Using Tranexamic Acid: Not If, But How
Most surgeons agree that tranexamic acid (TXA) is effective at reducing blood loss associated with a variety of surgical procedures, including total joint arthroplasty. The question is no longer whether it works but, more specifically, how is TXA most safely and effectively used. That was the main question Abdel et al. set out to answer in their study in the June 20, 2018 edition of The Journal. The authors completed a two-center randomized trial that compared blood loss, drain output, and transfusion rates among 320 total knee arthroplasty (TKA) patients who received intravenous (IV) TXA and 320 TKA patients who received topical TXA.
Statistically, the results of the study are clear: Patients who received intravenous TXA had significantly less blood loss (271 mL vs 324 mL; p=0.005) than those who received topical TXA. Furthermore, after authors controlled for several patient characteristics, they found that those who received topical TXA were 2.2 times more likely to receive a transfusion than those who received intravenous TXA. Still, both modalities resulted in very low transfusion and complication rates of <2% each.
Although IV TXA seems to be more effective at decreasing blood loss than topical TXA in the setting of TKA, Abdel et al. question whether the 53 mL difference is “clinically important,” considering the very low transfusion rates in both groups. What might be more clinically meaningful is the fact that the topical TXA group experienced a 5-minute delay during the procedure so the TXA could stay in contact with the tissues prior to suction and wound closure. Such a delay (which could account for about 5% of total surgical time) could put some patients at risk for other complications and is questionable without an appreciable benefit.
So, will every knee-replacement surgeon now use IV TXA instead of topical TXA? Of course not. Although the authors emphasize that there does not appear to be an increased risk of blood-clot-related complications when using IV TXA, some surgeons will still shy away from using that route of administration in certain patients. Also, some surgeons may question this study’s generalizability because of the number of perioperative variables described in the methods.
Still, I commend the authors on performing such a large, well-designed study. It is easy to pick apart data from the viewpoint of external validity, but these results are statistically steadfast. While we probably do not need more studies looking at the efficacy of TXA in total joint arthroplasty, further studies looking at the optimal manner in which the medication can be administered are welcomed.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
What’s New in Hip Replacement: Level I and II Studies
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the September 16, 2015 Specialty Update on hip replacement:
Transfusion and Blood Management
–Studies continue to demonstrate that tranexamic acid decreases the need for transfusion when used either intravenously or topically.
–The routine use of a drain following total hip replacement, even when used for reinfusion of shed blood, provides little to no benefit and does not decrease the risk of transfusion.1
Preoperative Patient Teaching
–A Cochrane review concluded that preoperative teaching resulted in only modest improvements in quality of life, pain scores, anxiety, and function. Patients with depression, anxiety, and unrealistic expectations might receive the most benefit from these interventions.2
Surgical Approaches
–A meta-analysis demonstrated short-term superiority of the direct anterior approach over the posterior approach, but the authors concluded there was insufficient evidence of clear long-term superiority of either approach.3
–A study that reviewed the results of two academic surgeons who exclusively used either the direct anterior approach or a miniposterior approach found no systematic advantage to either approach in terms of surgical time, pain, or function. This suggests that factors other than surgical approach may be more important in influencing early recovery after hip replacement.4
Surgical Fixation
–A randomized trial comparing survivorship in four cemented femoral stem designs concluded that, in the presence of a collar, surface finish did not significantly affect survivorship or function. Between the two collarless groups, a polished surface conferred improved survivorship.5
–A multivariate registry-based meta-analysis found that, in patients who were 75 years or older, uncemented fixation had a significantly higher risk of revision than hybrid fixation.
Bearing Materials
— A multivariate registry-based meta-analysis concluded that use of ceramic implants with a smaller head size in cementless hip arthroplasty was associated with a higher risk of revision, compared with metal-on-highly cross-linked polyethylene and >28-mm ceramic-on-ceramic implants.
–A registry-based cohort study comparing revision rates in metal-on-conventional polyethylene bearings with metal-on-highly cross-linked polyethylene bearings found a rate over seven years of 5.4% for the conventional polyethylene bearing versus 2.8% for the highly cross-linked bearing.6
–A randomized study comparing metal-ion levels five years after metal-on-metal and metal-on-polyethylene hip replacements found significantly lower cobalt and chromium levels in the metal-on-polyethylene group.
–A multivariate meta-analysis comparing the risk of revision for metal-on-conventional and metal-on-highly cross-linked polyethylene implants in patients 45 to 64 year old did not find a difference between the two groups.
–A meta-analysis comparing ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene found no differences in medium-term survivorship.7
References
- Thomassen BJ, den Hollander PH, Kaptijn HH, Nelissen RG, Pilot P. Autologous wound drains have no effect on allogeneic blood transfusions in primary total hip and knee replacement: a three-arm randomised trial. Bone Joint J. 2014 Jun;96-B(6):765-71.
- McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev.2014;5:CD003526. Epub 2014 May 13.
- Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015Mar;30(3):419-34. Epub 2014 Oct 22.
- Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res. 2015 Feb;473(2):623-31.
- Hutt J, Hazlerigg A, Aneel A, Epie G, Dabis H, Twyman R, Cobb A. The effect of a collar and surface finish on cemented femoral stems: a prospective randomised trial of four stem designs. Int Orthop. 2014 Jun;38(6):1131-7. Epub 2014 Jan 29.
- Paxton EW, Inacio MC, Namba RS, Love R, Kurtz SM. Metal-on-conventional polyethylene total hip arthroplasty bearing surfaces have a higher risk of revision than metal-on-highly crosslinked polyethylene: results from a US registry. Clin Orthop Relat Res. 2015 Mar;473(3):1011-21.
- Wyles CC, Jimenez-Almonte JH, Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, Trousdale RT.There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 Jun;473(6):2031-41. Epub 2014 Dec 17.
JBJS Editor’s Choice—Different Findings about Cell Salvage, Pre- and Post-2010
Orthopaedic surgeons have always been interested in limiting blood loss when it comes to major procedures. No procedures are more representative of that effort than hip and knee arthroplasty. A well-done meta-analysis by van Bodegan-Vos et al. in the June 17, 2015 JBJS looks at blood conservation through cell salvage—the perioperative suctioning, collection, concentration, and re-infusion of a patient’s own blood.
The authors report that cell salvage significantly protected patients from the need for allogeneic blood transfusions based on well-performed RCTs prior to 2010, but they found no significant effect in similar trials performed after 2010. What changed? Among other things, the surgical community adopted stricter transfusion-trigger criteria in uncomplicated cases, from a hemoglobin concentration of <10 g/dL to a hemoglobin concentration between 7 and 8 g/dL.
From my point of view, cell salvage is an example of technology that was developed to meet a clinical “standard” that was incompletely examined in prior research. There are many other clinical standards that we use in daily practice that have been inadequately evaluated; ordering blood cultures for febrile episodes and imposing BMI limits for surgery center-based procedures are just two examples.
It would certainly be preferable to examine the actual clinical validity and public health implications of these so-called standards before we develop expensive interventions, such as cell salvage, to respond to them. In that way the orthopaedic community can expand our role in meeting the goals of the Institute for Healthcare Improvement’s Triple Aim: better care for individuals, improved population health, and lower per capita health care costs.
Marc Swiontkowski, MD
JBJS Editor in Chief
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