Tranexamic acid may prevent heterotopic ossification after elbow trauma surgery

Michael D. McKee, MD, FRCS(C)

This retrospective review provides new and interesting information from a busy Chinese trauma center (187 operative radial head/neck cases in 2 years) that TXA may prevent heterotopic ossification after surgery for elbow trauma. Although the patients were not randomized to TXA use or not (it was based on surgeon discretion) the numbers are fairly convincing: a 16.2% rate of heterotopic ossification in the non-TXA group vs. an 8.7% rate in the group that received TXA. This was statistically significant, and I would argue clinically relevant, decrease in heterotopic ossification about the elbow. In addition, the group that received TXA had a decreased rate of “clinically important” heterotopic ossification. To my knowledge, no previous study has demonstrated this effect of TXA on the elbow. As we are aware, heterotopic ossification about the elbow is certainly a common and debilitating condition that can ruin technically excellent surgery and drastically decrease range of motion of the elbow. Reconstructive surgery (excision and release) in this setting is often far from perfect.

The authors describe the possible mechanism of action of TXA, detailing the potential inhibitory effect on TXA on the inflammatory process. I might suggest a simpler mechanism: the elimination of excessive bleeding or hematoma around the elbow which, anecdotally, often precedes heterotopic ossification formation. As the authors point out, there are drawbacks to this study, particularly the lack of randomization, the lack of standardization of delivery of the TXA (both local and systemic) and the small numbers of cases in some subgroups. Further confirmatory studies are needed, and I would encourage the authors to proceed with the prospective, randomized trial that they discuss: They certainly have the numbers to make it successful.