Skip to main content
SpringerLink
Log in

Low Risk of Thromboembolic Complications With Tranexamic Acid After Primary Total Hip and Knee Arthroplasty

  • Symposium: Papers Presented at the Annual Meetings of the Knee Society
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The use of antifibrinolytic medications in hip and knee arthroplasty reduces intraoperative blood loss and decreases transfusion rates postoperatively. Tranexamic acid (TXA) specifically has not been associated with increased thromboembolic (TE) complications, but concerns remain about the risk of symptomatic TE events, particularly when less aggressive chemical prophylaxis methods such as aspirin alone are chosen.

Questions/purposes

We determined whether the rate of symptomatic TE events differed among patients given intraoperative TXA when three different postoperative prophylactic regimens were used after primary THA and TKA.

Methods

We retrospectively reviewed 2046 patients who underwent primary THA or TKA and received TXA from 2007 to 2009. The three chemical regimens included aspirin alone, warfarin (target international normalized ratio, 1.8–2.2), and dalteparin. Primary outcome measures were venous TE events, including symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE), and arterioocclusive events, including myocardial infarction and cerebrovascular accident. Patients judged to be at high risk for TE due to recent cardiac stent placement or strong personal/family history of TE disease were excluded.

Results

For aspirin, warfarin, and dalteparin, the rates of symptomatic DVT (0.35%, 0.15%, and 0.52%, respectively) and nonfatal PE were similar (0.17%, 0.43%, and 0.26%, respectively). There were no fatal PE. Among the three groups, we found no difference in the rates of symptomatic DVT or PE with or without stratification by ASA score.

Conclusions

A low complication rate was seen when using TXA as a blood conservation modality during primary THA and TKA with less aggressive thromboprophylactic regimens such as aspirin alone and dose-adjusted warfarin.

Level of Evidence

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion. 2008;48:519–525.

    Article  PubMed  Google Scholar 

  2. Benoni G, Fredin H, Knebel R, Nilsson P. Blood conservation with tranexamic acid in total hip arthroplasty: a randomized, double-blind study in 40 primary operations. Acta Orthop Scand. 2001;72:442–448.

    Article  PubMed  CAS  Google Scholar 

  3. Camarasa MA, Olle G, Serra-Prat M, Martin A, Sanchez M, Ricos P, Perez A, Opisso L. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anaesth. 2006;96:576–582.

    Article  PubMed  CAS  Google Scholar 

  4. Cid J, Lozano M. Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion. 2005;45:1302–1307.

    Article  PubMed  CAS  Google Scholar 

  5. Colwell CW Jr. What is the state of the art in orthopaedic thromboprophylaxis in lower extremity reconstruction? Instr Course Lect. 2011;60:283–290.

    PubMed  Google Scholar 

  6. Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55:111–115.

    Article  PubMed  Google Scholar 

  7. Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007;89:2648–2657.

    Article  PubMed  Google Scholar 

  8. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs. 1999;57:1005–1032.

    Article  PubMed  CAS  Google Scholar 

  9. Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients? Chest. 2009;135:513–520.

    Article  PubMed  Google Scholar 

  10. Engel JM, Hohaus T, Ruwoldt R, Menges T, Jurgensen I, Hempelmann G. Regional hemostatic status and blood requirements after total knee arthroplasty with and without tranexamic acid or aprotinin. Anesth Analg. 2001;92:775–780.

    Article  PubMed  CAS  Google Scholar 

  11. Eubanks JD. Antifibrinolytics in major orthopaedic surgery. J Am Acad Orthop Surg. 2010;18:132–138.

    PubMed  Google Scholar 

  12. Fergusson DA, Hebert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, Teoh K, Duke PC, Arellano R, Blajchman MA, Bussieres JS, Cote D, Karski J, Martineau R, Robblee JA, Rodger M, Wells G, Clinch J, Pretorius R. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358:2319–2331.

    Article  PubMed  CAS  Google Scholar 

  13. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 suppl):381S–453S.

    Article  PubMed  CAS  Google Scholar 

  14. Gill JB, Rosenstein A. The use of antifibrinolytic agents in total hip arthroplasty: a meta-analysis. J Arthroplasty. 2006;21:869–873.

    Article  PubMed  Google Scholar 

  15. Haas SB, Barrack RL, Westrich G, Lachiewicz PF. Venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2008;90:2764–2780.

    PubMed  Google Scholar 

  16. Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2011;3:CD001886.

    PubMed  Google Scholar 

  17. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31:529–537.

    PubMed  CAS  Google Scholar 

  18. Hynes M, Calder P, Scott G. The use of tranexamic acid to reduce blood loss during total knee arthroplasty. Knee. 2003;10:375–377.

    Article  PubMed  CAS  Google Scholar 

  19. Intermountain Joint Replacement Center Writing Committee. A prospective comparison of warfarin to aspirin for thromboprophylaxis in total hip and total knee arthroplasty. J Arthroplasty. 2012;27:1–9.e2.

    Google Scholar 

  20. Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, Stringer TA, Tornetta P 3rd, Haralson RH 3rd, Watters WC 3rd. American Academy of Orthopaedic Surgeons clinical practice guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Bone Joint Surg Am. 2009;91:1756–1757.

    Article  PubMed  Google Scholar 

  21. Kagoma YK, Crowther MA, Douketis J, Bhandari M, Eikelboom J, Lim W. Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thromb Res. 2009;123:687–696.

    Article  PubMed  CAS  Google Scholar 

  22. Lee GC, Hawes T, Cushner FD, Scott WN. Current trends in blood conservation in total knee arthroplasty. Clin Orthop Relat Res. 2005;440:170–174.

    Article  PubMed  Google Scholar 

  23. Lemay E, Guay J, Cote C, Roy A. Tranexamic acid reduces the need for allogenic red blood cell transfusions in patients undergoing total hip replacement. Can J Anaesth. 2004;51:31–37.

    Article  PubMed  Google Scholar 

  24. Murkin JM, Haig GM, Beer KJ, Cicutti N, McCutchen J, Comunale ME, Hall R, Ruzicka BB. Aprotinin decreases exposure to allogeneic blood during primary unilateral total hip replacement. J Bone Joint Surg Am. 2000;82:675–684.

    PubMed  CAS  Google Scholar 

  25. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet. 2000;355:1295–1302.

  26. Shiga T, Wajima Z, Inoue T, Sakamoto A. Aprotinin in major orthopedic surgery: a systematic review of randomized controlled trials. Anesth Analg. 2005;101:1602–1607.

    Article  PubMed  CAS  Google Scholar 

  27. Veien M, Sorensen JV, Madsen F, Juelsgaard P. Tranexamic acid given intraoperatively reduces blood loss after total knee replacement: a randomized, controlled study. Acta Anaesthesiol Scand. 2002;46:1206–1211.

    Article  PubMed  CAS  Google Scholar 

  28. Yamasaki S, Masuhara K, Fuji T. Tranexamic acid reduces postoperative blood loss in cementless total hip arthroplasty. J Bone Joint Surg Am. 2005;87:766–770.

    Article  PubMed  Google Scholar 

  29. Zohar E, Fredman B, Ellis MH, Ifrach N, Stern A, Jedeikin R. A comparative study of the postoperative allogeneic blood-sparing effects of tranexamic acid and of desmopressin after total knee replacement. Transfusion. 2001;41:1285–1289.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Hugh Smith MD, PhD, Christopher Duncan MD, and Michael Kelm MD, of the Department of Anesthesiology, Mayo Clinic, and Youlonda Loechler with the Mayo Clinic Joint Registry for their contributions to the collection and organization of patient data.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Blake P. Gillette MD, Lori J. DeSimone PA, Robert T. Trousdale MD, Mark W. Pagnano MD & Rafael J. Sierra MD

Authors
  1. Blake P. Gillette MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lori J. DeSimone PA
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Robert T. Trousdale MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mark W. Pagnano MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Rafael J. Sierra MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rafael J. Sierra MD.

Additional information

One of the authors (RTT) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount in excess of $100,000 from DePuy Orthopaedics, Inc (Warsaw, IN, USA), Wright Medical Technology, Inc (Arlington, TN, USA), MAKO Surgical Corp (Ft Lauderdale, FL, USA), and Ortho Development Corp (Draper, UT, USA). One or more of the authors (MWP) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount in excess of $100,000 from DePuy, MAKO Surgical Corp, and Stryker Orthopaedics (Mahwah, NJ, USA). One of the authors (RJS) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount in excess of $10,000 from Biomet Inc (Warsaw, IN, USA) and Arthrex Inc (Naples, FL, USA). The institution of one of the authors (RTT) has received research support, during the study period, from Zimmer, Inc (Warsaw, IN, USA). The institution of one of the authors (RJS) has received research support, during the study period, from DePuy, Zimmer, and Stryker (RJS). The remaining authors certify that they, or a member of their immediate family, have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

The project described was supported by Grant Number 1 UL1 RR024150-01 from the National Center for Research Resources (NCRR), a component of the NIH, and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at http://www.ncrr.nih.gov/. Information on Reengineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overviewtranslational.asp.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Gillette, B.P., DeSimone, L.J., Trousdale, R.T. et al. Low Risk of Thromboembolic Complications With Tranexamic Acid After Primary Total Hip and Knee Arthroplasty. Clin Orthop Relat Res 471, 150–154 (2013). https://doi.org/10.1007/s11999-012-2488-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-012-2488-z

Keywords

Search

Navigation