Safety of Tranexamic Acid in Hip and Knee Arthroplasty in High-risk Patients

Abstract

Background With increasing use of tranexamic acid in total hip and knee arthroplasties, safety concerns remain. Using national claims data, this study examined tranexamic acid use in patients with preexisting comorbidities. The hypothesis was that tranexamic acid use is not associated with increased complication risk in hip and knee arthroplasty patients with comorbidities. Methods Among 765,011 total hip/knee arthroplasties (2013 to 2016, Premier Healthcare claims), tranexamic acid use was assessed in three high-risk groups: group I with patients with a history of venous thromboembolism, myocardial infarction, seizures, or ischemic stroke/transient ischemic attack (n = 27,890); group II with renal disease (n = 44,608); and group III with atrial fibrillation (n = 45,952). The coprimary outcomes were blood transfusion and new-onset “composite complications” (venous thromboembolism, myocardial infarction, seizures, and ischemic stroke/transient ischemic attack). Associations between tranexamic acid use and outcomes were measured separately by high-risk group. The odds ratios and Bonferroni-adjusted 99.9% CIs are reported. Results Overall, 404,974 patients (52.9%) received tranexamic acid, with similar frequencies across high-risk groups I (13,004 of 27,890 [46.6%]), II (22,424 of 44,608 [50.3%]), and III (22,379 of 45,952 [48.7%]). Tranexamic acid use was associated with decreased odds of blood transfusion in high-risk groups I (721 of 13,004 [5.5%] vs. 2,293 of 14,886 [15.4%]; odds ratio, 0.307; 99.9% CI, 0.258 to 0.366), group II (2,045 of 22,424 [9.1%] vs. 5,159 of 22,184 [23.3%]; odds ratio, 0.315; 99.9% CI, 0.263 to 0.378), and group III (1,325 of 22,379 [5.9%] vs. 3,773 of 23,573 [16.0%]; odds ratio, 0.321; 99.9% CI, 0.266 to 0.389); all adjusted comparisons P < 0.001. No increased odds of composite complications were observed in high-risk group I (129 of 13,004 [1.0%] vs. 239 of 14,886 [1.6%]; odds ratio, 0.89, 99.9% CI, 0.49 to 1.59), group II (238 of 22,424 [1.1%] vs. 369 of 22,184 [1.7%]; odds ratio, 0.98; 99.9% CI, 0.58 to 1.67), and group III (187 of 22,379 [0.8%] vs. 290 of 23,573 [1.2%]; odds ratio, 0.93; 99.9% CI, 0.54 to 1.61); all adjusted comparisons P > 0.999. Conclusions Although effective in reducing blood transfusions, tranexamic acid is not associated with increased complications, irrespective of patient high-risk status at baseline. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Fat Necrosis Following Application of a Tourniquet During Total Knee Arthroplasty

“…Single or multiple doses of this antifibrinolytic drug have been shown to reduce intraoperative bleeding and avoid blood transfusions following major surgery [18]. Tranexamic acid was also safe for use in patients at higher risk of thromboembolic events [19]. Zhao et al also noted that patients who had received multiple doses of tranexamic acid without a tourniquet experienced less total blood loss and inflammatory reactions with better early knee scores than patients who had a tourniquet applied [20].…”

Tranexamic Acid Should be Considered for High Risk Arthroplasty Patients

“…The safety of tranexamic acid in the high risk patient has been looked at from a registry level in anaesthesiology by Poeran et al [12] who found that tranexamic acid was not associated with an increase in complication irrespective of patient risk status whether these be vascular, renal or cardiac risks.…”

Application of an adjusted patient blood management protocol in patients undergoing elective total hip arthroplasty: towards a zero-percent transfusion rate in renal patients—results from an observational cohort study

“…In the present series, most of the renal patients received TXA. A recent registry study demonstrated the efficacy of TXA in TJA patients with renal impairment [ 9 ]. TXA reduced the transfusion rate from 23.3 to 9.1% in patients with renal impairment.…”

“…TXA reduced the transfusion rate from 23.3 to 9.1% in patients with renal impairment. Importantly, this registry study—which included 765,011 patients, of whom 44,506 had renal impairment – reported no increase in the rate of complications among patients who received TXA, including the high-risk patients [ 9 , 12 ].…”