamic acid on neural histologic features and function. We evaluated 35 rats by the dorsal gluteal splitting approach to expose the sciatic nerve for topical use of control and tranexamic acid. We evaluated EMG changes (distal latency, amplitude, nerve conduction velocity), histologic signs of nerve injury via macrophage recruitment, and changes in blood-nerve barrier permeability at early (4 days) and late (1 month) times after surgery, after application of subtherapeutic (1 mg/kg body weight [1.6 mg]), therapeutic (10 mg/kg [16 mg]), and supratherapeutic (100 mg/kg [160 mg]) concentrations of tranexamic acid. Differences in blood-nerve barrier permeability, macrophage recruitment, and EMG between normal and tranexamic acid-treated nerves were calculated using one-way ANOVA, with Newman-Keuls post hoc analyses, at each time. A post hoc power calculation showed that with the numbers available, we had 16% power to detect a 50% difference in EMG changes between the control, 1 mg/kg group, 10 mg/kg group, and 100 mg/kg group.

RESULTS

At the early and late times, with the numbers available, there were no differences in EMG except for distal latency at 4 days, macrophage recruitment, or changes in blood-nerve barrier between control rats and those with tranexamic acid-treated nerves. The distal latency in the 1 mg tranexamic acid-treated animals at 4 days was 1.06 ± 0.15 ms (p = 0.0036 versus all other groups, 95% CI, 0.89-1.25), whereas the distal latencies in the control, the 10 mg/kg, and 100 mg/kg tranexamic acid-treated animals were 0.83 ± 0.11, 0.89 ± 0.05, and 0.87 ± 0.13, respectively. Distal latencies were not increased in any of the groups at 1 month with the numbers available (0.81 ± 0.10, 0.89 ± 0.03, 0.81 ± 0.06, and 0.83 ± 0.08 ms, respectively, for controls; 1 mg/kg, 10 mg/kg, and 100 mg/kg for the tranexamic acid-treated groups).

CONCLUSION

In our in vivo rat model study, tranexamic acid did not appear to have any clinically relevant effect on the sciatic nerve resulting from topical administration up to 1 month. However, because our statistical power was low, these data should be considered hypothesis-generating pilot data for larger, more-definitive studies.

CLINICAL RELEVANCE

Topical tranexamic acid is effective in decreasing patient blood loss during THA, and results from our in vivo rat model study suggest there may be no electrophysiologic and histologic effects on the sciatic nerve, with the numbers available, up to 1 month.

Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty

TKA and THA are associated with blood transfusion and risk for postoperative venothromboembolism (VTE). Reports show that tranexamic acid (TA) may be safe to use in high-risk orthopedic patients, but further data are needed to substantiate its use. All patients who underwent primary or revision TKA or THA in a five year period were retrospectively identified. In 13,262 elective TKA or THA procedures, neither the odds of VTE (OR=0.98; 95% CI 0.67-1.45; P=0.939) or adjusted odds of death (OR=0.26; 95% CI 0.04-1.80; P=0.171) were significant with TA administration. The major findings of this large, single center, retrospective cohort study show the odds of postoperative VTE and 30-day mortality were unchanged with TA administration.

Evaluation of the efficacy and safety of tranexamic acid for reducing blood loss in bilateral total knee arthroplasty

Tranexamic acid (TA) has been reported to reduce blood loss after total joint arthroplasty; however, the literature is sparse in evaluating its efficacy in simultaneous bilateral total knee arthroplasty (TKA). In this retrospective study of consecutive patients, TA use in bilateral TKA was associated with a significant reduction in perioperative serum hemoglobin drop, as well as allogeneic blood transfusion needs from 50% to 11% of patients. No autologous blood donation or drains were used. There were no venous thromboembolic events reported. Implementation of a systematic intravenous TA protocol in simultaneous bilateral TKA appears highly effective in reducing transfusion requirements, potentially reducing healthcare resource utilization as well as the morbidity and complications associated with allogeneic blood transfusions.

The effect of tranexamic acid on transfusion rate in primary total hip arthroplasty

Total hip arthroplasty (THA) may produce blood loss requiring allogenic blood transfusion. Recently several authors have reported success decreasing their transfusion rate with tranexamic acid (TXA). We retrospectively reviewed our last 1595 primary THA in 1494 patients looking at whether the patients received TXA via IV infusion, topical application, or neither, and the need for a blood transfusion. Infusion of TXA acid produced a statistically significant difference in transfusion rate (p<0.001) while topical TXA failed to reach statistical significance (P=0.15). The transfusion rate without TXA was 19.86%, 4.39% with TXA infusion (odds ratio=5.36), and 12.86% (odds ratio=1.67) with topical TXA.

Preliminary results suggest tranexamic acid is safe and effective in arthroplasty patients with severe comorbidities

BACKGROUND

Tranexamic acid (TXA) reduces blood loss and transfusion after total joint arthroplasty (TJA) but concerns remain that patients with severe medical comorbidities might be at increased risk for thromboembolic complications.

QUESTIONS/PURPOSES

Among patients undergoing primary TJA with severe systemic medical disease, (1) was TXA associated with increased symptomatic thromboembolic events; (2) was TXA associated with decreased blood transfusion rates; and (3) were there differences in symptomatic thromboembolism or transfusions in the subset of patients with a history of, or risk factors for; thromboembolic disease?

METHODS

We performed a retrospective review of 1131 primary TJAs in 1002 patients with American Society of Anesthesiologists score III or IV. Of these, 402 had at least one of seven risk factors for thromboembolic events and were designated as high risk; 240 of those patients received TXA. Outcome measures included 30-day postoperative symptomatic thromboembolic events and postoperative transfusion.

RESULTS

There were no differences in symptomatic thromboembolic events within 30 days of surgery between patients who received TXA and those who did not (2.5% versus 2.6%, p = 0.97). Fewer patients treated with TXA received transfusions (11% with versus 41% without; p < 0.0001). In high-risk patients, TXA was not associated with an increase in symptomatic thromboembolic events (6.7% with versus 4.3% without; p = 0.27) and was associated with a decrease in transfusion rates (17% with versus 48% without; p = 0.001).

CONCLUSIONS

Although TXA seemed safe and effective in this database review of patients with severe medical comorbidities, a larger prospective trial is warranted to confirm these results.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement: a randomized controlled trial (TRANX-H)

BACKGROUND

Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid.

METHODS

A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications.

RESULTS

Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p &lt; 0.0001), the length of stay by 1.0 days (95% CI, -0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months.

CONCLUSIONS

Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration.

LEVEL OF EVIDENCE

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

[Tranexamic acid in orthopedic surgery]

Perioperative bleeding may require blood transfusions, which are sometimes not without complications and risks, with the subsequent increase in health care costs. Among other prevention methods, treatment with tranexamic acid (ATX) has shown to be effective in reducing surgical blood loss, especially in the immediate postoperative period. In this regard, studies evaluating ATX in orthopedic surgery show that it is effective and safe when administered intravenously or intra-articularly. The usual evaluated intravenous doses range between 10mg/Kg and 20mg/kg or a fixed dose of 1g to 2g; while intra-articularly, it varies between 250 mg and 3g. ATX, as an anti-fibrinolytic has a potential thrombotic effect, thus it is contraindicated in those patients at risk or with a history of thrombosis. Its topical administration may be safer, but studies are needed to confirm this.

Economic impact of tranexamic acid in healthy patients undergoing primary total hip and knee arthroplasty

Tranexamic acid (TA) has been shown to reduce perioperative blood loss and blood transfusion. While concern remains about the cost of antifibrinolytic medication, we hypothesized that routine use of tranexamic acid would result in lower direct hospital total cost by decreasing costs associated with blood transfusion, laboratory testing, and room & board. Patients with an American Society of Anesthesiologists (ASA) class II or less undergoing primary total hip or knee arthroplasty at a single institution during 2007-2008 were retrospectively reviewed. The estimated mean direct hospital total cost, operating room, blood/lab, room & board, and pharmacy costs were compared between patients who did and did not receive TA. The study population included 1018 patients, and 580 patients received TA. The mean direct total cost of hospitalization with and without TA was $15,099 and $15,978 (P<.0002) respectively, a difference of $879. The only increased cost associated with TA was the pharmacy cost which was $921 versus $781 (P<.0001). The routine use of tranexamic acid TA was associated with lower mean direct hospital total costs after primary total hip and knee arthroplasty as the increase in pharmacy costs was more than offset by cost savings in other categories.

Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss

Background

Tranexamic acid (TXA) reduces blood transfusion in surgery but the extent of the reduction in blood loss and how it relates to the dose of TXA is unclear.

Methods

A systematic review of randomized trials was performed. Data were extracted on blood loss from trials comparing intravenous TXA with no TXA or placebo in surgical patients. A Bayesian linear regression was used to describe the relationship between the reduction in blood loss with TXA and the extent of bleeding as measured by the mean blood loss in the control group. A meta-analysis of the log-transformed data was conducted to quantify the effect of TXA on blood loss, stratified by type of surgery, timing of TXA administration and trial quality. Meta-regression was used to explore the effect of TXA dosage.

Results

Data from 104 trials were examined. Although the absolute reduction in blood loss with TXA increased as surgical bleeding increased, the percentage reduction was similar. TXA reduced blood loss by 34 per cent (pooled ratio 0·66, 95 per cent confidence interval 0·65 to 0·67; P &lt; 0·001). The percentage reduction in blood loss with TXA differed by type of surgery, timing of TXA administration and trial quality, but the differences were small. The effect of TXA on blood loss did not vary over the range of doses assessed (5·5–300 mg/kg).

Conclusion

TXA reduces blood loss in surgical patients by about one-third. A total dose of 1 g appears to be sufficient for most adults. There is no evidence to support the use of high doses.

The effect of tranexamic acid in blood loss and transfusion volume in adolescent idiopathic scoliosis surgery: a single-surgeon experience

PURPOSE

Intraoperative blood loss in scoliosis surgery often requires transfusions. Autogenous blood decreases but does not eliminate risks typically associated with allogenic blood transfusion. Costs associated with transfusions are significant. Tranexamic acid (TXA) has been shown to decrease blood loss in cardiac and joint surgery. Few studies have examined its use in pediatric spine surgery, and the results are inconsistent. The aim of this study was to determine whether TXA decreases intraoperative blood loss and transfusion requirements in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion by a single surgeon.

METHODS

The medical records and operative reports of surgically treated patients with adolescent idiopathic scoliosis between 2000 and 2009 were retrospectively reviewed. The inclusion criteria were: (1) patients who underwent instrumented posterior spinal fusion, (2) had complete medical records, and (3) were treated by the same surgeon. Forty-nine patients who met the inclusion criteria were divided into two groups: Group A (25 patients) received TXA, while Group B (24 patients) did not receive TXA.

RESULTS

After controlling for age at the time of surgery, gender, and number of vertebral levels fused, the mean intraoperative blood loss was significantly lower in Group A (537 ml) than in Group B (1,245 ml) (p = 0.027). The mean volume of blood transfused intraoperatively was 426 and 740 ml for Group A and Group B, respectively. The difference was not statistically significant after controlling for age, gender, and number of levels fused (p = 0.078).

CONCLUSION

TXA significantly decreased intraoperative blood loss in posterior spinal fusions performed for adolescent idiopathic scoliosis.

Role of tranexamic acid in reducing postoperative blood loss and transfusion requirement in patients undergoing hip and femoral surgeries

CONTEXT

Pharmacological agents are used to reduce postoperative blood loss.

AIMS

To assess the effects of tranexamic acid on prevention of bleeding and requirement of blood transfusion after major hip and femoral surgeries.

SETTINGS AND DESIGN

A prospective, randomized, double blinded study was conducted in the tertiary care teaching hospital.

METHODS

Ninety ASA grade I-II patients undergoing hip fracture surgery were included in this prospective study. Forty-five patients received tranexamic acid (TA) given in a bolus dose of 500 mg 15 min before surgical incision followed by continuous infusion. The remaining, 45 patients were allocated as a control group. Postoperative bleeding (volume of blood in the drain), percentage fall of hemoglobin, transfusions and complications were recorded.

RESULTS

Mean volume of blood in the drain was 39.33±10.09 ml (mean±SD) as compared to 91.11±17.61 ml in placebo group showing a P<0.001. Mean percentage fall in Hb at day 0 was 2.99±3.45 in the study group as compared to 7.70±6.05 in the placebo group (P<0.001), and fall at day 2 in the study group was 0.35±0.74, compared to 2.72±2.70 in the placebo group (P<0.001). The number of patients required blood transfusions were lower in the study group than in the placebo group (P=0.01).

CONCLUSIONS

We conclude that tranexamic acid significantly reduces postoperative blood loss and transfusion requirements during major hip and femoral surgeries.

Tranexamic acid reduces postoperative blood loss of degenerative lumbar instability with stenosis in posterior approach lumbar surgery: a randomized controlled trial

STUDY DESIGN

This study is randomized controlled trial.

PURPOSE

To evaluate the effect of tranexamic acid (TXA) on reducing postoperative blood loss in posterior approach lumbar surgery for degenerative lumbar instability with stenosis.

METHODS

Sixty patients with degenerative lumbar instability with stenosis were randomized into TXA and control groups, receiving 15 mg/kg body weight of TXA or placebo (0.9 % Sodium chloride solution) intravenously, respectively, before the skin incision was made. The operation of pedicle screw system fixation was performed for all patients, and then selective laminectomy and posterior lumbar interbody fusion (PLIF) were carried out. Intraoperative and postoperative blood loss were compared between the two groups. And the complication of TXA was also investigated.

RESULTS

There were no statistically significant differences between the TXA and control groups in terms of age, sex, body mass index, and operation time. There was no significantly difference in intraoperative blood loss between the two groups. However, in the TXA group, postoperative blood loss was significantly lower than that in the control group (13.0 %). Especially, postoperative blood loss during the first 12 h was reduced by 29.9 % as compared to the control group. There were no thromboembolic events or other complications occurred in either group.

CONCLUSIONS

Preoperative single-dose TXA can significantly reduce postoperative blood loss in posterior approach lumbar surgery, and there were no significant side effects.

The effect of bolus administration of tranexamic acid in revision hip arthroplasty

We assessed the efficacy of tranexamic acid in reducing transfusion requirements in patients undergoing revision hip arthroplasty. A prospective cohort study was designed comparing Tranexamic acid administration in 30 patients compared to 30 patients in a control group. Blood loss was measured in theatre, pre- and postoperative haemoglobin measurements were recorded and postoperative haemodynamic parameters were evaluated. The mean postoperative haemoglobin was 9.5 g/dl in the tranexamic acid group and 8.2 g/dl in the control group (p<0.01). The mean haemoglobin reduction was 2.7 g/dl in the tranexamic acid group and 3.4 g/dl in the control group (p = 0.47). Mean transfusion requirements were 2.76 units in the study group and 4.0 units in the control group (p = 0.49) and the frequency of transfusion was reduced (p = 0.032). Infected revisions showed no reduction in transfusion requirements with tranexamic acid administration (p = 0.25). There was a reduced frequency of transfusion in patients when revision was performed for aseptic loosening (p = 0.027). This group of patients may benefit from tranexamic acid administration.

Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial

BACKGROUND

Postoperatively shed blood salvage is commonly used to reduce allogenic blood transfusion in patients undergoing total hip (THA) and knee arthroplasty (TKA). Autologous blood retransfusion is not devoid of risk. We hypothesized that adding tranexamic acid (TXA) to a restrictive blood transfusion protocol would reduce the need for postoperative autologous blood retransfusion in primary knee and hip arthroplasty.

STUDY DESIGN AND METHODS

Ninety-eight adult patients undergoing primary THA or TKA were randomly assigned to receive an intraoperative intravenous loading dose of 1.0 g of TXA followed by another 1.0-g dose 3 hours later (TXA group) or a matching volume 0.9% saline placebo (control group). A postoperatively shed autologous blood recovery system was used in all patients and the minimum reinfusion volume set at 250 mL. Red blood cells were transfused if hemoglobin level was less than 8 or if 8 to 10 g/dL with symptoms of anemia.

RESULTS

The proportion of patients receiving autologous blood reinfusion was significantly lower in the TXA group (5/49) compared to placebo (42/49) with an absolute difference of -75.5% (adjusted relative risk, 0.005), and none of the patients in the TXA group received more than 400 mL retransfused. Median total external blood loss during the first 24 hours was lower in the TXA group, 320 mL (range, 80-930 mL), compared to 970 mL (range, 100-2600 mL) in the placebo group (p < 0.001). There were no significant differences in homologous blood transfusions and hematologic variables between groups. Treatment differences were consistent by size and significance when the analysis was repeated separately in patients undergoing TKA or THA.

CONCLUSION

Addition of TXA to a restrictive transfusion protocol makes the use of a postoperative blood salvage system in patients undergoing primary hip and knee arthroplasty unnecessary.