Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2022
AIM: The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
Peri-articular administration of tranexamic acid is an alternative route in total knee arthroplasty: a systematic review and meta-analysis
Journal of orthopaedic surgery and research. 2022;17(1):211
BACKGROUND As an antifibrinolytic agent, tranexamic acid (TXA) is increasingly used in total knee arthroplasty (TKA) to reduce blood loss. The administration of intravenous and intra-articular TXA has been well explored, but the most efficient way to administer TXA remains in question. Peri-articular injection (PAI) of TXA is a recently mentioned method. A meta-analysis of the efficacy of PAI TXA in patients after TKA should be performed. METHODS A systematic search was performed within PubMed, Embase, and the Cochrane Library up to November 8, 2021. Two authors independently screened studies for eligibility and extracted data for analysis. The primary outcome was haemoglobin change. The secondary outcomes were haematocrit change, total drainage volume, thromboembolic events, and blood transfusion. RESULTS A total of ten studies were included in this meta-analysis. The results indicated that there was a significant decrease in haemoglobin change when using PAI TXA compared with no TXA (mean difference - 1.05; 95% CI - 1.28 to - 0.81; P < 0.00001; I(2) = 0%), but it had no significant differences compared with IA and IV (mean difference - 0.01; 95% CI - 0.17 to - 0.14; P = 0.85; I(2) = 39%). There were no significant differences between the TXA < 1.5 g subgroup (0.10, 95% CI - 0.27 to 0.46; P = 0.60; I(2) = 0%) and the TXA ≥ 1.5 g subgroup (0.18, 95% CI - 0.12 to 0.48; P = 0.24; I(2) = 74%). In addition, the combined group (PAI plus IV or IA) was superior to the IV or IA group in terms of haemoglobin change (mean difference - 0.51; 95% CI - 0.76 to - 0.27; P < 0.0001; I(2) = 19%). Regarding haematocrit change, the pooled result showed it was significantly less in the PAI group than the non-TXA group. Similarly, comparing it against the IV subgroup, the result revealed a difference in favour of the PAI group, with a mean difference of - 1.89 g/dL (95% CI - 2.82 to - 0.95; P < 0.0001; I(2) = 67%). For total drainage volume, the pooled result was in favour of PAI TXA over no TXA (297 ml, 95% CI - 497.26 to - 97.23; P = 0.004; I(2) = 87%), but it had no significant difference compared with IA and IV (mean difference - 37.98; 95% CI - 115.68 to 39.71; P = 0.34; I(2) = 95%). There was no significant difference in thromboembolic events (OR 0.74; 95% CI 0.25 to 2.21; P = 0.59; I(2) = 0%). Blood transfusion was not significantly different between the PAI group and the non-TXA group (OR 0.50; 95% CI 0.23 to 1.06; P = 0.07; I(2) = 21%), and there was no significant difference between PAI and the other two TXA injection methods (OR 0.72; 95% CI 0.41 to 1.25; P = 0.24; I(2) = 19%). CONCLUSION PAI has comparable effects to IV and IA injections. PAI is an alternative injection route of TXA for patients who have undergone TKA.
Topical Application of Tranexamic Acid Can Reduce Postoperative Blood Loss in Calcaneal Fractures: A Randomized Controlled Trial
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2022
The traditional lateral "L" approach is common for managing calcaneal fractures with a drawback of significant blood loss. Yet there are no prospective studies on the hemostatic effect of the topical use of tranexamic acid (TXA) in calcaneal fracture surgeries. The purpose of this study was to evaluate the role of topical administration of TXA in reducing postoperative blood loss in calcaneal fractures. Forty participants were randomly distributed into the TXA group (n = 20) and the control group (n = 20). All participants underwent the same surgery via the lateral "L" approach. At the end of the operation, the surgical wound was irrigated with 80 mL 0.5 g/L TXA in the TXA group and 80 mL 0.9% sodium chloride in the control group, followed by the routine use of a drainage tube when closing the incision. Then, 20 mL 0.5 g/L TXA (TXA group) or 20 mL 0.9% sodium chloride solution (control group) was injected retrogradely into the wound through the drainage tube, which was clipped for 30 minutes thereafter. There were no significant differences in the baseline data between the 2 groups (p > .05). There was significantly less blood loss in the first 24 hours and total blood loss postoperation in the TXA group (p < .01). The surgical wounds healed well after surgery in both groups with no complication. We concluded that topical application of TXA in calcaneal fracture surgeries is a safe and useful method that can reduce postoperative blood loss.
Combined and intravenous administration of TXA reduces blood loss more than topical administration in primary total knee arthroplasty: A randomized clinical trial
Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia. 2022;166(1):68-76
AIM: To determine the most effective administration of tranexamic acid (TXA) in patients with primary total knee arthroplasty (TKA). MATERIAL AND METHOD We enrolled a total of 400 patients (154 men and 346 women) in this randomized trial (4 groups, each of 100 patients). The first group (IV1) had a single intravenous dose (15 mg TXA/kg) prior to skin incision. Group 2 (IV2) had TXA in 2 intravenous doses (15 mg TXA/kg): prior to skin incision and 6 hours after the first dose. Group 3 (TOP) had 2 g TXA in 50 mL of saline irrigated topically at the end of the surgery. The fourth group (COMB) combined IV1 and TOP regimens. We monitored the amount of total blood loss (TBL), haemoglobin drop, use of blood transfusions (BTs), and complications in each patient. RESULTS The amount of TBL was significantly lower in IV1, IV2 and COMB regimens compared to the TOP (P<0.0001). The lowest decrease in haemoglobin within 12 hours after surgery was observed in intravenous regimens (P=0.045). A significant difference in haemoglobin decrease on day 1 after the surgery was demonstrated in the COMB and intravenous regimens (P=0.011). CONCLUSION In primary TKA, it is preferable to administer TXA intravenously in two doses or in a combined regimen. Simple topical administration of TXA was not as effective and is indicated only in cases where systemic administration of TXA is contraindicated. No substantial complications occurred in either group of patients.
Efficacy of extended oral tranexamic acid on blood loss in primary total knee arthroplasty
Acta ortopedica brasileira. 2022;30(spe1):e247197
INTRODUCTION Tranexamic acid is widely used for patients undergoing total knee arthroplasty (TKA). However, the duration of systemic tranexamic acid (TXA) administration varies in many reports. Hence, this study aims to compare blood loss between a single intravenous (IV) TXA dose, and one dose of IV TXA combined with oral TXA, during 48-hour postoperative care in primary TKA. METHODS Ninety-four patients with primary osteoarthritis, who underwent primary TKA, were randomized into two groups. The first group consisted of 47 patients and received a dose of 750 mg IV TXA and 750 mg oral TXA postoperatively at 8-hour intervals for 48 hours. In the second group, 47 patients received a single dose of IV TXA and a placebo at the same intervals for the same time duration. Hemoglobin (Hb) was measured at 4, 24 and 72 hours after operation. RESULTS The mean total blood loss were not different between the two groups (p=0.37). There was no difference in total Hb reduction or closed suction drainage outputs (p=0.9 and 0.07, respectively). CONCLUSION The extended use of oral TXA for 48-hour postoperative care did not decrease the total blood loss following TKA compared with a single dose of IV TXA. Level Of Evidence I; High quality randomized trial .
Is intravenous tranexamic acid effective in reduction of blood loss during pelvic and acetabular surgery?
International orthopaedics. 2022
PURPOSE Pelvic and acetabular surgery is associated with one of the highest amounts of blood loss. Tranexamic acid is a good choice to reduce blood loss during this type of surgery. However, being antifibrinolytic drug, the chance to have coagulation complications including DVT is a risk that should be considered particularly in such major trauma patients with the body's response to trauma and with possible prolonged bed stay. The aim of this study is to evaluate the effectiveness of intravenous tranexamic acid injection during pelvic and acetabular surgery for reduction of blood loss during surgery and after surgery and to evaluate any possible complications for its use. METHODS This prospective randomized clinical trial includes 97 patients divided between two groups; group 1 (G1) which received TXA, while the second group (G2) is the control group. The primary outcome measures were total blood loss (TBL), allogenic blood units transfused, and the blood lost intra-operatively (IBL). The TBL was calculated by the haemoglobin balance method while the intra-operative blood loss was measured by the gravimetric method. Any complications related to the drug were evaluated particularly DVT. RESULTS The study showed significantly less TBL (G1 = 829.7 ± 219.2, G2 = 1036.9 ± 314.9) and blood transfusion (G1 = 52.4 ± 40 g, G2 = 89.4 ± 60.6 g) in G1 compared to the G2. CONCLUSION This study proved the possible reduction of TBL and the need of blood transfusion by the use of TXA in pelvic and acetabular injuries.
The use of tranexamic acid reduces blood loss in osteotomy at knee level: a systematic review
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2022
PURPOSE Aim of this systematic review was to evaluate the literature regarding the effect of tranexamic acid (TXA) on the outcome after knee osteotomy. METHODS A systematic literature search was carried out in various databases on studies on the use of tranexamic acid in osteotomies around the knee. Primary outcome criterion was the hemoglobin (drop). Secondary outcome criteria were total blood loss, drainage volume, adverse effects such as thromboembolic events, blood transfusions, wound complications and clinical scores. A meta-analysis was performed for quantitative measures. The present study was registered prospectively ( www.crd.york.ac.uk/PROSPERO ; no.: CRD42021229624). RESULTS Seven studies with 584 patients (TXA group: 282 patients, non TXA group: 302 patients) Hemoglobin decrease (1.54 g/dl vs. 2.28 g/dl), blood loss (394.49 ml vs. 595.54 ml) and drainage volume (266.5 ml vs. 359.05 ml) were significantly less in the TXA group compared to the non TXA group. No thromboembolic event was noted in any study. In the non TXA group four blood transfusions were given. Eleven wound complications occurred in the non TXA group in comparison to two wound complications in the TXA group. CONCLUSIONS The results of the present study show that the application of TXA reduces hemoglobin drop, blood loss and drainage volume. These effects could be responsible for the lesser rate of side effects after administration of TXA during knee osteotomy.
Effect of Oral Tranexamic Acid on the Blood Transfusion Rate and the Incidence of Deep Vein Thromboembolism in Patients after TKA
Evidence-based complementary and alternative medicine : eCAM. 2022;2022:6041827
PURPOSE To explore the effect of oral tranexamic acid treatment on the blood transfusion rate and the incidence of deep vein thromboembolism after total knee arthroplasty (TKA). METHODS 90 patients undergoing TKA admitted to First People's Hospital of Changshu City from January 2019 to January 2020 were selected and randomized into the control group and the experimental group accordingly (45 cases in each group). The control group intravenously received 20 mL/kg tranexamic acid before the incision was closed. The experimental group was given 1 g of tranexamic acid orally before anesthesia, 6 h and 12 h after the operation. RESULTS The experimental group witnessed better perioperative indexes in relation to the control group. The experimental group displayed better postoperative coagulation function indexes as compared to the control group (P < 0.05). Remarkably lower postoperative vascular endothelial function indexes in the experimental group than in the control group were observed. The experimental group experienced a markedly lower incidence of deep vein thromboembolism in comparison with the control group (P < 0.05). The postoperative knee society score (KSS) score of the experimental group was significantly higher than that of the control group. A significantly higher postoperative modified rivermead mobility index (MRMI) score was yielded in the experimental group in contrast to the control group (P < 0.05). The experimental group obtained lower numerical rating scale (NRS) scores at T2 and T3 as compared to the control group. CONCLUSION Oral tranexamic acid is a suitable alternative for patients undergoing TKA in terms of reducing the blood transfusion rate, relieving pain, and accelerating the recovery of the patient's limbs.
Intra-articular Versus Intravenous Tranexamic Acid in Primary Total Knee Replacement
Background Total knee replacement (TKR) is an artificial joint surgical procedure that replaces the damaged articular surfaces of the knee joint. Despite several studies on the efficacy of intra-articular and intravenous Tranexamic acid (TX) use in reducing blood loss following TKR, the route of TXA administration is still an ongoing topic of debate. Our study aimed to compare total knee replacement efficacy (hemoglobin level, hematocrit level, hospital stay, and complications) of intra-articular and intravenous tranexamic acid administration. Material and Methods A Prospective study was conducted at the Department of Orthopedics, Shifa International Hospital, Islamabad. The study duration was six months (August 2020 to February 2021). A sample size of 60 patients was calculated using the WHO calculator. Patients were selected through non-probability consecutive sampling. Patients were randomly divided into two groups; Group A was given intraarticular TXA, while group B was given intra-venous TXA following total knee replacement. Patients were followed for 48 hours. Data were analyzed using SPSS version 24. An Independent T-test was applied, and a P value≤0.05 was considered significant. Results A total of 60 patients were included in the study. There were 20 (33.3%) male and female 40 (66.7%). The mean age of patients was 64.4±10.8SD. Post-operative hemoglobin level in group A was 11.09±0.39SD, and in group B was 9.93±1.73SD (p=0.03). Postoperatively, the mean HCT level in group A was 30.53±4.26SD and group B 26.88±5.48SD (p=0.01). Conclusion Intra-articular administration of TXA is more effective than intravenous administration in controlling postoperative blood loss following total knee replacement.
The efficacy and safety of combined administration of intravenous and intra-articular tranexamic acid in total knee arthroplasty: An update meta-analysis
Journal of clinical pharmacy and therapeutics. 2022
WHAT IS KNOWN AND OBJECTIVE This study was performed to compare the efficacy and safety of combined administration of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) with IV or IA TXA alone in total knee arthroplasty (TKA). METHODS PubMed, Embase, Cochrane Library and Web of Science were searched for randomized controlled trials (RCTs) in July 2021. Total blood loss, transfusion rate, postoperative haemoglobin drop, drain output, deep venous thrombosis (DVT) and pulmonary embolism (PE) were pooled. Data were analyzed using Stata 14.0 software. The study protocol was registered with PROSPERO, number CRD42020186654. RESULTS Ten RCTs involving 1306 patients were included. Combined TXA group provided lower total blood loss (SMD -0.47; 95% CI -0.64 to -0.30; p < 0.001), postoperative haemoglobin drop (SMD -0.47; 95% CI -0.60 to -0.33; p < 0.001) and drain output (SMD -0.50; 95% CI -0.71 to -0.29; p = 0.009) compared with IV or IA TXA alone group. No significant difference was found in terms of transfusion rate (OR 0.53; 95% CI 0.23 to 1.23; p = 0.137) and DVT (OR 0.55; 95% CI 0.18 to 1.68; p = 0.293). PE data was provided by all 10 studies, but PE only occurred in one patient in IV TXA alone group. WHAT IS NEW AND CONCLUSION Combined administration of IV and IA TXA was relatively more effective in reducing total blood loss, transfusion rate, postoperative haemoglobin drop, and drain output after TKA. TXA may not increase the risk of DVT/PE, but it also needs to be monitored in clinical application.