Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

IntroductionOpen reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial.Material and methodsSixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated.ResultsBoth groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups.ConclusionThere is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.     

大剂量氨甲环酸降低脊柱结核患者围手术期出血风险

目的探讨预防性应用大剂量氨甲环酸能否有效减少脊柱结核围手术期出血及相关不良事件。方法选择本院2016年1月-2018年12月行一期经椎间孔入路病灶切除椎间植骨融合内固定术治疗的腰椎结核患者90例,随机分为小剂量氨甲环酸治疗组(小剂量组)、大剂量氨甲环酸治疗组(大剂量组)和对照组,每组30例。所有患者全身抗结核治疗2~3周后行一期经椎间孔入路病灶切除椎间植骨融合内固定治疗。小剂量组静脉泵注含1 mg/kg氨甲环酸的生理盐水50 mL,大剂量组泵注含15 mg/kg氨甲环酸的生理盐水50 mL,对照组泵注等量生理盐水,均于术前30 min开始泵注。记录手术时间,术中和术后出血时间、出血量、输血量,手术前后凝血功能,术后引流量、血红蛋白量及红细胞比容,住院时间、术后恢复时间及其他不良事件。结果3组患者手术时间、术中及术后出血时间、术后出血量及输血量、手术前后凝血功能、住院时间、术后恢复时间差异均无统计学意义(P>0.05)。大剂量组术中出血量及输血量和术后引流量均较小剂量组和对照组降低,差异有统计学意义(P<0.05),小剂量组与对照组差异无统计学意义(P>0.05)。大剂量组术后血红蛋白水平、术后红细胞比容均高于小剂量组及对照组,差异有统计学意义(P<0.05),小剂量组与对照组之间差异无统计学意义(P>0.05)。所有患者围手术期均未发生手术部位感染、血管和神经损伤及静脉血栓等严重并发症。所有患者术后随访8~12个月,椎间植骨均获得骨性融合,未发生假关节形成,内固定物断裂、松动、脱落等情况。所有患者结核症状消失,病灶全部愈合,无复发。结论术前预防性应用大剂量氨甲环酸可降低脊柱结核患者围手术期出血风险,且不增加不良事件发生风险。     

Reducing blood loss in pediatric craniosynostosis surgery by use of tranexamic acid

IntroductionCraniosysnostosis surgical corrections are routine procedures in the pediatric neurosurgical field. However, these procedures result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic drug, which has demonstrated a significant reduction in perioperative blood loss in many pediatric surgical procedures such as cardiac surgery and scoliosis surgery. We conducted a systematic review to evaluate protocols of TXA use in pediatric craniosynostosis procedures and its effect on intraoperative blood loss and transfusions.Material and methodsA comprehensive literature review of the National Library of Medicine (PubMed) database was performed to identify relevant studies. We included any clinical study reporting on blood loss or blood transfusion for pediatric craniosynostosis surgery with intraoperative use of tranexamic acid, with the following limits: publication date from inception to May 2019; reports in English.ResultsThirteen studies were eligible for our review. Of the 13 studies, 4 were prospective, randomised, double-blind controlled trials, 9 were retrospective studies, tailored as a “before–after” studies, comparing blood loss and transfusion without/with TXA. TXA significantly decreases the number and volume of packed red blood cell transfusions and the rate of transfusion in children undergoing craniosynostosis surgery. Significantly fewer fresh frozen plasma transfusions were required in the TXA groups in 2 randomised studies. Length of stay in hospital was significantly lower with the use of TXA in three studies. Advantages of TXA administration also include an excellent patient tolerance of side effects, ease of administration and low cost.ConclusionTXA significantly reduces blood loss and the need for transfusions in children undergoing craniosynostosis surgery. TXA administration should be a routine part of strategy to reduce blood loss and limit transfusions in these procedures.     

氨甲环酸不同静脉给药方式对青少年特发性脊柱侧凸后路矫形术中出血量的影响

目的 对比氨甲环酸(TXA)不同静脉给药方式对青少年特发性脊柱侧凸(AIS)后路矫形术中出血量的影响及安全性.方法 2017年1月—2020年3月,廊坊市第四人民医院采用脊柱后路矫形术治疗AIS患者120例,按照随机数字表法分为3组,每组40例.A组切开皮肤前15 min静脉滴注TXA 30 mg/kg;B组切开皮肤前15 min静脉滴注TXA 15 mg/kg,术中给予TXA 10 mg/(kg·h)维持至术毕;C组围手术期不使用TXA.比较3组手术时间、术中出血量、异体血输注量、晶体输注量、胶体输注量、术后输血率、术后引流量及手术前后血红蛋白(Hb)水平、D-二聚体(D-D)水平等指标,并记录并发症发生情况.结果 所有手术顺利完成.A、B组术中出血量、异体血输注量、胶体输注量、术后输血率、术后1 d引流量低于C组,术后各时间点Hb水平高于C组,差异均有统计学意义(P<0.05);以上指标A、B组组间比较,差异无统计学意义(P>0.05).3组术后各时间点D-D水平均较术前明显升高,术后1 d达到最高值,之后逐渐下降;术后各时间点A、B组D-D水平低于C组,差异均有统计学意义(P<0.05);A、B组组间比较,差异无统计学意义(P>0.05).所有患者切口愈合良好,术后双下肢血管超声检查未见深静脉血栓形成.术后电话随访均未出现相关并发症.结论 术前TXA足够剂量静脉滴注可取得与首次负荷量联合术中维持量静脉滴注相同的止血效果,无安全隐患,术前单剂量静脉滴注在操作上更为简便,值得推广应用.     

The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial

BACKGROUND CONTEXTTranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction.PURPOSEThe primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects.STUDY DESIGNProspective, double-blinded, randomized controlled trial.PATIENT SAMPLEA total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study.OUTCOME MEASURESThe primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL.METHODSPatients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo.RESULTSThe mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1–786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6–763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL.CONCLUSIONSA multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.     

Tranexamic acid in non-elective primary total hip arthroplasty

PurposeBlood loss during and following elective total hip arthroplasty (THA) can be substantial and may require allogeneic blood transfusions which carries significant risks and morbidity for patients. Intraoperative use of tranexamic acid (TXA) has been proven to reduce the need for allogeneic blood transfusion in elective THA patients. Data regarding TXA efficacy in reducing blood loss in trauma patients undergoing non-elective primary THA is sparse, and its routine use is not well established.MethodsThis is a retrospective analysis of a consecutive cohort of patients who underwent non-elective primary THA in a tertiary medical center between January 1st 2011- December 31st 2019. The cohort was divided into two groups; one received perioperative TXA treatment while the other did not. Blood loss, blood product administration, peri and postoperative complications, readmissions and 1-year mortality were compared between groups.ResultsA total of 419 patients (146 males, 273 females) who underwent THA were included in this study. The "TXA" group consisted 315 patients compared to 104 patients in the "no TXA" group. TXA use reduced postoperative bleeding, as indicated by changes in hemoglobin levels before and after surgery (ΔHb= -2.75 gr/dL vs. ΔHb= -3.34 gr/dL, p<0.001) and by administration of allogeneic blood transfusions (7.0% vs. 16.3%, p = 0.004).ConclusionSimilar to the known effect of TXA in elective THA patients, the use of TXA treatment in patients undergoing non-elective THA led to a significant reduction in postoperative blood loss and in the proportion of patients requiring allogeneic blood transfusions.     

Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized,controlled study

BACKGROUND: Extensive blood loss in total knee replacement (TKR) surgery is well known and is associated with a high transfusion rate of allogenic blood. Tranexamic acid (TXA) has been shown to reduce blood loss by 50% in this patient group, but only in cases with a perioperative loss of 1400-1800 ml. This study was performed to see if TXA offers any advantages in knee replacement surgery with blood loss at 800 ml. METHODS: Thirty consecutive patients scheduled for TKR in spinal anesthesia with the use of a tourniquet, were randomized to TXA or non-TXA. Tranexamic acid 10 mg kg-1 was given at conclusion of surgery and again 3 h later. Blood loss was registered. RESULTS: Total blood loss was at all times significantly lower in the TXA group compared to the non-TXA group (409.7+/-174.9 ml vs. 761.7+/-313.1 ml; P<0.001). There were no differences in coagulation parameters. No patients in the TXA group had a blood transfusion vs. 13% in the non-TXA group (NS). No complications were registered in the two groups. CONCLUSION: We conclude that TXA significantly reduces blood loss after total knee replacement surgery.     

口服和静脉注射氨甲环酸对于腰椎椎管减压融合术的围手术期失血量影响

目的 ：探讨氨甲环酸（tranexamic acid,TXA）不同给药方式对腰椎椎管减压融合术围手术期失血量、隐性出血量、输血率,以及不良反应等各方面的影响。方法：对2019年7月至2020年7月接受腰椎椎管减压融合术的60例患者进行回顾性分析,根据TXA不同给药方式分为观察组和对照组,每组30例。观察组术前2 h口服2 g TXA;对照组在切皮前5～10 min予以1 g TXA静脉输注,术后6 h予以1 g TXA静脉输注1次。分别记录两组患者术中出血量、术后引流量、总失血量、隐性失血量、引流管拔除时间、输血率、静脉血栓形成率、不良事件发生率,观察术前和术后1、3 d血红蛋白（hemoglobin,Hb）,红细胞比容（hematocrit,HCT）的变化情况。结果：术后1、3 d的Hb及HCT均较术前有明显改善（P<0.01）,但组间比较差异无统计学意义（P>0.05）。两组术中出血量、术后引流量、总失血量、术中失血量、隐性失血量、拔管时间、输血率比较差异无统计学意义（P>0.05）。两组患者均未见静脉血栓形成和不良事件发生。结论：在腰椎椎管减压融合术围手术期口服...     

Tranexamic acid reduces blood loss in simultaneous bilateral total knee arthroplasty: a randomized control trial

Total knee arthroplasty (TKA) is a common procedure, and bilateral TKA ensures cost efficiency. Bilateral TKA is associated with increased requirement of blood transfusion (BT). BT is associated with hazards, therefore be avoided. Tranexamic acid (TXA) has been suggested to reduce the BT, and the use of TXA in bilateral TKA appears sparse in literature. This study aimed at assessing the effect of TXA in such patients. This prospective randomized controlled trial evaluated the use of TXA in bilateral TKA. Pre- and postoperative hemoglobin (Hb) and packed cell volume (PCV), blood loss and BT, hospital stay, and the cost of TXA compared to blood transfusion were the measured variables. 175 patients (n?=?88 TXA, n?=?87 CTRL) completed the study. The patients in the control (CTRL) group on an average received 0.3 units and 0.07 in TXA group. The average blood loss in the TXA group was significantly less than the CTRL (P?<?0.0001). There was no significant difference in the perioperative complications, hospital stay in the two groups. The use of TXA reduces the postoperative blood loss. The allogenic BT requirement in patients undergoing bilateral TKA is significantly decreased. The routine use of this drug is cost-effective and reduces postoperative blood loss.     

Combination effect of intraoperative and postoperative intravenous tranexamic acid in hip hemiarthroplasty. A propensity score matched analysis

BackgroundTranexamic acid (TXA) has been proven to reduce perioperative blood loss and the incidence of allogeneic blood transfusion in total joint arthroplasty (TJA). However, there is limited literature on the use of TXA in patients undergoing hip hemiarthroplasty. Furthermore, combination effect of intraoperative and postoperative intravenous TXA has not been investigated extensively. The purpose of this study was to evaluate this combination effect on hip hemiarthroplasty by a propensity score matched analysis (PSMA).MethodsThis is a retrospective cohort study involving hip hemiarthroplasty for femoral neck fracture. All patients received 1g intraoperative intravenous TXA. One group also received 1g intravenous TXA 6h after surgery, while the other group did not. Perioperative blood loss, the incidence of allogeneic blood transfusion and venous thromboembolism (VTE) were collected and compared.Results209 patients who underwent unilateral hip hemiarthroplasty were included. PSMA resulted in 66 matched pairs in each group. There were no significant differences in perioperative blood loss on postoperative day (POD) # 1, 3, 5 (637.2 ± 285.9 versus 653.6 ± 305.5, 726.6 ± 274.2 versus 676.3 ± 313.2, 795.5 ± 291.2 versus 759.9 ± 328.4), the incidence of allogeneic blood transfusion (9.1% versus 12.1%) and VTE (1.5% versus 1.5%) between the two groups (P value> 05) for up to one year.ConclusionIntraoperative and postoperative intravenous TXA have no combination effect on reducing perioperative blood loss, the incidence of allogeneic blood transfusion and VTE in patients undergoing hip hemiarthroplasty.     

围手术期全程血液管理在老年腰椎退行性疾病治疗中的应用

目的观察围手术期全程血液管理对老年腰椎退行性疾病患者术中出血量、术后引流量以及输血量的影响,探讨减少围手术期出血的有效方法。方法回顾性分析2014年1月—2016年12月收治的90例老年退行性腰椎疾病患者,早期45例患者采用围手术期常规血液管理模式(常规组),后期45例患者采用围手术期全程血管理模式(全程组)。记录并比较2组患者手术时间、术中出血量、术后引流量、输血例数及输血量、血红蛋白浓度和红细胞压积。结果全程组手术时间、术中出血量、术后引流量、输血例数、输血量均低于常规组,术后3 d及1周血红蛋白浓度、红细胞压积均高于常规组,差异均具有统计学意义(P0.05)。结论老年腰椎退行性疾病患者采用围手术期全程血液管理可有效降低术中出血量和术后引流量,降低输血量和输血率,有利于患者术后恢复。     

Hemostatic and Anti-Inflammatory Effects of Carbazochrome Sodium Sulfonate in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundPostoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.MethodsThis study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.ResultsTotal blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).ConclusionCSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications.     

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Tranexamic Acid Administration is Associated With a Decreased Odds of Prosthetic Joint Infection Following Primary Total Hip and Primary Total Knee Arthroplasty: A National Database Analysis

BackgroundTranexamic acid (TXA) for the reduction of blood loss in orthopedic surgery is coming into greater adoption. Because TXA administration lowers the incidence of blood transfusion and of hematoma formation, risk factors for infection, we asked whether TXA use might be associated with a lower incidence of periprosthetic joint infection (PJI) following orthopedic surgery.MethodsWe queried the Premier Healthcare database for ICD-9 codes corresponding to elective inpatient primary total hip replacement (THR) or total knee replacement (TKR) from 2012 to 2016, TXA administration on the day of surgery, and PJI during the hospital stay or within 90 days. We performed a multilevel multivariable logistic regression (SAS version 9.4. SAS Institute, Cary, NC) to determine if TXA administration or other covariates were a significant predictor of infection.ResultsAmong 914,990 total joint arthroplasty patients, 46.0% received TXA on the day of surgery. 0.13% developed PJI within 90 days. After adjusting for patient and hospital-related covariates, TXA use was associated with significantly lower odds of PJI within 90 days of surgery (OR 0.49 [0.69, 0.91]).ConclusionAdministration of TXA on the day of surgery in total knee and total hip arthroplasty was associated with a statistically significant decreased odds of PJI in the first 90 days. We therefore conclude that TXA might play an important role in our attempts to decrease PJI after joint arthroplasty. The exact mechanisms and ideal dosage by which TXA can contribute to such a reduction need further study.     

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

ObjectiveTo investigate the effect of tranexamic acid (TXA) on hidden bleeding in older intertrochanteric fracture patients treated with intramedullary nails.MethodBetween January 2016 and January 2017, 100 cases of intertrochanteric fractures eligible for the study were treated with proximal femoral nail antirotation (PFNA) in our hospital. All patients were divided into two groups of 50 patients each: the TXA group and a blank control group. In the TXA group, all patients received TXA at a dose of 10 mg/kg⁻¹ intravenously, 10 min preoperatively and 5 h postoperatively. The control group did not receive TXA. We recorded the volume of intraoperative blood loss and postoperative drainage, and the need for postoperative blood transfusion and transfusion volume for all patients. Blood routine examination was performed on the day of surgery and 2 days postoperatively. We calculated the total blood loss and hidden blood loss in the two groups separately according to the Gross equation. All patients underwent deep vein ultrasound of the lower limbs preoperatively and 1 week postoperatively to detect thrombosis.ResultsCompared with controls, patients in the TXA group had lower: overt bleeding (50.59 ml; p = .012), total blood loss (181.58 ml; p = .005), hidden blood loss (130.64 ml; p = .037), volume of blood transfusion (110.0 ml; p = .019), and 20% lower transfusion rate compared with the control group. Patients receiving short-nail fixation had significantly lower hidden blood loss compared with patients receiving long-nail fixation (p < .05). However, we found no statistically significant difference in the incidence of deep vein thrombosis in the lower limbs between the two groups (p = .938).ConclusionTXA significantly reduced hidden blood loss in older intertrochanteric fracture patients treated with intramedullary nails without an increased risk of thrombosis in lower limb deep veins.     

Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients

BackgroundTranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA.MethodsWe retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery.ResultsThere was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA.ConclusionTXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.     

The effect of tranexamic acid on wound complications in primary total Hip Arthroplasty: A meta-analysis

BackgroundAllogeneic blood transfusion has been linked with an increase in the risk of surgical site infections (SSIs) through the mechanism of immunomodulation. However, no studies to date have investigated the direct relationship between blood conserving strategies including antifibrinolytics and wound complications after total hip arthroplasties (THA).MethodsA systematic review and meta-analysis of published randomised controlled trials (RCTs) to investigate the effect of tranexamic acid (TXA) on wound complications after THAs has been conducted.ResultsWe identified 25 clinical trials which were suitable for detailed data extraction. There were no trials which utilised TXA in revision THA. All studies reported on wound complications including a total of 1608 patients. Using TXA led to a 2% reduction in the risk of developing wound complications compared to the control group with no significant statistical heterogeneity among the study groups (Risk Difference −0.02, 95%, confidence interval CI -0.04 to −0.00, P = 0.01, Heterogeneity I² = 0%). However, there was no significant difference in clinical outcomes in terms of antibiotic treatment or surgical intervention among the study groups. TXA also reduced intraoperative, postoperative and total blood loss and led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion with no significant differences in deep venous thrombosis, pulmonary embolisms, or other complications between the study groups.ConclusionTXA reduced blood loss and transfusion rates after primary THA surgery. It also reduced wound complication rates but the clinical significance of this needs further investigation through well designed and adequately powered RCTs.     

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

AimThe objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages.MethodsA systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri?operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events’ incidence. A subgroup analysis was performed with respect to TXA dosage.ResultsOut of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between “single” and “multiple doses” studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg.ConclusionsThis meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes.     

The administration of tranexamic acid for corrective surgery involving eight or more spinal levels: A systematic review and meta-analysis

As the number of fusion levels increases, the complexity of spinal correction surgery also increases. Thus, we conducted this study to determine the safety and efficacy of tranexamic acid (TXA) involving eight or more spinal fusion levels. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines, a search of the PubMed, Embase, CENTRAL, Web of Science, and ClinicalTrials.gov databases was conducted for relevant studies published prior to May 30, 2019. The primary outcomes, including blood loss and transfusion requirement, and the secondary outcomes, including general indices, postoperative hemoglobin, and coagulation function, were analyzed using Rev Man 5.3.5 software and STATA version 12.0. Eight randomized controlled trials (473 participants) were included in the study. Compared to the control treatments, TXA reduced intraoperative blood loss, total blood loss, transfusion volume, and prothrombin time. There were no significant differences between the TXA and non-TXA groups in transfusion rate, operative time, hospital stay, complications, hemoglobin level, and other coagulation function parameters. In the pediatric subgroup analysis, TXA additionally improved hemoglobin levels, platelet count, and prothrombin time international normalized ratio. The present meta-analysis showed that TXA reduced blood loss and transfusion volume in both adults and children. In pediatric patients, TXA led to a greater benefit in postoperative hemoglobin levels and coagulation function. Intravenous TXA is safe and effective in children with eight or more spinal corrective levels.     

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

IntroductionTopical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.MethodsA total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.ResultsThere was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760–1.795) in the TXA group and 1.078 L (IQR: 0.797–1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40–140) in the TXA group and 70 mL (IQR: 30–168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).ConclusionA 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.