Topical versus systemic tranexamic acid after total knee and hip arthroplasty

Abstract

Background:Tranexamic acid (TXA) is an antifibrinolytic drug widely used to reduce blood loss during joint replacements, including total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, there is no final consensus regarding the composition of an optimal administration of TXA regime between topical and systemic (intravenous). The purpose of our study was to compare the efficacy of topical and intravenous (IV) regimen of TXA during TKA and THA.Methods:Five relevant electronic online databases, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Chinese Biomedical Database were systematically searched in November 2015. Randomized controlled trials (RCTs) that compared topical with intravenous TXA in patients with TKA or THA were included. The search terms included “topical,” “intravenous,” “tranexamic acid,” “knee arthroplasty” and “hip arthroplasty.” Two reviewers independently extracted data and assessed the risk of bias and study quality. Data were analyzed with Review Manager 5.3 software. Grades of Recommendation Assessment, Development and Evaluation (GRADE) were used to assess the quality of evidence.Results:Sixteen RCTs with 1250 patients undergoing TKA and 4 RCTs involving 550 patients undergoing THA were included. There were no significant differences in total blood loss (mean difference [MD]TKA = −28.72 mL, 95% confidence interval [CI] −195.97 to 138.54 mL, P = 0.74; MDTHA = 14.03 mL, 95% CI −35.53 to 63.59 mL; P = 0.78), total drain out (MDTKA = −3.09 mL, 95% CI −39.05 to 32.88 mL; P = 0.87; MDTHA −31.00 mL, 95% CI −66.56 to 4.66 mL; P = 0.09), and transfusion rates (ORTKA = 0.90, 95% CI 0.58–1.40, P = 0.64; ORTHA = 1.19, 95% CI 0.67–2.09; P = 0.63) between topical and intravenous (IV) TXA.Conclusions:The current evidence suggested that topical TXA was equally effective and safe compared with intravenous TXA in reducing blood loss and transfusion rate following TKA or THA. We recommended that either topically or systemically could be used in TKA and THA to decrease perioperative blood loss.

Tranexamic acid is associated with increased mortality in patients with physiological fibrinolysis

“…Thus, administration of this medication may paradoxically increase organ specific bleeding, while causing fibrinolysis shutdown in others. Given that systemic inhibition of fibrinolysis appears to have adverse effects, a role of topical TXA, which in orthopedic surgery has the same efficacy of reducing blood products (18), would be worthy of investigation in future studies.…”

Tranexamic acid in adult elective orthopaedic and complex spinal surgery: A review

“…In the published literature the timing of exactly when these doses are administered varies and in several studies is not explicitly explained [8][9][10][11][12][13][14][15][16][17][18][19]. The most commonly cited doses for topical TXA are 1.5-3 grams for joint irrigation and 0.5-2 grams for intra-articular injection typically administered following tourniquet let down or immediately before closure [14,17,[20][21][22][23][24][25][26][27]. Investigations using these dosing strategies almost universally observe significant decreases in total blood loss, total hemoglobin reduction, and transfusion rates.…”

Establishing a Successful Outpatient Joint Arthroplasty Program

“…It is important to streamline the instrument sets used to minimize the number of trays opened for the procedure and ensure that the surgical team is competent in handling all instruments used for the procedure. Streamlined, standardized order sets and clinical pathways for the care provided help to reduce variations in practice and improve efficiency …”

“…Streamlined, standardized order sets and clinical pathways for the care provided help to reduce variations in practice and improve efficiency. 33 Leaders should evaluate the outcomes of their TJA program to understand the potential growth and sustainability of an outpatient program. Data collection that includes patient satisfaction scores and the rates of surgical site infection, hospital readmission, and return to surgery is instrumental in justifying TJA procedures being performed on an outpatient basis.…”