Tranexamic acid use decreased blood loss in patients undergoing THA, TKA

Peter V. Giannoudis, MD, FRCS, EEC

There are more than 1.2 million hip and knee total joint replacements per annum in the United States alone; therefore, one can appreciate the potential benefit of reducing the risk of bleeding and the need for allogeneic blood transfusions (minimizing the chance of patient-related immunological reactions) and decreasing the direct medical costs of treatment. Diminishing postoperative blood loss would facilitate rehabilitation and reduce perioperative morbidity in general.

Besides good surgical technique, other strategies have been evolving, utilizing pharmacotherapy, such as administration of antifibrinolytic agents (tranexamic acid [TXA]). While this drug has been developed to be administered intravenously, several investigators are exploring its potential use and effectiveness by topical administration due to the potential reduction of systemic side-effects such as thromboembolic events, ease of use and its lower cost. In the study by Martin and colleagues, the effectiveness of this approach was investigated in 100 patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a prospective, stratified, randomized, double-blind, placebo-controlled trial. The authors reported that the maximum decline in postoperative hemoglobin was significantly lower with the use of topical TXA when compared with placebo stratified by surgical site. The 30-day readmission rate was less also for the TXA treatment group with a stratified odds-ratio of 0.37 with a 95% confidence interval of 0.07 to 2.03. This study, however, has limitations, which the authors acknowledged, such as selection of the drop in hemoglobin as the primary outcome and insufficient power of the study to detect a statistical significance for the secondary outcome points. The authors concluded that the topical application of 2 g TXA in THA and TKA without drains results in a significant decline in blood loss, with no measurable side effects.

The safety of topical application of TXA has been reported by other studies and a recent meta-analysis noted that in patients undergoing TKA and who were given topical TXA, there was a significantly postoperative reduction in drain output and a lower risk of transfusion requirements without increased risk of thromboembolic events. It appears, therefore, that topical TXA use can be effective following THA/TKA with no safety concerns. Further larger scale trials will provide more robust evidence about its effectiveness and safety of use.