The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials

Abstract

BackgroundThe combined administration of intravenous (IV) and topical tranexamic acid (TXA) in primary total knee (TKA) knee remains controversial. The purpose of this meta-analysis was to assess the efficacy and safety of combined administration of IV and topical TXA in primary TKA.MethodsPubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Google Search Engine and China National Knowledge Infrastructure databases were searched for randomized controlled trials (RCTs) were comparing the combined administration of IV and topical TXA following primary TKA. The primary outcomes were total blood loss, maximum hemoglobin drop, and deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The second outcomes were drainage volume and transfusion requirements. Data were analyzed using RevMan 5.3.ResultsA total of 6 RCTs involving 701 patients were included in the meta-analysis. The combined group provided lower total blood loss (MD − 156.34 mL, 95% CI, − 241.51 to − 71.18; P = 0.0003), drainage volume (MD − 43.54 mL, 95% CI, − 67.59 to − 19.48; P = 0.0004), maximum hemoglobin drop (MD − 0.56 g/dl, 95% CI, − 0.93 to − 0.19; P = 0.003) than IV TXA alone. No significant difference were found in terms of transfusion requirements (RR 0.48, 95% CI, 0.16 to 1.44; P = 0.19), DVT (RR 1.01, 95% CI, 0.14 to 7.12; P = 0.99) and PE (RR 0.33, 95% CI, 0.01 to 7.91; P = 0.49) between the two group. Subgroup analyses shows that the combined group was less total blood loss in non-tourniquet (P = 0.0008), topical TXA dose > 1.5 g (P < 0.00001) and number of IV TXA ≥ 2 doses (P = 0.005) of TXA compared with the IV group alone.ConclusionsThe available evidence indicates combined group were associated with lower total blood loss, drainage volume, and maximum hemoglobin drop. A similar transfusion requirement was found in both groups. Subgroup analyses demonstrates that total blood loss was less in patients with non-tourniquet, topical TXA dose > 1.5 g and number of IV TXA ≥ 2 doses of TXA. There was no increase the rates of DVT and PE.

Monitoring of fibrinolytic system activity with plasminogen, D-dimers and FDP in primary total knee arthroplasty (TKA) after topical, intravenous or combined administration of tranexamic acid

“…Here we found the smallest incidence of complications with intravenous TXA regimens and a combined mode. In this case, the results correspond to large studies, respectively meta-analyses 10,11,13 .…”

“…TXA has gradually become a routine part of perioperative care in primary total arthroplasty of the hips and knees 5,6 . Therefore, the clinical utility of this intervention is unquestionable and is supported by several meta-analyses of RCTs (randomized clinical trials) for primary hips and knees [7][8][9][10][11] . TXA can be administered by the intravenous route, orally or topically into the joint 1 .…”

Topical Tranexamic Acid in Total Knee Arthroplasty: Does It Augment the Effect of the Intravenous Administration in Patients with Moderate-to-High Risk of Bleeding? A Randomized Clinical Trial

“…Although similar results for the use of tourniquet or nontourniquet during TKA in affecting TBL and transfusion rate were reported, 14,27,42 we preferred to use it to minimize the intraoperative blood loss and to improve the visualization of the surgical field.…”

Editorial Commentary: Tranexamic Acid: Okay, It Reduces the Bleeding, but Are We Sure Topical Use Is Not Harmful to the Cartilage?

“…By decreasing other costs, TXA is cost-effective in specific orthopaedic surgical procedures. [1][2][3][4][5][6][7][8] The use of TXA to reduce operative and postoperative bleeding and the subsequent need for blood transfusion is well defined for certain orthopaedic procedures, yet it still raises some questions for arthroscopic surgeons. 9,10 The subject of this commentary is the well-performed study in this issue on reducing hemarthrosis after anterior cruciate ligament reconstruction (ACLR) by Chiang, Chen, Wang, Ma, Chang, Liu, Chen 11 titled "Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study."…”