We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) -164 to -44, p = 0.0006, heterogeneity I(2) 0%), postoperative blood loss by a mean of 172 ml (95% CI -263 to -81, p = 0.0002, heterogeneity I(2) 63%) and total blood loss by a mean of 289 ml (95% CI -440 to -138, p < 0.0002, heterogeneity I(2) 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference -0.20, 95% CI -0.29 to -0.11, p < 0.00001, I(2) 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

BackgroundThe increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost.Questions/purposesWe compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections.MethodsBetween 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3–9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45–87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation.ResultsNone of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p = 0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p < 0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group.ConclusionsOur data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings.Level of EvidenceLevel III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.