Topical Tranexamic Acid Research Articles

Advances in surgical hemostasis: a comprehensive review and meta-analysis on topical tranexamic acid in spinal deformity surgery.

Tranexamic acid (TXA) is an effective and commonly used hemostatic agent for perioperative blood loss in various surgical specialties. It is being increasingly used in spinal deformity surgery. We aimed to evaluate the safety and efficacy of topical TXA (tTXA) compared to both placebo and/or intravenous (IV) TXA in patients undergoing spinal deformity surgery. We conducted a systematic review of the electronic databases using different MeSH terms from January 1970 to August 2019. Pooled and subgroup analysis was performed using fixed and random-effect model based upon the heterogeneity (I2). A total of 609 patients (tTXA: n = 258, 42.4%) from 8 studies were included. We found that there was a statistically significant difference in terms of (i) postoperative blood loss [mean difference (MD) - 147.1, 95% CI - 189.5 to - 104.8, p < 0.00001], (ii) postoperative hemoglobin level (MD 1.09, 95% CI 0.45 to 1.72, p = 0.0008), (iii) operative time (MD 7.47, 95% CI 2.94 to 12.00, p < 0.00001), (iv) postoperative transfusion rate [odds ratio (OR) 0.39, 95% CI 0.20 to 0.78, p = 0.007], postoperative drain output (MD, - 184.0, 95% CI - 222.03 to - 146.04, p < 0.00001), and (v) duration of hospital stay (MD - 1.14, 95% CI - 1.44 to - 0.85, p < 0.00001) in patients treated with tTXA compared to the control group. However, there was no significant difference in terms of intraoperative blood loss (p = 0.13) and complications (p = 0.23) between the two comparative groups. Furthermore, low-dose (250-500mg) tTXA (p < 0.00001) reduced postoperative blood loss more effectively compared to high-dose tTXA (1-3g) (p = 0.001). Our meta-analysis corroborates the effectiveness and safety of tTXA in spinal deformity surgery.

Evaluating the role of topical tranexamic acid in cancers of the head-and-neck: A single-center randomized controlled trial

Background: Closed suction drains can reduce the complications associated with neck dissection (ND) by facilitating the removal of bodily fluids from the operated site. A lower drain output helps in faster wound healing, thereby leading to early drain removal and better recovery. Topical application of tranexamic acid (TXA) to the raw area created by surgery has been shown to be beneficial in reducing the bleeding in cardiac, orthopedic, and endoscopic nasal surgeries.Objectives: This study aimed at assessing whether the topical application of TXA after ND reduced the drain output, time to drain removal, and postoperative complications in patients undergoing surgery for head and neck cancers.Materials and Methods: The present study was performed in a tertiary care teaching hospital in north India between August 2014 and December 2017. One hundred patients with head and neck cancer who underwent ND were randomized into two groups. Group 1 received 20 ml of 25 mg/ml topical TXA per neck after hemostasis, and Group 2 underwent routine neck closure. Primary end points included the daily drain output until postoperative day 5 and the day of drain removal. Age, lymph node yield, operative time, type of reconstruction, and postoperative complications till 30 days postoperatively were also recorded.Results: The demographic and clinicopathological profiles were comparable between the two groups. Output from the neck drains was significantly lower in the TXA group compared to the standard closure group (208.29 ± 84.18 ml vs. 344.56 ± 110.93 ml; respectively, P < 0.0001). In addition, drain removal in the tranexamic acid group was done earlier than in the standard closure group (6.11 ± 1.20 days vs. 7.56 ± 1.42 days, respectively,P < 0.0001). Postoperative complications and requirement of secondary procedures were comparable between the two groups.Conclusions: Topical TXA effectively reduces the postoperative drain output after ND in patients with head and neck cancer. It facilitates the early removal of the drain and helps in better recovery without any significant difference in the rate of postoperative complications.

Effect of tranexamic acid on symptomatic venous thromboembolism in patients undergoing primary total knee arthroplasty

IntroductionThis study aimed to investigate the effect of tranexamic acid (TXA) with sequential routine anticoagulation on postoperative symptomatic venous thromboembolism (VTE) in patients undergoing primary total knee arthroplasty (TKA).Material and methodsThis was a prospective study with randomized trials. From January 2013 to May 2015, 1880 patients undergoing primary TKA were enrolled in this study. Seven hundred and twenty patients who received TXA injection were included in the TXA group while 1160 patients who received placebo injection were included in the control group. Patients in the TXA group were treated with intravenous TXA or topical intravenous TXA, and all received sequential routine anticoagulation 12 h after the operation. We extracted data of patients’ sex, age, primary diagnoses, and comorbidities that could potentially affect the prevalence rate of VTE. To discuss the risk factors of symbolic VTE, comparisons were made within the TXA group between patients with symbolic VTE and non-symbolic VTE. Logistic regression analysis was performed to analyze the concurrent effects of various factors on the prevalence rate of postoperative VTE.ResultsThigh perimeter was not closely associated with TXA injection. Within the TXA group, 24 (3.3%) patients had perioperative symptomatic VTE, 16 (2.2%) deep vein thrombosis (DVT) and 8 (1.1%) pulmonary embolism. High body mass index (BMI), low fibrinogen (Fbg) and simultaneous bilateral TKA were significant risk factors in both univariate analysis and multivariate analysis.ConclusionsIncreased BMI, low Fbg, and simultaneous bilateral TKA could act as risk factors for postoperative symptomatic VTE treated with TXA.

Tranexamic acid versus topical mesolightening mixture using the dermaroller in the treatment of melisma

Background Use of localized microinjection of tranexamic acid (TA) has been studied for the treatment of melasma and was proved to be effective, but transdermal delivery of this agent has not been well studied. The use of Dermaroller may increase the effective delivery of active ingredients in topical mesolightening mixture and TA. Aim The aim of this split-face study was to compare the safety and efficacy of transdermal delivery of TA versus topical mesolightening mixture using the Dermaroller in the treatment of melasma. Patients and methods This split-face study was carried out on 15 patients having melasma. For each patient, the following was done after taking an informed consent: history taking, dermatological examination, Wood’s light examination, Melanin Area and Severity Index (MASI) score calculation, photography, physician’s global assessment by independent investigators, patient’s global evaluation, eight sessions of transdermal delivery of TA and topical mesolightening mixture, with a session every week (mixture of kojic acid 3%, TA 0.01%, azelaic acid 4% (19,20), L-ascorbic acid 1 g, and water for injection), and recording of the adverse effects every session. This was followed by 3 months of follow-up. Results The initial (pre-4) reduction of MASI (after the first four sessions) on the left side (TA treated) was significantly higher than that on the right side. Similarly, the later (four to eight sessions) (upon comparing the second set with the first set of sessions) and overall reduction was higher on the left side compared with that on the right side; however, these differences were not statistically significant in terms of MASI. Conclusion TA and topical mesolightening mixture are individually effective in the treatment of melasma. TA is superior to mesolightening, as well as cost-effective in the treatment of melasma.

The effect of tranexamic acid in reducing postoperative hemorrhage in patients undergoing coronary artery bypass graft.

Introduction:Nowadays, cardiovascular diseases such as coronary heart disease are one of the most important causes of human mortality worldwide. Coronary artery bypass graft (CABG) surgery is a standard therapy approach for those suffering from coronary artery disease. Tranexamic acid (TXA), an antifibrinolytic drug, which, in turn, inhibits fibrinolysis, leading to the prevention of bleeding, thus, the present study aimed to evaluate the effect of topical TXA on bleeding reduction after coronary artery CABG.Materials and Methods:In this study 62 patients were randomly divided into two groups of TXA and control. After surgery and removal from the cardiopulmonary pump, TXA (2 g) was injected locally into the mediastinum by the surgeon. In the second group (control) the same amount of normal saline (100 cc) was given. Data were analyzed by SPSS 19 software via the t-test and Fisher's test.Results:A significant difference was found between the 2 groups in terms of postoperative hemorrhage, packed cell volume, platelet transfusion, duration of surgery, and received FFP (P = 0.0001; P = 0.01; P = 0.0001; P = 0.0001; P = 0.0001), where were found to be lower in the TXA group than in the placebo group. There was no significant difference in age, sex, return to the operating room, and discharge.Conclusion:The use of topical TXA in GABC significantly reduced postoperative hemorrhage, packed cell volume, platelet transfusion, and FFP after surgery. Besides, it had no significant effect on the return to the operating room and mortality.

Utility of topical tranexamic acid in head-and-neck cancer surgery: A myth or reality?

Utility of topical tranexamic acid in head-and-neck cancer surgery: A myth or reality?

Exploring the efficacy of topical tranexamic acid in headand-neck cancer surgery

Exploring the efficacy of topical tranexamic acid in headand-neck cancer surgery

Clinical Study of Tranexamic Acid in Treatment of Cervical Ectopy-AnInstitutional Experience

Background: Cervical ectopy is a common entity among women attending gynaecological OPD for various complaints which itself could be the cause or present otherwise. The treatment modalities currently available are electrocoagulation, cry cauterization, laser cauterization, and drug treatment. Most of these procedures require a high learning curve, associated with side-effects, and are costly. Furthermore, routine treatment for ectopy has long been debated and there are no current guidelines for the same. Tranexamic acid, with its easy applicability, availability, and minimal costs could be an effective alternative. Objective: To evaluate the therapeutic effectiveness and safety of topical tranexamic acid for the treatment of cervix erosion. Methodology: A total of 75 cases of cervical erosion were taken who satisfied the inclusion and exclusion criteria of the study. Patients were randomized into two groups. Local application of tranexamic acid (Group A, n=38) or povidone-iodine solution (Group B, n=37) for 5 minutes were applied with the patient position kept constant for 15 minutes and daily dosage were given for 10 days. All the patients were followed up at the end of 2nd and 4th week and after 3 months for complete healing, relief of symptoms like chronic pelvic pain, recurrent vaginitis, contact bleeding, and vaginal discharge, and possible side effects. Results: In group A, all 7 and 20 patients complaining of chronic pelvic pain and contact bleeding respectively were cured of it (100% cure). For the other symptoms such as recurrent vaginitis and vaginal discharge, cure rates were 81.25% and 87.5% respectively. In group B, the cure was seen only in vaginal discharge with 12 patients getting cured out of 33 (36.36%) and no response in other symptoms. Side effect in the form of vaginal irritation was found only in group B in 17 patients (45.94%) whereas none were observed in group A who received the tranexamic acid application. We observed a positive correlation between cervical erosion and tranexamic acid application in terms of healing and side effects. Conclusion: Tranexamic acid application is a promising new treatment modality of cervical erosion in symptomatic women.

Comparative study between topical tranexamic acid and intradermal tranexamic acid injection in treatment of melasma

Comparative study between topical tranexamic acid and intradermal tranexamic acid injection in treatment of melasma

Utilización del ácido tranexámico tópico en la artroplastia total primaria de cadera. Eficacia y seguridad. Nuestra experiencia

Background and aimIntravenous tranexamic acid has been shown to reduce bleeding and the need for transfusions in total hip arthroplasty, although it has a theoretical risk of producing thromboembolic phenomena. Recently some papers have been published using the topical application of tranexamic acid, but the ideal administration protocol has not yet been clearly defined. The aim of this paper was to demonstrate that our protocol of topical tranexamic acid is effective and safe. Materials and methodsProspective data collection from a case series of 80 primary hip arthroplasties, in which the following topical tranexamic acid protocol is used: 1.5 grams diluted to a total volume of 60ml were administered, applying 20ml in the acetabular bed, 20ml in the femoral canal and 20ml through the Redon drain, keeping it closed for 20minutes. ResultsEighty patients were operated. Preoperative haemoglobin 14.26g / dL; preoperative haematocrit 42.39%. An average loss of 2.74g / dL of haemoglobin and 8% of haematocrit was obtained. Eleven percent of the patients required transfusion, of whom 67% had known previous anaemia; only 3 patients without prior anaemia required transfusion (4%). There were no thromboembolic complications in our series. ConclusionsThe use of topical tranexamic acid was safe and effective in primary total hip arthroplasty, reducing the need for blood transfusion compared to that described in the literature in untreated patients.

Combined use of intravenous and topical tranexamic acid in patients aged over 70\u2009years old undergoing total hip arthroplasty

PurposeThe present study was designed to evaluate the efficacy and safety of combined use of intravenous (IV) TXA administration and topical intraarticular tranexamic acid (TXA) strategy in patients aged over 70 undergoing total hip arthroplasty (THA).MethodsOne hundred eighty patients were randomized into three groups, including an IV group, a local group, and a combined group. Patients were administrated with 15 mg/kg of IV-TXA in the IV group, 2 g TXA in the topical group, or 15 mg/kg IV-TXA combined with 2 g TXA in the combined group. Total blood loss (TBL), maximum hemoglobin drop, the transfusion rate and the number of allogeneic blood units, and the incidence of deep venous thrombosis (DVT), and pulmonary embolism (PE) were recorded and analyzed.ResultsTBL was 757.75 ± 188.95 mL in the combined group, which was significantly lower than in the IV group (892.75 ± 218.47) or the topical group (1015.75 ± 288.71) (p = 0.015, p = 0.001 respectively). The mean values of maximum hemoglobin drop in the combined, IV, and topical groups were 2.67 ± 0.42, 3.28 ± 0.52, and 3.75 ± 0.62 g/dL, respectively, with a significant intergroup difference (p < 0.001 for all). PE was not detected within 1 month after the surgery. Asymptomatic DVT was reported in 1 patient of the IV group, and in 2 patients from the combined group, while the difference was not statistically significant.ConclusionsCompared to intravenous or topical use of TXA, the combined therapy effectively decreased total blood loss and reduced the transfusion rate, simultaneously possessed the same degree of safety in primary THA patients aged over 70.

The efficiency and safety of oral tranexamic acid in total hip arthroplasty: A meta-analysis.

Background:Intravenous (IV), topical and combination of both application of tranexamic acid (TXA) can reduce blood loss, hemoglobin drop, and transfusion rate in patients following total hip arthroplasty (THA). Lately, published articles reported that oral TXA had as similar blood-saving as IV and topical TXA in THA. The purpose of this meta-analysis is to investigate the efficiency and safety of oral TXA in THA.Methods:We systematically searched articles about oral administration of TXA in THA from PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Chinese Wanfang database. Study eligibility criteria:1.Patients underwent primary THA;2.The intervention was oral application of TXA in THA;3.Outcomes included hemoglobin drop, total blood loss, transfusion rate, length of stay, and complications;4.The studies were designed as randomized controlled trials (RCTs) or clinical comparative trial (CCT).The outcomes were collected and analyzed by the Review Manager 5.3.Results:Nine RCTs and 1 CCT, containing 1305 patients, were ultimately included according to the inclusion criteria and exclusion criteria in the meta-analysis. The effectiveness of oral TXA was as similar as the IV or topical TXA in regard to hemoglobin drop (SMD = −0.14; 95% CI, [−0.28, 0.01]; P = .06), total blood loss (SMD = 0.01; 95% CI, [−0.13, 0.16]; P = .84), transfusion rate (OR = 0.76; 95% CI, [0.38, 1.55]; P = .37). Compared with single oral TXA or blank group, multiple oral TXA effectively reduced hemoglobin drop (SMD = −1.06; 95% CI, [−1.36, −0.77]; P < .05), total blood loss (SMD = −1.30; 95% CI, [−1.66, −0.94]; P < .05), transfusion rate (OR = 0.53; 95% CI, [0.29, 0.95]; P = .03). There were no significant difference in terms of length of stay and complication among all of enrolled studies.Conclusion:Oral TXA has favorable effect of blood-saving and do not increase risk of complication in patients following THA. Oral TXA may have no effect in the length of stay. More high quality RCTs are necessary.

Effet de l’acide tranexamique en injection locale dans l’arthroplastie totale de hanche chez les patients sous aspirine continue : une étude randomisée

BackgroundDue to differences in pharmacological mechanism of action, the effect of tranexamic acid (TA) on aspirin-related bleeding remains unknown. We therefore conducted a prospective randomized study to elucidate (1) the effect of topical TA administration on blood loss and transfusion rate in total hip arthroplasty (THA) patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events; (2) 90-day complications of topical TA administration; (3) possible variables contributing to blood transfusion. HypothesisTopical TA administration reduces blood loss and transfusion rate in THA patients receiving continuous aspirin. Patients and methodsA total of 102 consecutive THA patients taking continuous aspirin were enrolled and randomized into two groups. In the topical TA (TTA) group (n=55), topical TA was administered at three points during THA; in the control group (n=47), the patients received saline solution as placebo. Based on drop in hemoglobin concentration, total estimated blood loss was calculated as the main assessment criterion. Secondary assessment criteria included transfusion rate and 90-day complications. Finally, a multivariate regression model was used to assess possible predictive factors for blood transfusion. Results(1) Significantly lower total blood loss was observed in the TTA group than in the control group (897±177ml vs. 1153±345ml, P<0.001). Furthermore, lower transfusion rate was observed in the TTA group than in the control group (34.0% vs. 10.9%, P=0.005). (2) No significant difference was observed between the two groups regarding 90-day complications. (3) We identified higher preoperative hemoglobin level (OR=0.675, P=0.002) and topical TA administration (OR=0.002, P=0.012) as negative predictive factors for blood transfusion. DiscussionTopical application of TA was safe and beneficial in THA patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events, to reduce blood loss and transfusion rate, without increasing the risk of 90-day complications.

Use of Topical Tranexamic Acid Reduces Direct and Indirect Blood Loss and Transfusion Rates in Revision Total Hip Arthroplasty.

In primary total hip arthroplasty (THA), evidence supports the use of tranexamic acid (TXA) as an effective strategy for reducing blood loss, but scant evidence supports its use in revision THA. We aimed to evaluate whether the use of topical TXA in revision THA is associated with less blood loss and lower transfusion rates and to assess its safety, specifically as it relates to thromboembolic complications. In this retrospective comparative study, two groups who underwent revision THA between 2005 and 2017 were defined: 98 patients who received 3g of topical TXA (study group) and 475 patients who did not receive TXA (control group). Subjects were divided into subgroups according to the type of revision. Hemoglobin and hematocrit levels, blood loss, and transfusions were recorded. The follow-up period was 6weeks. Median estimated blood loss, hidden blood loss, hemoglobin drop, and transfusion rates were significantly lower in the study group. The rates of post-operative thromboembolism were similar in the two groups. According to subgroup analysis, patients with revision of the femoral component, both components, and staged exchange revisions showed significantly lower rates of transfusion. Topical TXA administration during revision THA effectively reduced direct and indirect blood loss, including hidden losses, without increasing the rates of thromboembolic events. This effect appeared to be enhanced when thefemoral component was revised.

Topical tranexamic acid inhibits fibrinolysis more effectively when formulated with self‐propelling particles

BackgroundEndogenous fibrinolytic activation contributes to coagulopathy and mortality after trauma. Administering tranexamic acid (TXA), an antifibrinolytic agent, is one strategy to reduce bleeding; however, it must be given soon after injury to be effective and minimize adverse effects. Administering TXA topically to a wound site would decrease the time to treatment and could enable both local and systemic delivery if a suitable formulation existed to deliver the drug deep into wounds adequately. ObjectivesTo determine whether self‐propelling particles could increase the efficacy of TXA. MethodsUsing previously developed self‐propelling particles, which consist of calcium carbonate and generate CO2 gas, TXA was formulated to disperse in blood and wounds. The antifibrinolytic properties were assessed in vitro and in a murine tail bleeding assay. Self‐propelled TXA was also tested in a swine model of junctional hemorrhage consisting of femoral arteriotomy without compression. ResultsSelf‐propelled TXA was more effective than non‐propelled formulations in stabilizing clots from lysis in vitro and reducing blood loss in mice. It was well tolerated when administered subcutaneously in mice up to 300 to 1000 mg/kg. When it was incorporated in gauze, four of six pigs treated after a femoral arteriotomy and without compression survived, and systemic concentrations of TXA reached approximately 6 mg/L within the first hour. ConclusionsA formulation of TXA that disperses the drug in blood and wounds was effective in several models. It may have several advantages, including supporting local clot stabilization, reducing blood loss from wounds, and providing systemic delivery of TXA. This approach could both improve and simplify prehospital trauma care for penetrating injury.

Effect of topical tranexamic acid in total hip arthroplasty patients who receive continuous aspirin for prevention of cardiovascular or cerebrovascular events: A prospective randomized study

BackgroundDue to differences in pharmacological mechanism of action, the effect of tranexamic acid (TA) on aspirin-related bleeding remains unknown. We therefore conducted a prospective randomized study to elucidate: (1) the effect of topical TA administration on blood loss and transfusion rate in total hip arthroplasty (THA) patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events; (2) 90-day complications of topical TA administration; (3) possible variables contributing to blood transfusion. HypothesisTopical TA administration reduces blood loss and transfusion rate in THA patients receiving continuous aspirin. Patients and MethodsA total of 102 consecutive THA patients taking continuous aspirin were enrolled and randomized into two groups. In the topical TA (TTA) group (n=55), topical TA was administered at three points during THA; in the control group (n=47), the patients received saline solution as placebo. Based on drop in hemoglobin concentration, total estimated blood loss was calculated as the main assessment criterion. Secondary assessment criteria included transfusion rate and 90-day complications. Finally, a multivariate regression model was used to assess possible predictive factors for blood transfusion. Results(1) Significantly lower total blood loss was observed in the TTA group than in the control group (897±177ml vs. 1153±345ml, p<0.001). Furthermore, lower transfusion rate was observed in the TTA group than in the control group (10.9% vs. 34.0%, p=0.005). (2) No significant difference was observed between the two groups regarding 90-day complications. (3) We identified higher preoperative hemoglobin level (OR=0.675, p=0.002) and topical TA administration (OR=0.002, p=0.012) as negative predictive factors for blood transfusion. DiscussionTopical application of TA was safe and beneficial in THA patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events, to reduce blood loss and transfusion rate, without increasing the risk of 90-day complications.

Cytotoxicity and effect on wound re-epithelialization after topical administration of tranexamic acid.

BackgroundTopical administration of tranexamic acid (TXA) reduces bleeding from surgical wounds similarly to intravenous use, but with negligible risk of adverse systemic events. Topical use is expanding, but is off‐label. Surgeons lack guidelines regarding safe topical dosages and modes of administration. The effects of topical TXA on skin cells and wound healing are unknown. This study investigated whether topical TXA might be cytotoxic or affect wound re‐epithelialization.MethodsHuman keratinocytes and fibroblast cell cultures and an ex vivo human skin wound model were subjected to both short (limited) and long (chronic) exposure to various clinically relevant concentrations of TXA to mimic different modalities of topical administration. Cytotoxicity and effects on wound re‐epithelialization were evaluated.ResultsIn cell culture, toxicity from chronic exposure was associated with increasing concentration and exposure time. Limited exposure to TXA did not cause significant cytotoxicity even at high concentrations. Re‐epithelialization was completely absent in wounds chronically exposed to TXA concentrations of 25 mg/ml or above, and 50–100 mg/ml induced epidermolysis of normal epithelium, possibly by a non‐toxic mechanism. Wound re‐epithelialization was slightly delayed, but not impaired, by limited exposure to 100 mg/ml or chronic exposure to 6·25 mg/ml.ConclusionAlthough short exposure to even high concentrations of topical TXA seems well tolerated in vitro, prolonged exposure can be cytotoxic and may affect wound re‐epithelialization. Surgeons should adjust the TXA concentration to the planned mode of topical administration in clinical practice. Surgical relevanceTopical tranexamic acid (TXA) may reduce bleeding from surgical wounds similarly to intravenous administration without the risk of systemic effects. Little is known, however, regarding the adverse effects of TXA on exposed tissues.We exposed in vitro human keratinocytes and fibroblasts and an ex vivo human skin wound model to TXA at various concentrations and time intervals and found that short exposure to even high concentrations or prolonged exposure to low concentrations of TXA was well tolerated. Prolonged exposure to increasing concentrations increased keratinocyte and fibroblast toxicity, and TXA concentrations of 25 mg/ml or above completely prevented wound‐re‐epithelialization.Prolonged exposure to high concentrations of topical TXA may exert unwanted local tissue effects. This study suggests that surgeons should adjust TXA concentration to the planned mode of topical administration in clinical practice.

Tranexamic acid in cardiac surgery: a systematic review and meta-analysis (protocol)

IntroductionBleeding during cardiac surgery is associated with increased morbidity and mortality. Tranexamic acid is an antifibrinolytic with proven efficacy in major surgeries. Current clinical practice guidelines recommend intraoperative use in...

2019 Mark Coventry Award: A multicentre randomized clinical trial of tranexamic acid in revision total knee arthroplasty: does the dosing regimen matter?.

Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA. The purpose of this multicentre randomized clinical trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. From six-centres, 233 revision TKAs were randomized to one of four regimens: 1 g of intravenous (IV) TXA given prior to the skin incision, a double-dose regimen of 1 g IV TXA given both prior to skin incision and at time of wound closure, a combination of 1 g IV TXA given prior to skin incision and 1 g of intraoperative topical TXA, or three doses of 1950 mg oral TXA given two hours preoperatively, six hours postoperatively, and on the morning of postoperative day one. Randomization was performed based on the type of revision procedure to ensure equivalent distribution among groups. Power analysis determined that 40 patients per group were necessary to identify a 1 g/dl difference in the reduction of haemoglobin postoperatively between groups with an alpha of 0.05 and power of 0.80. Per-protocol analysis involved regression analysis and two one-sided t-tests for equivalence. In total, one patient withdrew, five did not undergo surgery, 16 were screening failures, and 25 did not receive the assigned treatment, leaving 186 patients for analysis. There was no significant difference in haemoglobin reduction among treatments (2.8 g/dl for single-dose IV TXA, 2.6 g/dl for double-dose IV TXA, 2.6 g/dl for combined IV/topical TXA, 2.9 g/dl for oral TXA; p = 0.38). Similarly, calculated blood loss (p = 0.65) and transfusion rates (p = 0.95) were not significantly different between groups. Equivalence testing assuming a 1 g/dl difference in haemoglobin change as clinically relevant showed that all possible pairings were statistically equivalent. Despite the higher risk of blood loss in revision TKA, all TXA regimens tested had equivalent blood-sparing properties. Surgeons should consider using the lowest effective dose and least costly TXA regimen in revision TKA. Cite this article: Bone Joint J 2019;101-B(Supple 7):10-16.

Topical tranexamic acid in elderly patients with femoral neck fractures treated with hemiarthroplasty: efficacy and safety? - a case-control study

BackgroundPerioperative blood management is an important issue in the treatment of elderly patients at an increased risk of postoperative complications. Accordingly, tranexamic acid (TXA) is widely administered to reduce blood loss and transfusion requirements. In this case-control study, the effect of topical TXA on the outcomes of elderly patients with femoral neck fractures after hemiarthroplasty was evaluated.MethodsThis study enrolled elderly patients (age ≥ 70 years) who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between January 2015 and January 2017. The study group comprised 72 patients who received TXA via topical administration during surgery. After propensity matching, the control group comprised 72 patients who did not receive topical TXA. The perioperative and postoperative parameters of the two groups were compared.ResultsThe estimated blood loss, vacuum tube drainage, and total transfusion volume were significantly lower in the study group than the control (p = 0.024, 0.003, and 0.019, respectively). Despite a lack of significant intergroup differences in the lengths of ICU and hospital stays; rates of ICU admission, venous thromboembolism, delirium, and readmission; and rates of in-hospital and 1-year mortality, the incidence of postoperative medical complications was significantly lower in the study group (p = 0.003).ConclusionTopical TXA administration appears to be a simple and effective option for reducing blood loss, transfusion requirements, and medical complications after hemiarthroplasty in elderly patients with femoral neck fractures.