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Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial

  • Knee Arthroplasty
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Tranexamic acid (TXA) is becoming widely used in orthopedic surgery to reduce blood loss and transfusion requirements, but consensus is lacking regarding the optimal route and dose of administration. The aim of this study was to compare the efficacy and safety of topical and intravenous routes of TXA with routine hemostasis in patients undergoing primary total knee arthroplasty (TKA).

Materials and methods

We performed a randomized, multicenter, parallel, open-label clinical trial in adult patients undergoing primary TKA. Patients were divided into three groups of 50 patients each: Group 1 received 1 g topical TXA, Group 2 received 2 g intravenous TXA, and Group 3 (control group) had routine hemostasis. The primary outcome was total blood loss. Secondary outcomes were hidden blood loss, blood collected in drains, transfusion rate, number of blood units transfused, adverse events, and mortality.

Results

One hundred and fifty patients were included. Total blood loss was 1021.57 (481.09) mL in Group 1, 817.54 (324.82) mL in Group 2 and 1415.72 (595.11) mL in Group 3 (control group). Differences in total blood loss between the TXA groups and the control group were clinically and statistically significant (p < 0.001). In an exploratory analysis differences between the two TXA groups were not statistically significant (p = 0.073) Seventeen patients were transfused. Transfusion requirements were significantly higher in Group 3 (p = 0.005). No significant differences were found between groups regarding adverse events.

Conclusion

We found that 1 g of topical TXA and 2 g of intravenous TXA were both safe strategies and more effective than routine hemostasis to reduce blood loss and transfusion requirements after primary TKA.

Level of evidence

I.

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Acknowledgments

The authors wish to thank Esther Cánovas Martínez and Mercedes Subiela for data collection, Gemma Horta for logistic support, Sebastíà Videla for assistance with methodology and the revision of the manuscript, the staff at the Orthopedic Surgery Department, the secretary staff of the Iberoamerican Cochrane Centre-Clinical Epidemiology and Public Health Department, and Carolyn Newey for editing the text. The authors would also like to convey thanks to Rottapharm/Madaus for providing the tranexamic acid ampoules. Dr. Xavier Aguilera is a PhD candidate in the Surgery Department, Universitat Autónoma de Barcelona. Spain. This project was funded principally by a grant from the Spanish Ministry of Health and Social Policy to promote independent clinical research 2010 (EC10-73).

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Orthopedic Surgery and Traumatology Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Mª Claret 167, 08025, Barcelona, Spain

    X Aguilera, M. Jordán, J. C. González & F. Celaya

  2. Iberoamerican Cochrane Centre, CIBER de Epidemiología y Salud Pública (CIBERESP), IIB Sant Pau, Sant Antoni Mª Claret 171, 08041, Barcelona, Spain

    M. J. Martínez-Zapata

  3. Orthopedic Surgery and Traumatology Department, Parc de Salut Mar, Sant Josep de la Muntanya 12, 08024, Barcelona, Spain

    P. Hinarejos, J. Leal, J. C. Monllau, X. Pelfort & L. l. Puig-Verdie

  4. Pharmacy Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Mª Claret 167, 08025, Barcelona, Spain

    A. Rodríguez-Arias

  5. Anesthesiology Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Mª Claret 167, 08025, Barcelona, Spain

    J. A. Fernández

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  1. X Aguilera
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Corresponding author

Correspondence to M. J. Martínez-Zapata.

Appendix 1

Appendix 1

Calculation of postoperative blood loss on the basis of hemoglobin (Hb) balance according to equations described by Nadler et al. [20].

Hbloss = BV × (Hbi − Hbe) × 0.001 + Hbt.

Blood loss = 1000 × Hbloss/Hbi, where Hbloss is the amount (g) of hemoglobin lost, Hbi is the hemoglobin level (g/L) before surgery, Hbe is either the lowest postoperative recording of the hemoglobin level (g/L) or the hemoglobin level (g/L) recorded right before any transfusion, and Hbt is the total amount (g) of allogeneic or autologous hemoglobin transfused. A unit of banked allogeneic blood is considered to contain 52 g of hemoglobin according to Canadian Blood Services.

Predicted blood volume is estimated for each patient according to Nadler’s method:

PBVmale = (0.3669 × Ht3 (M)) + [0.03219 × Wt (Kg)] + 0.6041.

PBVfemale = (0.3561 × Ht3 (M)) + [0.03308 × Wt (Kg)] + 0.1833, where PBV is predicted blood volume (mL), Ht = height (m), and Wt = weight (kg).

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Aguilera, X., Martínez-Zapata, M.J., Hinarejos, P. et al. Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial. Arch Orthop Trauma Surg 135, 1017–1025 (2015). https://doi.org/10.1007/s00402-015-2232-8

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