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Topical (Intra-Articular) Tranexamic Acid Reduces Blood Loss and Transfusion Rates Following Total Hip ReplacementA Randomized Controlled Trial (TRANX-H)
Sattar Alshryda, MBChB, MRCS, MRCSEd, FRCS(Tr&Orth), PhD1; James Mason, DPhil, MSc, BSc(Hons)2; Praveen Sarda, MBBS, MRCS, FRCS(Tr&Orth)3; Antoni Nargol, MBBS, FRCS, FRCS(Tr&Orth)3; Nick Cooke, FRCS(Tr&Orth)3; Hafeez Ahmad, FRCS3; S. Tang, FRCS3; Raj Logishetty, MBBS, FRCS, FRCS(Tr&Orth)3; Manesh Vaghela, MBBS, MS, MSc3; Lynne McPartlin, BSc(SCP), Diploma(ODP)3; 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. E-mail address for J. Mason: j.m.mason@durham.ac.uk. E-mail address for A.P.S. Hungin: dean.medicine@durham.ac.uk
3 University Hospitals of North Tees and Hartlepool, Hardwick Road, Stockton-on-Tees, TS19 8PE, United Kingdom. E-mail address for P. Sarda: Praveen.Sharda@nth.nhs.uk. Email address for A. Nargol: antoni.nargol@nth.nhs.uk. E-mail address for N. Cooke: nickjcooke@hotmail.com. E-mail address for A. Hafeez: Hafeez.Ahmad@nth.nhs.uk. E-mail address for S. Tang: Siu.Tang@nth.nhs.uk. E-mail address for R. Logishetty: rlogishetty@hotmail.com. E-mail address for M. Vaghela: manesh.vaghela@nth.nhs.uk. E-mail address for L. McPartlin: Lynne.McPartlin@nth.nhs.uk
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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):1969-1974. doi: 10.2106/JBJS.L.00908
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Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip 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 161 patients undergoing unilateral primary total hip 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 Hip Score, length of stay, a cost analysis, and complications.


Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p < 0.0001), the length of stay by 1.0 days (95% CI, −0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months.


Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration.

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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