Tranexamic Acid Should be Considered for High Risk Arthroplasty Patients
Keywords:TXA, Tranexamic acid, Arthroplasty, VTE, Venothromboembolism, Joint replacement
Tranexamic acid significantly reduces blood loss and transfusion requirements in arthroplasty patients. However, it is often avoided in patients who have had previous arterial and thromboembolic disease despite the absence of evidence of hazard in this group of patients. We examined the use of tranexamic acid in unselected hip and knee arthroplasty patients including those considered to be ‘high risk’.
A 2-year retrospective multicentre study was performed with patients who underwent hip or knee arthroplasty surgery. A blood management protocol included universal tranexamic acid use for all patients. Blood loss, transfusion volumes and complications were analysed.
A total of 958 patients were included in the study, 130 patients were considered ‘high risk’ of thromboembolic complications and 828 patients were considered ‘low risk’. 879 patients received tranexamic acid with a significant reduction in blood loss (p<0.001) in these patients.
Two of 130 (1.5%) ‘high risk’ patients and 14 of 828 (1.7%) ‘low risk’ patients had post-operative VTE. There was no significant difference in rate of VTE between the ‘high risk’ and ‘low risk’ patients (p=0.6) or in the subgroup of ‘high risk’ patients who had received TXA (p=1).
The efficacy of tranexamic acid is overwhelming and outweighs any potential risks. Tranexamic acid should be considered for use in all arthroplasty patients including those with prior history of venous or arterial thrombosis.
Franchini M, Mengoli C, Marietta M, Marano G, Vaglio S, Pupella S, et al. Safety of intravenous tranexamic acid in patients undergoing major orthopaedic surgery: A meta-analysis of randomised controlled trials. Blood Transfus. 2018;16(1):36–43.
Dastrup A, Pottegard A, Hallas J, Overgaard S. Perioperative tranexamic acid treatment and risk of cardiovascular events or death after total hip arthroplasty. J Bone Jt Surg - Am Vol. 2018;100(20):1742–9.
Niskanen RO, Korkala OL. Tranexamic acid reduces blood loss in cemented hip arthroplasty: A randomized, double-blind study of 39 patients with osteoarthritis. Acta Orthop. 2005;76(6):829–32.
Benoni G, Lethagen S, Fredin H. The effect of tranexamic acid on local and plasma fibrinolysis during total knee arthroplasty. Thromb Res. 1997;88(2):251.
Yang Y, Lv YM, Ding PJ, Li J, Ying-Ze Z. The reduction in blood loss with intra-articular injection of tranexamic acid in unilateral total knee arthroplasty without operative drains: A randomized controlled trial. Eur J Orthop Surg Traumatol. 2015;25(1):135–9.
Jang B, Kao M, Bohm MT, Harris IA, Chen DB, MacDessi SJ. Intra-articular injection of tranexamic acid to reduce blood loss after total knee arthroplasty. J Orthop Surg. 2014 Aug;22(2):146–9.
Watts CD, Houdek MT, Sems SA, Cross WW, Pagnano MW. Tranexamic Acid Safely Reduced Blood Loss in Hemi- and Total Hip Arthroplasty for Acute Femoral Neck Fracture: A Randomized Clinical Trial. J Orthop Trauma. 2017 Jul;31(7):345–51.
Goobie SM. Tranexamic acid: Still far to go. Br J Anaesth. 2017;118(3):293–5.
Administration TG. Australian Public Assessment Report for Tranexamic acid Proprietary Product Name : Cyklokapron [Internet]. Therapeutic Goods Administration. 2010. Available from: https://www.tga.gov.au/sites/default/files/auspar-cyklokapron.pdf
Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, et al. Tranexamic acid in total joint arthroplasty: The endorsed clinical practice guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and . Reg Anesth Pain Med. 2019;44(1):7–11.
Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, et al. The Safety of Tranexamic Acid in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty. 2018;33(10):3070-3082.e1.
Poeran J, Chan JJ, Zubizarreta N, Mazumdar M, Galatz LM, Moucha CS. Safety of Tranexamic Acid in Hip and Knee Arthroplasty in High-risk Patients. Anesthesiology. 2021;57–68.
Porter SB, White LJ, Osagiede O, Robards CB, Spaulding AC. Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients. J Arthroplasty. 2020;35(1):45-51.e3.
Sabbag OD, Abdel MP, Amundson AW, Larson DR, Pagnano MW. Tranexamic Acid Was Safe in Arthroplasty Patients With a History of Venous Thromboembolism: A Matched Outcome Study. J Arthroplasty [Internet]. 2017;32(9):S246–50. Available from: http://www.elsevier.com/inca/publications/store/6/2/3/1/4/1/index.htt
Sabbag OD, Abdel MP, Amundson AW, Larson DR, Pagnano MW. Tranexamic Acid Was Safe in Arthroplasty Patients With a History of Venous Thromboembolism: A Matched Outcome Study. J Arthroplasty. 2017;32(9):S246–50.
Macdessi S, Chen D, Goyal N, Harris I, Kirsh G, Rowden N. Intravenous versus Intra-articular Tranexamic Acid in Patients Undergoing Primary Unilateral Total Knee Arthroplasty. Orthop J Sport Med. 2016;4(2_suppl):2325967116S0000.
Newman C, Tran P, McGregor S, Bramley D. Patient blood management strategies in total hip and knee arthroplasty. Curr Orthop Pract. 2018;29(1).
Boyle N, Brook C. Towards better, safer blood transfusion– A report for the Australian Council for Safety and Quality in Health Care, Commonwealth of Australia 2005. Aust Comm Saf Qual Heal Care. 2005;(December).
Kildow BJ, Howell EP, Karas V, Baumgartner WT, Cunningham DJ, Green CL, et al. When Should Complete Blood Count Tests Be Performed in Primary Total Hip Arthroplasty Patients? J Arthroplasty. 2018;33(10):3211–4.
Halawi MJ, Plourde JM, Cote MP. Routine Postoperative Laboratory Tests Are Not Necessary After Primary Total Hip Arthroplasty. J Arthroplasty. 2019;34(3):538–41.
Frank SM, Rothschild JA, Masear CG, Rivers RJ, Merritt WT, Savage WJ, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology. 2013;118(6):1286–97.
National Blood Authority. Three pillars of patient blood management. [Internet]. Available from: https://www.blood.gov.au/system/files/documents/pbm-3-pillars.pdf
Isbister JP. The three-pillar matrix of patient blood management-An overview. Best Pract Res Clin Anaesthesiol [Internet]. 2013;27(1):69–84. Available from: http://dx.doi.org/10.1016/j.bpa.2013.02.002
Hofmann A, Farmer S, Towler SC. Strategies to preempt and reduce the use of blood products: An Australian perspective. Curr Opin Anaesthesiol. 2012;25(1):66–73.
Spahn DR, Goodnough LT. Alternatives to blood transfusion. Lancet [Internet]. 2013;381(9880):1855–65. Available from: http://dx.doi.org/10.1016/S0140-6736(13)60808-9
Kearney B, To J, Southam K, Howie D, To B. Anaemia in elective orthopaedic surgery - Royal Adelaide Hospital, Australia. Intern Med J. 2016 Jan;46(1):96–101.
How to Cite
Copyright (c) 2022 Andy Ho, David Campbell, Shanil Yapa, Ibrahim Malek, Pier Yates
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright and License Agreement:
Authors who publish with the Reconstructive Review agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work. Reconstructive Review follows the Creative Commons Attribution-NonCommercial CC BY-NC. This license allows anyone to download works, build upon the material, and share them with others for non-commercial purposes as long as they credit the senior author, Reconstructive Review, and the Joint Implant Surgery & Research Foundation (JISRF). An example credit would be: "Courtesy of (senior author's name), Reconstructive Review, JISRF, Chagrin Falls, Ohio". While works can be downloaded and shared they cannot be used commercially.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.