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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 20, Issue 9, pp 1742–1752 | Cite as

The effect of tranexamic acid on blood loss and use of blood products in total knee arthroplasty: a meta-analysis

  • Haoran Zhang
  • Junmin ChenEmail author
  • Fei Chen
  • Wenzhong Que
Knee

Abstract

Purpose

Studies have shown that tranexamic acid (TXA) reduces blood loss and transfusion need in patients undergoing total knee arthroplasty (TKA). However, no single study has been large enough to definitively determine whether the drug is safe and effective. We report a systematic review and meta-analysis of randomised controlled trials evaluating the efficacy and safety of TXA in reducing blood loss and transfusion in TKA.

Methods

A comprehensive literature search was done in Cochrane Library, MEDLINE, EMBASE, and CNKI. Two reviewers independently identified the eligible studies, assessed their methodological quality, and extracted data. The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. The relevant data were analyzed using RevMan 5.0.

Results

Fifteen randomized controlled trials involving 842 patients were included. The use of TXA reduced total blood loss by a mean of 487 ml [95% confidence interval (CI) −629 to −344], intra-operative blood loss by a mean of 127 ml (95% CI −313–59), and post-operative blood loss by a mean of 245 ml (95% CI −410 to −80). TXA led to a significant reduction in the proportion of patients requiring blood transfusion (risk difference −0.4). There were no significant differences in deep-vein thrombosis (DVT), pulmonary embolism, or other complications among the study groups.

Conclusion

Meta-analysis indicates that TXA may reduce post-operative, total blood loss and transfusion in patients undergoing TKA. TXA led to a significant reduction in the proportion of patients requiring blood transfusion.

Level of evidence

Therapeutic study (Systematic review of Level I studies with inconsistent results), Level II.

Keywords

Tranexamic acid Total knee arthroplasty Blood loss Transfusion Meta-analysis 

Notes

Conflict of interest

The authors state that they have no conflict of interest.

References

  1. 1.
    Barwell J, Anderson G, Hassan A, Rawlings I (1997) The effects of early tourniquet release during total knee arthroplasty: a prospective randomized double-blind study. J Bone Joint Surg [Br] 79:265–268CrossRefGoogle Scholar
  2. 2.
    Benoni G, Fredin H (1996) Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty. J Bone Joint Surg [Br] 78:434–440Google Scholar
  3. 3.
    Camarasa MA, Ollé G, Serra-Prat M, Martín A et al (2006) Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anaesth 96:576–582PubMedCrossRefGoogle Scholar
  4. 4.
    Cardone D, Klein AA (2009) Perioperative blood conservation. Eur J Anaesth 26:722–729CrossRefGoogle Scholar
  5. 5.
    Cid J, Lozano M (2005) Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion 45:1302–1307PubMedCrossRefGoogle Scholar
  6. 6.
    Coetzee MJ (2007) The use of topical crushed tranexamic acid tablets to control bleeding after dental surgery and from skin ulcers in haemophilia. Haemophilia 13:443–444PubMedCrossRefGoogle Scholar
  7. 7.
    DeFrances CJ, Podgornik MN (2006) 2004 National hospital discharge survey. Adv Data 4:1–19Google Scholar
  8. 8.
    Dhillon MS, Bali K, Prabhakar S (2011) Tranexamic acid for control of blood loss in bilateral total knee replacement in a single stage. Indian J Orthop 45:148–152PubMedCrossRefGoogle Scholar
  9. 9.
    Dietrich W, Spannagl M, Boehm J, Hauner K et al (2008) Tranexamic acid and aprotinin in primary cardiac operations: an analysis of 220 cardiac surgical patients treated with tranexamic acid or aprotinin. Anesth Analg 107:1469–1478PubMedCrossRefGoogle Scholar
  10. 10.
    Dunn CJ, Goa KL (1999) Tranexamic acid: a review of its use in surgery and other indications. Drugs 57:1005–1032PubMedCrossRefGoogle Scholar
  11. 11.
    Ellis MH, Fredman B, Zohar E, Ifrach N et al (2001) The effect of tourniquet application, tranexamic acid, and desmopressin on the procoagulant and fibrinolytic systems during total knee replacement. J Clin Anesth 13:509–513PubMedCrossRefGoogle Scholar
  12. 12.
    Engel JM, Hohaus T, Ruwoldt R, Menges T et al (2001) Regional hemostatic status and blood requirements after total knee arthroplasty with and without tranexamic acid or aprotinin. Anesth Analg 92:775–780PubMedCrossRefGoogle Scholar
  13. 13.
    Good L, Peterson E, Lisander B (2003) Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 90:596–599PubMedCrossRefGoogle Scholar
  14. 14.
    Handoll H, Elstub L, Elliott J, Stott D et al (2008) Cochrane Bone, Joint and Muscle Trauma Group. About the Cochrane collaboration (Cochrane Review Groups (CRGS)) Issue 4. Art. No: MUSKINJGoogle Scholar
  15. 15.
    Hayes A, Murphy DB, McCarroll M (1996) The efficacy of single-dose aprotinin 2 million KIU in reducing blood loss and its impact on the incidence of deep venous thrombosis in patients undergoing total hip replacement surgery. J Clin Anesth 8:357–360PubMedCrossRefGoogle Scholar
  16. 16.
    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558PubMedCrossRefGoogle Scholar
  17. 17.
    Hiippala S, Strid L, Wennestrand M, Arvela V et al (1995) Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth 74:534–537PubMedCrossRefGoogle Scholar
  18. 18.
    Hiippala ST, Strid LJ, Wennerstrand MI, Arvela JVV et al (1997) Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg 84:839–844PubMedGoogle Scholar
  19. 19.
    Ho KM, Ismail H (2003) Use of intravenous tranexamic acid to reduce allogenic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care 31:529–537PubMedGoogle Scholar
  20. 20.
    Ido K, Neo M, Asada Y, Kondo K et al (2000) Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties. Arch Orthop Trauma Surg 120:518–520PubMedCrossRefGoogle Scholar
  21. 21.
    Jansen AJ, Andreica S, Claeys M, D’Haese J et al (1999) Use of tranexamic acid for an effective blood conservation strategy after total knee arthroplasty. Br J Anaesth 83:596–601PubMedCrossRefGoogle Scholar
  22. 22.
    Johansson T, Pettersson LG, Lisander B (2005) Tranexamic acid in total hip arthroplasty saves blood and money. Acta Orthop 76:314–319PubMedGoogle Scholar
  23. 23.
    Kagoma YK, Crowther MA, Douketis J, Bhandari M et al (2009) Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopaedic surgery: a systematic review of randomized trials. Thromb Res 123:687–696PubMedCrossRefGoogle Scholar
  24. 24.
    Kakar PN, Gupta N, Govil P, Shah V et al (2009) Efficacy and safety of tranexamic acid in control of bleeding following TKR: a randomized clinical trial. Indian J Anaesth 53:667–671PubMedGoogle Scholar
  25. 25.
    Kumar A (2009) Perioperative management of anemia: limits of blood transfusion and alternatives to it. Cleve Clin J Med 76:112–118CrossRefGoogle Scholar
  26. 26.
    Lemaire R (2008) Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg [Br] 90:1128–1136CrossRefGoogle Scholar
  27. 27.
    Lotke PA, Faralli VJ, Orenstein EM, Ecker ML (1991) Blood loss after total knee replacement: effects of tourniquet release and continuous passive motion. J Bone Joint Surg [Am] 73:1037–1040Google Scholar
  28. 28.
    Lumsden MA, Wedisinghe L (2011) Tranexamic acid therapy for heavy menstrual bleeding. Expert Opin Pharmacother 12:2089–2095PubMedCrossRefGoogle Scholar
  29. 29.
    MacGillivray RG, Tarabichi SB, Hawari MF, Raoof NT (2011) Tranexamic acid to reduce blood loss after bilateral total knee arthroplasty: a prospective, randomized double blind study. J Arthroplast 26:24–28CrossRefGoogle Scholar
  30. 30.
    Matziolis D, Perka C, Hube R, Matziolis G (2011) Influence of tourniquet ischemia on perioperative blood loss after total knee arthroplasty. Orthopade 40:178–182PubMedCrossRefGoogle Scholar
  31. 31.
    Moher D, Liberati A, Tetzlaff J, Altman DG et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535PubMedCrossRefGoogle Scholar
  32. 32.
    Nielsen HJ (1995) Detrimental effects of perioperative blood transfusion. Br J Surg 82:582–587PubMedCrossRefGoogle Scholar
  33. 33.
    Niskanen RO, Korkala OL (2005) Tranexamic acid reduces blood loss in cemented hip arthroplasty. Acta Orthop 26:829–832CrossRefGoogle Scholar
  34. 34.
    Orpen NM, Little C, Walker G, Crawford EJP (2006) Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomized controlled trial of 29 patients. Knee 13:106–110PubMedCrossRefGoogle Scholar
  35. 35.
    Phillips B, Ball C, Sackett D, Badenoch D et al (2001) Levels of evidence and grades of recommendations. Oxford Centre for evidence-based medicine levels of evidence. http://www.cebm.net/index.aspx?o=1025
  36. 36.
    Rajesparan K, Biant LC, Ahmad M, Field RE (2009) The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement. J Bone Joint Surg [Br] 91:776–783CrossRefGoogle Scholar
  37. 37.
    Rannikko A, Pétas A, Taari K (2004) Tranexamic acid in control of primary hemorrhage during transurethral prostatectomy. Urology 64:955–958PubMedCrossRefGoogle Scholar
  38. 38.
    Rao SV, Eikelboom JA, Granger CB, Harrington RA et al (2007) Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes. Eur Heart J 28:1193–1204PubMedCrossRefGoogle Scholar
  39. 39.
    Tanaka N, Sakahashi H, Sato E, Hirose K et al (2001) Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. J Bone Joint Surg Br 83:702–705PubMedCrossRefGoogle Scholar
  40. 40.
    Thorey F, Stukenborg-Colsman C, Windhagen H, Wirth CJ (2008) The effect of tourniquet release timing on perioperative blood loss in simultaneous bilateral cemented total knee arthroplasty: a prospective randomized study. Technol Health Care 16:85–92PubMedGoogle Scholar
  41. 41.
    Veien M, Sørensen JV, Madsen F, Juelsgaard P (2002) Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study. Acta Anaesthesiol Scand 46:1206–1211PubMedCrossRefGoogle Scholar
  42. 42.
    Yang X, Alexander KP, Chen AY, Roe MT et al (2005) The implications of blood transfusions for patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol 46:1490–1495PubMedCrossRefGoogle Scholar
  43. 43.
    Zanasi S (2011) Innovations in total knee replacement: new trends in operative treatment and changes in peri-operative management. Eur Orthop Traumatol 2:21–31PubMedCrossRefGoogle Scholar
  44. 44.
    Zufferey P, Merquiol F, Laporte S, Decousus H et al (2006) Do antifibrinolytics reduce allogeneic blood transfusion in orthopaedic surgery? Anesthesiology 105:1034–1046PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Haoran Zhang
    • 1
  • Junmin Chen
    • 1
    Email author
  • Fei Chen
    • 2
  • Wenzhong Que
    • 1
  1. 1.Department of Hematology and RheumatologyThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina
  2. 2.Department of OrthopedicsThe First Affiliated Hospital of Fujian Medical UniversityFuzhouChina

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