Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations

Figures & data

Table 1 Summary of Current Evidence on Use of TXA in Orthopedic Surgery

	Name of Study	OP	Type	Population	Methods	Conclusion
Arthroplasty	Lei et al, 2020^Citation14	TKA	RCT	132 patients	Patients groups: (A) no TXA (B) before incision, 3, 6, and 12 h later (C) before incision, 3, 6, 12, and 18 h later (D) before incision, 3, 6, 12, 18, and 24 h later	- A high initial-dose (60 mg/kg) IV-TXA before surgery followed by five doses is an effective approach to reduce blood loss, provide additional fibrinolysis and inflammation control, and ameliorate postoperative pain following TKA. - This will not increase the risk of treatment-related complications.
	Zhang et al, 2021^Citation18	TKA	RCT	175 patients	Patients groups (A) placebo (B) a single preoperative dose of 20 mg/kg IV-TXA (C) six-dose IV-TXA from the beginning of the procedure to subsequent 24 hours with the total dosage more than 6 g	The administration of six-dose IV-TXA during the first 24 hours resulted in reduced HBL following TKA without a measured increase in thromboembolic events.
	Zhao et al, 2019^Citation20	THA	Meta analysis	32 RCTs 2476 patients		Intravenous TXA may be the best way to reduce the need for transfusion and total blood loss.
	Xie et al, 2017^Citation24	TKA THA	RCT	18 RCTs involving TKA and 4 RCTs involving THA 2260 patients		- Topical and intravenous tranexamic acid have similar transfusion requirements and safety in THA and TKA. - Intravenous injection is associated with a smaller maximum drop in hemoglobin.
	Zhang et al, 2017^Citation25	THA	Meta analysis	7 RCTs 1762 patients	Combined application versus individual topical and intravenous application of tranexamic acid	The combined application showed lower transfusion rates, hemoglobin decline and total blood loss compared to the individual administrations.
	Yu et al 2017^Citation38	SA	Meta analysis	Two RCTs and 2 non-RCTs 580 patients		TXA in SA decreases postoperative hemoglobin reduction, drainage volume, and total blood loss and does not increase the risk of complications
	Rojas et al, 2021^Citation37	SA	Meta analysis	4 RCTs 375 patients		There was no conclusive evidence for a positive effect of tranexamic acid upon transfusion rate, infection rates or hematoma formation in patients undergoing primary shoulder arthroplasty.
	Abildgaard et al, 2016^Citation36	SA	Retrospective comparison	77 TSAs and 94 RTSAs performed in 168 patients.		Use of TXA perioperatively in patients undergoing primary shoulder arthroplasty can decrease perioperative blood loss, change in Hgb and Hct, and postoperative drain output
Trauma	Zhu et al, 2018^Citation40	ITF	Meta analysis	7 RCTs 746 patients		- Administration of TXA in Intertrochanteric Fracture Surgery significantly reduced surgical blood loss and total blood loss - It had no significant effect on transfusion rate, postoperative drainage, and the risk of thromboembolic events
	Ma et al, 2021^Citation41	ITF	RCT	125 patients		Early IV TXA intervention was shown to reduce post-traumatic HBL and pre-operative transfusion rate in elderly patients with intertrochanteric fractures without increasing the risk of venous thrombosis.
	Zhang et al, 2018^Citation42	FF	Meta analysis	12 RCTs, and one was a retrospective cohort study. Approximately 1063 patients		IV and topical routes of TXA administration in patients undergoing surgical fixation for unspecified femoral fractures were both very useful in reducing the rate of blood transfusions
	Qi et al, 2019^Citation43	HF	Meta analysis	10 RCTs Approximately 854 patients		The use of TXA in hip fracture surgery showed a significant decrease in transfusion rates without a concurrent increase in the incidence of thromboembolic events
	Xiao et al, 2019^Citation44	HF	Meta analysis	11 RCTs 892 patients		Significant decrease in transfusion rates in the TXA group without a concurrent increase in the incidence of thromboembolic events
	Gausden et al, 2017^Citation45	TRAUMA	Meta analysis	12 studies 1333 patients		TXA reduces the risk of blood transfusion, reduces perioperative blood loss, and has no significant effect on the risk of symptomatic thromboembolic events when used in patients with orthopedic trauma surgery
Spine	Bai et al, 2019^Citation46	SPINE	Meta analysis	9 studies with 713 total patients		- TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability who underwent PLF surgery. - There was no significant difference in blood transfusion rates between the two groups.
	He et al, 2020^Citation47	SPINE	RCT prospective randomized, double-blind, placebo-controlled trial	40 patients	Patients groups (A) TXA group (B) control group (placebo)	In patients undergoing transforaminal lumbar interbody fusion (TLIF), the TXA group have significantly showed reduced intraoperative hemorrhage and time to ambulation after surgery but showed similar hospital stay, postoperative drainage, time for drainage removal, postoperative Hb one day after surgery, and adverse events.
	Zhang et al, 2019^Citation52	SPINE	Meta analysis	11 studies (6 RCTs and 5 retrospective studies)		The use of TXA can effectively reduce intraoperative blood loss and perioperative blood transfusion in patients undergoing multiple-level spine surgery, and it can also restore hemoglobin levels after surgery.
Sports Medicine	Ersin et al, 2020^Citation54	SPORT SHOULDER ROTATOR CUFF	RCT	60 patients	Patients groups (A) control (Saline) (B) IV TXA	Preoperative IV TRX administration in patients undergoing arthroscopic rotator cuff repair had improved visual clarity and reduced need for high pressure and amount of irrigation fluid during the surgery
	Bayram et al, 2021^Citation55	SHOULDER ROTATOR CUFF	RCT	90 patients	Patients groups (A) TXA infused irrigation fluid (B) epinephrine infused irrigation fluid	Adding TXA to the irrigation fluid during arthroscopic rotator cuff repair can provide similar visual quality to the EPN infused irrigation method.
	Liu et al, 2020^Citation57	SHOULDER	RCT	72 patients	Patients groups (A) preoperative 1 g of IV TXA (B) preoperative placebo	- IV administration of TXA is an alternative way to improve visual clarity in arthroscopic shoulder surgery. - It also reduces subjective pain and analgesic consumption in the early postoperative period without significant side effects.
	Hartland et al, 2021^Citation58	SHOULDER	Meta analysis	7 RCT Approximately 708 patients	Examined the use of intraoperative TXA use in various shoulder surgery procedures including, TSA, rTSA, open Latarjet, and arthroscopic rotator cuff repair	Patients given TXA had reduced blood loss as measured by drain output
	Gao et al, 2020^Citation59	SHOULDER	RCT	60 patients	Observation group and control group, 30 cases in each group	- There was no significant difference in hemoglobin levels between patients given TXA and those given placebo. - The TXA group had a significant smaller shoulder circumference indicating relatively reduced swelling.
	Chiang et al, 2019^Citation63	KNEE ACL	RCT	304 patients	Patients groups (A) received a 10-mL intra-articular injection of TXA (100 mg/mL) (B) No TXA	- TXA use could significantly reduce postoperative intra-articular bleeding in the first 24 hours in patients receiving arthroscopic ACLR. - TXA may also decrease pain and the grade of hemarthrosis in the early postoperative period. - No systemic side effects or need for aspiration was noted during the follow-up period.
	Felli et al, 2019^Citation64	KNEE ACL	RCT	80 patients	Patients groups (A) intravenous infusion of 15 mg/kg of TXA (B) No TXA	In patients undergoing ACLR, the use of TXA can reduce hemarthrosis as well as reduce volume of blood suctioned during the operation
	Fried et al, 2021^Citation65	KNEE ACL	RCT	110 patients	Patients groups (A) received two 1-g boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure (B) No TXA	TXA had no significant impact on perioperative blood loss, postoperative pain, and incidence of hemarthrosis
	Ma et al, 2021^Citation66	KNEE ACL	RCT	120 patients	Patients groups (A) IV group, received (15 mg/kg in 100 mL of saline solution) 10 min before tourniquet release (B) IA group, received intra-articular TXA (15 mg/kg in 100 mL of saline solution) injected via the drainage tube (C) placebo group, received an equivalent volume of normal saline administered into the knee joint cavity and intravenously	- In ACL reconstruction, both intravenous administration and intra-articular injection can reduce intra-articular hemarthrosis, joint pain and swelling. - No significant difference in the efficacies of reducing hemarthrosis, joint pain and swelling was found between intravenous administration and intra-articular injection.
	Ma et al, 2021^Citation74	HTO	Meta analysis	5 studies 532 patients		In high tibial osteotomy, the use of TXA demonstrated reduced incidence of wound complications and smaller decreases of postoperative hemoglobin.
	Li et al, 2020^Citation72	HTO	Retrospective case control study	24 patients in the combined group and 21 in the solo group.	Patients groups (A) combined group, 100 mL saline containing 1 g TXA was intravenously administered before application of a tourniquet, and 20 mL saline containing 2 g TXA was injected through a drainage tube after closure of the incision (B) solo group, 100 mL of saline containing 1 g TXA was intravenously administered before application of a tourniquet	Combined use of Intravenous and topical TXA in HTO is superior to intravenous administration alone for reducing postoperative blood loss and drainage volume without thromboembolic complications.
	Yao et al, 2019^Citation73	HTO	Meta analysis	6 studies 665 patients	665 patients. Three studies were Peri-acetabulum (PAO), and the other three were High Tibia (HTO0	There was no difference in wound complication rates in patients receiving TXA versus placebo during HTO

Abbreviations: TKA, total knee arthroplasty; THA, total hip arthroplasty; SA, shoulder arthroplasty; ITF, intertrochanteric fracture; FF, femoral fracture; HF, hip fracture; HTO, high tibial osteotomy.

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