Tranexamic acid (TXA) use is undeniably one of the most important recent advances in primary total hip arthroplasty. Pharmacologically, TXA, a synthetic drug, inhibits fibrinolysis and therefore fibrin clot degradation and also activates plasminogen, thus reducing hemorrhage in several surgical fields. TXA use has not been cleared by the U.S. Food and Drug Administration (FDA) for total hip arthroplasty and its use remains off-label. Many clinical studies, including randomized controlled trials (RCTs) and meta-analyses, demonstrated that TXA is safe and effective in reducing perioperative blood loss and significantly reduces blood transfusion1. Different methods of delivery, single or double intravenous (IV), topical, or combined IV and topical with various dosages, have all been reported to be safe and effective2. However, to date, there is no unanimous agreement about the dosage and form of administration of TXA in primary total hip arthroplasty.
Yi et al. performed an RCT to compare single IV TXA use (15 mg/kg), a combination of single IV use (15 mg/kg) with topical TXA (1 g/100 mL), and a placebo in patients undergoing primary total hip arthroplasty. The main primary outcomes were the amount of blood loss and transfusion values, and the secondary outcomes included length of hospital stay, range of motion, Harris hip scores, and prevalence of deep vein thrombosis and pulmonary embolism. In comparison with the other 2 groups, the combined-delivery group had reduced total blood loss (p < 0.05) and fewer transfusions (p < 0.05). There were no differences between the combined group and the other 2 groups with regard to any of the secondary outcomes. These findings are consistent with those of other studies that showed TXA to effectively reduce blood loss and transfusion requirements1,3. The authors of the current paper combined topical administration with the aim of reducing intraoperative and drained blood loss and IV administration to reduce hidden and systemic blood loss. This hypothesis, however, remains unproven by this study and additional pharmacokinetic and other studies—in vitro and in vivo—are required to further elucidate these mechanisms.
In the most recent RCT on the administration of TXA in total hip arthroplasty, authors from the same center found that a group that was administered 1 g of IV TXA combined with 2 g of topical TXA had significantly less total blood loss than a group treated with 3 g of topical TXA or a group that received 1.5 g of IV TXA (p = 0.001 and 0.015, respectively)4.
Finally, TXA use in total hip arthroplasty is effective and safe and also cost-effective. It is a major advancement in the management of patients undergoing total hip arthroplasty and necessary for rapid recovery protocols. The information provided by the existing literature is variable and heterogeneous, and all studies are underpowered3. The appropriate dosage, the timing, and the most effective administration route of TXA in total hip arthroplasty remain controversial. The current paper along with the similar paper from the same center4 showed that combining IV and topical TXA may be the most efficacious strategy while remaining safe for patients. Larger studies are required, however, for a sound recommendation and agreement on the best method of delivery.
↵* The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article.
- Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated