TRANEXAMIC ACID

Based on the available evidence, both intravenous (IV) and topical tranexamic acid (TXA) have shown significant positive effects on various outcomes in patients undergoing total hip arthroplasty. One high-quality article by Rizzo (2020) indicated that the combination of IV and topical TXA had significantly positive effects on hemoglobin levels and reduced the number of transfusions required.

Thirteen studies, including nine high-quality, one moderate-quality, and three low-quality studies, investigated the effects of IV TXA alone. The majority of these studies (nine high-quality, one moderate-quality) found significantly positive effects of IV TXA on various outcomes, including reduced blood loss, decreased number of transfusions, lower amounts of blood transfused, improved hemoglobin levels, reduced drainage, and decreased complication rates.

Four articles were identified that studied the effects of topical TXA alone, including three high-quality and one low-quality studies. These studies collectively demonstrated that topical TXA also had significantly positive effects on blood loss, number of transfusions, hemoglobin levels, drainage, and complication rates.

One study by Chin (2020) which was a moderate-quality study on IV TXA did not find any significant effects on the outcomes mentioned above. However, this study's reliability is compromised due to missing key information, such as the patient demographics and group characteristics, which may limit the validity of its conclusions.

Furthermore, Fraval (2017) and Fraval (2019) conducted two high-quality studies with similar methodologies, the latter including additional deep vein thrombosis (DVT) chemoprophylactics (Enoxaparin and Aspirin). Both studies found no significant effects of TXA on patient-reported outcome measures (PROMs) or functional outcomes.

Benefits/Harms of Implementation
While there is concern that there may be contraindications to the use of TXA, none of the papers cited above demonstrated an increased risk of adverse events related to the perioperative use of TXA for total hip arthroplasty (THA).

Outcome Importance
Reducing blood loss and transfusion rates after total hip arthroplasty has a major impact on improving outcomes, reducing complications, and improving value.

Cost Effectiveness/Resource Utilization
Reductions in perioperative blood loss and transfusion rates improve perioperative recovery, costs related to transfusion, and utilization of limited resources.

Acceptability
Some stakeholders may have concerns regarding the risk/benefit profile of tranexamic acid in higher risk patients with vascular disease, coronary stents, and thromboembolic disease. However, prior retrospective studies have found tranexamic acid use to be safe in these high-risk patients (Porter 2020). Randomized, prospective trials to address these concerns would be beneficial.

Future Research
Randomized, prospective trials comparing IV TXA, topical TXA, and oral TXA are warranted to specifically assess dosing, technique and timing of administration, uniform measures of perioperative blood loss, cost, including impact on blood transfusion, and contraindications. Studies focused on refining dosing recommendations and risks/benefits in higher risk patients may be of particular value.