Not all patients benefit from the postoperative antifibrinolytic treatment: clinical evidence against the universal use of tranexamic acid following total knee arthroplasty

Tranexamic acid in hip and spine surgery for children with cerebral palsy - a PRISMA-compliant scoping review

Many children with cerebral palsy (CP) are frail and require major hip and/or spine surgeries associated with substantial blood loss. Tranexamic acid (TXA) is commonly used to reduce blood loss, but there is uncertainty around the optimal dose and timing of administration. There have been reviews in sub-populations and specific dosing regimens, but a broad overview of the available literature is lacking. The aim of this review was to map available evidence on TXA in hip and spine surgery for children with CP. Given the heterogeneous literature, a prospectively registered scoping review was conducted. Eligibility criteria were broad. Three screeners were involved, with the senior author consulted when disagreements were not resolved through discussion.Titles and abstracts of 14,609 records were screened, with 52 records included. Two additional records were obtained from grey literature and citation searching. Cohort studies (50.0%) were the most common. Most records (76.9%) were on spine surgery. TXA dose varied widely. Loading doses range from 5 to 100 mg/kg and intraoperative infusions from 1 to 10 mg/kg/h. Dose was not reported in 35.2% of records. Primary outcome measures included blood loss and transfusion requirements. TXA was generally reported to be safe. None of the included records reported postoperative TXA administration.While TXA is generally considered safe, there was mixed evidence on efficacy. Much of the evidence was drawn from studies in which TXA was used in patients at higher risk of bleeding or with reduced physiological reserve. There was no evidence for TXA being used postoperatively, when a large proportion of transfusions occur.

The Statistical Fragility of Tranexamic Acid Use in the Orthopaedic Surgery Literature: A Systematic Review of Randomized Controlled Trials

INTRODUCTION

Randomized controlled trials (RCTs) represent the highest level of evidence in orthopaedic surgery literature, although the robustness of statistical findings in these trials may be unreliable. We used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate the statistical stability of outcomes reported in RCTs that assess the use of tranexamic acid (TXA) across orthopaedic subspecialties.

METHODS

PubMed, EMBASE, and MEDLINE were queried for RCTs (2010-present) reporting dichotomous outcomes with study groups stratified by TXA administration. The FI and rFI were defined as the number of outcome event reversals needed to alter the significance level of significant and nonsignificant outcomes, respectively. FQ was determined by dividing the FI or rFI by sample size. Subgroup analyses were conducted based on orthopaedic subspecialty.

RESULTS

Six hundred five RCTs were screened with 108 studies included for analysis comprising 192 total outcomes. The median FI of the 192 outcomes was 4 (IQR 2 to 5) with an associated FQ of 0.03 (IQR 0.019 to 0.050). 45 outcomes were reported as statistically significant with a median FI of 1 (IQR 1 to 5) and associated FQ of 0.02 (IQR 0.011 to 0.034). 147 outcomes were reported as nonsignificant with a median rFI of 4 (IQR 3 to 5) and associated FQ of 0.04 (IQR 0.023 to 0.051). The adult reconstruction, trauma, and spine subspecialties had a median FI of 4. Sports had a median FI of 3. Shoulder and elbow and foot and ankle had median FIs of 6.

DISCUSSION

Statistical outcomes reported in RCTs on the use of TXA in orthopaedic surgery are fragile. Reversal of a few outcomes is sufficient to alter statistical significance. We recommend reporting FI, rFI, and FQ metrics to aid in interpreting the outcomes reported in comparative trials.

Does the clamping method in local and systemic TXA applications in total knee arthroplasty change the game?: A retrospective comparative cohort study

Many different methods and drain clamping periods have been described in systemic and local tranexamic acid (TXA) applications, and the superiority of the methods to each other has not been clearly demonstrated. The method of local infusion in combined TXA applications may not alter the Hb drop or total or hidden blood loss. We aim to compare two different combined TXA application methods. We retrospectively analyzed 182 patients who underwent total knee arthroplasty between 2018 and 2021. Patients over 40 years of age who underwent TKA for degenerative knee arthritis were included in the study. Unicondylar, revision, or bilateral arthroplasties and patients with the cardiovascular or cerebrovascular disease were excluded from the study. All patients in the study received 1 g TXA intravenously half an hour before the incision. For the first group, 1 g TXA was given intra-articularly at the drain site after closure, and the clamp was kept closed for 1 hour. In the second group, the drain was clamped for an additional 6 hours, and a 1 g intravenous dose was administered at the 5th hour postoperatively. No local applications were used in the control group. Total, hidden, and visible blood loss (total blood loss, hidden blood loss, visible blood loss), postoperative decreases in hemoglobin and hematocrit level (ΔHgb, ΔHtc), blood transfusion rates, and hospital stay durations were evaluated. There were 72 patients in the first group, 52 in the second, and 58 in control. A total of 37 patients received one or more blood transfusions postoperatively, and there was no statistical difference in the need for blood transfusions between the groups (P = .255). Although a statistically significant difference (P = .001) in total blood loss, hidden blood loss, visible blood loss and ΔHgb values was observed between the groups, the difference between the first and second groups was insignificant (P = .512). The duration of hospital stay was observed to be less in the first and second groups (P = .024). Local and systemic TXA applications were observed to be more effective than only systemic applications in reducing blood loss after total knee arthroplasty, regardless of the local method.