Is combined topical and intravenous tranexamic acid superior to single use of tranexamic acid in total joint arthroplasty?: A meta-analysis from randomized controlled trials

Navigating anemia and anticoagulation in elderly patients undergoing orthopedic surgery: strategies for preventing complications and implementing treatments

BACKGROUND

Elderly populations face an increased risk of anemia, leading to elevated transfusion requirements during surgery, especially major orthopedic procedures. Anemia itself increases the risk of thromboembolic events, thus compounding complications in elderly individuals. Polypharmacy and the prevalent use of oral anticoagulants (OAC), particularly for atrial fibrillation, contribute to bleeding risks in this population. Data available in the literature on the peri-operative management of anemia in patients taking OAC is limited and often heterogeneous.

MATERIALS AND METHODS

This narrative case-based review focuses on the peri-operative management of elderly patients on OAC undergoing major orthopedic surgery. PubMed/Medline was used to search for relevant literature.

RESULTS

With reference to two cases, we critically evaluate the literature, and focus on risk factors, and preventive and therapeutic strategies as fundamental tools to reduce bleeding and correct anemia as soon as possible in elderly patients undergoing major orthopedic surgery.

DISCUSSION

Peri-operative management of these patients, especially those on OAC, requires a balanced approach considering bleeding and thrombotic risks. Intravenous iron therapy and tranexamic acid emerge as valuable strategies in minimizing transfusion requirements and optimizing patients' outcomes.

Perioperative bleeding control in total hip arthroplasty: hemostatic powder vs. tranexamic acid-a prospective randomized controlled trial

BACKGROUND

Perioperative bleeding in total hip arthroplasty (THA) can lead to various problems, so effective management of blood loss is needed. This prospective, single-blind, randomized controlled trial aimed to compare the efficacy of topical administration of SURGICEL® (a hemostatic agent of oxidized regenerated cellulose) powder (SP) and tranexamic acid (TXA) in controlling perioperative bleeding during THA.

MATERIALS AND METHODS

In total, 114 patients undergoing THA for osteoarthritis were randomized to either group S (THA with SP) or group T (THA with TXA). Data including patient demographics, laboratory data (C-reactive protein [CRP], hemoglobin, and hematocrit), operative time, and intraoperative blood loss were analyzed. Clinical outcomes were assessed using WOMAC, JOA, FJS scores, and visual analog scale (VAS) scores. Primary outcomes were estimated total and postoperative blood loss, while secondary outcomes included hematological test results and various clinical scores.

RESULTS

57 patients were allocated to each group, with 55 in group S and 56 in group T were finally included in the analysis. There was no significant difference (p = 0.141) in estimated total blood loss between group S (788.2 ± 350.1 ml) and group T (714.1 ± 318.4 ml). Hemoglobin and hematocrit levels and WOMAC, and FJS scores were not significantly different between the two groups at any time point. CRP levels were significantly different on postoperative days 4 and 7, and JOA score was significantly different on preoperative and postoperative period. However, the differences in CRP and JOA score values themselves were relatively small and not clinically different.

CONCLUSIONS

Topical administration of SP is as effective as TXA in reducing perioperative bleeding in patients undergoing THA. Additionally, no significant difference was observed in early postoperative clinical outcomes between SP and TXA.

LEVEL OF EVIDENCE

Therapeutic Level I.

TRIAL REGISTRATION

The University Hospital Medical Information Network (UMIN) registration number UMIN000047607.

Are The Applications of Tranexamic Acid in Reverse Hybrid Total Knee Arthroplasty (TKA) The Same as Those in Fully Cemented TKA?: A Randomized Controlled Trial

INTRODUCTION

Traditional fully cemented prosthesis for total knee arthroplasty (TKA) has many disadvantages. Current studies have shown that the effects of mixed fixation TKA are the same as or even better than those of fully cemented TKA. We aimed to compare the total blood loss (TBL) in the two fixation types of TKA and the hemostatic effects of different doses of tranexamic acid (TXA) for reverse hybrid TKA.

METHODS

From September 2018 to November 2020, 233 patients with knee osteoarthritis undergoing unilateral TKA were randomly divided into four groups: groups 1 and 2: fully cemented TKA + intra-articular injection (IAI) of either 1 g TXA (n = 54) or 2 g TXA (n = 60); groups 3 and 4: reverse hybrid TKA + IAI of either 1 g TXA (n = 56) or 2 g TXA (n = 63). All patients were administered intravenous drip of TXA (20 mg/kg) as the basic drug. Perioperative and follow-up data of all patients were compared.

RESULTS

The TBL in groups 1, 2, and 3 was higher than that in group 4 (P < 0.0001). The TBL in group 1 was significantly less than that in group 3 (P < 0.05). Although there was no significant difference in blood transfusion demand among the four groups (P > 0.05), the number of anemic patients who did not meet the standard of blood transfusion in group 4 decreased significantly (P < 0.0001). There was no significant difference in pain, function or thrombotic complications among all patients.

CONCLUSION

The TBL in reverse hybrid TKA is larger than in fully cemented TKA. For reverse hybrid TKA, the hemostatic effect of TXA with 2 g of IAI was significantly better than with 1 g. Although this method does not reduce the need for blood transfusion, it can significantly reduce the incidence of postoperative anemia.

Effectiveness and Safety of the Combined Use of Tranexamic Acid: A Comparative Observational Study of 1909 Cases

BACKGROUND

Tranexamic acid (TA) use in lower‑limb arthroplasty has been valued in these surgeries high‑risk hemorrhagic due to its antifibrinolytic action. The objective of the present study was to determine the effectiveness of the combined intravenous (IV) and intraarticular (IA) administration of TA in lower‑limb arthroplasty.

METHODS

We conduct a prospective observational study between January 1, 2014, and December 31, 2017, including all programmed lower‑limb arthroplasties. Patients were divided into four groups: no TA, 15 mg/kg IV TA, 3 g IA TA, and 15 mg/kg IV and 3 g IA. The effect on calculated total blood loss (milliliter of red blood cell [RBC]), hemoglobin, transfusion, and duration of hospitalization was studied after adjustment on age, American Society of Anesthesiologists, surgery, and postoperative curative anticoagulation. Complications related to TA administration were systematically reported.

RESULTS

A total of 1909 patients were included - "no TA," n = 184; "IV," n = 1137; "IA," n = 214; and "IV + IA," n = 374. In the IV + IA group, a decrease in blood loss was observed compared to the no TA group (+ 220 ml 95% confidence interval [CI] [184; 255] of RBC P < 0.001) and in the IA group (+ 65 ml 95% CI [30; 99] of RBC P < 0.001). The length of hospital stay of the IV + IA group was shorter compared to the no TA group (hazard ratio [HR] 0.35, 95% CI [0.29; 0.43], P < 0.001) to the IA group (HR 0.57, 95% CI [0.48; 0.69], P < 0.001) and the IV group (HR 0.45, 95% CI [0.39; 0.50], P < 0.001). One case of deep vein thrombosis occurred in the group without TA.

CONCLUSION

Administration of combined TA appears effective and safe; further studies are needed in order to establish a consensual protocol.

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.

Effectiveness and Safety of the Combined Use of Tranexamic Acid: A Comparative Observational Study of 1909 Cases

BACKGROUND

Tranexamic acid (TA) use in lower-limb arthroplasty has been valued in these surgeries high-risk hemorrhagic due to its antifibrinolytic action. The objective of the present study was to determine the effectiveness of the combined intravenous (IV) and intraarticular (IA) administration of TA in lower-limb arthroplasty.

METHODS

We conduct a prospective observational study between January 1, 2014, and December 31, 2017, including all programmed lower-limb arthroplasties. Patients were divided into four groups: no TA, 15 mg/kg IV TA, 3 g IA TA, and 15 mg/kg IV and 3 g IA. The effect on calculated total blood loss (milliliter of red blood cell [RBC]), hemoglobin, transfusion, and duration of hospitalization was studied after adjustment on age, American Society of Anesthesiologists, surgery, and postoperative curative anticoagulation. Complications related to TA administration were systematically reported.

RESULTS

A total of 1909 patients were included - "no TA," n = 184; "IV," n = 1137; "IA," n = 214; and "IV + IA," n = 374. In the IV + IA group, a decrease in blood loss was observed compared to the no TA group (+220 ml 95% confidence interval [CI] [184; 255] of RBC P < 0.001) and in the IA group (+65 ml 95% CI [30; 99] of RBC P < 0.001). The length of hospital stay of the IV + IA group was shorter compared to the no TA group (hazard ratio [HR] 0.35, 95% CI [0.29; 0.43], P < 0.001) to the IA group (HR 0.57, 95% CI [0.48; 0.69], P < 0.001) and the IV group (HR 0.45, 95% CI [0.39; 0.50], P < 0.001). One case of deep vein thrombosis occurred in the group without TA.

CONCLUSION

Administration of combined TA appears effective and safe; further studies are needed in order to establish a consensual protocol.

Efficacy and safety of tranexamic acid usage in patients undergoing posterior lumbar fusion: a meta-analysis

Background

The purpose of this meta-analysis is to evaluate the efficacy and safety of tranexamic acid (TXA) for patients with degenerative lumbar disc herniation, stenosis or instability undergoing posterior lumbar fusion (PLF) surgery.

Methods

We searched PubMed, Embase, and Cochrane Library until May 1, 2018. Two reviewers selected studies, assessed quality, extracted data, and evaluated the risk of bias independently. Weighted mean difference (WMD) and relative risk (RR) were calculated as the summary statistics for continuous data and dichotomous data, respectively. We chose fixed-effects or random-effects models based on I² statistics. RevMan 5.0 and STATA 14.0 software were used for data analysis.

Results

Nine studies enrolling 713 patients for the study. The pooled outcomes demonstrated that TXA can decrease total blood loss (TBL) in patients underwent PLF surgery [WMD = -250.68, 95% CI (− 325.06, − 176.29), P<0.001], intraoperative blood loss (IBL) [WMD = -72.57, 95% CI (− 103.94, − 41.20), P<0.001], postoperative blood loss (PBL) [WMD = -127.57, 95% CI (− 149.39, − 105.75), P<0.001], and the loss of hemoglobin (Hb) in postoperative 24 h [WMD = -0.31, 95% CI (− 0.44, − 0.18), P<0.001]. However, there is no significant difference between two groups in transfusion rate [RR =0.34, 95% CI (0.09, 1.28), P = 0.11], and none thrombotic event was happened in the two groups.

Conclusion

Our meta-analysis demonstrated that TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability underwent PLF surgery. However, there was no significant difference in blood transfusion rates between the two groups.

Multi-route applications of tranexamic acid to reduce blood loss after total knee arthroplasty: a randomized controlled trial

BACKGROUND

Perioperative bleeding during total knee arthroplasty (TKA) is an ongoing problem for surgeons. Intravenous or topical application of tranexamic acid (TXA) can effectively stop bleeding, but there is still no uniform standard for the best method of administration and dose.

METHODS

From October 2016 to September 2018, 218 patients with unilateral primary knee osteoarthritis requiring knee replacement were enrolled and randomly divided into four groups. Group 1 (n = 55) received intra-articular injection (IAI) of TXA and peri-articular injection (PAI) of placebo, group 2 (n = 55) received IAI of placebo and PAI of TXA, group 3 (n = 51) received IAI of TXA and PAI of TXA, and group 4 (n = 57) received double placebo (IAI of placebo and PAI of placebo). The demographic characteristics, surgical indices, hematological indices, wound healing history, and thromboembolic events were investigated.

RESULTS

Eight patients were lost to follow-up and 210 patients were included in the analysis. The median TBLs in patients who received IAI of TXA and PAI of placebo and those who received IAI of placebo and PAI of TXA were 470.81 ml and 481.54 ml, respectively. These TBL levels were significantly higher compared to those in patients who received IAI of TXA and PAI of TXA (359.18 ml, P ≤ .001), but significantly lower compared to those in patients who received the double placebo (522.71 ml, P ≤ .001). Compared to other groups, more patients in the double placebo group needed a blood transfusion (P = .013). In the short-term, the double placebo group had higher VAS pain scores and less ROM after surgery (P = .011 and P = .001, respectively). In the long-term (6-month follow-up), there were no significant differences in ROM, VAS, DVT, PE, or wound-related complications.

CONCLUSION

The combined use of IAI and PAI of TXA can significantly reduce the TBL and the need for blood transfusion without delaying wound healing or increasing the risk of DVT and PE. In the short-term after surgery, this combined method reduces the pain VAS scores and improves the ROM; however, there are no long-term effects on VAS and ROM.

Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials

OBJECTIVE

This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).

DESIGN

This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE).

SETTING

We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration.

PARTICIPANTS

Patients undergoing TKA or THA.

INTERVENTIONS

Intravenous, topical or combined intravenous and topical TXA.

RESULTS

Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles.

CONCLUSIONS

The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.