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

The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion

PURPOSE

This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion.

METHODS

A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model.

RESULTS

Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis.

CONCLUSION

Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.

A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery.

METHODS

We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT).

RESULTS

We found that the use of TXA statistically significantly reduced total perioperative blood loss (P=0.04) and postoperative drain output (P=0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative (P=0.02) and postoperative (P<0.01) blood loss.

CONCLUSIONS

This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors.

LEVEL OF EVIDENCE

Level III.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis

BACKGROUND

Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care.

OBJECTIVES

To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology.

SEARCH METHODS

We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received.

MAIN RESULTS

We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials).

AUTHORS' CONCLUSIONS

We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.

Risk Factors for Prolonged Hospital Stay After Femoral Neck Fracture

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64-98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211-217.].

Local Versus Systemic Tranexamic Acid in Total Hip Arthroplasty in Young Adults

Background Total hip arthroplasty (THA) is the most successful orthopedic elective surgical procedure for end-stage hip arthritis. THA is linked with significant blood loss, ranging from 1,188 to 1,651 mL, and a transfusion rate of 16-37%, which frequently results in postoperative blood transfusions. Postoperative blood transfusions can be avoided by using autologous blood transfusion, intraoperative blood saving, local anesthetic, hypotensive anesthesia, and antifibrinolytic medications such as tranexamic acid (TXA) administration. Methodology A double-blinded, placebo-controlled, randomized, controlled study was conducted with three prospective groups to investigate the efficacy of topical and systemic routes of a single intraoperative dose (1.5 g) of TXA. Patients were recruited from our center between October 2021 to March 2022 who were undergoing primary total hip replacement. Estimated blood loss was calculated and compared in groups, and a p-value of <0.05 was taken as significant. Results A total of 60 patients were recruited in our study. Estimated blood loss was similar in both treatment groups, 816.8 ± 219.9 mL in the systemic TXA group and 775.5 ± 107.2 mL in the topical TXA group. The placebo group had 1,066.3 ± 150.4 mL estimated blood loss, which was significantly higher compared to the treatment groups. Conclusions Administration of TXA (1.5 g) significantly lowers blood loss without increasing problems, which can eliminate concerns about intravenous TXA use. TXA reduces blood loss by 270 mL on average.

The optimal regimen, efficacy and safety of tranexamic acid and aminocaproic acid to reduce bleeding for patients after total hip arthroplasty: A systematic review and Bayesian network meta-analysis

OBJECTIVES

We aimed to evaluate the optimal regimen, efficacy and safety of tranexamic acid (TXA) and aminocaproic acid (EACA) for patients after total hip arthroplasty (THA).

METHODS

The network meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. The outcomes were total blood loss, transfusion rates, hemoglobin (HB) drop, and risk for pulmonary embolism (PE) or deep vein thrombosis (DVT). Subgroup analyses were performed among most effective regimens to determine the influences of timing and number of doses.

RESULTS

A total of 56 eligible RCTs with different regimens were assessed. For reducing total blood loss, all high doses of TXA and EACA except high dose of intra-articular (IA) TXA, as well as medium dose of combination of intravenous and intra-articular (combined IV/IA) TXA were most effective. All high doses of TXA, as well as medium dose of combined IV/IA TXA did not show inferiority in reducing transfusion rates and HB drop compared with other regimens. No regimens showed higher risk for PE or DVT compared with placebo, and no statistical differences were seen among most effective regimens in subgroup analyses.

CONCLUSIONS

As effective as high doses of EACA and TXA, medium dose (20-40 mg/kg or 1.5-3.0 g) of combined IV/IA TXA was enough to control bleeding for patients after THA without increasing risk for PE/DVT. TXA was at least 5 times more potent than EACA. Timing and number of doses had few influences on blood conserving efficacy.

LEVEL OF EVIDENCE

Level I.

Quality of life and cost-effectiveness analysis of topical tranexamic acid and fibrin glue in femur fracture surgery

Background

We assessed quality of life (QoL) of patients undergoing surgery for proximal femur fracture and performed a cost-effectiveness analysis of haemostatic drugs for reducing postoperative bleeding.

Methods

We analysed data from an open, multicentre, parallel, randomized controlled clinical trial (RCT) that assessed the efficacy and safety of tranexamic acid (TXA group) and fibrin glue (FG group) administered topically prior to surgical closure, compared with usual haemostasis methods (control group).

For this study we conducted a cost-effectiveness analysis of these interventions from the Spanish Health System perspective, using a time horizon of 12 months. The cost was reported in $US purchasing power parity (USPPP). We calculated the incremental cost-effectiveness ratio (ICER) per QALY (quality-adjusted life-year).

Results

We included 134 consecutive patients from February 2013 to March 2015: 42 patients in the TXA group, 46 in the FG group, and 46 in the control group. Before the fracture, EuroQol visual analogue scale (EQ-VAS) health questionnaire score was 68.6. During the 12 months post-surgery, the intragroup EQ-VAS improved, but without reaching pre-fracture values.

There were no differences between groups for EQ-VAS and EuroQol 5 dimensions 5 levels (EQ-5D-5L) health questionnaire score, nor in hospital stay costs or medical complication costs. Nevertheless, the cost of one FG treatment was significantly higher (399.1 $USPPP) than the cost of TXA (12.9 $USPPP) or usual haemostasis (0 $USPPP).

When comparing the cost-effectiveness of the interventions, FG was ruled out by simple dominance since it was more costly (13,314.7 $USPPP) than TXA (13,295.2 $USPPP) and less effective (utilities of 0.0532 vs. 0.0734, respectively). TXA compared to usual haemostasis had an ICER of 15,289.6 $USPPP per QALY).

Conclusions

There were no significant differences between the intervention groups in terms of postoperative changes in QoL. However, topical TXA was more cost-effective than FG or usual haemostasis.

Trial registration

ClinicalTrials.gov: NCT02150720. Date of registration 30/05/2014. Retrospectively registered.

Tranexamic acid reduces blood loss in primary total hip arthroplasty performed using the direct anterior approach: a one-center retrospective observational study

BACKGROUND

It is still unknown whether tranexamic acid (TXA) is beneficial for the minimally invasive surgical approach to total hip arthroplasty (THA). The aim of this study is to investigate the efficacy and safety of intravenous TXA in primary THA via the direct anterior approach (DAA).

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data on 70 patients with nontraumatic avascular necrosis of the femoral head who underwent THA via the DAA between October 2017 and October 2018. Patients were divided into two groups: TXA group (39 patients received 1.5 g TXA intravenously) and control group (31 patients did not receive TXA). Patients were assessed by operative time, postoperative hemoglobin (HB) drop, transfusion rate, postoperative length of hospital stays (LHS), deep vein thrombosis (DVT), and Harris hip score (HHS).

RESULTS

Total blood loss, hidden blood loss, and postoperative HB drop in the TXA group were significantly lower than in the control group (p < 0.05). There was no statistical difference between the two groups in terms of intraoperative blood loss, operative time, transfusion rate, postoperative LHS, HHS, or incidence of DVT (p > 0.05).

CONCLUSIONS

TXA may reduce perioperative blood loss without increasing complications in THA via the DAA.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

O papel do ácido tranexâmico na prevenção e gerenciamento da perda de sangue na artroplastia total de articulação

Objective  To collect data on the role played by tranexamic acid in the prevention and management of blood loss in patients undergoing total hip arthroplasty and total knee arthroplasty.

Methods  In the present prospective, comparative study, 30 patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) were randomly allocated into 1 of 2 groups with 15 patients each. Tranexamic acid was administered by intravenous and topical routes in the study group, but it was not administered in the control group. Preoperative blood parameters, intraoperative and postoperative blood loss, and need for blood transfusion were noted. Statistical analysis was performed using the chi-squared test and the independent t -test.

Results  The study group had statistically significant higher postoperative hemoglobin values ( p  = 0.03), less difference between pre and postoperative hemoglobin value ( p  = 0.046), less difference between pre and postoperative packed-cell volume ( p  = 0.06), less intraoperative measured blood loss ( p  = 0.015), and less volume of blood collected in the drain ( p  = 0.0291) compared with the control group. There was also reduced frequency of blood transfusions in the study group ( p  = 0.0008).

Conclusion  Tranexamic acid is associated with reduced intra and postoperative blood loss and reduced frequency of blood transfusions in patients undergoing THA/TKA.

Tranexamic acid is associated with decreased transfusion, hospital length of stay, and hospital cost in simultaneous bilateral total knee arthroplasty

Tranexamic acid (TXA) reduces blood loss and transfusion rates in unilateral total knee arthroplasty (TKA), but there is limited data regarding its efficacy in bilateral TKA. This study reports the impact TXA has on clinical outcomes and hospital cost of care in simultaneous, primary bilateral TKA. The 449 patients were retrospectively reviewed. Primary outcomes included the rates of allogeneic and autologous blood transfusion. Secondary outcomes included hospital length of stay (HLOS), post-hospital discharge disposition, 30-day thromboembolic events (TEE), and mean hospital cost of care. Total direct medical costs were obtained from an institutional research database and adjusted to nationally representative unit costs in 2013 inflation-adjusted dollars. Our study revealed that in patients undergoing simultaneous bilateral TKA, TXA use was associated with reduced allogeneic (OR 0.181, 95% CI 0.090-0.366, p < 0.001) and combined allogeneic and autologous transfusion rates (OR 0.451, 95% CI 0.235-0.865, p = 0.017). TXA was associated with a HLOS reduction of 0.9 days (β-coefficient −0.582, 95% CI −1.008-−0.156, p = 0.008), an increased likelihood of hospital discharge over skilled nursing facility (SNF) (OR 2.25, 95% CI 1.117-4.531, p = 0.023) and reduced total hospital cost of care by 6.45% (p < 0.001), room and board costs by 11.76% (p < 0.001), and transfusion costs by 81.65% (p < 0.001). In conclusion, TXA use in bilateral TKA is associated with lower blood transfusion rates, reduced hospital length of stay, reduced cost of hospital care and skilled nursing facility avoidance.

Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty

AIMS

The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA.

METHODS

This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo).

RESULTS

Mean total blood loss (TBL) in groups A (605.0 ml (SD 235.9)), B (790.9 ml (SD 280.7)), and C (844.8 ml (SD 248.1)) were lower than in group D (1,064.9 ml (SD 318.3), p < 0.001). We also found that compared with group D, biomarker level of inflammation, transfusion rate, pain score, and hip range of motion at discharge in groups A, B, and C were significantly improved. There were no differences among the four groups in terms of intraoperative blood loss (IBL), intramuscular venous thrombosis (IMVT), and length of hospital stay (LOS).

CONCLUSION

The combined application of CSS and TXA is more effective than TXA alone in reducing perioperative blood loss and transfusion rates, inflammatory response, and postoperative hip pain, results in better early hip flexion following THA, and did not increase the associated venous thromboembolism (VTE) events. Intravenous combined with topical injection of CSS was superior to intravenous or topical injection of CSS alone in reducing perioperative blood loss. Cite this article: Bone Joint Res 2021;10(6):354-362.

The Fragility of Statistically Significant Findings From Randomized Controlled Trials in Hip and Knee Arthroplasty

BACKGROUND

The Fragility Index (FI) is a method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs) beyond the P value in trials with dichotomous outcomes. The FI is defined as the number of patients in one arm of a trial that would have to have a different outcome to change the results of the trial from statistically significant to nonsignificant. This review assessed the FI in arthroplasty RCTs.

METHODS

A systematic search was conducted in MEDLINE, Embase, and Web of Science for RCTs related to primary total joint arthroplasty (TJA) from 2010 to 2020. Trials with a statistically significant dichotomous primary outcome were included. The FI was calculated using Fisher's exact test to determine how many events would need to be reversed to change a study from statistically significant to nonsignificant.

RESULTS

A total of 34 RCTs were included. The median sample size was 103 patients (range 24-791). The median FI was 1 (range 0-45), meaning that reversing the outcome of just one patient in either treatment group of each trial would change it from a significant to a nonsignificant result.

CONCLUSION

Hip and knee arthroplasty RCTs with statistically significant dichotomous outcomes in TJA are fragile. The median FI in TJA is lower than the FI in any of the other previously reported orthopedic subspecialties. Fragility is another reason to be cautious when conducting or interpreting small trials, and to continue to strive toward large trials to answer important questions in TJA.

LEVEL OF EVIDENCE

Level I.

Tranexamic acid lowers transfusion requirements and hospital length of stay following revision total hip or knee arthroplasty

Backgroud

Intravenous tranexamic acid (TXA) has been shown to reduce blood loss in patients undergoing total joint arthroplasty without systemic complications. There is limited evidence of its effectiveness in revision procedures. This study evaluated intravenous TXA effect on blood loss, transfusion rates, and length of hospital stay in revision joint replacement.

Methods

One-hundred revision total joint arthroplasty patients were retrospectively reviewed [44 revision total hip arthroplasty (THA) and 54 revision total knee arthroplasty (TKA)] who underwent surgery from 2013 to 2016. Fifty-four revision joint patients (23 THA and 31 TKA) received intravenous TXA intra-operatively, while 46 revision joint patients (23 THA/TKA) did not. Primary outcome measures were blood loss, transfusion rates, and length of hospital stay.

Results

The mean blood loss difference between revision THA patients who received TXA vs. not receiving TXA was 180ml in revision THA patients (p < .005). Mean length of hospital stay was 6 days in non-TXA vs. 3 days in TXA patients (p < .001). Eighteen patients received transfusions in the non-TXA revision TKA group compared to nine patients in the TXA revision TKA group (p < .001). Average length of hospital stay was 5 days in the non-TXA revision TKA group compared to 3 days in the TXA revision TKA group (p < .003). There was no increased risk of thromboembolic complications in TXA groups for either procedure.

Conclusions

Intravenous TXA reduced length of hospital stay in both revision cohorts, decreased blood loss in revision THA and decreased the rate of transfusion in revision TKA without an increase in thromboembolic complications.

Level of Evidence

Level III (Case-control study)

Impact of tranexamic acid on blood loss and transfusion rate in children with cerebral palsy undergoing hip reconstruction with two or more osteotomies

PURPOSE

Tranexamic acid (TXA), a synthetic lysine analogue, has been used in orthopedic procedures to limit blood loss and prevent allogeneic blood transfusions. However, data are scarce on its use in hip reconstruction of patients with cerebral palsy (CP). This study examines the effect of TXA on patients with CP undergoing hip reconstruction with at least two osteotomies.

METHODS

This is a single-center, retrospective study of patients with CP who underwent hip reconstruction with two or more osteotomies from January 2013 to April 2019. There were 43 patients, with a mean age of 9.9 years. Age, procedure, preoperative and postoperative hemoglobin/hematocrit, estimated blood loss (EBL), transfusions and length of stay were recorded. The patients were split into the following two groups: 24 patients who had received intraoperative TXA and 19 who had not.

RESULTS

Age, EBL, mean preoperative and postoperative hemoglobin or hematocrit, preoperative to postoperative hematocrit drop, and length of stay were similar for the two groups (p > 0.05). The risk for intraoperative transfusion (21 vs. 17%), postoperative transfusion (26 vs. 8%), and any transfusion (42 vs. 21%) appeared to be greater in the group that did not receive TXA, but this difference did not achieve statistical significance.

CONCLUSION

This pilot study shows patients with CP undergoing hip reconstruction with two or more osteotomies; the use of TXA, while not statistically significant, shows a trend toward a decreased need for allogeneic blood transfusion.

Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials

Objective

Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures.

Design

A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates.

Results

A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route.

Conclusions

There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.

The Optimal Dosing Regimen for Tranexamic Acid in Revision Total Hip Arthroplasty: A Multicenter Randomized Clinical Trial

BACKGROUND

The purpose of this multicenter, randomized trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss in revision total hip arthroplasty.

METHODS

Six centers prospectively randomized 175 patients to 1 of 4 regimens: (1) 1-g intravenous (IV) TXA prior to incision (the single-dose IV group), (2) 1-g IV TXA prior to incision followed by 1-g IV TXA after arthrotomy wound closure (the double-dose IV group), (3) a combination of 1-g IV TXA prior to incision and 1-g intraoperative topical TXA (the combined IV and topical group), or (4) 3 doses totaling 1,950-mg oral TXA (the multidose oral group). Randomization was based on revision subgroups to ensure equivalent group distribution. An a priori power analysis (α = 0.05; β = 0.80) determined that 40 patients per group were required to identify a >1-g/dL difference in postoperative hemoglobin reduction between groups. Per-protocol analysis involved an analysis of variance, Fisher exact tests, and two 1-sided t tests for equivalence. Demographic and surgical variables were equivalent between groups.

RESULTS

No significant differences were found between TXA regimens when evaluating reduction in hemoglobin (3.4 g/dL for the single-dose IV group, 3.6 g/dL for the double-dose IV group, 3.5 g/dL for the combined IV and topical group, and 3.4 g/dL for the multidose oral group; p = 0.95), calculated blood loss (p = 0.90), or transfusion rates (14% for the single-dose IV group, 18% for the double-dose IV group, 17% for the combined group, and 17% for the multidose oral group; p = 0.96). Equivalence testing revealed that all possible pairings were statistically equivalent, assuming a >1-g/dL difference in hemoglobin reduction as clinically relevant. There was 1 venous thromboembolism, with no differences found between groups (p = 1.00).

CONCLUSIONS

All 4 TXA groups tested had equivalent blood-sparing properties in the setting of revision total hip arthroplasty, with a single venous thromboembolism reported in this high-risk population. Based on the equivalence between groups, surgeons should utilize whichever of the 4 investigated regimens is best suited for their practice and hospital setting. Given the transfusion rate in revision total hip arthroplasty despite TXA utilization, further work is required in this area.

LEVEL OF EVIDENCE

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

Reduction of Blood Loss by Intra-articular Injection of Tranexamic Acid Combined with Knee and Hip Flexion at 45° During Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Objective

To explore the hemostatic effect of intra‐articular administration of tranexamic acid (TXA) combined with knee flexion in total knee arthroplasty (TKA).

Methods

This randomized controlled trial was conducted at the Third Affiliated Hospital of Southern Medical University (Guangzhou, China) from January 2017 to February 2018. The patients were randomized 1:1 to the TXA group (TXA 500 mg into the joint after closure, knee, and hip flexed at 45° for 4 h) or the control group (physiological saline, with limb fully extended). The primary endpoint was postoperative hemoglobin reduction. The postoperative levels of hemoglobin were measured at four time points: 6 h after operation, and on the first, second, and third postoperative days. Calculated blood loss (CBL) at 3 days, transfusion rate, range of motion (ROM), VAS pain score, and knee circumference increment were the secondary endpoints. Ninety‐four (47/group) patients were analyzed.

Results

Postoperatively, there were statistically significant differences between the TXA and control groups in CBL (791 ± 212 mL vs 1175 ± 273 mL, P < 0.05). Hemoglobin reduction was significantly lower in the TXA group (2.0 ± 0.9 g/dL vs 4.5 ± 0.7 g/dL, P < 0.05). Based on the transfusion criteria, 3 out of 47 (6.4%) patients in the TXA group and 13 out of 47 (27.6%) patients in the control group received blood transfusions (P = 0.006). ROM (90.8° ± 6.2° vs 87.6° ± 6.4°, P = 0.004), VAS pain score (4.1 ± 1.1 vs 4.8 ± 1.3, P = 0.004), and KCI (2.4 ± 0.9 cm vs 3.2 ± 1.0 cm, P = 0.01) were better in the TXA group compared with thecontrols. There was no deep venous thrombosis (DVT), wound infection or other adverse events in either group. In the control group, 2 patients had a fever after blood transfusion.

Conclusion

Intra‐articular injection of TXA combined with knee and hip flexion at 45° can effectively attenuate CBL and hemoglobin reduction during primary TKA, without an additional adverse event.

Patient blood management interventions do not lead to important clinical benefits or cost-effectiveness for major surgery: a network meta-analysis

Background

Patient blood management (PBM) interventions aim to improve clinical outcomes by reducing bleeding and transfusion. We assessed whether existing evidence supports the routine use of combinations of these interventions during and after major surgery.

Methods

Five systematic reviews and a National Institute of Health and Care Excellence health economic review of trials of common PBM interventions enrolling participants of any age undergoing surgery were updated. The last search was on June 1, 2019. Studies in trauma, burns, gastrointestinal haemorrhage, gynaecology, dentistry, or critical care were excluded. The co-primary outcomes were: risk of receiving red cell transfusion and 30-day or hospital all-cause mortality. Treatment effects were estimated using random-effects models and risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity assessments used I². Network meta-analyses used a frequentist approach. The protocol was registered prospectively (PROSPERO CRD42018085730).

Results

Searches identified 393 eligible randomised controlled trials enrolling 54 917 participants. PBM interventions resulted in a reduction in exposure to red cell transfusion (RR=0.60; 95% CI 0.57, 0.63; I²=77%), but had no statistically significant treatment effect on 30-day or hospital mortality (RR=0.93; 95% CI 0.81, 1.07; I²=0%). Treatment effects were consistent across multiple secondary outcomes, sub-groups and sensitivity analyses that considered clinical setting, type of intervention, and trial quality. Network meta-analysis did not demonstrate additive benefits from the use of multiple interventions. No trial demonstrated that PBM was cost-effective.

Conclusions

In randomised trials, PBM interventions do not have important clinical benefits beyond reducing bleeding and transfusion in people undergoing major surgery.

Does Intra-Wound Vancomycin Powder Affect the Action of Intra-Articular Tranexamic Acid in Total Joint Replacement?

The intra-articular use of tranexamic acid (TXA) has contributed to reduced blood loss in total joint arthroplasty (TJA). The purpose of this study is to assess the efficacy of simultaneously topical use of tranexamic acid and vancomycin powder within the TJA space. From 2016 to 2017, 219 consecutive total hip arthroplasties (THAs) and 272 total knee arthroplasties (TKAs) were performed in a tertiary care center, with a group of patients receiving intra-articular TXA and vancomycin, compared to patients receiving only TXA and to a control group that did not receive anything. Haemoglobin and hematocrit were measured preoperatively, on the first and third days. Transfusions and adverse events were recorded. Haemoglobin and hematocrit dropped significantly in all THA and TKA groups till the third day postoperatively, with a major reduction in the control group, compared to the other two treatment groups. Infections and thromboembolic events were similar in either group of the TJAs. In conclusion, the topical use of tranexamic acid mixed with the vancomycin powder within the joint space after the TJAs of the hip and knee did not alter the anti-fibrinolytic effect of TXA.

Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies

OBJECTIVE

Blood transfusions are given to approximately one-fifth of patients undergoing elective lumbar spine surgery, and previous studies have shown that transfusions are accompanied by increased complications and additional costs. One method for decreasing transfusions is administration of tranexamic acid (TXA). The authors sought to evaluate whether the cost of TXA is offset by the decrease in blood utilization in lumbar spine surgery patients.

METHODS

The authors retrospectively reviewed patients who underwent elective lumbar or thoracolumbar surgery for degenerative conditions at a tertiary care center between 2016 and 2018. Patients who received intraoperative TXA (TXA patients) were matched with patients who did not receive TXA (non-TXA patients) by age, sex, BMI, ASA (American Society of Anesthesiologists) physical status class, and surgical invasiveness score. Primary endpoints were intraoperative blood loss, number of packed red blood cell (PRBC) units transfused, and total hemostasis costs, defined as the sum of TXA costs and blood transfusion costs throughout the hospital stay. A subanalysis was then performed by substratifying both cohorts into short-length (1-4 levels) and long-length (5-8 levels) spinal constructs.

RESULTS

Of the 1353 patients who met inclusion criteria, 68 TXA patients were matched to 68 non-TXA patients. Patients in the TXA group had significantly decreased mean intraoperative blood loss (1039 vs 1437 mL, p = 0.01). There were no differences between the patient groups in the total costs of blood transfusion and TXA (p = 0.5). When the 2 patient groups were substratified by length of construct, the long-length construct group showed a significant net cost savings of $328.69 per patient in the TXA group (p = 0.027). This result was attributable to the finding that patients undergoing long-length construct surgeries who were given TXA received a lower amount of PRBC units throughout their hospital stay (2.4 vs 4.0, p = 0.007).

CONCLUSIONS

TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels. Furthermore, the use of TXA in patients who received short constructs led to no additional net costs. With the increasing emphasis put on value-based care interventions, use of TXA may represent one mechanism for decreasing total care costs, particularly in the cases of larger spine constructs.

Daily Postoperative Complete Blood Counts After Primary Total Joint Arthroplasty May Not Always Be Necessary

As the incidence of primary total hip and knee arthroplasties increases and reimbursement models shift toward a more quality-based model, orthopedic surgeons must focus on maintaining quality while containing costs. With current blood conservation strategies, serial laboratory testing after total joint arthroplasty (TJA) may not always be necessary. This study investigated the need for routine postoperative complete blood counts (CBCs) by determining preoperative and postoperative day 1 hemoglobin values that predict the need for a postoperative blood transfusion. Data were used to estimate potential cost savings. The medical records of all patients who underwent primary unilateral TJA performed by a single surgeon between October 2014 and September 2017 were reviewed. Patient demographic and procedural data were recorded, and statistical and cost analyses were performed. Of 108 TJAs, 9 (8.3%) patients received a blood transfusion during their postoperative inpatient stay. A preoperative hemoglobin value of 12.5 g/dL or less and a postoperative day 1 hemoglobin value of 10 g/dL or less were strong predictors of meeting the threshold transfusion trigger for a postoperative blood transfusion (area under the curve, 0.845 and 0.943, respectively). A 56% cost reduction ($845) could have been achieved by eliminating CBCs performed after postoperative day 1 in patients at low risk for transfusion. Patients with preoperative hemoglobin value levels greater than 12.5 g/dL and postoperative day 1 hemoglobin value levels greater than 10 g/dL may not require routine serial CBC monitoring after primary TJA. The cost savings in a high-volume joint center could be significant. [Orthopedics. 2020; 43(1): e31-e36.].

Dissection and ligation of the lateral circumflex femoral artery is not necessary when using the direct anterior approach for total hip arthroplasty

BACKGROUND

Branches of the lateral circumflex femoral artery (LCFA) stretch across the surgical field during a direct anterior total hip arthroplasty. It is an anatomical marker in direct anterior approach. As an important vessel around the hip joint, this vessel was ligated in most situations. Although ligation of the vascular pedicle of the LCFA is a common, traditional procedure used to decrease bleeding, the ligation of the pedicle of the vessel is tedious and time-consuming.

AIM

To explore whether this ligation is truly necessary in a direct anterior approach to total hip arthroplasty.

METHODS

This single-center, single-surgeon, prospective study was performed to compare patients’ bleeding undergoing ligation of the branches of the LCFA pedicle (group A) vs those treated with electrocautery from the branches of the LCFA (group B). In both groups, the pedicles were identified in the intermuscular plane between the tensor fasciae lata and the rectus femoris muscles. In group A, the pedicles were ligated with a silk ligature. In group B, the branches coming off the LCFA were controlled with electrocautery. We compared preoperative vs postoperative changes in blood hemoglobin levels, intraoperative blood loss, operative time, rates of transfusion, re-bleeding, and hematoma between the two groups.

RESULTS

The reduction of hemoglobin in group A was 20.9 ± 7.0, and in group B it was 21.2 ± 4.9. There was no statistically significant difference between the two groups (P > 0.05). The actual calculated blood loss in group A was 784 ± 125 mL, and in group B it was 722 ± 153 mL. There was a trend in group A having more blood loss (P = 0.078). The estimated blood loss in group A was 344 ± 88 mL, and in group B it was 346 ± 73 mL. There was no statistically significant difference between the two groups (P = 0.883). In addition, there were no significant differences in the rates of postoperative transfusion (10% vs 6.7%, P > 0.05), postoperative hematomas (6.7% vs 13.3%, P > 0.05), or re-bleeding (13.3% vs 20%, P > 0.05) between the two groups.

CONCLUSION

Ligation of the pedicle of the LCFA has no advantage in preventing or decreasing bleeding during or after a total hip arthroplasty using the direct anterior approach. Ligation of the pedicle of the vessel is a cumbersome, unnecessary procedure and can be replaced by electrocautery control of the branches off this artery that course through the surgical field.

Application of thromboelastography to evaluate the effect of different routes administration of tranexamic acid on coagulation function in total hip arthroplasty

Background

Tranexamic acid (TXA) is widely used to reduce blood loss and transfusion rates in total hip arthroplasty(THA). Thromboelastography, which can monitor coagulation changes from clotting to fibrinolysis dynamically. In this study, thromboelastography was used to assess the dynamic changes in the coagulation of patients who underwent THA with the administration of TXA.

Methods

This randomized controlled trial consisted of 207 consecutive patients who underwent primary total hip arthroplasty. Patients were randomized into three groups: topical-TXA group received a topical application of TXA, IV-TXA group received an intravenous injection of TXA, and control group. Thromboelastography was performed 1 day before surgery and first, fourth, seventh days after surgery. The primary outcomes were thromboelastography parameters, the rates of deep vein thrombosis(DVT), and pulmonary embolism(PE). Secondary outcomes included perioperative blood loss, transfusion rates, and other perioperative complications.

Results

The mean calculated total blood loss in the Topical-TXA group were 832.7 ± 279.84 ml and 834.8 ± 322.94 ml in the IV-TXA group, which were significantly reduced (p < 0.05) compared with control groups at 1093.3 ± 379.7 ml. There were no significant differences between topical-TXA and IV-TXA groups in total blood loss or transfusion rates. K and R have reached a nadir from preoperative levels to 4th day postoperatively and then began to increase.α angle and CI peaked from preoperative levels to the fourth day postoperatively and then began to decline.IV-TXA significantly (p < 0.05) promoted coagulation levels compared with topical-TXA and control groups in the early postoperative period. Almost no significant differences were observed between topical-TXA and control groups in thromboelastography parameters.No significant differences were observed in the incidence of thromboembolic complications and other perioperative complications.

Conclusions

The topical administration of TXA had the same hemostatic effect as intravenous injection tranexamic acid. Coagulation function peaked on 4th day postoperatively and then began to decline. IV-TXA was more enhanced coagulation functions compared with topical-TXA.

The combined administration of systemic and topical tranexamic acid for total hip arthroplasty: Is it better than systemic?

Obective

The aim of this study was to evaluate the effect of combined intravenous and topical use of tranexamic acid (TXA) on total blood loss and transfusion rate in total hip arthroplasty.

Methods

This prospective randomized study included 57 patients who had undergone total hip arthroplasty between September 2016 and September 2017. The IV administration group (Group 1) consisted of 26 patients (mean age: 63.73 ± 10.29 years), while the IV and topical administiration group (Group 2) consisted of 22 patients (62.82 ± 8.31 years). Demographic data and outcomes were obtained through a review of individual medical records. Medical comorbidities, body mass index (BMI), ASA and CCI, preoperative and postoperative hemoglobin levels, postoperative transfusion records and 90-day joint-related (implant subsidence, dislocation, postoperative anemia, deep infection, hematoma and/or wound problem, postoperative periprosthetic fracture) readmission rate and complication rate were compared between the groups.

Results

No significant differences were observed between the 2 groups in terms of age, gender, height, weight, body mass index (BMI), the level of preoperative Hb values, and the American Society of Anesthesiologists (ASA) and Charleson Comorbidty Index (CCI) rating (p > 0.05). The mean postoperative Hgb in the group 2 was higher by a small amount compared to the group 1. No statistically significant difference was determined between the groups in respect of the Hgb values (p = 0.562). Hgb Delta in the group 2 was lower than that of the group 1. The difference between the groups in the Hgb Delta values was not statistically significant (p = 0.268). The mean total blood loss was lower in the group 2 than in the group 1 but the difference was not statistically significant (p = 0.788). There was no significant difference observed in terms of any adverse complications among the 2 groups (p > 0.05).

Conclusion

The combined administration of IV and topical TXA compared with IV alone can decrease total blood loss and the number of blood transfusions required without increasing the risk of DVT or/and PE in total hip arthroplasty. But the statistical analysis and clinical relevance is not significant.

Level of Evidence

Level I Therapeutic Study.

Prevention of postoperative bleeding in hip fractures treated with prosthetic replacement: efficacy and safety of fibrin sealant and tranexamic acid. A randomised controlled clinical trial (TRANEXFER study)

INTRODUCTION

We assessed the efficacy of fibrin sealant (FS) and tranexamic acid (TXA) administered topically in patients with a hip fracture treated with prosthetic replacement.

MATERIALS AND METHODS

Parallel, multicentre, open label, randomised, clinical trial. We compared three interventions to reduce blood loss: (1) 10 ml of FS, (2) 1 g of topical TXA, both administered at the end of the surgery, and (3) usual haemostasis (control group). The main outcome was blood loss collected in drains. Other secondary variables were total blood loss, hidden blood loss, transfusion rate, average hospital stay, complications, adverse events, and mortality.

RESULTS

A total of 158 patients were included, 56 in the FS group, 52 in the TXA group, and 50 in the control group. The total amount of blood collected in drains was lower in the TXA group (148.6 ml, SD 122.7 in TXA; 168.2 ml, SD 137.4 in FS; and 201.5 ml, SD 166.5 in control group) without achieving statistical significance (p = 0.178). The transfusion rate was lower in the TXA group (32.7%), compared with FS group (42.9%) and control group (44.0%), without statistical significance (p = 0.341). There were no complications or adverse effects related to the evaluated interventions.

CONCLUSIONS

The use of TXA and FS administered topically prior to surgical closure in patients with a sub-capital femoral fracture undergoing arthroplasty did not significantly reduce either postoperative blood loss or transfusion rate, compared with a group that only received usual haemostasis.

Intra-Articular Tranexamic Acid Mitigates Blood Loss and Morphine Use After Total Knee Arthroplasty. A Randomized Controlled Trial

BACKGROUND

Tranexamic acid (TXA) has been widely used in total knee arthroplasty (TKA) for blood loss reduction. Given limited evidence on potential relationship between the TXA and improvement of pain control and functional outcome after TKA, this study aimed at comparing the blood loss, pain scores, morphine consumption, and knee flexion across the TXA administration routes.

METHODS

The 228 primary TKA were randomized into no TXA use (No-TXA), intra-articular TXA (15 mg/kg) use (IA-TXA), and intravenous TXA (10 mg/kg) use (IV-TXA). A multivariate regression analysis was used for comparing perioperative blood loss (PBL), drain output, average number of units of blood transfused (ANUBT), visual analogue scales (VAS) for pain, amount of morphine consumption, and knee flexion angle.

RESULTS

The IA-TXA and IV-TXA group had 193.26 (P < .01) and 160.30 mL (P < .01) less PBL than No-TXA, respectively. No-TXA significantly required higher ANUBT than IA-TXA and IV-TXA (P = .03). The IA-TXA group had lower VAS at 6 (P = .04), 12 (P = .03), and 24 hours (P = .02) postoperative when compared to No-TXA, while IV-TXA had no effect. The IA-TXA required 18.26 mg less total morphine at 48 hours than No-TXA (P = .02), whereas IV-TXA used insignificantly (5.31 mg; P = .31) less total morphine at 48 hours than No-TXA. Both TXA routes tended to improve knee flexion, but not statistically significant.

CONCLUSION

Both IA-TXA and IV-TXA could significantly reduce PBL and ANUBT. The IA-TXA could significantly mitigate VAS and morphine use after TKA. Hence, IA-TXA could minimize blood loss and may be considered as an adjunct to pain control following TKA.

Dose optimization of topical tranexamic acid for primary total hip arthroplasty: A prospective cohort study

BACKGROUND

Recently, the topical application of tranexamic acid has become widespread, and it is effective in reducing postoperative blood loss and transfusion rate in total hip arthroplasty. There is no consensus on the optimal dose of topical tranexamic acid. This study aimed to assess the efficacy and safety of topical tranexamic acid on postoperative blood loss and determine the optimal topical dose for primary total hip arthroplasty.

METHODS

This prospective cohort study with a robust protocol enrolled 79 patients who received either 1 or 2 g of topical tranexamic acid in 30 mL normal saline solution or an equivalent volume of normal saline at the end of surgery. The primary outcomes were postoperative drain blood loss and hemoglobin decrease on postoperative day 7. The secondary outcomes were transfusion rate, d-dimer level on postoperative day 7, symptomatic deep vein thrombosis rate, and duration of hospital stay.

RESULTS

Both 1 and 2 g tranexamic acid significantly reduced postoperative drain blood loss (p < 0.001). These doses also reduced the hemoglobin concentration decrease on postoperative day 7, but not significantly. Furthermore, 1 and 2 g doses of tranexamic acid had similar effects on postoperative blood loss and hemoglobin concentration decrease. There was no difference in the transfusion rate, d-dimer level, symptomatic deep vein thrombosis rate, and length of hospital stay.

CONCLUSIONS

The use of topical tranexamic acid at the end of surgery is effective and safe for reducing postoperative blood loss in primary total hip arthroplasty. Topical tranexamic acid at a dose of 1 g may be sufficient and cost-effective, with fewer side effects than the higher dose.

Comparative efficacy and safety of different hemostatic methods in total hip arthroplasty: a network meta-analysis

Background

It is unclear which kind of interventional therapy is the best when reducing blood loss in patients prepared for total hip arthroplasty (THA). We performed this network meta-analysis to rank the best intervention arm for blood loss control in THA patients.

Methods

We searched electronic databases about randomized controlled trials (RCTs) to compare three treatments (topical tranexamic acid (TXA), intravenous TXA, and topical fibrin sealant (FS)) versus placebo for the people prepared for THA. Traditional and network meta-analyses were performed. The quality assessment was conducted using Cochrane Collaboration’s tool. The network meta-analysis was conducted using Stata 13.0 software.

Results

Finally, a total of 32 RCTs were included in this network meta-analysis. Topical TXA, intravenous TXA, and topical FS significantly decreased the need for transfusion and total blood loss when compared with placebo. And intravenous TXA ranks the first hemostasis agent for reducing the need for transfusion and total blood loss. There was no significant difference between these three treatments (intravenous TXA, topical TXA, and topical FS) in the occurrence of deep venous thrombosis (DVT).

Conclusion

Intravenous TXA may be the best way to reduce the need for transfusion and total blood loss. More direct studies that focused on topical TXA versus FS are needed in the future.

Concurrent femoral head reduction and periacetabular osteotomies for the treatment of severe femoral head deformities

AIMS

The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities.

PATIENTS AND METHODS

Between 2011 and 2016, six female patients were treated with a combined FHRO and PAO. The mean patient age was 13.6 years (12.6 to 15.7). Clinical data, including patient demographics and patient-reported outcome scores, were collected prospectively. Radiologicalally, hip morphology was assessed evaluating the Tönnis angle, the lateral centre to edge angle, the medial offset distance, the extrusion index, and the alpha angle.

RESULTS

The mean follow-up was 3.3 years (2 to 4.6). The modified Harris Hip Score improved by 33.0 points from 53.5 preoperatively to 83.4 postoperatively (p = 0.03). The Western Ontario McMasters University Osteoarthritic Index score improved by 30 points from 62 preoperatively to 90 postoperatively (p = 0.029). All radiological parameters showed significant improvement. There were no long-term disabilities and none of the hips required early conversion to total hip arthroplasty.

CONCLUSION

FHRO combined with a PAO resulted in clinical and radiological improvement at short-term follow-up, suggesting it may serve as an appropriate salvage treatment option for selected young patients with severe symptomatic hip deformities.

Optimal use of tranexamic acid for total hip arthroplasty: A network meta-analysis

Background

Tranexamic acid (TXA) has been demonstrated to minimize blood loss after total hip arthroplasty. There are three main routes: intravenous (IV), intra-articular (topical), and combined (IV and topical) but little consensus support which is most effective and safe. We performed network meta-analysis.to assess the comparative efficacy and safety of three different administration routes of TXA.

Methods

Twenty-five randomized controlled trials (RCT) were evaluated. Interventions were classified as: combined, IV multiple, IV single, topical and placebo. The primary outcome was effectiveness (transfusion rate, total blood loss, and total drain out). The secondary outcome was safety, based on the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE).

Results

A total of 2227 patients were included in the 5 categories: 564 IV single, 319 IV multiple, 398 topical, 120 combined, and 826 placebo. A network meta-analysis identified the most effective interventions in terms of reducing the need for transfusion as follows: combined = 98.2%, IV single = 54.0%, IV multiple = 78.6%, topical = 66.1%, placebo = 0.0%. Compared with placebo, the IV single, IV multiple, topical, and combined interventions showed no difference in the rate of occurrence of DVT and PE.

Conclusions

A network meta-analysis indicated that combined administration of TXA (IV and topical) was effective in reducing the transfusion rate after hip arthroplasty compared with IV or topical alone. As no high-risk patients were evaluated in the RCTs, it is not known whether the combined method is safer for patients susceptible to DVT or PE.

Is topical or intravenous tranexamic acid preferred in total hip arthroplasty? A randomized, controlled, noninferiority clinical trial

Purpose

The present study aimed to confirm the efficacy and safety of topical and intravenous tranexamic acid (TXA) compared with that of topical placebo and to assess the noninferiority between the two application methods of TXA in patients undergoing unilateral primary total hip arthroplasty.

Methods

Our randomized controlled trial investigated 170 patients with 1:1:1 allocation to two doses of 10-mg/kg intravenous TXA, 3-g topical TXA, and topical placebo of 60-ml physiological saline groups. The primary outcome, total blood loss, was calculated with Nadler and Gross formula. The secondary outcomes included allogeneic blood transfusion requirement, drain blood loss, decreased hemoglobin level. Noninferiority would be established when the upper limit 95% CI is lower than 250 ml of the noninferiority margin for the mean difference of total blood loss between topical and intravenous TXA. Thromboembolic complication incidence was considered as a safety outcome.

Results

The total blood loss of patients administered intravenous (mean±standard deviation, 1125±514 ml) and topical TXA (1211±425 ml) was significantly reduced compared with that of those administered topical placebo (1464±556 ml) (p = 0.0012). Drain blood loss and hemoglobin level reduction in patients administered with TXA were also significantly lower than those in patients administered topical placebo. The mean difference of total blood loss between topical and intravenous TXA is 86 ml (95% CI, −88 to 260 ml). The complications were comparable between patients managed with TXA and patients with topical placebo.

Conclusion

The noninferiority of topical TXA to intravenous TXA can not be concluded. Considering no significant difference was found in all efficacy outcomes between the two administration methods. Any of the two TXA administration methods can be adopted for blood loss prevention in total hip arthroplasty.

The Safety of Tranexamic Acid in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Tranexamic acid (TXA) is effective in reducing blood loss in total joint arthroplasty (TJA), but concerns still remain regarding the drug's safety. The purpose of this direct meta-analysis was to evaluate and establish a basis for the safety recommendations of the combined clinical practice guidelines on the use of TXA in primary TJA.

METHODS

A search was completed for studies published before July 2017 on TXA in primary TJA. We performed qualitative and quantitative homogeneity testing and a direct comparison meta-analysis. We used the American Society of Anesthesiologists (ASA) score of 3 or greater as a proxy for patients at higher risk for complications in general and performed a meta-regression analysis to investigate the influence of comorbidity burden on the risk of arterial thromboembolic event and venous thromboembolic event (VTE).

RESULTS

Topical, intravenous, and oral TXA were not associated with an increased risk of VTE after TJA. In addition, meta-regression demonstrated that TXA use in patients with an ASA status of 3 or greater was not associated with an increased risk of VTE after total knee arthroplasty.

CONCLUSION

Although most studies included in our analysis excluded patients with a history of prior thromboembolic events, our findings support the lack of evidence of harm from TXA administration in patients undergoing TJA. Moderate evidence supports the safety of TXA in patients undergoing total knee arthroplasty with an ASA score of 3 or greater. The benefits of using TXA appear to outweigh the potential risks of thromboembolic events even in patients with a higher comorbidity.

The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used to reduce blood loss in total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy of TXA in primary THA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty.

METHODS

A search was performed using Ovid-MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases to identify all publications before July 2017 on TXA in primary THA. We completed qualitative and quantitative homogeneity testing of all included studies. Direct and indirect comparisons were analyzed using a network meta-analysis followed by consistency testing of the results.

RESULTS

Two thousand one hundred thirteen publications underwent critical appraisal with 34 publications identified as representing the best available evidence for inclusion in the analysis. Topical, intravenous, and oral TXA formulations provided reduced blood loss and risk of transfusion compared to placebo, but no formulation was clearly superior. Use of repeat doses, higher doses, or variation in timing of administration did not significantly reduce blood loss or risk of transfusion.

CONCLUSIONS

Strong evidence supports the use of TXA to reduce blood loss and risk of transfusion after primary THA. No specific routes of administration, dosage, dosing regimen, or time of administration provides clearly superior blood-sparing properties.

Transperitoneal versus extraperitoneal approach in laparoscopic radical prostatectomy: A meta-analysis

BACKGROUND

To compare the transperitoneal approach with extraperitoneal approach in laparoscopic radical prostatectomy (LRP) (including pure and robotic-assisted LRP) using meta-analytic techniques.

METHODS

Medline (PubMed), Embase, Ovid, CMB, and Cochrane databases were searched for studies that compared the transperitoneal and extraperitoneal approaches in LRP from January 2000 to January 2017. Outcomes included were operative time, operative bloods joss (milliliters), rate of transfusion, rate of open conversion, rate of intraoperative complications, rate of postoperative complications, and time of postoperative catheterization.

RESULTS

Thirteen studies including 1674 patients were selected for the meta-analysis. 850 (50.8%) cases had undergone transperitoneal LRP (TLRP) and 824 (49.2%) cases had undergone the extraperitoneal LRP (ELRP). Comparison of operative time between the TLRP group and the ELRP group showed no significant differences (weighted mean difference [WMD] = 21.21,95%CI = -1.16-43.57, P = .06). No significant differences were observed in blood loss (WMD = -6.04, 95%CI = -43.38-31.29, P = .75) and the rate of transfusion (odds ratio [OR] = 1.03, 95%CI = 0.55-1.96, P = .92) between the 2 groups. No significant differences were observed for the rate of intraoperative complications (OR = 1.25, 95%CI = 0.57-2.21, P = .75) and the rate of open conversion (OR = 1.12, 95%CI = 0.32-4.97, P = .75). Significant differences were observed in the TLRP group compared with the ELRP group (OR = 1.69, 95%CI: 1.23-2.32, P = .001) regarding the rate of postoperative complications.

CONCLUSIONS

Our meta-analysis findings revealed that the TLRP group showed no significant differences in most important indicators compared with ELRP. Moreover, TLRP showed higher rate of postoperative complications compared with ELRP.

Tranexamic acid use during total hip arthroplasty: A single center retrospective analysis

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent that has shown promise in reducing blood loss during total hip arthroplasty (THA). Several studies have reported side effects of high-dose TXA administration, including myocardial infarction (MI), thromboembolic events, and seizures. These possible side effects have prevented the widespread adoption of TXA in the surgical community.

METHODS

We conducted a retrospective chart review of 564 primary and revision THAs performed at a single academic center. Surgical patients received either no TXA or 1 g IV TXA at the beginning of surgery followed by a second bolus just before the surgical wound closure, at the surgeon's discretion. We analyzed differences in hemoglobin (Hb), hematocrit (Hct), estimated blood loss (EBL), and adverse events in patients receiving TXA versus patients not receiving TXA up to 2 days following surgery.

RESULTS

Significantly higher Hb and Hct values were found across all time points among patients undergoing primary posterior or revision THA who had received TXA. In addition, transfusion rates were significantly decreased in both primary posterior THAs and revision THAs when TXA was administered. Patients who received TXA experienced significantly fewer adverse events than those who did not for all surgery types.

CONCLUSION

Administration of low-dose intravenous (IV) and intra-articular (IA) TXA does not appear to increase rates of adverse events and may be effective in minimizing blood loss, as reflected by Hb and Hct values following THA.

Transfusion-free treatment strategies for acute anemia in critical care

Acute anemia is a frequently encountered diagnosis in critically ill patients, and can be a challenge if blood products are not readily available or if patients refuse these products on the basis of their religious beliefs. This article discusses the goals of anemia management and summarizes several alternatives to blood transfusions that can be used to prevent and treat acute anemia.

The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis

Tranexamic acid (TXA) is an effective hemostatic agent used for the reduction of blood loss and transfusion. However, the safety profile of TXA remains in question due to a potential increased risk of venous thromboembolism. By applying TXA topically as opposed to intravenously, systemic absorption may be reduced and unwanted side-effects mitigated. The objective of our review is to investigate the efficacy and safety of topically applied tranexamic acid compared to both placebo, and the intravenous administration. Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ISI Web of Science, PubMed, and Clinicaltrials.gov were searched from inception to November, 2016. We included randomized controlled trials that compared topical tranexamic acid to either placebo (or standard care) or intravenous administration, in adult patients. Surgical and non-surgical trials were included. Abstract, full-text selection, data extraction and risk of bias assessment were all performed in duplicate. In total, 67 studies involving 6,034 patients met inclusion criteria. The majority of trials evaluated orthopedic procedures. Compared to placebo, the administration of topical TXA significantly reduced the odds of receiving a blood transfusion (pooled OR 0.28, 95% CI 0.20 to 0.38; P < 0.001) and significantly reduced mean blood loss (WMD -276.6, 95% CI -327.8 to -225.4; P < 0.0001). When compared to the intravenous administration, there was no difference between the two groups in terms of transfusion requirements (pooled OR 1.03, 95% CI 0.72 to 1.46; P=0.88) or blood loss (WMD -21.95, 95% CI -66.61 to 27.71; P=0.34). There was no difference in the odds of developing a venous thromboembolic complication between the topical TXA and control groups (pooled OR=0.78, 95% CI 0.47 to 1.29; P=0.33) or the topical and intravenous groups (pooled OR=0.75, 95% CI 0.39 to 1.46; P=0.40). The topical application of TXA effectively reduces both transfusion risk and blood loss compared to placebo, without increasing thromboembolic risks. There were no major differences between topical and intravenous tranexamic acid with respect to safety and efficacy, and both were superior to placebo with regards to blood loss and transfusion requirements. Further study of the topical application is required outside of the field of orthopedics.

The effect of oral versus intravenous tranexamic acid in reducing blood loss after primary total hip arthroplasty: A randomized clinical trial

BACKGROUND

The purpose of this study was to determine whether the administration of multiple boluses of oral and intravenous tranexamic acid (TXA) postoperatively was equivalent in reducing blood loss in primary THA.

METHODS

A total of 108 patients were randomized into two groups: oral TXA group (54 patients receiving 1 dose of 20 mg/kg intravenous TXA 5-10 min before skin incision and 3 doses of 2 g oral TXA 4 h, 10 h and 16 h postoperatively) and intravenous TXA group (54 patients receiving 1 dose of 20 mg/kg intravenous TXA 5-10 min before skin incision and 3 doses of 1 g intravenous TXA 6 h, 12 h and 18 h postoperatively). The primary outcomes were total blood loss, hidden blood loss, length of hospital stay, hemoglobin (Hb) and hematocrit (Hct) drop. The secondary outcomes were the level of inflammation markers and complications.

RESULTS

There was no difference in the mean total blood loss or hidden blood loss [728.4 (645.8-806.9) mL vs 703.6 (576.9-832.8) mL, p = 0.745; 634.6 (552.0-715.7) mL vs 606.4 (480.1-734.5) mL, p = 0.710] and length of hospital stay was similar between the two groups. No patients received allogenic blood transfusion. The Hb and Hct drop on the first and second postoperative days were similar (p > 0.05). The level of inflammation markers did not reach statistical significance. The incidence of complications did not differ significantly between the two groups.

CONCLUSIONS

Multiple boluses of oral TXA and intravenous TXA postoperatively are equivalent in reducing blood loss, Hb and Hct drop in primary THA without increasing the risk of thromboembolic diseases and wound complications.

Tranexamic acid reduces blood loss after primary shoulder arthroplasty: a double-blind, placebo-controlled, prospective, randomized controlled trial

Background

Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease blood loss and transfusion rates after hip and knee arthroplasty, with only limited evidence to support its use in shoulder arthroplasty. This study was conducted to determine whether intravenous (IV) TXA is more effective than placebo in reducing blood loss after primary total shoulder arthroplasty (TSA).

Methods

In this prospective, double-blind, placebo-controlled, randomized clinical trial, patients undergoing primary anatomic and reverse TSA were randomized to receive 1 g of intravenous TXA or a placebo of an equivalent volume of intravenous normal saline administered 10 minutes before the incision. The primary outcome measurement was calculated postoperative blood loss. Secondary outcomes included transfusion rates, weight of hemoglobin loss, hospital length of stay, and thromboembolic events.

Results

The study enrolled 110 patients, 2 of whom were excluded because they did not have a postoperative hemoglobin measurement, and the remaining 108 patients (52 for TXA, 56 for placebo) were analyzed. There were no significant differences between TXA and placebo groups in preoperative characteristics. For the primary outcome, the TXA group had significantly lower postoperative blood loss of 1100.9 ± 367.4 mL compared with 1274.5 ± 460.0 mL for the placebo group (P = .03). For secondary outcomes, TXA had lower weight of hemoglobin loss compared with placebo (152.2 ± 57.3 g vs. 178.0 ± 65.8 g; P = .03). No patients in the TXA or placebo groups required a transfusion.

Conclusions

Intravenous TXA reduced blood loss after primary TSA compared with placebo.

Efficacy of a Pelvic Lateral Positioner With a Mechanical Cup Navigator Based on the Anatomical Pelvic Plane in Total Hip Arthroplasty

BACKGROUND

The acetabular component orientation in total hip arthroplasty (THA) is of critical importance to the good clinical results. However, traditional widely used cup alignment guides for cup placement are reported to be relatively unreliable. The present study aims at comparing a novel cup alignment guide, which can be attached to our anatomical pelvic plane (APP) pelvic lateral positioner for reducing discrepancies in sagittal pelvic tilt and indicate a targeted cup angle based on the APP, with a conventional cup alignment guide.

METHODS

The subjects were 136 hips of 136 patients who underwent unilateral THA using the APP positioner. The procedure was performed with the conventional cup alignment guide (conventional group; 60 hips) and with the novel cup navigator (mechanical navigator group; 76 hips). Postoperative cup angles and discrepancies of postoperative cup angles (inclination and anteversion angles) from the targeted angles were compared between the 2 groups to evaluate the usefulness of these navigators.

RESULTS

The mean cup angles in the conventional group were 39.0° ± 5.3° for the inclination angle and 21.7° ± 6.4° for the anteversion angle, whereas those in the mechanical navigator group were 40.6° ± 3.2° and 18.3° ± 4.6°, respectively (P = .018, P < .0001). The discrepancies from the targeted angles were 3.5° ± 3.1° for the inclination angle and 4.6° ± 3.4° for the anteversion angle in the conventional group and 2.3° ± 2.3° and 3.2° ± 2.7°, respectively, in the mechanical navigator group (P = .020, P = .012).

CONCLUSION

The mechanical cup navigator easily attachable to the APP positioner is a tool that can improve the accuracy of cup placement in a simple, economical, and noninvasive manner in THA via the lateral position.

Efficacy and safety of the topical application of tranexamic acid in primary cementless hip arthroplasty: prospective, randomised, double-blind and controlled study

OBJECTIVE

To evaluate the efficacy of topical tranexamic acid topical in cementless total hip arthroplasty from the point of view of bleeding, transfusion requirements and length of stay, and describe the complications of use compared to a control group.

MATERIAL AND METHODS

A prospective, randomised, double-blinded and controlled study including all patients undergoing cementless total hip arthroplasty in our centre between June 2014 and July 2015. Blood loss was estimated using the formula described by Nadler and Good.

RESULTS

The final analysis included 119 patients. The decrease in haemoglobin after surgery was lower in the tranexamic acid group (3.28±1.13g/dL) than in the controls (4.03±1.27g/dL, P=.001) and estimated blood loss (1,216.75±410.46mL vs. 1,542.12±498.97mL, P<.001), the percentage of transfused patients (35.9% vs. 19.3%, P<.05) and the number of transfused red blood cell units per patient (0.37±0.77 vs. 0.98±1.77; P<.05). There were no differences between groups in the occurrence of complications or length of stay.

CONCLUSIONS

The use of topical tranexamic acid in cementless total hip arthroplasty results in a decrease in bleeding and transfusion requirements without increasing the incidence of complications.

Preoperative screening and intervention for mild anemia with low iron stores in elective hip and knee arthroplasty

BACKGROUND

Preoperative anemia in patients undergoing elective hip and knee arthroplasty is associated with increased postoperative morbidity and mortality, red blood cell (RBC) transfusion, and length of stay (LOS). The aim of this study was to assess the effect of optimizing hemoglobin (Hb) levels before elective primary hip and knee arthroplasty.

STUDY DESIGN AND METHODS

This is a prospective comparative cohort study of patients who underwent elective hip and knee arthroplasty before (control) and after (intervention) the launch of a Hb optimization program. Patients with anemia followed an agreed upon algorithm dependent on their medical history and blood variables taken on listing for surgery. The primary outcome for this study was the requirement for allogenic RBC transfusion. Secondary outcomes included hospital LOS, admission to critical care, readmission, medical complications, incidence of thromboembolic events, mortality, and costs.

RESULTS

A total of 1814 control patients operated between February 2012 and February 2013 were compared to 1622 intervention patients operated between February 2013 and May 2014. In the intervention group transfusion was significantly reduced (108 [6%] vs. 63 [4.1%], p = 0.005) as well as readmission (81 [4.5%] vs. 48 [2.3%], p= 0.020) and critical care admission (23 [1.3%] vs. 9 [0.5%], p = 0.030). LOS was significantly reduced from 3.9 days to 3.6 days (p = 0.017). The saving for the cohort was £263,000 ($342,000).

CONCLUSIONS

Algorithm-led preoperative anemia screening and management in elective arthroplasty was associated with reduced RBC transfusion, readmission, critical care admission, LOS, and costs.

Tranexamic Acid in Knee Surgery Study-A Multicentered, Randomized, Controlled Trial

BACKGROUND

Postoperative anemia following elective arthroplasty can lead to prolonged hospital stay and delays in rehabilitation and is often poorly tolerated in patients with cardiovascular disease. Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in total knee arthroplasty (TKA). However, questions over its optimal route of administration remain.

METHODS

A double-blinded, placebo, multicentered, randomized, controlled trial investigating the efficacy of topical and systemic routes of a single intraoperative dose (1.5 g) of TXA was conducted. Patients undergoing primary, unilateral TKA were screened for eligibility. Eligible patients were consecutively enrolled from 5 New Zealand centers between July 2014 and November 2015. Three prospective groups running in parallel (topical TXA [tTXA], systemic TXA [sTXA], and placebo) were investigated for a primary outcome of estimated perioperative blood loss. An intention-to-treat analysis was used to compare outcomes between the study groups (P value <.05).

RESULTS

One hundred and thirty-four patients across the 5 hospitals were recruited into the study. Estimated blood loss was equivalent in the 2 treatment groups, sTXA (749 mL [95% confidence interval, 637-860]) and tTXA (723 mL [620-826]). Compared to the placebo group (1090 mL [923-1257]), blood loss was significantly lower in both treatment groups (P = .001 and P = .0003, respectively). There were no significant differences in secondary outcomes, including rates of symptomatic deep vein thrombosis and pulmonary embolism (P = .759).

CONCLUSION

In the setting of elective TKA, a single 1.5-g dose of tTXA given intraoperatively either systemically or topically effectively reduces blood loss without an increase in complications.

An Aprotinin Containing Fibrin Sealant Does Not Reduce Blood Loss in Total Hip Arthroplasty

BACKGROUND

Fibrin sealants are topical agents used to reduce perioperative blood loss; however, their efficacy in total hip arthroplasty (THA) remains uncertain. The purpose of this study was to determine if a fibrin sealant containing aprotinin as an antifibrinolytic agent, TISSEEL (Baxter, Deerfield, IL), reduces postoperative blood loss and transfusion during THA when compared with intravenous (IV) tranexamic acid (TXA) and control groups.

METHODS

Three retrospective uniform cohorts of primary THA procedures were identified, from a prospectively maintained database: 1 group who received TISSEEL, 1 group who received 1 g IV TXA, and 1 group who received neither (control). There were 80 patients in each group. Outcome measures included the lowest measured hemoglobin during postoperative hospitalization, greatest decrease in hemoglobin from preoperative to postoperative values, and blood transfusion rates.

RESULTS

The minimum postoperative hemoglobin level was significantly lower for TISSEEL patients compared with that of IV TXA patients (P = .021) and no different when compared with that of control patients (P = .134). Patients receiving fibrin sealant had a greater hemoglobin level decrease compared with that of IV TXA (P = .029) and control (P = .036). Postoperative transfusion rates were no different for the group receiving TISSEEL compared with those of control (P = .375) and were statistically greater when compared with those of IV TXA (P = .002).

CONCLUSION

TISSEEL fibrin sealant does not reduce postoperative blood loss or transfusions; however, IV TXA reduced postoperative transfusions compared with TISSEEL and control. Therefore, TXA is recommended to reduce perioperative blood loss, while, utilization of a fibrin sealant requires further refinements before being adopted for routine use in THA.