Intravenous administration of tranexamic acid significantly reduces blood loss, drainage collection, and transfusion requirement postoperatively. Ten high quality studies (Sahin 2019, Lacko 2017, Sun 2017, Tzatzairis 2016, Drosos 2016, Aguilera 2015, Ye 2019, Keyhani 2016, Seo 2013, Molloy 2007) have demonstrated reduced blood loss postoperatively.
Intra-articular injection of tranexamic acid reduces blood loss postoperatively. Ten high quality studies (Lei 2020, Sahin 2019, Wong 2015, Yang 2015, Li 2018, Seo 2013, Sa Ngasoongsong 2013, Sarzaeem, 2014, Antinolfi, 2013, Gautam, 2011) demonstrated reduced blood loss postoperatively after intra-articular injection of tranexamic acid. Three high quality studies (Digas 2015, Oztas 2015, Sa-Ngasoongsong 2011) demonstrated reduced post-operative drainage in addition to reduced blood loss.
Studies published by Seo (2013), Digas (2015) and Lacko (2017) demonstrated reduced blood transfusion.
Five high quality studies have reported reduced blood loss after topical use of Tranexamic acid. However, the term Intra-articular versus topical was used interchangeably. Drosos (2016) and Georgiadis (2013) used a topical administration technique in which the drug was poured into the joint. Tzatzairis (2016), Aguilera (2015) and Keyhani (2016) described their use as topical, but the drug was injected into the joint space.
Benefits/ Harms of Implementation
Reduction in blood loss and blood transfusion will improve patient outcome. However, there are statistically non-significant reports of complication of deep vein thrombosis by three high quality studies (Yang 2015, Oztas 2015, Seo 2013). Yang (2015) and Seo (2013) also reported increased pulmonary embolism. There were reports of wound healing (Wang 2015) and would hematoma (Yang 2015). All the reports of complications were either statistically insignificant high-quality studies or low-quality studies. Therefore, the benefit of TXA administration outweighs the risk.
Outcome Importance
Reduction in blood loss and blood transfusion is a significant benefit directly to patients. In addition, health care settings will benefit from the savings and efficiency of avoiding additional care.
Cost Effectiveness / Resource Utilization
While the cost of different administration routes of TXA (oral versus IV versus topical or IA) differ, TXA is economical and has low resource utilization in in-patient and outpatient settings.
Acceptability
TXA use, with the resulting reduction in blood loss and blood transfusion, is desirable and acceptable.
Feasibility
TXA has been used extensively and is deemed feasible.
Future Research
Contraindication for tranexamic acid in TKA has not yet been very well defined and should be the subject of future research. Tranexamic acid is still an FDA “off label” that can be used in arthroplasty. FDA contraindications for TXA’s approved usages include patients with acquired defective color vision, patients with subarachnoid hemorrhage, patients with active intravascular clotting, and in patients with hypersensitivity to tranexamic acid (accessdata.fda.gov). Most of the studies have used thromboembolic disorders, cerebrovascular conditions, and cardiovascular disorder as an exclusion criterion.
- Georgiadis, A. G., Muh, S. J., Silverton, C. D., Weir, R. M., Laker, M. W. A prospective double-blind placebo controlled trial of topical tranexamic acid in total knee arthroplasty. Journal of Arthroplasty 2013; 8: 78-82
- Gautam, P. L., Katyal, S., Yamin, M., Singh, A. Effect of tranexamic acid on blood loss and transfusion requirement in total knee replacement in the Indian population: A case series. Indian Journal of Anaesthesia 2011; 6: 590-593
- Drosos, G. I., Ververidis, A., Valkanis, C., Tripsianis, G., Stavroulakis, E., Vogiatzaki, T., Kazakos, K. A randomized comparative study of topical versus intravenous tranexamic acid administration in enhanced recovery after surgery (ERAS) total knee replacement. Journal of Orthopaedics 2016; 3: 127-131
- Digas, G., Koutsogiannis, I., Meletiadis, G., Antonopoulou, E., Karamoulas, V., Bikos, Ch Intra-articular injection of tranexamic acid reduce blood loss in cemented total knee arthroplasty. European journal of orthopaedic surgery & traumatologie 2015; 7: 1181-8
- Clinical study of the optimal dose of intravenous tranexamic acid guided by thrombelastogram during the perioperative period of total knee arthroplasty. International Journal of Clinical and Experimental Medicine 2019; 6: 6989-6998
- Antinolfi,P., Innocenti,B., Caraffa,A., Peretti,G., Cerulli,G. Post-operative blood loss in total knee arthroplasty: knee flexion versus pharmacological techniques. Knee Surg Sports Traumatol.Arthrosc. 2013/9/29; 0: -
- Aguilera, X., Martínez-Zapata, M. J., Hinarejos, P., Jordán, M., Leal, J., González, J. C., Monllau, J. C., Celaya, F., Rodríguez-Arias, A., Fernández, J. A., Pelfort, X., Puig-Verdie, L. Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial. Archives of Orthopaedic and Trauma Surgery 2015; 7: 1017-1025
- Li, Q., Xiao, J., Zhu, H., Zheng, S., Shi, Z. Effects of tranexamic acid administration on recovery after unilateral total knee arthroplasty. Farmacia 2018; 4: 718-724
- Molloy, D. O., Archbold, H. A., Ogonda, L., McConway, J., Wilson, R. K., Beverland, D. E. Comparison of topical fibrin spray and tranexamic acid on blood loss after total knee replacement: a prospective, randomised controlled trial. Journal of Bone & Joint Surgery - British Volume 2007; 3: 306-9
- Öztas, S., Öztürk, A., Akalin, Y., Sahin, N., Özkan, Y., Otuzbir, A., Avcu, B. The effect of local and systemic application of tranexamic acid on the amount of blood loss and allogeneic blood transfusion after total knee replacement. Acta Orthopaedica Belgica 2015; 4: 698-707
- Sa-Ngasoongsong, P., Channoom, T., Kawinwonggowit, V., Woratanarat, P., Chanplakorn, P., Wibulpolprasert, B., Wongsak, S., Udomsubpayakul, U., Wechmongkolgorn, S., Lekpittaya, N. Postoperative blood loss reduction in computer-assisted surgery total knee replacement by low dose intra-articular tranexamic acid injection together with 2-hour clamp drain: a prospective triple-blinded randomized controlled trial. Orthopedic Reviews 2011; 2: e12
- Sa-Ngasoongsong, P., Wongsak, S., Chanplakorn, P., Woratanarat, P., Wechmongkolgorn, S., Wibulpolprasert, B., Mulpruek, P., Kawinwonggowit, V. Efficacy of low-dose intra-articular tranexamic acid in total knee replacement; A prospective triple-blinded randomized controlled trial. BMC Musculoskeletal Disorders 2013; 0
- Sahin, I. G., Akalin, Y., Cevik, N., Otuzbir, A., Ozkan, Y., Ozturk, A. Tranexamic acid in total knee replacement which protocol? which application form? A prospective randomised study. Acta Orthopaedica Belgica 2019; 4: 484-493
- Sarzaeem, M. M., Razi, M., Kazemian, G., Moghaddam, M. E., Rasi, A. M., Karimi, M. Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty. Journal of Arthroplasty 2014; 8: 1521-1524
- Seo, J. G., Moon, Y. W., Park, S. H., Kim, S. M., Ko, K. R. The comparative efficacies of intra-articular and IV tranexamic acid for reducing blood loss during total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2013; 8: 1869-74
- Sun, Q., Yu, X., Nie, X., Gong, J., Cai, M. The Efficacy Comparison of Tranexamic Acid for Reducing Blood Loss in Total Knee Arthroplasty at Different Dosage Time. Journal of Arthroplasty 2017; 1: 33-36
- Tzatzairis, T. K., Drosos, G. I., Kotsios, S. E., Ververidis, A. N., Vogiatzaki, T. D., Kazakos, K. I. Intravenous vs Topical Tranexamic Acid in Total Knee Arthroplasty Without Tourniquet Application: A Randomized Controlled Study. Journal of Arthroplasty 2016; 11: 2465-2470
- Wong, J., Abrishami, A., El Beheiry, H., Mahomed, N. N., Roderick Davey, J., Gandhi, R., Syed, K. A., Muhammad Ovais Hasan, S., De Silva, Y., Chung, F. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. Journal of Bone & Joint Surgery - American Volume 2010; 15: 2503-13
- Yang, Y., Lv, Y. M., Ding, P. J., Li, J., Ying-Ze, Z. The reduction in blood loss with intra-articular injection of tranexamic acid in unilateral total knee arthroplasty without operative drains: a randomized controlled trial. European journal of orthopaedic surgery & traumatologie 2015; 1: 135-9
- Ye, X., Chen, Y., Lin, K., Zheng, Y., & Jiang, C. Clinical study of the optimal dose of intravenous tranexamic acid guided by thrombelastogram during the perioperative period of total knee arthroplasty. International Journal of Clinical and Experimental Medicine 2019; 6: 6989-6998
- Lei, Y., Xie, J., Huang, Q., Huang, W., Pei, F. Additional benefits of multiple-dose tranexamic acid to anti-fibrinolysis and anti-inflammation in total knee arthroplasty: a randomized controlled trial. Archives of Orthopaedic and Trauma Surgery 2020; 8: 1087-1095
- Lacko, M., Cellar, R., Schreierova, D., Vasko, G. Comparison of intravenous and intra-articular tranexamic acid in reducing blood loss in primary total knee replacement. Eklem hastaliklari ve cerrahisi = Joint Diseases & Related Surgery 2017; 2: 64-71
- Keyhani, S., Esmailiejah, A. A., Abbasian, M. R., Safdari, F. Which Route of Tranexamic Acid Administration is More Effective to Reduce Blood Loss Following Total Knee Arthroplasty?. Arch Bone Jt Surg 2016; 1: 65-9