Combined use of intravenous and topical versus intravenous tranexamic acid in primary total knee and hip arthroplasty: a meta-analysis of randomised controlled trials

Jun-Feng Li, Hang Li, Hui Zhao, Jun Wang, Shen Liu, Yang Song, Hong-Fen Wu, Jun-Feng Li, Hang Li, Hui Zhao, Jun Wang, Shen Liu, Yang Song, Hong-Fen Wu

Abstract

Background: This meta-analysis aimed to evaluate the efficiency and safety of combined intravenous and topical methods of application versus single intravenous of tranexamic acid in primary total knee and hip arthroplasty.

Methods: A systematic search was carried out in MEDLINE (from 1966 to 25 September 2016), PubMed (from 1966 to 25 September 2016), Embase (from 1980 to 25 September 2016), ScienceDirect (from 1985 to 25 September 2016) and the Cochrane Library. Only high-quality randomised controlled trials (RCT) were identified. Two authors independently performed data extraction and quality assessment of included studies. Meta-analysis was conducted using Review Manager 5.1 software.

Results: Six RCTs that included 687 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences in terms of total blood loss (MD = -193.59, 95% CI -338.06 to -49.13, P = 0.009), transfusion rate (RD = -0.07, 95% CI -0.12 to -0.03, P = 0.001), haemoglobin decline (MD = -0.51, 95% CI -0.83 to -0.18, P = 0.01) and length of stay (MD = -0.20, 95% CI -0.38 to -0.02, P = 0.03) between groups.

Conclusions: Combined administration of tranexamic acid (TXA) in patients with total knee and hip arthroplasty was associated with significantly reduced total blood loss, transfusion requirements, postoperative haemoglobin decline and length of stay compared to single application alone but was not associated with prolonged operation time. Moreover, no adverse effects, such as superficial infection, deep vein thrombus (DVT) or pulmonary embolism (PE), were associated with TXA. We suggest that combined administration of TXA demonstrated excellent clinical efficacy and safety in patients with total knee and hip arthroplasty. More importantly, well-designed studies with larger sample size are needed to provide further reliable evidence for the combined use of TXA.

Keywords: Blood loss; Meta-analysis; Total hip replacement; Total knee and hip arthroplasty; Total knee replacement; Tranexamic acid.

Figures

Fig. 1
Fig. 1
Search results and the selection procedure
Fig. 2
Fig. 2
Forest plot diagram showing effect of combination TXA on total blood loss
Fig. 3
Fig. 3
Forest plot diagram showing effect of combination TXA on transfusion rate
Fig. 4
Fig. 4
Forest plot diagram showing effect of combination TXA on haemoglobin decline
Fig. 5
Fig. 5
Forest plot diagram showing effect of combination TXA on drainage volume
Fig. 6
Fig. 6
Forest plot diagram showing effect of combination TXA on operation time
Fig. 7
Fig. 7
Forest plot diagram showing effect of combination TXA on length of stay
Fig. 8
Fig. 8
Forest plot diagram showing effect of combination TXA on risk of superficial infection
Fig. 9
Fig. 9
Forest plot diagram showing effect of combination TXA on risk of deep vein thrombosis
Fig. 10
Fig. 10
Sensitivity analysis on total blood loss

References

    1. Mannucci PM, Levi M. Prevention and treatment of major blood loss. N Engl J Med. 2007;356(22):2301–2311. doi: 10.1056/NEJMra067742.
    1. Sculco TP. Global blood management in orthopaedic surgery. Clin Orthop Relat Res. 1998;357:43–49. doi: 10.1097/00003086-199812000-00007.
    1. Bilgili MG, Ercin E, Peker G, Kural C, Basaran SH, Duramaz A, Avkan C. Efficiency and cost analysis of cell saver auto transfusion system in total knee arthroplasty. Balkan Med J. 2014;31(2):149–153. doi: 10.5152/balkanmedj.2014.13267.
    1. Conteduca F, Massai F, Iorio R, Zanzotto E, Luzon D, Ferretti A. Blood loss in computer-assisted mobile bearing total knee arthroplasty. A comparison of computer-assisted surgery with a conventional technique. Int Orthop. 2009;33(6):1609–1613. doi: 10.1007/s00264-008-0651-7.
    1. Benoni G, Lethagen S, Fredin H. The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res. 1997;85(3):195–206. doi: 10.1016/S0049-3848(97)00004-2.
    1. Lin SY, Chen CH, Fu YC, Huang PJ, Chang JK, Huang HT. The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty. J Arthroplast. 2015;30(5):776–780. doi: 10.1016/j.arth.2014.12.001.
    1. Huang Z, Ma J, Shen B, Pei F. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplast. 2014;29(12):2342–2346. doi: 10.1016/j.arth.2014.05.026.
    1. Nielsen CS, Jans O, Orsnes T, Foss NB, Troelsen A, Husted H. Combined intra-articular and intravenous tranexamic acid reduces blood loss in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2016;98(10):835–841. doi: 10.2106/JBJS.15.00810.
    1. Song EK, Seon JK, Prakash J, Seol YJ, Park YJ, Jin C. Combined administration of IV and topical tranexamic acid is not superior to either individually in primary navigated TKA. J Arthroplasty. 2017;32(1):37–42.
    1. Wu YG, Zeng Y, Yang TM, Si HB, Cao F, Shen B. The efficacy and safety of combination of intravenous and topical tranexamic acid in revision hip arthroplasty: a randomized, controlled trial. J Arthroplasty. 2016;31(11):2548–53.
    1. Xie J, Ma J, Yue C, Kang P, Pei F. Combined use of intravenous and topical tranexamic acid following cementless total hip arthroplasty: a randomised clinical trial. Hip Int. 2016;26(1):36–42. doi: 10.5301/hipint.5000291.
    1. Jain NP, Nisthane PP, Shah NA. Combined administration of systemic and topical tranexamic acid for total knee arthroplasty: can it be a better regimen and yet safe? A randomized controlled trial. J Arthroplast. 2016;31(2):542–547. doi: 10.1016/j.arth.2015.09.029.
    1. Reikeras O, Clementsen T. Time course of thrombosis and fibrinolysis in total knee arthroplasty with tourniquet application. Local versus systemic activations. J Thromb Thrombolysis. 2009;28(4):425–428. doi: 10.1007/s11239-008-0299-6.
    1. Sperzel M, Huetter J. Evaluation of aprotinin and tranexamic acid in different in vitro and in vivo models of fibrinolysis, coagulation and thrombus formation. J Thromb Haemost. 2007;5(10):2113–2118. doi: 10.1111/j.1538-7836.2007.02717.x.
    1. Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg Br Vol. 1996;78(3):434–440.
    1. Camarasa MA, Olle G, Serra-Prat M, Martin A, Sanchez M, Ricos P, Perez A, Opisso L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anaesth. 2006;96(5):576–582. doi: 10.1093/bja/ael057.
    1. Hiippala S, Strid L, Wennerstrand M, Arvela V, Mantyla S, Ylinen J, Niemela H. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth. 1995;74(5):534–537. doi: 10.1093/bja/74.5.534.
    1. Veien M, Sorensen JV, Madsen F, Juelsgaard P. Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study. Acta Anaesthesiol Scand. 2002;46(10):1206–1211. doi: 10.1034/j.1399-6576.2002.461007.x.
    1. Danninger T, Rasul R, Poeran J, Stundner O, Mazumdar M, Fleischut PM, Poultsides L, Memtsoudis SG. Blood transfusions in total hip and knee arthroplasty: an analysis of outcomes. TheScientificWorldJOURNAL. 2014;2014:623460. doi: 10.1155/2014/623460.
    1. Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ, Silverton CD. Predictors and complications of blood transfusion in total hip and knee arthroplasty. J Arthroplast. 2014;29(9 Suppl):189–192. doi: 10.1016/j.arth.2014.03.048.
    1. Klika AK, Small TJ, Saleh A, Szubski CR, Chandran Pillai AL, Barsoum WK. Primary total knee arthroplasty allogenic transfusion trends, length of stay, and complications: nationwide inpatient sample 2000-2009. J Arthroplast. 2014;29(11):2070–2077. doi: 10.1016/j.arth.2014.06.018.
    1. Yoshihara H, Yoneoka D. National trends in the utilization of blood transfusions in total hip and knee arthroplasty. J Arthroplast. 2014;29(10):1932–1937. doi: 10.1016/j.arth.2014.04.029.
    1. Soriano A, Bori G, Garcia-Ramiro S, Martinez-Pastor JC, Miana T, Codina C, Macule F, Basora M, Martinez JA, Riba J, et al. Timing of antibiotic prophylaxis for primary total knee arthroplasty performed during ischemia. Clin Infect Dis. 2008;46(7):1009–1014. doi: 10.1086/529145.
    1. Raveendran R, Wong J. Tranexamic acid: more evidence for its use in joint replacement surgery. Transfusion. 2014;54(1):2–3. doi: 10.1111/trf.12494.

Source: PubMed

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