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Topical (Intra-Articular) Tranexamic Acid Reduces Blood Loss and Transfusion Rates Following Total Knee ReplacementA Randomized Controlled Trial (TRANX-K)
Sattar Alshryda, MBChB, MRCS, MRCSEd, FRCS(Tr&Orth), PhD1; James Mason, DPhil, MSc, BSc(Hons)2; Manesh Vaghela, MBBS, MS, MSc3; Praveen Sarda, MBBS, MRCS, FRCS(Tr&Orth)3; Antoni Nargol, MBBS, FRCS, FRCS(Tr&Orth)3; S. Maheswaran, MBBS, FRCS3; Chris Tulloch, FRCS3; Sanjeev Anand, MBBS, FRCSI, FRCS(Tr&Orth), MFSEM3; Raj Logishetty, MBBS, FRCS, FRCS(Tr&Orth)3; Brian Stothart, NMC(ENB), NCFE3; A. Pali S. Hungin, MD, FRCGP, FRCP, FRSA2
1 The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, United Kingdom. E-mail address: Sattar26@doctors.org.uk
2 Wolfson Research Institute, School of Medicine, Pharmacy and Health, Queen’s Campus, Durham University, University Boulevard, Stockton-on-Tees, TS17 6BH, United Kingdom
3 University Hospitals of North Tees and Hartlepool, Hardwick Road, Stockton-on-Tees, TS19 8PE, United Kingdom
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Investigation performed at the University Hospitals of North Tees and Hartlepool, Stockton-on-Tees, United Kingdom

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Nov 06;95(21):1961-1968. doi: 10.2106/JBJS.L.00907
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Approximately one-third of patients undergoing total knee replacement require one to three units of blood postoperatively. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been successfully used intravenously to stop bleeding after total knee replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid.


A double-blind, randomized controlled trial of 157 patients undergoing unilateral primary cemented total knee replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Knee Score, length of stay, a cost analysis, and complications as per the protocol definitions.


Tranexamic acid reduced the absolute risk of blood transfusion by 15.4% (95% confidence interval [CI], 7.5% to 25.4%; p = 0.001), from 16.7% to 1.3%, and reduced blood loss by 168 mL (95% CI, 80 to 256 mL; p = 0.0003), the length of stay by 1.2 days (95% CI, 0.05 to 2.43 days; p = 0.041), and the cost per episode by £333 (95% CI, £37 to £630; p = 0.028). (In 2008, £1 = 1.6 U.S. dollars.) Oxford Knee Scores and EuroQol EQ-5D scores were similar at three months.


Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement without important additional adverse effects.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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