Is there a role for antifibrinolytics in pelvic and acetabular fracture surgery?

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Is intravenous tranexamic acid effective in reduction of blood loss during pelvic and acetabular surgery?

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.

Tranexamic acid use in pelvic and/or acetabular fracture surgery: A systematic review and meta-analysis

Purpose

The purpose of this study is to determine whether tranexamic acid (TXA) use was associated with lower rates of blood transfusion in patients undergoing pelvic and/or acetabular fracture surgery.

Methods

Four studies were included, 3 of which were included in the pooled data analysis for a total of 308 patients.

Results

The transfusion rate was significantly lower in the TXA group (44%) compared with the non-TXA group (57%) (P = 0.02).

Conclusion

TXA use was associated with a significantly lower transfusion rate in patients who underwent pelvic and/or acetabular fracture surgery.

Level of evidence

Level 3. Systematic review of retrospective cohort studies and prospective randomized controlled trials.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery

PURPOSE

Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration.

METHODS

We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion.

RESULTS

Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p < 0.01) and intraoperative IV fluids (p < 0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70 years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion.

CONCLUSION

In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.

[Research progress on tranexamic acid in traumatic orthopedic surgery]

OBJECTIVE

To summarize the research progress on the application of tranexamic acid (TXA) in traumatic orthopedic surgery in recent years.

METHODS

The domestic and foreign literature in recent years was reviewed, and the efficacy and safety of TXA in traumatic orthopedic surgeries with different regimen, dose and route of administration were comprehensively summarized and compared.

RESULTS

The application of TXA in traumatic orthopedic surgeries increased gradually in recent years. Intravenous or topical administration of TXA efficaciously reduced blood loss and transfusion requirements during hip fracture surgery without significantly increasing the risk of thromboembolic events. However, the efficacy was not clear in other traumatic orthopedic surgeries such as pelvic and acetabular fractures.

CONCLUSION

More studies are needed to confirm the efficacy and safety of TXA in traumatic orthopedic surgeries.

Role of Local Infiltration of Tranexamic Acid in Reducing Blood Loss in Peritrochanteric Fracture Surgery in the Elderly Population

Introduction: Peritrochanteric fractures are common injuries occurring in elderly patients. Surgeries for these fractures are associated with significant blood loss. Intravenous tranexamic acid has a proven track record in many orthopaedic surgeries including trauma, arthroplasty and spine surgeries.

Objective: To study the effect of local subfascial and intramuscular infiltration of tranexamic acid in reducing blood loss and the requirement for blood transfusion in intertrochanteric fracture surgery.

Study Design: Single centre prospective analytical study.

Materials and Methods: One hundred and thirty seven patients above 65 years of age were included in the study, divided into two groups: the intervention group received subfascial and intramuscular infiltration of 2g tranexamic acid before wound closure and the control group of alternate patients did not receive any tranexamic acid infiltration. The postoperative drain output was recorded, as well as the haemoglobin level and the patients needing blood transfusion.

Results and Conclusions: The preoperative and postoperative haemoglobin values were recorded. The mean preoperative haemoglobin was 10.9% and 10.8% (p=0.79) in the trial and control groups respectively. The mean postoperative haemoglobin was 9.5gm% and 9.2gm% (p=0.36) in the two groups. The total postoperative blood loss in the tranexamic acid group and the control group was 190.3ml and 204.3ml respectively (p=0.25). Ten patients (14.9%) in the intervention group and 12 patients (17.1%) in the control group required blood transfusion. We conclude that tranexamic acid does not play a significant role in reducing postoperative blood loss and blood transfusion when used locally in peritochanteric fracture surgery. However a larger double blinded study comparing various modalities of use of tranexamic acid is needed to conclusively establish its role.