TRANEXAMIC ACID
In patients with no known contraindications, tranexamic acid (TXA) should be used because its use decreases postoperative blood loss, postoperative drain collection, and reduces the necessity of postoperative transfusions following total knee arthroplasty (TKA).

Rationale

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.