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Coeckelberghs E, Vanhaecht K, Akiki A, Castillón P, Cox B, Attal RE, Foss NB, Frihagen F, Gerich TG, Kanakaris NK, Kristensen MT, Mohaddes M, Panella M, Pape HC, Sermon A, Seys D, Nijs S. Variation in care and outcome for fragile hip fracture patients: a European multicentre study benchmarking fulfilment of established quality indicators. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02549-0. [PMID: 38819678 DOI: 10.1007/s00068-024-02549-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/08/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Despite the availability of clinical guidelines for hip fracture patients, adherence to these guidelines is challenging, potentially resulting in suboptimal patient care. The goal of this study was (1) to evaluate and benchmark the adherence to recently established quality indicators (QIs), and (2) to study clinical outcomes, in fragile hip fracture patients from different European countries. METHODS This observational, cross-sectional multicenter study was performed in 10 hospitals from 9 European countries including data of 298 consecutive patients. RESULTS A large variation both within and between hospitals were seen regarding adherence to the individual QIs. QIs with the lowest overall adherence rates were the administration of systemic steroids (5.4%) and tranexamic acid (20.1%). Indicators with the highest adherence rates (above 95%) were pre-operative (99.3%) and post-operative haemoglobin level assessment (100%). The overall median time to surgery was 22.6 h (range 15.7-42.5 h). The median LOS was 9.0 days (range 5.0-19.0 days). The most common complications were delirium (23.2%) and postsurgical constipation (25.2%). CONCLUSION The present study shows large variation in the care for fragile patients with hip fractures indicating room for improvement. Therefore, hospitals should invest in benchmarking and knowledge-sharing. Large quality improvement initiatives with longitudinal follow up of both process and outcome indicators should be initiated.
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Affiliation(s)
- E Coeckelberghs
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium.
- European Pathway Association, Leuven, Belgium.
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
- European Pathway Association, Leuven, Belgium
- Department of Quality, University Hospitals Leuven, Leuven, Belgium
| | - A Akiki
- Hôpital Riviera Chablais, Rennaz, Switzerland
| | - P Castillón
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España
| | - B Cox
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
| | - R El Attal
- Klinik für Orthopädie und Unfallchirurgie, Sporttraumatologie, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - N B Foss
- Departments of Anaesthesia and Intensive Care, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
- Denmark Institute for clinical medicine, University of Copenhagen, Copenhagen, Denmark
| | - F Frihagen
- Orthopedic Department, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - T G Gerich
- Head of orthopaedic trauma, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - N K Kanakaris
- Leeds Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - M T Kristensen
- Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - M Mohaddes
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - M Panella
- European Pathway Association, Leuven, Belgium
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - H C Pape
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Zurich, Switzerland
| | - A Sermon
- Traumatology Department at University Hospitals Leuven, Leuven, Belgium
| | - D Seys
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
| | - S Nijs
- Traumatology Department at University Hospitals Leuven, Leuven, Belgium
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Yakel S, Than J, Sharp J, Coskey O, Den H, Krumrey J. The Efficacy of Tranexamic Acid for Reducing Blood Transfusion Rates in Extracapsular Hip Fractures: A Single-Center Randomized Controlled Trial. Orthopedics 2023; 46:e303-e309. [PMID: 36853931 DOI: 10.3928/01477447-20230224-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Perioperative allogenic blood transfusions for patients with hip fractures are associated with increased costs and complications. This prospective randomized controlled trial evaluated whether tranexamic acid (TXA) reduces blood transfusion rates and blood loss in extracapsular hip fractures, when administered at the time of hospital admission. Patients with closed intertrochanteric or subtrochanteric femur fractures undergoing intramedullary nailing (n=100) were enrolled from October 2015 to January 2019. On arrival to the hospital, patients were randomized to receive either 1 g of intravenous TXA or normal saline. Blood transfusion rates from hospital arrival to postoperative day 5 or discharge, blood loss from hospital arrival to postoperative day 3 or 4, intraoperative blood loss, length of hospital stay, 30-day mortality, and major complications were evaluated. Six patients from the TXA group and five from the placebo group were excluded because of canceled surgery, study drug infusion after incision, multiple fractures, or dropout. Patient characteristics were similar between the groups. Postoperative transfusion rates were 17.5% (7 of 40) in the TXA group and 36.7% (18 of 49) in the placebo group (relative risk, 0.48; 95% CI, 0.22-1.03; P=.046). Total blood loss was significantly less in the TXA group (mean difference, 367 mL; 95% CI, 76-657; P=.01). No significant differences were found for intraoperative blood loss, length of hospital stay, 30-day mortality, or 30-day major complications. TXA administered on hospital arrival decreased the risk of postoperative blood transfusion and mean perioperative blood loss in patients with extracapsular hip fractures. We recommend a single-dose intravenous administration of TXA at the time of hospital admission for patients with extracapsular hip fractures. [Orthopedics. 2023;46(5):e303-e309.].
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Zhang J, Fan X, Zheng Y, Wu J, Yuan X. Intravenous application of tranexamic acid in intramedullary nailing for the treatment of geriatric intertrochanteric fractures: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:614. [PMID: 37501145 PMCID: PMC10373423 DOI: 10.1186/s12891-023-06725-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Meta-analyses on the use of tranexamic acid (TXA) in intertrochanteric fractures have shown inconsistent results due to variations in inclusion criteria and clinical heterogeneity. To address these limitations, we conducted a rigorous analysis of recent randomized controlled trials (RCTs) with strict inclusion criteria. The aim of this study was to objectively evaluate the effects and safety of intravenous TXA administration in the treatment of geriatric intertrochanteric femoral fractures with intramedullary nailing. METHODS PubMed, Embase, and the Cochrane Library were searched for RCTs published from the database inception to August 2022. The date of total blood loss (TBL), intra-operative blood loss (IBL), hidden blood loss (HBL), transfusion rate, transfusion units, thromboembolic events, and mortality were extracted. Review Manager 5.3 was used for the analysis. RESULTS A total of six RCTs involving 689 patients were included. Meta-analyses indicated that TXA can significantly reduce TBL (WMD = -232.82; 95% CI -312.81 to -152.84; p < 0.00001), IBL (WMD = -36.33; 95% CI -51.38 to -21.28; p < 0.00001), HBL (WMD = -189.23; 95% CI -274.92 to -103.54; p < 0.0001), transfusion rate (RR = 0.53; 95% CI 0.33 to 0.85; p = 0.008), and transfusion units (WMD = -0.58; 95% CI -0.75 to -0.41; p < 0.01). No increase in thromboembolic events rate (RR = 0.75; 95% CI 0.38 to 1.50; p = 0.42) and mortality (RR = 1.36; 95% CI 0.61 to 3.04; p = 0.45) was observed. CONCLUSIONS Our meta-analysis provides robust evidence supporting the efficacy and safety of intravenous TXA administration in treating geriatric intertrochanteric femoral fractures with intramedullary nailing. TXA significantly reduces blood loss and transfusion requirements without increasing the risk of thromboembolic events or mortality.
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Affiliation(s)
- Jiakai Zhang
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Xiaoyuan Fan
- Department of Gastroenterology, The Affiliated People's Hospital of Ningbo University, Ningbo, 315040, Zhejiang, China
| | - Yi Zheng
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Junlong Wu
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Xinhua Yuan
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China.
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Yusufu A, Haibier A, Ren Z, Qin Q, Zhang Z, Zhou Y, Ran J. Efficacy and safety of using aminocaproic acid and tranexamic acid during the perioperative period for treating trochanteric fractures in elderly femurs. BMC Musculoskelet Disord 2023; 24:546. [PMID: 37400783 DOI: 10.1186/s12891-023-06627-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has long been the antifibrinolytic hemostatic drug of choice for orthopedic surgery. In recent years, the hemostatic effect of epsilon aminocaproic acid (EACA) has gradually been recognized by orthopedic surgeons and has begun to be used in hip and knee arthroplasty with little mention of the comparison of these two drugs; Therefore, this study compared the efficacy and safety of EACA and TXA in the perioperative period of elderly patients with trochanteric fractures to verify whether EAC could be a "qualified alternative" to TXA and to provide theoretical support for the clinical application of TXA. METHODS Two hundred and forty-three patients who received proximal femoral nail antirotation (PFNA) for trochanteric fractures from January 2021 to March 2022 at our institution were included and divided into the EACA group (n = 146) and the TXA group. (n = 97) determined by the drugs used in the perioperative period The main observations were blood loss and blood transfusion.The second second outcome was blood routine, coagulation, Hospital complications and complications after discharge. RESULTS The perioperative EACA patients had significantly lower significant blood loss (DBL) than the TXA group (p < 0.0001) and statistically significant lower C-reactive protein in the EACA group than in the TXA group on postoperative day 1 (p = 0.022). Patients on perioperative TXA had better postoperative day one (p = 0.002) and postoperative day five erythrocyte width than the EACA group (p = 0.004). However, there was no statistically significant difference between the two groups in the remaining indicators in both drugs: blood items, coagulation indicators, blood loss, blood transfusion, length of hospital(LOH), total hospital expense, and postoperative complications (p > 0.05). CONCLUSION The hemostatic effects and safety of EACA and TXA in the perioperative application of trochanteric fractures in the elderly are essentially similar, and EACA can be considered for use as an alternative to TXA, increasing the flexibility of physicians to use it in the clinical setting. However, the limited sample size included necessitated a high-quality, large sample of clinical studies and long-term follow-up.
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Affiliation(s)
- Alimujiang Yusufu
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Abuduwupuer Haibier
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Zheng Ren
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Qi Qin
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Ziyi Zhang
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Yuan Zhou
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Jian Ran
- Department of Orthopedics of Trauma, Sixth Affiliated Hospital of Xinjiang Medical University, Orthopaedic Hospital of Xinjiang Uygur Autonomous Region, No.39 Wuxing Road, Urumqi, People's Republic of China.
- Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, People's Republic of China.
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Lewis SR, Pritchard MW, Estcourt LJ, Stanworth SJ, Griffin XL. Interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD013737. [PMID: 37294864 PMCID: PMC10249061 DOI: 10.1002/14651858.cd013737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Following hip fracture, people sustain an acute blood loss caused by the injury and subsequent surgery. Because the majority of hip fractures occur in older adults, blood loss may be compounded by pre-existing anaemia. Allogenic blood transfusions (ABT) may be given before, during, and after surgery to correct chronic anaemia or acute blood loss. However, there is uncertainty about the benefit-risk ratio for ABT. This is a potentially scarce resource, with availability of blood products sometimes uncertain. Other strategies from Patient Blood Management may prevent or minimise blood loss and avoid administration of ABT. OBJECTIVES To summarise the evidence from Cochrane Reviews and other systematic reviews of randomised or quasi-randomised trials evaluating the effects of pharmacological and non-pharmacological interventions, administered perioperatively, on reducing blood loss, anaemia, and the need for ABT in adults undergoing hip fracture surgery. METHODS In January 2022, we searched the Cochrane Library, MEDLINE, Embase, and five other databases for systematic reviews of randomised controlled trials (RCTs) of interventions given to prevent or minimise blood loss, treat the effects of anaemia, and reduce the need for ABT, in adults undergoing hip fracture surgery. We searched for pharmacological interventions (fibrinogen, factor VIIa and factor XIII, desmopressin, antifibrinolytics, fibrin and non-fibrin sealants and glue, agents to reverse the effects of anticoagulants, erythropoiesis agents, iron, vitamin B12, and folate replacement therapy) and non-pharmacological interventions (surgical approaches to reduce or manage blood loss, intraoperative cell salvage and autologous blood transfusion, temperature management, and oxygen therapy). We used Cochrane methodology, and assessed the methodological quality of included reviews using AMSTAR 2. We assessed the degree of overlap of RCTs between reviews. Because overlap was very high, we used a hierarchical approach to select reviews from which to report data; we compared the findings of selected reviews with findings from the other reviews. Outcomes were: number of people requiring ABT, volume of transfused blood (measured as units of packed red blood cells (PRC)), postoperative delirium, adverse events, activities of daily living (ADL), health-related quality of life (HRQoL), and mortality. MAIN RESULTS We found 26 systematic reviews including 36 RCTs (3923 participants), which only evaluated tranexamic acid and iron. We found no reviews of other pharmacological interventions or any non-pharmacological interventions. Tranexamic acid (17 reviews, 29 eligible RCTs) We selected reviews with the most recent search date, and which included data for the most outcomes. The methodological quality of these reviews was low. However, the findings were largely consistent across reviews. One review included 24 RCTs, with participants who had internal fixation or arthroplasty for different types of hip fracture. Tranexamic acid was given intravenously or topically during the perioperative period. In this review, based on a control group risk of 451 people per 1000, 194 fewer people per 1000 probably require ABT after receiving tranexamic acid (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.46 to 0.68; 21 studies, 2148 participants; moderate-certainty evidence). We downgraded the certainty for possible publication bias. Review authors found that there was probably little or no difference in the risks of adverse events, reported as deep vein thrombosis (RR 1.16, 95% CI 0.74 to 1.81; 22 studies), pulmonary embolism (RR 1.01, 95% CI 0.36 to 2.86; 9 studies), myocardial infarction (RR 1.00, 95% CI 0.23 to 4.33; 8 studies), cerebrovascular accident (RR 1.45, 95% CI 0.56 to 3.70; 8 studies), or death (RR 1.01, 95% CI 0.70 to 1.46; 10 studies). We judged evidence from these outcomes to be moderate certainty, downgraded for imprecision. Another review, with a similarly broad inclusion criteria, included 10 studies, and found that tranexamic acid probably reduces the volume of transfused PRC (0.53 fewer units, 95% CI 0.27 to 0.80; 7 studies, 813 participants; moderate-certainty evidence). We downgraded the certainty because of unexplained high levels of statistical heterogeneity. No reviews reported outcomes of postoperative delirium, ADL, or HRQoL. Iron (9 reviews, 7 eligible RCTs) Whilst all reviews included studies in hip fracture populations, most also included other surgical populations. The most current, direct evidence was reported in two RCTs, with 403 participants with hip fracture; iron was given intravenously, starting preoperatively. This review did not include evidence for iron with erythropoietin. The methodological quality of this review was low. In this review, there was low-certainty evidence from two studies (403 participants) that there may be little or no difference according to whether intravenous iron was given in: the number of people who required ABT (RR 0.90, 95% CI 0.73 to 1.11), the volume of transfused blood (MD -0.07 units of PRC, 95% CI -0.31 to 0.17), infection (RR 0.99, 95% CI 0.55 to 1.80), or mortality within 30 days (RR 1.06, 95% CI 0.53 to 2.13). There may be little or no difference in delirium (25 events in the iron group compared to 26 events in control group; 1 study, 303 participants; low-certainty evidence). We are very unsure whether there was any difference in HRQoL, since it was reported without an effect estimate. The findings were largely consistent across reviews. We downgraded the evidence for imprecision, because studies included few participants, and the wide CIs indicated possible benefit and harm. No reviews reported outcomes of cognitive dysfunction, ADL, or HRQoL. AUTHORS' CONCLUSIONS Tranexamic acid probably reduces the need for ABT in adults undergoing hip fracture surgery, and there is probably little or no difference in adverse events. For iron, there may be little or no difference in overall clinical effects, but this finding is limited by evidence from only a few small studies. Reviews of these treatments did not adequately include patient-reported outcome measures (PROMS), and evidence for their effectiveness remains incomplete. We were unable to effectively explore the impact of timing and route of administration between reviews. A lack of systematic reviews for other types of pharmacological or any non-pharmacological interventions to reduce the need for ABT indicates a need for further evidence syntheses to explore this. Methodologically sound evidence syntheses should include PROMS within four months of surgery.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael W Pritchard
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Simon J Stanworth
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Trauma & Orthopaedics Surgery Group, Blizard Institute, Queen Mary University of London, London, UK
- The Royal London Hospital Barts Health NHS Trust, London, UK
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Gibbs VN, Geneen LJ, Champaneria R, Raval P, Dorée C, Brunskill SJ, Novak A, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures. Cochrane Database Syst Rev 2023; 6:CD013499. [PMID: 37272509 PMCID: PMC10241722 DOI: 10.1002/14651858.cd013499.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications. OBJECTIVES To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones. SEARCH METHODS We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data. MAIN RESULTS We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence). It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence). We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect. Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants). All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here. AUTHORS' CONCLUSIONS We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration). We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Parag Raval
- Trauma and Orthopaedic Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Leverett GD, Marriott A. Intravenous tranexamic acid and thromboembolic events in hip fracture surgery: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2023; 109:103337. [PMID: 35643364 DOI: 10.1016/j.otsr.2022.103337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Osteoporotic hip fractures are a major health problem in developed countries. Surgical management is the mainstay of treatment for these injuries, and historically presents an increased risk of thromboembolism, blood loss and blood transfusion. Despite the demonstrated safety of tranexamic acid (TXA) in elective hip arthroplasty, there is uncertainty regarding the risk of thromboembolism with the administration of TXA during hip fracture surgery. This study aims to address the following questions regarding patients undergoing traumatic hip fracture surgery: 1. Does intravenous TXA increase the risk of thromboembolic events? 2. Does intravenous TXA reduce peri-operative blood loss? 3. Does intravenous TXA increase the risk of non-thromboembolic complications or post-operative mortality? METHODS A literature search of Ovid MEDLINE, Embase, PubMed, the Cochrane Register of Controlled Trials and CINAHL was conducted, assessing results from database inception until the 11th May, 2021. We included randomised controlled trials that investigated perioperative administration of intravenous TXA in patients undergoing hip fracture surgery, compared to a control cohort. We excluded articles published in a language other than English, evaluated elective hip arthroplasty, or did not report thromboembolic events. Included trials were analysed using RevMan v5.3. RESULTS Sixteen articles encompassing 1491 patients met inclusion criteria. The risk difference of thromboembolic events in the TXA group was 0.02 (95%C.I. -0.01-0.04; p=0.17). TXA reduced post-operative transfusion rates by 42% (range: 28-54%, p<0.0001). The mean haemoglobin was higher in the TXA group on post-operative day one (0.77g/dL, p<0.0001), day two (0.56g/dL, p<0.0001) and day three (0.42g/dL, p<0.0001). There was no statistically significant difference in non-thromboembolic complications or post-operative mortality across the two cohorts. DISCUSSION There is no conclusive evidence from the current published literature that peri-operative intravenous TXA administration increases the risk of thromboembolic events after hip fracture surgery. This meta-analysis reinforces that TXA is effective in reducing post-operative transfusions and haemoglobin decline after hip fracture surgery. This study found that TXA did not increase non-thromboembolic complications or post-operative mortality. Further large-scale studies evaluating thromboembolic complications as a primary outcome are required to definitively establish the safety of TXA in hip fracture surgery. LEVEL OF EVIDENCE I; meta-analysis of randomised controlled trials.
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Affiliation(s)
- Gregory D Leverett
- Department of Anaesthesia and Perioperative Medicine, Eastern Health, Victoria, Australia; Department of Medicine and Veterinary Science, University of Edinburgh, Edinburgh, Scotland.
| | - Andrew Marriott
- Department of Anaesthetics, Perioperative and Pain Medicine, Barwon Health, Victoria, Australia; Clinical Associate Professor, School of Medicine, IMPACT SRC, Deakin University, Victoria, Australia
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Chowdhury D. To Assess the Outcomes Associated With the Use of Tranexamic Acid in the Open Fixation of Pelvic and Acetabular Fractures. Cureus 2023; 15:e38232. [PMID: 37261178 PMCID: PMC10226826 DOI: 10.7759/cureus.38232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
There is a growing knowledge base for the use of antifibrinolytic therapy in trauma and orthopaedic surgery. The mechanism of action of tranexamic acid (TXA) is through the inhibition of fibrinolysis. The role of TXA in hip fractures has been researched extensively. However, the research has been limited to the cases of pelvic and acetabular fractures. This systematic review aimed to examine the effect of TXA on patients undergoing open pelvic and acetabular fracture surgery. The primary goal of the study was to examine the estimated blood loss (EBL) and blood transfusion rates in patients who received TXA versus those who did not receive TXA. The secondary goal was to examine the rates of deep venous thrombosis (DVT). A literature search was carried out using PubMed, Medline and the Cochrane database. The selection criteria for the systematic review were studies investigating intravenous TXA in the form of randomised controlled trials (RCTs), as well as cohort studies. Five studies were included in the systematic review with 625 total patients. The EBL between the two groups was noted to be 661 mL in the control group and 850 mL in the TXA (p=0.49). There was a marginally lower number of units transfused in the control group vs the TXA group (1.9 vs 2.2) (p=0.27). The rates of transfusion in the TXA group were 29% TXA whilst, in the control group, it was 31% (p=0.13). The overall incidence of DVT was 2.8% in the TXA group and 1.7% in the control group (p=0.097).
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Affiliation(s)
- Debkumar Chowdhury
- Department of Emergency Medicine, Manchester Royal Infirmary, Manchester, GBR
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9
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Lam KM, Hsu YC. A retrospective cohort study of the effect of intravenous tranexamic acid infusion on geriatric hip fractures patients undergoing proximal femoral nail antirotation. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2023. [DOI: 10.1177/22104917231161831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Background: Tranexamic acid (TXA) has been used in the management of bleeding. We are conducting a retrospective cohort study to analyse the effect of intravenous TXA infusion on the surgical outcomes of geriatric hip fracture cases which undergoes proximal femoral nail antirotation. Methods: In this study, 364 patients who had undergone proximal femoral nail antirotation between January 2018 and December 2019 in United Christian Hospital have been recruited. Two-hundred thirteen patients were recruited in controlled group and 151 patients were recruited in TXA group. One gram of TXA acid was injected intravenously on induction of anaesthesia and before surgical incision. Outcomes including length of stay, operation time, intraoperative blood loss, haemoglobin and haematocrit drop and post-operative blood transfusion have been measured. Results: There was a reduction in operative time, intraoperative blood loss, post-operative haemoglobin and haematocrit drop and post-operative blood transfusion in TXA group, with a reduction in the intraoperative blood loss (Controlled group: 97.8 ± 67.7 ml, TXA group: 76.0 ± 71.4, Difference −22.3%, p-value: 0.0036) and post-operative haematocrit drop (Controlled group: 0.04 ± 0.03, TXA group: 0.03 ± 0.03, Difference −25%, p-value: 0.05) being statistically significant. The length of stay is not statistically significant between the two groups. TXA is an antifibrinolytic agent which acts by binding to plasminogen which inhibits plasma formation. It has a potential reduction in blood loss in major operations. Conclusion: Intravenous TXA infusion helps to reduce blood loss in a patient undergoing proximal femoral nail antirotation. It is safe to use in the geriatric group of patients. We would recommend the usage of TXA infusion to improve the surgical outcome.
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Affiliation(s)
- Ka Mun Lam
- Department of Orthopaedics and Traumatology, United Christian Hospital, Hong Kong
| | - Yung Chak Hsu
- Department of Orthopaedics and Traumatology, United Christian Hospital, Hong Kong
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Zhang J, Fan X, Zheng Y, Wu J, Yuan X. Topical tranexamic acid in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e32854. [PMID: 36820553 PMCID: PMC9907902 DOI: 10.1097/md.0000000000032854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Numerous studies have demonstrated that the use of tranexamic acid (TXA) intravenously minimizes bleeding, lowers transfusion rates, and does not raise the risk of complications during major orthopedic surgery. Concerning the effectiveness of the topical application, there are, nevertheless, inconsistent findings. We aimed to develop a protocol for systematic review and meta-analysis on the benefits and safety of topical TXA in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly. METHODS PubMed, Embase, and the Cochrane Library will all be searched for randomized controlled trials published from the database inception to October 15, 2022. The primary outcomes will be intraoperative blood loss, hidden blood loss, total blood loss, transfusion rate, transfusion units, operative time, thromboembolic events, and mortality. The risk of bias will be evaluated using the Cochrane risk of bias assessment tool. Review Manager 5.3 will be used for the analysis. RESULTS The effects and safety of topical TXA in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly will be quantified in this study. CONCLUSIONS The study's findings will assist doctors in determining if topical TXA use is secure and efficient.
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Affiliation(s)
- Jiakai Zhang
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, China
| | - Xiaoyuan Fan
- Department of Gastroenterology, The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Yi Zheng
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, China
| | - Junlong Wu
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, China
| | - Xinhua Yuan
- Department of Orthopedics, Ningbo No.2 Hospital, Ningbo, China
- * Correspondence: Xinhua Yuan, Department of Orthopedics, Ningbo No.2 Hospital, Ningbo 315000, China (e-mail: )
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Wilharm A, Wutschke I, Schenk P, Hofmann GO. Tranexamic Acid in Hip Hemiarthroplasty Surgery: A Retrospective Analysis of Perioperative Outcome. Geriatr Orthop Surg Rehabil 2023; 14:21514593221147817. [PMID: 36654888 PMCID: PMC9841876 DOI: 10.1177/21514593221147817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/24/2022] [Accepted: 11/21/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction: Implantation of a dual-head hip prosthesis to treat medial femoral neck fractures is often associated with significant blood loss. In elective endoprosthetics procedures, it has already been demonstrated that administration of tranexamic acid (TXA) reduces blood loss and need for postoperative transfusions, as well as reducing the frequency of postoperative complications. The aim of this study is to show whether the administration of TXA also leads to a reduction in perioperative blood loss and haemorrhage-associated complications when applied as part of treatment of femoral neck fractures using a dual-head prosthesis. Methods: In a single-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 93 patients who had suffered from femoral neck fractures. This group was compared to a comparison group of 65 patients who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, frequency of transfusion, and frequency of specific complications occurring. Results: The transfusion rate in the TXA group was 6% lower, whereby the volume of blood transfused was 26.7% lower than in the nonTXA group. However, neither result was significant. The calculated perioperative blood loss remained the same. Similarly, the incidence of postoperative renal failure was not significantly lower in the TXA group, at 6.5%, as compared to the nonTXA group (7.7%). A higher rate of complications or deaths as a result of TXA administration was not observed. The tranexamic acid effect seems to be related to the dose. Conclusion: Preoperative administration of TXA during implantation of a dual-head prosthesis for treatment of a femoral neck fracture does not lead to an increased complication rate. The study revealed a trend towards fewer transfusions required, but a significant reduction in blood loss could not be demonstrated. There should be further investigation of other factors influencing blood loss, in particular the dosing regimen followed for perioperative administration of TXA. Level of Evidence: Level 4: retrospective case-control study.
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Affiliation(s)
- Arne Wilharm
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany,Arne Wilharm, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, Jena 07747, Germany.
| | - Isabell Wutschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Philipp Schenk
- Department of Research Executive, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Gunther Olaf Hofmann
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany
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Intravenous Tranexamic Acid Given at Femoral Fragility Fracture Surgery Reduces Blood Transfusion Requirements Fourfold. World J Surg 2023; 47:912-921. [PMID: 36725742 PMCID: PMC9971041 DOI: 10.1007/s00268-022-06886-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 02/03/2023]
Abstract
AIMS This study aims to determine whether intraoperative intravenous (IV) tranexamic acid (TXA) affects blood loss following the surgical management of femoral fragility fractures (FFF). METHODS This was a single centre (university teaching hospital) non-randomised case-control study. There were 361 consecutive patients with FFF admitted over a 4-month period were included (mean age 81.4yrs; mean BMI 23.5; 73.7% female). Patient demographics, comorbidities, preoperative anticoagulation use, surgical management, intravenous TXA use, perioperative haemoglobin (Hb) and haematocrit, and requirement for blood transfusion were recorded. The primary outcome was postoperative blood transfusion requirement. Secondary outcomes included postoperative day one calculated blood loss (CBL) (using the Nadler and Gross formulae) and fall in Hb (percentage) from preoperative levels; and the incidence of thrombotic events and mortality up to 30 days. RESULTS Groups were well matched in terms of patient demographics, comorbidities, preoperative anticoagulation use, injury types and surgical management. Intravenous TXA 1 g given at the beginning of surgery at the discretion of the operating team: 178 (49%) received TXA and 183 (51%) did not. The requirement for postoperative blood transfusion was significantly less in the TXA group: 15/178 (8.4%) compared to 58/183 (31.7%) (p < 0.001; Chi square). TXA significantly reduced both the percentage fall in Hb (mean difference 4.3%, p < 0.001) and the CBL (mean difference -222 ml, p < 0.001). There was no difference in VTE (2 vs 1, p = 0.620) or other thrombotic events (2 vs 0, p = 0.244) between groups. CONCLUSION 1 g of intraoperative intravenous TXA during the surgical management of FFF was associated with reduced rate of transfusion, CBL and the percentage drop in HB. The use of TXA in this study was not randomised, so there could be un-quantifiable bias in the patient selection.
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Does tranexamic acid reliably reduce blood loss in proximal femur fracture surgery? Eur J Trauma Emerg Surg 2023; 49:209-216. [PMID: 35852549 PMCID: PMC9925497 DOI: 10.1007/s00068-022-02042-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The aim of our study was to investigate the use of tranexamic acid in patients with proximal femoral fractures and compare the total blood loss, transfusion rates, complications, and the application method. METHODS A retrospective single center cohort study (level I trauma center) with 1479 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 was performed. 1 g of tranexamic acid was applied (systemic, topic or combined application). Patient data, surgical procedure, complications, and mortality were assessed. Hemoglobin levels, blood loss and transfusion rates for patients with and without tranexamic acid and the application methods were compared. RESULTS 667 femoral neck fractures, 701 pertrochanteric and 109 subtrochanteric fractures were included. Mean age was 80.8 years. 274 patients received tranexamic acid. At admission average hemoglobin was 12.2 g/l. Hemoglobin drop postoperatively was less after tranexamic acid (9.72 vs. 9.35 g/dl). Transfusion rates were lowered significantly by 17.1% after tranexamic acid. Blood loss was reduced for all patients after tranexamic acid independent of fracture morphology. The combination of 1 g i.v. and 1 g topical-applied tranexamic acid seems to be more effective. Complication rates did not differ. CONCLUSION Tranexamic acid is effective in reducing blood loss and transfusion rates, without increasing the risk of thromboembolic events after proximal femoral fractures. For open reduction and nailing and arthroplasty in fracture setting combined topical and single i.v. application seems most effective and closed reduction with nailing can be treated by single dose i.v. application of 1 g tranexamic acid.
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Agius C, Cole E, Mifsud MG, Vasireddy A. The Use of Tranexamic Acid in Hip Fracture Surgery-A Systematic Review and Meta-analysis. J Orthop Trauma 2022; 36:e442-e448. [PMID: 36399681 DOI: 10.1097/bot.0000000000002440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze the effect of intravenous tranexamic acid (TXA) on blood transfusion requirements in adult patients undergoing hip fracture surgery. Secondary aim was to evaluate the safety by assessing thromboembolic events. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline, PubMed, and Embase were searched for randomized controlled trials published in English from 2010. STUDY SELECTION Studies eligible for inclusion were randomized controlled trials that analyzed the use of intravenous TXA on blood transfusion requirement in hip fracture surgery. DATA EXTRACTION Titles and abstracts were screened and assessed for eligibility by 2 independent reviewers. Quality and risk of bias was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach and the Cochrane risk-of-bias tool (RoB2). DATA SYNTHESIS Meta-analysis with random and fixed effect models was performed. Risk ratio (RR) was calculated for dichotomous outcomes and estimated with a 95% confidence interval (CI). For continuous data, the risk difference (RD) was estimated with a 95% CI. RESULTS A total of 13 trials involving 1194 patients were included. Pooled results showed that patients in the TXA group had significantly lower transfusion requirements (RR 0.50, 95%CI 0.30-0.84, P = 0.009). Similar findings were observed in the subcohort of patients with transfusion threshold of Hb < 8g/dL, (RR 0.42, 95%CI 0.31-0.56, P < 0.0001). This risk reduction was not observed in the subcohort of patients with transfusion threshold of Hb 8.1-10g/dL who received TXA (RR 0.77, 95%CI 0.51-1.18, P = 0.23) and no statistically significant differences were found for total thromboembolic events (RR 0.01, 95%CI -0.02-0.04, P = 0.47). CONCLUSION This meta-analysis demonstrated that intravenous TXA reduced blood transfusion rates and did not increase the risk of thromboembolic events. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christabel Agius
- Department of Orthopaedic Surgery, Trauma & Sports Medicine, Mater Dei Hospital, Msida, Malta
- Blizard Institute, Queen Mary University of London, London, United Kingdom; and
| | - Elaine Cole
- Blizard Institute, Queen Mary University of London, London, United Kingdom; and
| | - Mary Grace Mifsud
- Department of Orthopaedic Surgery, Trauma & Sports Medicine, Mater Dei Hospital, Msida, Malta
| | - Aswinkumar Vasireddy
- Blizard Institute, Queen Mary University of London, London, United Kingdom; and
- Department of Trauma and Orthopaedic Surgery, King's College Hospital, London, United Kingdom
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Hanke J, Mendel T, Wingert M, Schenk P, Heinecke M, Wilharm A. Tranexamic acid in pertrochanteric fractures: a retrospective analysis of perioperative outcomes after fixation with a proximal femoral nail. BMC Musculoskelet Disord 2022; 23:950. [PMID: 36324129 PMCID: PMC9632134 DOI: 10.1186/s12891-022-05889-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022] Open
Abstract
Background Treatment of pertrochanteric femoral fractures is often associated with significant blood loss. It has already been demonstrated that the administration of tranexamic acid (TXA) for endoprosthetic procedures reduces blood losses and leads to a decreased frequency of postoperative complications. The aim of this study is to demonstrate whether the administration of TXA as part of osteosynthesis treatment for pertrochanteric fractures using a proximal femoral nail reduces perioperative blood losses and haemorrhage-related complications. Methods In a two-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 294 patients who had suffered from pertrochanteric femoral fractures. The subjects were compared clinically to a historical control group who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, transfusion requirement, and occurrence of complications. Results The TXA group showed evidence of a reduction in blood loss (TXA = 0.97 ± 0.47 l; nonTXA = 1.06 ± 0.47 l; p = 0.004) and a lower frequency of transfusion (TXA = 20%; nonTXA = 31%; p = 0.032) as compared to the nonTXA group. However, evidence of this therapeutic effect could only be demonstrated at one of the centres on subgroup comparison between the two centres. At the second centre, the data did not show a significant difference. A trend could be seen towards a reduction in postoperative renal failure. No complications occurred resulting from the administration of tranexamic acid. Conclusion Preoperative administration of TXA does not lead to an increased rate of thromboembolic complications when applied for treatment of pertrochanteric femoral fractures. Evidence of a positive effect could be seen in principle in relation to the reduction in perioperative blood loss and the frequency of transfusion. The difference in effect between the two centres remains to be clarified: for this reason, it is possible to assume that further factors influencing the efficacy of TXA administration are at play which were not taken into account in this study.
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Affiliation(s)
- John Hanke
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany
| | - Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany
| | - Matthias Wingert
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Philipp Schenk
- Research Executive Department, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany
| | - Markus Heinecke
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle gGmbH, Merseburger Strasse 165, 06120, Halle (Saale), Germany
| | - Arne Wilharm
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany.
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Liu W, Deng S, Liang J. Tranexamic acid usage in hip fracture surgery: a meta-analysis and meta-regression analysis of current practice. Arch Orthop Trauma Surg 2022; 142:2769-2789. [PMID: 34709457 DOI: 10.1007/s00402-021-04231-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/14/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The use of tranexamic acid (TXA) in hip fracture surgery remains inconclusive. The aim of the present meta-analysis was to assess the role of TXA use in hip fracture surgery, and attempt to disclose possible factors which might influence TXA efficacy and safety. MATERIALS AND METHODS A systematic computerized literature search was conducted to retrieve all randomized controlled trials (RCTs) and cohort studies regarding TXA use in hip fracture surgery. Overall efficacy and safety were evaluated. Then, subgroup and meta-regression analyses were conducted to disclose the influence of geographic area, fracture type, administration route, frequency and dosage of TXA, blood transfusion threshold, and follow-up duration on the overall effect. RESULTS Thirty-four RCTs and 11 cohort studies were included. Patients receiving TXA had a significant decrease in the need for blood transfusion, reduced total, intra-operative and post-operative blood loss, a decrease in pre- and postoperative hemoglobin difference, without increasing thromboembolic events risk. Subgroup analysis showed that topical TXA had a lower transfusion rate compared with controls, yet the result did not reach statistical significance. Also, TXA had similar efficacy and safety profiles in patients with different frequency and dosage of TXA. CONCLUSION Current evidence indicated that intravenous administration of TXA could significantly reduce blood transfusion and blood loss without increasing risk of thromboembolic events. The frequency and dosage of TXA might not alter the beneficial effect. The application of topical TXA should be cautious.
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Affiliation(s)
- Wenhua Liu
- Department of Emergency Surgery, People's Hospital of Shenzhen Baoan District, Shenzhen, 518100, China
| | - Shaojie Deng
- Department of Orthopedics, People's Hospital of Shenzhen Baoan District, No.118 Longjing second road, Bao'an district, Shenzhen, 518100, China
| | - Jinfeng Liang
- Department of Orthopedics, People's Hospital of Shenzhen Baoan District, No.118 Longjing second road, Bao'an district, Shenzhen, 518100, China.
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Jiang J, Xing F, Zhe M, Luo R, Xu J, Duan X, Xiang Z. Efficacy and safety of tranexamic acid for patients with intertrochanteric fractures treated with intramedullary fixation: A systematic review and meta-analysis of current evidence in randomized controlled trials. Front Pharmacol 2022; 13:945971. [PMID: 36199695 PMCID: PMC9528975 DOI: 10.3389/fphar.2022.945971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Tranexamic acid (TXA) has been widely applied to reduce perioperative bleeding. Recently, several studies focused on the administration of TXA in the treatment for with intertrochanteric fracture patients treated with intramedullary fixation. However, the efficacy and safety of TXA in these studies remain controversial. Therefore, we performed this systematic review and meta-analysis to investigate the efficacy and safety of TXA in intertrochanteric fracture patients treated with intramedullary fixation.Methods: We systematically searched electronic databases, including Cochrane, PubMed, and EMBASE, up to 16 May 2022. The efficacy and safety of TXA was evaluated in four aspects, which were bleeding-related outcomes, non-bleeding-related outcomes, thromboembolic events, and other complications. The outcomes of these studies were extracted and analyzed by RevMan Manager 5.4.Results: Finally, nine randomized controlled trials, involving nine hundred and seventy-two intertrochanteric fracture patients treated with TXA, were enrolled in this study. In the bleeding-related outcomes, TXA group was significantly lower than the control group in terms of total blood loss (MD = −219.42; 95% CI, −299.80 to −139.03; p < 0.001), intraoperative blood loss (MD = −36.81; 95% CI, −54.21 to −19.41; p < 0.001), hidden blood loss (MD = −189.23; 95% CI, −274.92 to −103.54; p < 0.001), and transfusion rate (RR = 0.64; 95% CI, 0.49 to 0.85; p = 0.002). Moreover, the postoperative hemoglobin on day 3 of the TXA group was significantly higher than that of the control group (MD = 5.75; 95% CI, 1.26 to 10.23; p = 0.01). In the non-bleeding-related outcomes, the length of hospital stays was significantly shorter in the TXA group (MD = −0.67; 95% CI, −1.12 to −0.23; p = 0.003). In terms of thromboembolic events, there was no significant differences between the TXA group and control group in deep vein thrombosis, pulmonary embolism, myocardial infarction, and ischemic stroke. As for complications and mortality, there was no significant differences between the TXA group and control group in respiratory infection, renal failure, and postoperative mortality within 1 year.Conclusion: TXA is an effective and safe drug for perioperative bleeding control in intertrochanteric fracture patients treated with intramedullary fixation. However, the long-term efficacy of TXA still needs to be investigated by large-scale multicenter randomized controlled trials.Level of evidence: II, Systematic review and Meta-analysis.Systematic Review Registration:https://inplasy.com/, identifier [INPLASY202280027]
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Affiliation(s)
- Jiabao Jiang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Xing
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Man Zhe
- Animal Experiment Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rong Luo
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jiawei Xu
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Xin Duan
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xin Duan, ; Zhou Xiang,
| | - Zhou Xiang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xin Duan, ; Zhou Xiang,
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McKibben NS, Lindsay SE, Friess DM, Zusman NL, Working ZM. Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review. J Orthop Trauma 2022; 36:e215-e226. [PMID: 34799543 DOI: 10.1097/bot.0000000000002313] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma. DATA SOURCES A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010. STUDY SELECTION English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion. DATA EXTRACTION Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I. DATA SYNTHESIS The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible. CONCLUSIONS Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.
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Affiliation(s)
- Natasha S McKibben
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
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Li RY, Xie T, Zhao YK, Qi YM, Li YJ, Wang Z, Qiu XD, Sun J, Zhang M, Wang L, Chen H, Rui YF. Oral versus intravenous tranexamic acid in elderly patients with intertrochanteric fracture undergoing proximal femur intramedullary nailing: A prospective cohort study. J Orthop Translat 2022; 34:85-90. [PMID: 35847604 PMCID: PMC9253036 DOI: 10.1016/j.jot.2022.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 12/30/2022] Open
Abstract
Objective Methods Results Conclusion The translational potential of this article
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Affiliation(s)
- Ru-Ya Li
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Ya-Kuan Zhao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Yi-Ming Qi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Ying-Juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Zhen Wang
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Xiao-Dong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Jie Sun
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Min Zhang
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Department of Blood Transfusion, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Ling Wang
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Department of Ultrasonography, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Orthopaedic Trauma Institute (OTI), Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, PR China
- Corresponding author. Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, No. 87 Ding Jia Qiao, Nanjing, 210009, Jiangsu Province, China.
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Yee DKH, Wong JSH, Fang E, Wong TM, Fang C, Leung F. Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial. Injury 2022; 53:603-609. [PMID: 34895712 DOI: 10.1016/j.injury.2021.11.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Topical 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. METHODS A 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. RESULTS There 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). CONCLUSION A 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.
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Affiliation(s)
- Dennis King-Hang Yee
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
| | - Janus Siu Him Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong.
| | - Evan Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
| | - Tak-Man Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
| | - Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
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Masouros P, Antoniou G, Nikolaou VS. Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials. Injury 2022; 53:294-300. [PMID: 34689986 DOI: 10.1016/j.injury.2021.09.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/19/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023]
Abstract
AIM The 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. METHODS A 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. RESULTS Out 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. CONCLUSIONS This 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.
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Affiliation(s)
| | - Georgia Antoniou
- Evangelismos General Hospital, Orthopaedic Department, Athens, Greece
| | - Vasileios S Nikolaou
- Konstandopoulio General Hospital, 2nd Academic Department of Orthopaedics, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.
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22
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SJ K, Ethiraj P, Shanthappa AH, Vellingiri K. Is Tranexamic Acid Safe and Efficacious in Hip Surgeries? Cureus 2022; 14:e21249. [PMID: 35186537 PMCID: PMC8844131 DOI: 10.7759/cureus.21249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background The incidence of hip fractures is increasing in the current population. It is estimated by the year 2050 around 6.3 million hip fractures may occur per year. Management of hip fractures and replacement surgeries might be associated with substantial blood loss which leads to perioperative anemia. Tranexamic acid is an antifibrinolytic agent that has evidence of reducing blood loss during arthroplasty surgeries. This study aims to evaluate the efficacy and safety of tranexamic acid in patients undergoing hip surgeries. Materials and methods This is a cross-sectional study of the patients during the period of May 2020 to April 2021. Forty-eight patients who underwent hip surgery during this period were taken up for the study. Patients were divided into the following groups: group T (n=24) and group P (n=24). Group T received tranexamic acid 10 mg/kg intravenously, as a bolus slowly, 30 minutes prior to skin incision and 1 mg/kg/h intravenous infusion till the closure of skin incision. Group P received normal saline 0.1 ml/kg intravenously, as a bolus slowly, 30 minutes prior to skin incision, and then 1 ml/kg/h intravenous infusion till the skin closure. The primary outcome measured was the total blood loss using Gross and Nadel formulaand the secondary outcomes measured were packed red blood cell (PRBC) transfusion requirement, length of hospital stay, drop-in hematocrit value, ambulation time, and incidence of any other adverse event between the two groups. Results The total blood loss in group T patients was 474.12 (± 90.35) ml and in group P was 647.41 (± 114.58) ml, the p-value was <0.001 which was statistically significant. The overall PRBC transfusion rate was 75% (18 patients) in group P and 37.5% (nine patients) in group T with a p-value of 0.020. Nine (37.5%) patients included in group T began to ambulate within 24 hours of surgery while six patients in group P were ambulated within 24 hours with a p-value of <0.001. Conclusion Preoperative infusion of tranexamic acid is effective in reducing intraoperative blood loss and blood transfusion requirement rates. It is also safe and efficacious in patients undergoing hip surgeries.
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Jiganti M, Pipitone O, Than J, Stanley R, Passanise A, Krumrey J. A Single Dose Versus Two Doses of Tranexamic Acid for Extracapsular Hip Fractures. Cureus 2022; 14:e21239. [PMID: 35174034 PMCID: PMC8841038 DOI: 10.7759/cureus.21239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/05/2022] Open
Abstract
Objective In this study, we aimed to compare the effectiveness of one dose of tranexamic acid (TXA) at the time of hospital admission versus two doses of TXA (one at the time of hospital admission and another dose intraoperatively) in reducing perioperative total blood loss in patients with extracapsular hip fractures. Methods This retrospective cohort study included 80 patients from a single institution who underwent surgical fixation for extracapsular hip fractures. Forty patients received a single dose of 1 gram of TXA at the time of hospital admission (per standardized protocol of an ongoing research study at the time), and 40 patients received the same dose of TXA on hospital admission as well as a second dose of 1 gram of TXA intraoperatively at the time of incision (per standard practice change following the completion of the research study). The primary study outcome of interest was total blood loss, which was calculated by estimating blood volume via Nadler’s formula followed by calculating the total blood loss with the hemoglobin dilution method. Secondary outcomes included blood transfusion rates, hospital length of stay (LOS), and 30-day mortality. Results Patient gender, age, the American Society of Anesthesiologists (ASA) score, procedure length, fracture type, hardware type, and hemoglobin on hospital arrival were similar across the study groups (all p>0.05), though the twice-dosed group had a higher average BMI (26.4 kg/m2 vs. 24 kg/m2, p=0.04). When adjusting for BMI, the twice-dosed group was estimated to have a slightly larger but non-significant difference in total blood loss (115-ml difference, 95% CI: 158.2-389.3, p=0.40) compared to the single-dose TXA group. More patients in the twice-dosed group required blood transfusion compared to the single-dose TXA group, though this was not statistically significant (30.0% vs. 17.5%, adjusted OR=1.64, 95% CI: 0.55-5.12, p=0.38). The distribution of hospital LOS and 30-day mortality rates were similar across the groups (p=0.13 and p>0.99). Conclusion In the setting of surgically treated extracapsular hip fractures, patients who received one dose of TXA at the time of hospital admission and a second intraoperative dose of TXA did not demonstrate significant differences in total blood loss or a need for blood transfusion compared to patients who only received a single dose of TXA at the time of hospital admission.
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Liu J, Lei Y, Liao J, Liang X, Hu N, Huang W. Study protocol: haemostatic efficacy and safety of preemptive antifibrinolysis with multidose intravenous tranexamic acid in elderly hip fracture patients: design of a prospective randomised controlled trial. BMJ Open 2021; 11:e047382. [PMID: 34907040 PMCID: PMC8671918 DOI: 10.1136/bmjopen-2020-047382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Hip fracture surgery is often associated with substantial blood loss and a high allogeneic blood transfusion (ABT) rate. Preoperative hidden blood loss (HBL) has been observed clinically but there is little evidence for the efficacy of tranexamic acid (TXA) in controlling preoperative HBL. We designed a randomised controlled trial to evaluate the efficacy of preemptive antifibrinolysis with multidose intravenous TXA (IV-TXA) in reducing preoperative HBL in elderly patients with hip fractures. METHODS AND ANALYSIS This is a prospective, randomised, placebo-controlled clinical trial. Patients older than 65 years diagnosed with primary unilateral femoral neck fracture or intertrochanteric fracture will be randomly assigned to group A (receiving 100 mL of intravenous normal saline every 12 hours preoperatively and 1.5 g of IV-TXA every 12 hours postoperatively for 3 days) or group B (receiving 1.5 g of IV-TXA every 12 hours preoperatively and 1.5 g of IV-TXA every 12 hours postoperatively for 3 days). The primary outcomes will be the hidden blood loss, haemoglobin decrease and ABT rate. The secondary outcomes include the levels of inflammatory factors (such as C reactive protein) and coagulation and fibrinolysis parameters (such as D-dimer). Other outcomes such as injury time, length of stay and hospitalisation expenses will also be compared between groups. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University. The findings of the study will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER ChiCTR2100045960.
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Affiliation(s)
- Jiacheng Liu
- Department of Orthopaedics, Orthopaedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yiting Lei
- Department of Orthopaedics, Orthopaedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Junyi Liao
- Department of Orthopaedics, Orthopaedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xi Liang
- Department of Orthopaedics, Orthopaedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Ning Hu
- Department of Orthopaedics, Orthopaedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Wei Huang
- Department of Orthopaedics, Orthopaedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Viberg B. Tranexamic Acid: When is It Indicated in Orthopaedic Surgery? ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021. [PMID: 34902870 DOI: 10.1055/a-1666-9382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Tranexamic acid (TXA) has been studied extensively during the last 5-8 years. It inhibits clot dissolution during surgery and can therefore reduce blood loss. However, there has been concern that this could result in more frequent complications, specifically in terms of thromboembolic events. The indications for TXA are widespread, and this review covers the literature on orthopaedic indications such as joint replacement, fracture surgery, and arthroscopic procedures. In general, TXA is safe and can be used in a wide variety of orthopaedic procedures, lowering blood loss without increasing the risk of complications.
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Affiliation(s)
- Bjarke Viberg
- Orthopaedic Surgery and Traumatology, Hospital Lillebaelt - University Hospital of Southern Denmark, Kolding, Denmark.,Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
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Rowe S, Liu A, Zagales I, Awan M, Santos R, McKenney M, Elkbuli A. Effectiveness and Safety of Tranexamic Acid Use in Acute Traumatic Injury in the Prehospital and In-hospital Settings: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. ANNALS OF SURGERY OPEN 2021; 2:e105. [PMID: 37637875 PMCID: PMC10455131 DOI: 10.1097/as9.0000000000000105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background and Objectives This systematic review and meta-analysis of randomized controlled trials (RCTs) aims to assess efficacy and safety of tranexamic acid (TXA) use in acute traumatic injuries. Methods PubMed and Cochrane libraries were searched for relevant RCTs published between January 2011 and January 3, 2021. Cohen's Q Test for heterogeneous effects was used to determine the appropriateness of fixed versus random effects models. Results Twenty-two studies met inclusion criteria. Meta-analysis of relative risk of mortality between treatment and placebo groups in the in-hospital, and perioperative settings was not significant. However, the risk of mortality is significantly lower in the treatment versus placebo group when TXA was given as loading dose only. Ten of the 11 studies evaluating perioperative use of TXA included in systematic review found significantly lower blood loss in the treatment compared with placebo groups, but results of meta-analysis showed no significant difference. Results of meta-analysis indicate that the risk of venous thromboembolism (VTE) in the in-hospital treatment group is greater than that of the placebo. In subset analysis of studies using only a single loading dose, there were no significant differences in VTE. Conclusions Systematic review supports TXA benefits are most evident when given shortly after injury and meta-analysis supports TXA reduces mortality as a single loading dose. Systematic review supports perioperative use of TXA when large volume blood loss is anticipated. Meta-results showed no significant difference in risk of thromboembolism in single-dose TXA treatment compared with placebo. These findings suggest that TXA is safe and effective for control of traumatic bleeding.
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Affiliation(s)
- Scott Rowe
- From the Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Amy Liu
- From the Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Israel Zagales
- From the Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Muhammad Awan
- From the Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Radleigh Santos
- Department of Mathematics, Nova Southeastern University, Davie, FL
| | - Mark McKenney
- From the Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
- Department of Surgery, University of South Florida, Tampa, FL
| | - Adel Elkbuli
- From the Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
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Expanded use of tranexamic acid is safe and decreases transfusion rates in patients with geriatric hip fractures. OTA Int 2021; 4:e147. [PMID: 34765898 PMCID: PMC8575430 DOI: 10.1097/oi9.0000000000000147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 07/19/2021] [Indexed: 12/01/2022]
Abstract
Objectives: To determine the effect of a standardized tranexamic acid (TXA) protocol on red blood cell transfusions and adverse events in fragility hip fracture patients. Design: Retrospective cohort study. Setting: Academic Tertiary Care Center. Patients/Participants: Series of 209 patients with fragility hip fractures treated operatively from April 1, 2019 to September 30, 2019. Intervention: Eligible patients received 4 intravenous doses of TXA. Some patients missed doses and only received between 1 and 3 doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture > 48 hours prior to presentation. Main Outcome Measures: Red blood cell transfusion; major adverse vascular events; minor drug related adverse events. Results: Patients who received all 4 doses of TXA (n = 70) had a significantly lower transfusion rate compared to those who did not receive any TXA (7.1% vs 28.1%, P = .003). There were no significant differences in the number of major or minor adverse events between the 2 groups. Conclusions: The use of a standardized TXA protocol of 4 doses significantly decreases transfusion rates in eligible patients undergoing operative intervention for fragility hip fracture without an increase in major or minor adverse events. These findings are even more pronounced in patients with decreased preoperative hemoglobin. Level of Evidence: Prognostic Level III
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The Use of Tranexamic Acid in Hip and Pelvic Fracture Surgeries. J Am Acad Orthop Surg 2021; 29:e576-e583. [PMID: 33788803 DOI: 10.5435/jaaos-d-20-00750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/08/2021] [Indexed: 02/01/2023] Open
Abstract
Tranexamic acid (TXA) use has expanded across many surgical specialties. It has been shown to reduce blood loss, decrease transfusion rates, and, in some cases, improve mortality. Within orthopaedic surgery, its popularity has primarily grown within arthroplasty and spinal surgery. It has only recently gained traction within the field of orthopaedic trauma and fracture care. At this time, most literature focuses on hip fracture and pelvic trauma surgery. For hip fractures, the results are encouraging and generally support the claim that TXA may lower overall blood loss and decrease transfusions. Conversely, less support exists for TXA use in fractures of the acetabulum or pelvic ring. Based on the current fracture-related studies, TXA does not seem to carry an increased risk of thromboembolism or other complications. In addition, few studies have been noted discussing the route of administration, timing, or dosage. This article reviews the most current literature regarding TXA use in fracture care and expands on the need for further research to evaluate the role of TXA in orthopaedic trauma populations who carry a high risk for transfusion.
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Yu X, Wang J, Wang X, Xie L, Chen C, Zheng W. The efficacy and safety of tranexamic acid in the treatment of intertrochanteric fracture: an updated meta-analysis of 11 randomized controlled trials. J Thromb Thrombolysis 2021; 50:243-257. [PMID: 31902124 DOI: 10.1007/s11239-019-02034-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This meta-analysis was performed to investigate the efficacy and safety of tranexamic acid (TXA) in the elderly patients undergoing intertrochanteric fracture surgery from the current literatures. The electronic literature database of PubMed, Embase and Cochrane library were searched in October 2019. The intraoperative blood loss, hidden blood loss, postoperative drainage and total blood loss, postoperative hemoglobin, length of stay, transfusion rate, mortality rate, thromboembolic events and wound complications were extracted. Stata 14.0 software was used for our meta-analysis. A total of 11 RCTs (3 new RCTs in 2019) with 1202 patients met our inclusion criteria. This meta-analysis showed that administration of TXA can reduce intraoperative blood loss (P = 0.009), hidden blood loss (P = 0.000), total blood loss (P = 0.000), length of stay (P = 0.003), transfusion rate (P = 0.000) and the occurrence of wound complications (P = 0.006). Furthermore, administration of TXA was associated with an increase in the postoperative Hb level at day 1, 2 and 3 (P = 0.000, P = 0.000 and P = 0.000, respectively) after surgery. However, no significant difference was found between the TXA group and control group regarding the occurrence of thromboembolic events (P = 0.978, including deep vein thrombosis, P = 0.850; pulmonary embolism, P = 0.788; cerebrovascular accident, P = 0.549; myocardial infarction, P = 0.395) and mortality rate (P = 0. 338). Our meta-analysis suggested that administration of TXA is effective in reducing intraoperative blood loss, hidden blood loss, total blood loss, length of stay, transfusion rate, wound complications and enhancing postoperative Hb without increasing the risk of thromboembolic events and mortality rate in intertrochanteric fracture surgery. More large multi-center and high-quality RCTs are required for further research.
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Affiliation(s)
- Xianbin Yu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, China
| | - Jinwu Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, China
| | - Xingyu Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, China
| | - Linzhen Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, China
| | - Chunhui Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, China
| | - Wenhao Zheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xueyuan Xi Road, Wenzhou, 325000, China.
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The factors that affect blood loss in intertrochanteric fractures treated with proximal femoral nail in the elderly. Eur J Trauma Emerg Surg 2021; 48:1879-1884. [PMID: 33864094 DOI: 10.1007/s00068-021-01670-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/07/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Intertrochanteric femur fractures (IFF) is one of the biggest health problems in elderly population and mostly treated by proximal femoral nails. Although it is done in less invasive technique this method can cause higher blood loss than expected and subsequent allogenic blood transfusions. In this study, we aimed to investigate the factors that were related to the blood loss in proximal femoral nail fixation of IFF including patients' ongoing anticoagulant treatments. METHODS 231 consecutive patients with IFF who treated with proximal femoral nail anti-rotation between January 2017 and December 2019 were included the study. The factors that can affect the blood loss determined as patients demographics, time from injury to operation, duration of operation, the American Society of Anesthesiologists (ASA) scores, preoperative anticoagulant medications. Hematocrit and hemoglobin were obtained on admission day, postoperative day one and postoperative day 3. Total blood loss and allogenic blood transfusions assessed. RESULTS Higher BMI is found related to higher blood loss. The patients who were operated in the first two days after admission had lower blood loss levels independent from anticoagulant use (p = 0.027). Preoperative Hct was higher in patients who did not need RBCs in the perioperative period (p = 0.039). According to the AO classification, A2.1 fractures had lower blood loss levels. CONCLUSION This study demonstrated that ongoing anticoagulant treatments of intertrochanteric fracture patients did not increase the perioperative blood loss. The factors affecting blood loss in the proximal femoral nail fixation were BMI, the time to surgery, and fracture type in the elderly.
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Nikolaou VS, Masouros P, Floros T, Chronopoulos E, Skertsou M, Babis GC. Single dose of tranexamic acid effectively reduces blood loss and transfusion rates in elderly patients undergoing surgery for hip fracture: a randomized controlled trial. Bone Joint J 2021; 103-B:442-448. [PMID: 33641430 DOI: 10.1302/0301-620x.103b3.bjj-2020-1288.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. METHODS In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. RESULTS Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. CONCLUSION Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442-448.
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Affiliation(s)
- Vasileios S Nikolaou
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Themistoklis Floros
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Chronopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Skertsou
- Department of Haematology, Konstandopoulio General Hospital, Athens, Greece
| | - George C Babis
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
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Ma H, Wang H, Long X, Xu Z, Chen X, Li M, He T, Wang W, Liu L, Liu X. Early intravenous tranexamic acid intervention reduces post-traumatic hidden blood loss in elderly patients with intertrochanteric fracture: a randomized controlled trial. J Orthop Surg Res 2021; 16:106. [PMID: 33536047 PMCID: PMC7860029 DOI: 10.1186/s13018-020-02166-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/20/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Elderly patients with intertrochanteric fractures exhibit post-traumatic hidden blood loss (HBL). This study aimed to evaluate the efficacy and safety of reducing post-traumatic HBL via early intravenous (IV) tranexamic acid (TXA) intervention in elderly patients with intertrochanteric fracture. METHODS A prospective randomized controlled study was conducted with 125 patients (age ≥ 65 years, injury time ≤ 6 h) who presented with intertrochanteric fracture from September 2018 and September 2019. Patients in the TXA group (n = 63) received 1 g of IV TXA at admission, whereas those in the normal saline (NS) group (n = 62) received an equal volume of saline. Hemoglobin (Hgb) and hematocrit (Hct) were recorded at post-traumatic admission (PTA) and on post-traumatic days (PTDs) 1-3. HBL was calculated using the Gross formula. Lower extremity venous ultrasound was performed to detect venous thrombosis. RESULTS Hgb on PTDs 2 and 3 was statistically higher in the TXA group than in the NS group. Hct and HBL on PTDs 1-3 were significantly less in the TXA group compared to the NS group. Preoperative transfusion rate was significantly lower in the TXA group compared with the NS group. There was no difference between the two groups with regard to the rates of complications. CONCLUSION Early IV TXA intervention could reduce post-traumatic HBL and pre-operative transfusion rate in elderly patients with intertrochanteric fractures without increasing the risk of venous thrombosis.
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Affiliation(s)
- Huixu Ma
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Hairuo Wang
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Xiaotao Long
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Zexiang Xu
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Xiaohua Chen
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Mingjin Li
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Tao He
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Wei Wang
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Lei Liu
- Department of Orthopedics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
| | - Xi Liu
- Department of Radiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, 400022, People's Republic of China.
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Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6961540. [PMID: 33532495 PMCID: PMC7834786 DOI: 10.1155/2021/6961540] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
Objective Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. Design A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. Results A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. Conclusions There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.
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Haj-Younes B, Sivakumar BS, Wang M, An VV, Lorentzos P, Adie S. Tranexamic acid in hip fracture surgery: A systematic review and meta-analysis. J Orthop Surg (Hong Kong) 2020; 28:2309499019887995. [PMID: 31835969 DOI: 10.1177/2309499019887995] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AIMS The primary objective of this review was to determine whether tranexamic acid (TXA) reduces transfusion rates in patients undergoing surgery for hip fractures. The secondary objective was to assess the effects of TXA on mortality and thromboembolic events in the same cohort. METHODS A systematic review of electronic databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials comparing perioperative TXA in patients treated surgically for hip/proximal femoral fractures against placebo. The primary outcome was the proportion of patients requiring blood transfusion. Secondary outcomes were blood loss, mortality, and complications. Meta-analysis was performed using inverse variance and random effects model. RESULTS The pooled data from 10 studies involving 842 patients showed that the proportion of patients requiring blood transfusion was significantly less in the TXA group (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.59-0.88). There was no difference between TXA and control groups when comparing mortality (RR 1.17, 95% CI 0.65-2.10), deep venous thrombosis (RR 1.14, 95% CI 0.43-3.06), pulmonary embolism (RR 0.53, CI 0.09-3.02), acute coronary syndrome (RR 1.52, CI 0.18-12.98), cerebrovascular events (RR 0.78, CI 0.16-3.68), or wound complications (RR 1.61, CI 0.51-5.13). CONCLUSION There is evidence that TXA reduces the proportion of patients requiring blood transfusions when undergoing hip fracture surgery. However, the small sample size and low event rates for adverse effects preclude any definitive conclusions from being established regarding adverse effects. Future trials should be powered to further assess potential complications and determine the ideal dosage and regime.
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Affiliation(s)
- Bashar Haj-Younes
- Department of Orthopaedics, Westmead Hospital, Westmead, New South Wales, Australia
| | - Brahman S Sivakumar
- Department of Orthopaedics, Hornsby Hospital, Hornsby New South Wales, Australia
| | | | - Vincent Vg An
- Royal Prince Alfred Hospital, University of Sydney, Sydney Medical School, Camperdown, New South Wales, Australia
| | - Peter Lorentzos
- Department of Orthopaedics, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Sam Adie
- Department of Orthopaedics, St George Hospital, Kogarah, New South Wales, Australia
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Better Treatment Values in Local Application of Tranexamic Acid (TXA) than Intravenous Application with the Same Dose in Total Hip Arthroplasty. Adv Ther 2020; 37:4346-4355. [PMID: 32840767 DOI: 10.1007/s12325-020-01454-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The aim of our study was to investigate the hemostatic effect of local and intravenously administered tranexamic acid (TXA) at the same dose in total hip arthroplasty. METHODS The prospective study included 72 patients who underwent total hip arthroplasty in our hospital between March 2018 and March 2019. The patients enrolled in the study were randomly divided into two groups: the observation group (36 patients were injected with 2.0 g TXA in 10 mL 0.9% NaCl using the joint cavity drainage tube after suturing the joint capsule) and the control group (36 patients were given an intravenous infusion of 2 g TXA in 200 mL 0.9% NaCl 30 min before the operation). In each patient, apparent blood loss, hidden blood loss, average blood transfusion, and the number of cases receiving blood transfusion were compared between the two groups after treatment. Hematocrit (Hct) and hemoglobin (Hb) levels were recorded at postoperative day (POD) 1, 2, 3, 7, and 10. We also recorded the levels of C-reactive protein (CRP) and interleukin-6 (IL-6) before the operation and 12 h postoperative and POD 1, 3, 7, and 10. The incidence of deep venous thrombosis and pulmonary embolism was also taken into account. RESULTS In the observation group, apparent blood loss, hidden blood loss, average blood transfusion volume, and the number of patients receiving blood transfusion were lower compared than the control group (P < 0.001). The levels of Hct and Hb were compared between the two groups at POD 1, 2, 3, 7, and 10, and the observation group reported higher levels of Hct and Hb (P < 0.001). The levels of CRP and IL-6 were compared between the two groups at POD 1, 3, 7, and 10, and the observation group reported lower levels of CRP and IL-6 than the control group (P < 0.001). On POD 7, there was no pulmonary embolism in both groups, and no significant difference was observed in the incidence of deep venous thrombosis between the two groups (P > 0.05). CONCLUSIONS Local and intravenous applications of TXA at the same dose are effective approaches in terms of reducing bleeding and inflammatory reaction with a good safety profile; however, the effect of local application had superior therapeutic values.
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Tranexamic acid safely reduces hidden blood loss in patients undergoing intertrochanteric fracture surgery: a randomized controlled trial. Eur J Trauma Emerg Surg 2020; 48:731-741. [PMID: 32415365 DOI: 10.1007/s00068-020-01387-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/02/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate the efficacy and safety of intravenous tranexamic acid (IV-TXA) in patients undergoing intertrochanteric fracture surgery. METHODS A total of 122 patients were included in this double-blinded trial and equally randomized to receive 1 g of IV-TXA or normal saline 10 min before incision and 3 h later. The primary efficacy outcome was calculated hidden blood loss (HBL). The secondary efficacy outcome was allogeneic erythrocyte transfusion rate during hospitalization. Safety outcome was a composite of thromboembolic events including deep venous thrombosis (DVT) up to 90 days. A meta-analysis combining this study with previous randomized controlled trials in hip fracture surgery (total sample size: 1112 patients) was also conducted. RESULTS The mean HBL in TXA group (640.96 ± 421.63 ml) was significantly lower than that in placebo group (1010.11 ± 398.96 ml, P < 0.001). The rate of erythrocyte transfusions was 29.5% in TXA group and 60.7% in placebo group (P = 0.001). The incidence of thromboembolic events at 90 days was 4.9% in TXA group and 1.6% in placebo group (P = 0.619). The updated meta-analysis showed that IV-TXA significantly reduced erythrocyte transfusion in hip fracture surgery (risk ratio 0.60, 95% confidence intervals 0.53-0.68), and IV-TXA caused no increased risk of thromboembolic events (risk difference 0.01, 95% confidence intervals - 0.02-0.04). CONCLUSION IV-TXA could effectively reduce the HBL and allogeneic erythrocyte transfusion requirements in patients undergoing intertrochanteric fracture surgery without an increase of thromboembolic events including DVT. TRIAL REGISTRATION Clinical trials: safety and efficiency of tranexamic acid in hip fracture patients. Date of registration: August 31, 2018. TRIAL REGISTRATION NUMBER ChiCTR1800018110.
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Xing F, Chen W, Long C, Huang F, Wang G, Xiang Z. Postoperative outcomes of tranexamic acid use in geriatric trauma patients treated with proximal femoral intramedullary nails: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2020; 106:117-126. [PMID: 31928976 DOI: 10.1016/j.otsr.2019.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/07/2019] [Accepted: 10/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recently, there has been a series of clinical studies focusing on the perioperative administration of tranexamic acid (TXA) in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery. However, the safety and efficacy of TXA in these patients remains controversial. Therefore, we performed a systematic review to focus on two questions: (1) would TXA reduce perioperative blood loss in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? and (2) would TXA increase the rate of perioperative complications in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? PATIENTS AND METHODS We systematically searched electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) up to April 20, 2019. The perioperative blood loss and complication data were extracted and analysed by RevMan Manager 5.3. RESULTS Finally, five randomized controlled studies, involving 539 geriatric intertrochanteric fracture patients undergoing proximal femoral intramedullary nail surgery, were enrolled in this systematic review. Compared with the control group, the TXA group had significantly lower total perioperative blood loss (WMD=-172.84; 95% CI, -241.44 to -104.24; I2=0%), intraoperative blood loss (WMD=-34.20; 95% CI, -46.04 to -22.36; I2=0%), total perioperative hidden blood loss (WMD=-139.05; 95% CI, -213.67 to -64.43; I2=0%), perioperative transfusion rates (RR =-0.16; 95% CI, -0.24 to -0.08; I2=22%), length of hospital stay (WMD=-1.18; 95% CI, -1.91 to -0.46; p=0.001; I2=12%), and postoperative wound haematoma rates (RD=-0.05; 95% CI, -0.09 to 0.00; p=0.03; I2=0%). In addition, there were no significant differences between TXA and control groups in the terms of surgical time, postoperative mortality, total thromboembolic events, wound infections, cerebrovascular accidents, respiratory infections, and renal failure. DISCUSSION TXA in geriatric trauma patients undergoing intramedullary nail surgery is effective for perioperative haemostasis without increasing the incidence of postoperative complications. LEVEL OF EVIDENCE II, Systematic review and Meta-analysis.
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Affiliation(s)
- Fei Xing
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Wei Chen
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Cheng Long
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Fuguo Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Guanglin Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Zhou Xiang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China.
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Cheung ZB, Anthony SG, Forsh DA, Podolnick J, Zubizarreta N, Galatz LM, Poeran J. Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study. J Orthop 2020; 20:167-172. [PMID: 32025142 DOI: 10.1016/j.jor.2020.01.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 11/26/2022] Open
Abstract
Objective To assess the effect of tranexamic acid (TXA) use in hip fracture surgery. Methods A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost. Results In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost. Conclusion Our results are in support of a wider use of TXA in hip fracture surgery. Level of evidence Level III.
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Affiliation(s)
- Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Shawn G Anthony
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - David A Forsh
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Jeremy Podolnick
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
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Luo X, Huang H, Tang X. Efficacy and safety of tranexamic acid for reducing blood loss in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery: A meta-analysis of randomized controlled trials. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:4-14. [PMID: 32175891 DOI: 10.5152/j.aott.2020.01.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and safety of tranexamic acid (TXA) in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. METHODS We searched MEDLINE, the Cochrane Library and EMBASE for published randomized clinical trials relevant to use of TXA in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery. Meta-analysis was performed according to the guidelines of the Cochrane Reviewer's Hand book. RESULTS Five trials assessing 540 patients were included for meta-analysis. The pooled results showed that the mean total blood loss in TXA group was significant lower than that in the control group (mean difference - 172.83, 95% CI -241.43 to -104.23; p<0.00001, fixed-effect model). The intra- and postoperative transfusion rate for the TXA group was 34.4% (91/264) and for the control group was 49.27% (136/276), and the relative risk was 0.71 (95% CI 0.52 to 0.97; p<0.03, random-effect model) with substantial heterogeneity (I2=63%, p=0.03). The overall incidence of thrombotic events was 6.43% (17/264) in the intravenous TXA group, 7.63% (21/275) in the control group, with no significant difference (relative risk 0.84, 95% CI 0.46 to 1.54; p=0.57, fixed-effect model). CONCLUSION The present evidence shows that TXA can significantly reduce total and hidden blood loss, transfusion rate, and do not increase the risk of thrombotic events in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. However, the impact of TXA on thrombotic events needs to be researched in more high-quality, large-sample randomized clinical trials. LEVEL OF EVIDENCE Level I Therapeutic Study.
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Affiliation(s)
- Xiangping Luo
- Department of Orthopaedics, Hengyang Central Hospital, Hunan, China
| | - Hangqing Huang
- Department of Orthopaedics, Hengyang Central Hospital, Hunan, China
| | - Xiong Tang
- Department of Orthopaedics, Hengyang Central Hospital, Hunan, China
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Houston BL, Uminski K, Mutter T, Rimmer E, Houston DS, Menard CE, Garland A, Ariano R, Tinmouth A, Abou-Setta AM, Rabbani R, Neilson C, Rochwerg B, Turgeon AF, Falk J, Breau RH, Fergusson DA, Zarychanski R. Efficacy and Safety of Tranexamic Acid in Major Non-Cardiac Surgeries at High Risk for Transfusion: A Systematic Review and Meta-Analysis. Transfus Med Rev 2020; 34:51-62. [DOI: 10.1016/j.tmrv.2019.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/06/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022]
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A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures. J Am Acad Orthop Surg 2019; 27:887-894. [PMID: 30829898 DOI: 10.5435/jaaos-d-18-00374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. METHODS In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. RESULTS After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. DISCUSSION A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Zhang S, Xiao C, Pei F. [Research progress on tranexamic acid in traumatic orthopedic surgery]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1457-1461. [PMID: 31650766 PMCID: PMC8337457 DOI: 10.7507/1002-1892.201902030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 07/22/2019] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Shaoyun Zhang
- Department of Orthopedics, the Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang Sichuan, 621000, P.R.China
| | - Cong Xiao
- Department of Orthopedics, the Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang Sichuan, 621000, P.R.China
| | - Fuxing Pei
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Qi YM, Wang HP, Li YJ, Ma BB, Xie T, Wang C, Chen H, Rui YF. The efficacy and safety of intravenous tranexamic acid in hip fracture surgery: A systematic review and meta-analysis. J Orthop Translat 2019; 19:1-11. [PMID: 31844608 PMCID: PMC6896672 DOI: 10.1016/j.jot.2019.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE The present meta-analysis was conducted to compare the efficacy and safety of intravenous application of tranexamic acid (TXA) with placebo in patients with hip fracture undergoing hip surgeries. METHODS PubMed, EMBASE and Cochrane Library were searched from inception until March 2018. A combined searching strategy of subject words and random words was adopted. Only randomized clinical trials were included. The comparisons regarding transfusion rate, total blood loss, intraoperative blood loss, postoperative blood loss, postoperative haemoglobin and postoperative thromboembolic complications were conducted. The meta-analysis was performed using Review Manager 5.3, and the bias evaluation was based on the Cochrane Handbook 5.1.0. RESULTS Ten randomized controlled trials published from 2007 to 2018 were included in the meta-analysis. The results showed that there were significant differences in the two groups concerning transfusion rate of allogeneic blood [risk ratio (RR) = 0.66, 95% confidence interval (CI): 0.56 to 0.78, P = 0.003], total blood loss [mean difference (MD) = -273.00, 95% CI: -353.15 to -192.84, P < 0.00001], intraoperative blood loss (MD = -76.63, 95% CI: -139.55 to -13.71, P = 0.02), postoperative blood loss (MD = -125.29, 95% CI: -221.96 to -28.62, P = 0.01) and postoperative haemoglobin (MD = 0.80, 95% CI: 0.38 to 1.22, P = 0.0002). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 1.38, 95% CI: 0.74 to 2.55, P = 0.31). CONCLUSIONS This meta-analysis of the available evidence implies that the intravenous route of TXA shows an ability to reduce transfusion requirements and total blood loss, not increasing the incidence of thromboembolic events in patients undergoing hip surgeries. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE The result of this meta-analysis shows that the utilization of intravenous TXA in patients with hip fracture undergoing hip surgeries possesses great potential in reducing blood loss and allogeneic blood transfusion safely.
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Key Words
- Allogeneic blood transfusion
- Blood loss
- Hip fracture
- Meta-analysis
- Randomized controlled trial, RCT
- Thromboembolic events
- Tranexamic acid
- Tranexamic acid, TXA
- cerebrovascular accident, CVA
- confidence interval, CI
- deep vein thrombolism, DVT
- haemoglobin, Hb
- mean difference, MD
- pulmonary embolism, PE
- risk ratio, RR
- standard deviation, SD
- total hip arthroplasty, THA
- total knee arthroplasty, TKA
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Affiliation(s)
- Yi-ming Qi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Hai-peng Wang
- The Department of Orthopedics, Jing' An District Centre Hospital of Shanghai (Huashan Hospital Fudan University Jing' An Branch), 20040, China
| | - Ying-juan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Bin-bin Ma
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
| | - Yun-feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- Orthopaedic Trauma Institute of Southeast University, Nanjing, Jiangsu 210009, PR China
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Comprehensive Management, Zhongda Hospital, School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
- School of Medicine, Southeast University, NO. 87 Ding Jia Qiao, Nanjing, Jiangsu 210009, PR China
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Zhou XD, Zhang Y, Jiang LF, Zhang JJ, Zhou D, Wu LD, Huang Y, Xu NW. Efficacy and Safety of Tranexamic Acid in Intertrochanteric Fractures: A Single-Blind Randomized Controlled Trial. Orthop Surg 2019; 11:635-642. [PMID: 31419080 PMCID: PMC6712408 DOI: 10.1111/os.12511] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 07/04/2019] [Accepted: 07/10/2019] [Indexed: 12/31/2022] Open
Abstract
Objective To investigate the efficacy and safety of tranexamic acid (TXA) in the reduction of bleeding and the need for transfusion in elderly intertrochanteric fracture patients. Methods A total of 100 patients with intertrochanteric fractures undergoing surgery were enrolled and randomly allocated to the TXA group in which patients (75.10 ± 8.27 years old) were treated with 1 g of TXA, or the control group (77.82 ± 6.42 years old) treated with a placebo. Surgery was performed by two senior orthopaedic surgeons from two institutions. The proximal femoral nail antirotation (PFNA) was conducted using the standard procedure. Three outcome measures, including blood loss, transfusion, and complications, were recorded. Blood loss and transfusion were investigated to assess TXA's effectiveness, while complications were investigated to assess TXA's safety. Statistical indicators for blood loss included total, intraoperative, postoperative, and hidden blood loss volumes, calculated by hemoglobin levels, hematocrit levels, and drainage volume. The number and amount of blood transfusions were recorded. Complications associated with surgery, including deep vein thrombosis, pulmonary embolism, wound hematoma, wound infection, cardiovascular and cerebrovascular accidents, and respiratory infections, were also recorded. Results All patients were followed up for 1 month after surgery. There were no significant differences in demographic and clinical characteristics between the two groups. The TXA group suffered significantly less total blood loss (563.37 ± 197.51 vs 819.25 ± 273.96 mL, 95% CI: −349.49 to −162.27, P < 0.01), intraoperative blood loss (140.3 ± 80.64 vs 230.5 ± 130.56 mL, 95% CI −132.74 to −47.66, P < 0.01), and hidden blood loss (410.42 ± 178.23 vs 571.19 ± 218.13 mL, 95% CI: −238.85 to −82.69, P < 0.01) than the control group. However, postoperative total blood loss was not significantly different (97.5 ± 20.93 vs 94.7 ± 35.78 mL; P = 0.63). A total of 5 patients from the TXA group and 27 from the control group received packed RBC for postoperative transfusion, but the mean number of transfusion units was not significantly different between groups. Complications including deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic cerebral infarction, hematoma, and infection were observed in both groups, but no significant differences were found. Conclusions In intertrochanteric fracture surgery performed using PFNA, intravenous administration of TXA significantly reduced the risk of intraoperative, total and hidden blood loss, in addition to the need for allogeneic transfusion, without increasing the rate of complications.
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Affiliation(s)
- Xin-Die Zhou
- Department of Orthopaedics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Yi Zhang
- Department of Orthopaedics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Li-Feng Jiang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun-Jie Zhang
- Department of Orthopaedics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Dong Zhou
- Department of Orthopaedics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Li-Dong Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong Huang
- Department of Orthopaedics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Nan-Wei Xu
- Department of Orthopaedics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
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Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial. J Orthop Trauma 2019; 33:371-376. [PMID: 30939507 DOI: 10.1097/bot.0000000000001480] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur. DESIGN Prospective, randomized controlled trial. SETTING Single Level 1 trauma center. PATIENTS Forty-seven patients were randomized to the study group, and 46 patients comprised the control group. INTERVENTION The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose. MAIN OUTCOME MEASUREMENTS Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)]. RESULTS TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57). CONCLUSION The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Xiao C, Zhang S, Long N, Yu W, Jiang Y. Is intravenous tranexamic acid effective and safe during hip fracture surgery? An updated meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2019; 139:893-902. [PMID: 30637503 DOI: 10.1007/s00402-019-03118-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The efficacy and safety of intravenous (IV) tranexamic acid (TXA) during hip fracture surgery remain controversial. This meta-analysis aimed to assess the efficacy of IV-TXA administration during hip fracture surgery for reducing the transfusion requirement and blood loss as well as its safety regarding the risk of thrombolysis. MATERIALS AND METHODS PubMed, EMBASE, Web of Science, and the Cochrane Library Database were systematically searched for randomized controlled trials (RCTs) that focused on the efficacy and safety of IV-TXA in patients during hip fracture surgery. The primary outcome was the transfusion requirement. Secondary outcomes included total blood loss (TBL), deep vein thrombosis (DVT), and total thromboembolic events (TTEs). Risk ratio (RR), risk difference (RD), and mean difference (MD) for dichotomous and continuous data outcomes were determined from the meta-analysis. Data were analyzed using Rev Man 5.3. RESULTS Altogether, 11 RCTs were included (total sample size 892 patients). IV-TXA significantly reduced the transfusion requirement [RR 0.60, 95% confidence interval (CI) 0.38-0.93, P = 0.02] and TBL (MD 326.64 ml, 95% CI - 462.23 to - 191.06, P < 0.00001) vs. cosntrol group. IV-TXA caused no increased risk of DVT (RD 0.02, 95% CI - 0.01 to 0.04, P = 0.13) or TTEs (RD 0.02, 95% CI - 0.01 to 0.05, P = 0.12). CONCLUSION Available evidence indicates that IV-TXA efficaciously reduces TBL and transfusion requirements during hip fracture surgery without significantly increasing the risk of TTEs including DVT.
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Affiliation(s)
- Cong Xiao
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Nengji Long
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Wei Yu
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China
| | - Yishan Jiang
- Department of Orthopedics, The Third Hospital of Mianyang (Sichuan Mental Health Center), No. 190 The East Jiannan Road, Mianyang, 621000, China.
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Xie J, Hu Q, Huang Q, Chen G, Zhou Z, Pei F. Efficacy and safety of tranexamic acid in geriatric hip fracture with hemiarthroplasty: a retrospective cohort study. BMC Musculoskelet Disord 2019; 20:304. [PMID: 31248398 PMCID: PMC6598293 DOI: 10.1186/s12891-019-2670-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 06/06/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Geriatric hip fracture patients are particularly susceptible to blood loss and venous thromboembolism (VTE) during hemiarthroplasty, yet relatively few studies have examined the safety and efficacy of tranexamic acid (TXA) in these patients. METHODS This cohort study of hip fracture patients (≥65 years) undergoing hemiarthroplasty between January 2013 and September 2016 involved 289 patients who received 15 mg/kg TXA prior to surgery and 320 who received no TXA. All patients underwent a fast-track program including nutrition, blood, and pain management; VTE prophylaxis; early mobilization; and early intake. The primary outcome was red cell transfusion requirement. Secondary outcomes included blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay. Multivariate logistic regression and meta-analysis of the literature were also performed to control for confounding factors and identify risk factors of red cell transfusion. RESULTS The proportion of patients receiving at least 1 U of erythrocytes was significantly lower in the TXA group (8.65%) than in the control group (24.06%, OR 0.299, p < 0.001). Mean Hb level was significantly higher in the TXA group on postoperative day 1 (111.70 ± 18.40 vs 107.29 ± 18.70 g/L, p = 0.008) and postoperative day 3 (108.16 ± 17.25 vs 104.22 ± 15.16 g/L, p = 0.005). A significantly higher proportion of TXA patients began to ambulate within 24 h after surgery (37.02% vs 26.25%, p = 0.004), and their length of hospitalization was significantly shorter (11.82 ± 4.39 vs 15.96 ± 7.30 days, p = 0.003). TXA did not increase risk of DVT (OR 0.70, 95%CI 0.25 to 1.97). Logistic regression showed that, after adjusting for covariates, TXA was associated with 62% lower risk of red blood cell transfusion (0.327, 95%CI 0.214 to 0.696), and a similar result was obtained in meta-analysis of unadjusted data from the present study and the literature (OR 0.33, 95%CI 0.25 to 0.43). CONCLUSION TXA appears to be safe and effective for reducing blood loss and red blood cell transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty.
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Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37#Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Qinsheng Hu
- Department of Orthopaedic surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37#Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedic surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37#Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Guo Chen
- Department of Orthopaedic surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37#Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Zongke Zhou
- Department of Orthopaedic surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37#Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China.
| | - Fuxing Pei
- Department of Orthopaedic surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, 37#Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China.
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Zhou XD, Li J, Fan GM, Huang Y, Xu NW. Efficacy and safety of tranexamic acid in elderly patients with intertrochanteric fracture: An updated meta-analysis. World J Clin Cases 2019; 7:1302-1314. [PMID: 31236394 PMCID: PMC6580343 DOI: 10.12998/wjcc.v7.i11.1302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/15/2019] [Accepted: 03/16/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Intertrochanteric fracture (ITF) is a common type of injury, and nearly 30% of ITF patients die in the first 12 mo, especially the elderly with limited activity. Tranexamic acid (TXA) has been widely used in reducing traumatic and surgical bleeding, however, the paucity of studies regarding its use in orthopedic trauma surgery has limited its integration into this field, which may benefit most from TXA. The safety of TXA in this group has not achieved a consensus.
AIM This meta-analysis was designed to investigate the efficacy and safety of TXA in elderly ITF patients undergoing surgery.
METHODS Databases, including Medline and PubMed, were searched for randomized controlled trials (RCTs) that were published before October 2018 and that addressed the efficacy and safety of TXA in patients who underwent ITF surgery. The Consolidated Standards of Reporting Trials 2010 Statement Checklist was used to assess the methodological quality of each study. Trials without and with heterogeneity were compared by fixed-effects analysis and random-effects analysis, respectively. For each study, odds ratio (OR) and 95%CI and mean differences and 95%CI were calculated for dichotomous and continuous outcomes, respectively. The Power and Sample Size Program software was used to calculate power and sample size. Stability of the results was assessed via sensitivity analysis.
RESULTS A total of 836 patients from eight RCTs were subjected to meta-analysis. TXA treatment compared with the control group significantly reduced postoperative blood loss (95%CI, -20.83 to -7.93 mL, P < 0.0001), hidden blood loss (95%CI, -213.67 to -64.43 mL, P = 0.0003), and total blood loss (95%CI, -332.49 to -23.18 mL, P = 0.02) by weighted mean differences of -14.38, -139.05, and -177.83 mL, respectively. However, no significant difference was observed between groups for analysis of intraoperative blood loss. The meta-analysis also proved that the usage of TXA in ITFs may not significantly increase the incidence of deep venous thrombosis. Allogeneic blood transfusion data showed that significantly fewer patients in the TXA group (42%) required transfusion than the control group (95%CI, 0.36 to 0.69; P < 0.0001).
CONCLUSION In ITF surgery, intravenous administration of TXA reduces the risk of hidden blood loss and the need for allogeneic transfusion, without increasing thrombotic risk.
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Affiliation(s)
- Xin-Die Zhou
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Jin Li
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Guo-Ming Fan
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China
| | - Yong Huang
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Nan-Wei Xu
- Department of Orthopedics, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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50
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Patient blood management for liver resection: consensus statements using Delphi methodology. HPB (Oxford) 2019; 21:393-404. [PMID: 30446290 DOI: 10.1016/j.hpb.2018.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.
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