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Update in Orthopaedics

Tranexamic acid optimal blood loss management in surface replacement arthroplasty

A. Sassoon, D. Nam, R. Jackups, S. R. Johnson, R. M. Nunley, R. L. Barrack
DOI: 10.1302/0301-620X.98B2.36776 Published 5 February 2016

Abstract

Aims: This study investigated whether the use of tranexamic acid (TXA) decreased blood loss and transfusion related cost following surface replacement arthroplasty (SRA).

Methods: A retrospective review of patients treated with TXA during a SRA, who did not receive autologous blood (TXA group) was performed. Two comparison groups were established; the first group comprised of patients who donated their own blood pre-operatively (auto group) and the second of patients who did not donate blood pre-operatively (control). Outcomes included transfusions, post-operative haemoglobin (Hgb), complications, and length of post-operative stay.

Results: Between 2009 and 2013, 150 patients undergoing SRA were identified for inclusion: 51 in the auto, 49 in the control, and 50 in the TXA group. There were no differences in the pre-operative Hgb concentrations between groups. The mean post-operative Hgb was 11.3 g/dL (9.1 to 13.6) in the auto and TXA groups, and 10.6 g/dL (8.1 to 12.1) in the control group (p = 0.001). Accounting for cost of transfusions, administration of TXA, and length of stay, the cost per patient was $1731, $339, and $185 for the auto, control and TXA groups, respectively.

Discussion: TXA use demonstrated higher post-operative Hgb concentrations when compared with controls and decreased peri-operative costs.

Tranexamic acid is an anti-fibrinolytic agent commonly used in orthopaedic, cardiac, urological, obstetric and gynecological surgery [1]. It works as a competitive inhibitor of plasminogen binding sites, thereby decreasing the conversion of plasminogen to plasmin which stabilizes clot formation [1].

A number of Level 1 studies have confirmed the overall benefit of using TXA in reducing blood loss and transfusion rates with no significant associated complications in hip and knee arthroplasty surgery [1-3]. However, despite a few studies comparing the cost associated with TXA usage to allogeneic blood transfusion, not much has been reported in terms of a direct comparison between TXA and routine preoperative autologous blood transfusion [4, 5].

According to the authors of this study, TXA safely limited allogeneic transfusion in both the auto and control groups, maintained post-operative haemoglobin, and decreased direct and indirect transfusion related costs in surface replacement arthroplasty. Patients in the TXA group received 1 gram of TXA intravenously before incision and another 1 gram at the start of wound closure. History of deep vein thrombosis (DVT) and having undergone coronary artery stent placement within the previous year were exclusion criteria. The decision to perform an allogeneic transfusion was made by the treating surgeon and was dependent on a variety of clinical parameters. For example, symptomatic patients with orthostatic hypotension and lightheadedness, and those with a postoperative Hgb of < 8 g/dL or Hct < 25% received a blood transfusion. If any of the patients had a history of coronary artery disease, or other cardiac risk factors, blood was transfused to ensure a Hgb of 10 g/dL or Hct of 30%. Intravenous heparin, as a single dose of 1000 units, was administered before hip dislocation. Drains were not routinely used. DVT prophylaxis was administered after assessing the risk of individual patients. The protocol for standard-risk anticoagulation therapy consisted of aspirin therapy (325 mg twice daily) for six weeks post-operatively and continued use of a mobile compression device for 23 hours a day for ten days post-operatively. High-risk patients were treated with warfarin therapy beginning the night before surgery and continued for four weeks post-operatively.

Strengths of this study include the homogeneity of the study population and comparing TXA to autologous blood transfusion and assessing allogeneic blood transfusion requirements.

Despite the retrospective nature of this study, it adds to the current literature further evidence to the benefit of using TXA in arthroplasty surgery. A well designed randomized controlled study would be ideal to confirm these study findings.

References:

1. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br. 2011; 93(1): 39-46.
2. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br. 2011 Dec; 93(12): 1577-85.
3. Alshryda S, Sukeik M, Sarda P, Blenkinsopp J, Haddad FS, Mason JM. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J. 2014 Aug; 96-B(8): 1005-15.
4. McGoldrick NP, O'Connor EM, Davarinos N, Galvin R, Quinlan JF. Cost benefit analysis of the use of tranexamic acid in primary lower limb arthroplasty: A retrospective cohort study. World J Orthop. 2015;6(11):977-82.
5. Phan DL, Ani F, Schwarzkopf R. Cost Analysis of Tranexamic Acid in Anemic Total Joint Arthroplasty Patients. J Arthroplasty.  2015 Oct [Epub ahead of print]