Topical Versus Intravenous Administration of Tranexamic Acid in Primary Total Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Sammy A Hanna, Anoop Prasad, Joshua Lee, Pramod Achan, Sammy A Hanna, Anoop Prasad, Joshua Lee, Pramod Achan

Abstract

Tranexamic acid (TA) is widely used by orthopedic surgeons to decrease blood loss and the need for transfusion following total hip arthroplasty (THA). Although both intravenous and topical applications are described in the literature, there remains no consensus regarding the optimal regimen, dosage and method of delivery of TA during THA. In addition, concerns still exist regarding the risk of thromboembolic events with intravenous administration. The purpose of this meta-analysis was to compare the efficacy and safety of topical versus intravenous administration of TA in THA. A systemic review of the electronic databases PubMed, CENTRAL, EMBASE and Google Scholar was undertaken to identify all randomized controlled trials (RCTs) comparing the topical and intravenous administration of TA during THA, in terms of total blood loss, rate of blood transfusion and incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) post-operatively. A meta-analysis was performed to evaluate and compare the efficacy and safety of both methods of administration. Of 248 potentially relevant papers, three RCTs comprising (482) were eligible for data extraction and meta-analysis. The results showed a slightly higher amount of blood loss [Mean Difference (MD) - 46.37, P=0.12, 95% confidence interval (CI) - 12.54 to 105.29] and rate of transfusion (Risk Ratio 1.30, P=0.39, 95%CI 0.71 to 2.37) postoperatively in the topical TA group, but both did not reach statistical significance. There were 3 cases (1.2%) of DVT/PE in the intravenous group and one case (0.4%) in the topical group. Topical TA is an effective and safe method to reduce blood loss and the rate of transfusion following primary THA. It has comparative effectiveness to IV administration with slightly less post-operative thromboembolic complications. Larger and better-designed RCTs are required to establish the optimum dosage and regimen for topical use.

Keywords: Tranexamic acid; intravenous; topical; total hip arthroplasty; transfusion.

Conflict of interest statement

the authors declare no potential conflict of interest.

Figures

Figure 1.
Figure 1.
Flowchart of the study selection.
Figure 2.
Figure 2.
Meta-analysis results for total blood loss total blood loss.
Figure 3.
Figure 3.
Meta-analysis results for rate of blood transfusion.
Figure 4.
Figure 4.
Meta-analysis results for the incidence of deep venous thrombosis/pulmonary embolus.

References

    1. National Joint Registry. Annual Report, 2013. Available from:
    1. American Academy of Orthopaedic Surgeons. Total hip replacement. Available from:
    1. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780.
    1. Toy PT, Kaplan EB, McVay PA, et al. Blood loss and replacement in total hip arthroplasty: a multicenter study. The preoperative autologous blood donation study group. Transfusion 1992;32:63-7.
    1. Blumberg N, Kirkley SA, Heal JM. A cost analysis of autologous and allogeneic transfusion in hip-replacement surgery. Am J Surg 1996;171:324-30.
    1. Madjdpour C, Spahn DR. Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth 2005;95:33-42.
    1. Klein HG. Allogeneic transfusion risks in the surgical patient. Am J Surg 1995;170: 21S-26S.
    1. Schreiber GB, Busch MP, Kleinman SH, Korelitz JJ. The risk of transfusion-transmitted viral infections. The Retrovirus Epidemiology Donor Study. N Engl J Med 1996;334:1685-90.
    1. Dunn CJ, Goa KL. Tranexamic acid. A review of its use in surgery and other indications. Drugs 1999;57:1005-32.
    1. Hoylaerts M, Lijnen HR, Collen D. Studies on the mechanism of the antifibrinolytic action of tranexamic acid. Biochim Biophys Acta 1981;673:75-85.
    1. Okamoto S, Sato S, Takada Y, Okamoto U. An active stereo-isomer (trans-form) of AMCHA and its antifibrinolytic (antiplasminic) action in vitro and in vivo. Keio J Med 1964;13:177-85.
    1. Melander B, Gliniecki G, Granstrand B, Hanshoff G. Biochemistry and toxicology of amikapron; the antifibrinolytically active isomer of AMCHA. (A comparative study with epsilon-aminocaproic acid). Acta Pharmacol Toxicol (Copenh) 1965;22:340-52.
    1. Hiippala ST, Strid LJ, Wennerstrand MI, et al. Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg 1997;84:839-44.
    1. Ekbäck G, Axelsson K, Ryttberg L, et al. Tranexamic acid reduces blood loss in total hip replacement surgery. Anesth Analg 2000;91:1124-30.
    1. Huang F, Wu Y, Yin Z, et al. A systematic review and meta-analysis of the use of antifibrinolytic agents in total hip arthroplasty. Hip Int 2015;25:502-9.
    1. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br 2011;93:39-46.
    1. Raveendran R, Wong J. Tranexamic acid reduces blood transfusion in surgical patients while its effects on thromboembolic events and mortality are uncertain. Evid Based Med 2013;18:65-6.
    1. Wong J, Abrishami A, El Beheiry H, et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am 2010;92:2503-13.
    1. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. 2011. Available from:
    1. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1-12.
    1. Wei W, Wei B. Comparison of topical and intravenous tranexamic acid on blood loss and transfusion rates in total hip arthroplasty. J Arthroplasty 2014;29:2113-6.
    1. Xie J, Ma J, Yue C, et al. Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. 2016;26:36-42.
    1. North WT, Mehran N, Davis JJ, et al. Topical vs intravenous tranexamic acid in primary total hip arthroplasty: a double-blind, randomized controlled trial. J Arthroplasty 2016;31:928-9.
    1. Carson JL, Terrin ML, Jay M. Anemia and postoperative rehabilitation. Can J Anaesth 2003;50:S60-4.
    1. Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of bloodmanagement in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81:2-10.
    1. Triulzi DJ, Vanek K, Ryan DH, Blumberg N. A clinical and immunologic study of blood transfusion and postoperative bacterial infection in spinal surgery. Transfusion 1992;32:517-24.
    1. Kim C, Park SS, Davey JR. Tranexamic acid for the prevention and management of orthopedic surgical hemorrhage: current evidence. J Blood Med 2015;6:239-44.
    1. Alshryda S, Sukeik M, Sarda P, et al. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. J Bone Joint Surg Br 2014;96-B:1005-15.

Source: PubMed

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