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Perioperative tranexamic acid (TXA) use with total knee arthroplasty (TKA) is widely accepted today. Recently, a few international groups have published on the safety and outcomes of extending TXA use in the postoperative period. Through a double-blinded, randomized control trial (RCT), we aimed to investigate the safety and clinical efficacy of extended postoperative oral TXA use in TKA performed in an American, free-standing ambulatory surgery center (ASC). Based on a power analysis, 40 patients undergoing primary TKA were randomized into 2 groups: extended oral TXA versus placebo. Both groups received a standard 1g intravenous TXA dose prior to incision and at the time of closure. The extended TXA group received an additional 1.95 g oral TXA dose following ambulation the day of surgery, plus on postoperative days 1,2, and 3. Patients who had a history of venous thromboembolism (VTE) or cancer were excluded. All patients received 81 mg of aspirin twice daily for VTE prophylaxis. Patients were followed on postoperative day 3 and weeks 2 and 6. Paired t -tests determined statistical significance. Extended TXA patients showed significantly increased knee flexion at 6 weeks (116.05 versus 106.5, P =.0308), improved VAS at 2 (2.5 versus 3.85, P =.039) and 6 weeks (1.35 versus 2.8, P =.011), and superior KOOS JR at 2 (66.87 versus 60.63, P =.03) and 6 weeks (73.33 versus 62.47, P =.0019) compared to placebo patients. No significant differences were found for changes in hemoglobin levels at any time points. No significant differences were found at 12 weeks for any clinical endpoints. No adverse events were noted in either cohort. When compared to placebo, the extended use of oral TXA in the postoperative period may safely result in improved motion, pain, and functional scores. Further investigation into 1-to-2-year outcomes, as well as the duration and dose of postoperative TXA use is warranted. [ABSTRACT FROM AUTHOR]

While patients who have a preoperative coagulopathy have an increased risk of perioperative blood loss, tranexamic acid (TXA) has been shown to decrease the risk of complications in this subset. However, a direct comparison of the use of TXA in coagulopathic and noncoagulopathic patients has not been performed. In addition to comparing differences in decreases in hemoglobin, transfusions, and complications, this study examined whether the use of TXA in coagulopathic patients normalized the risk of blood loss relative to matched noncoagulopathic patients. We performed a retrospective review of 230 patients who had a preoperative coagulopathy and underwent primary total joint arthroplasty (127 hips, 103 knees) from 2012 to 2019 and received TXA. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/mL (mL). A matched comparison group of 689 patients who did not have a coagulopathy and received TXA was identified. A 2 1-sided test (TOST) analysis was performed to test for equivalence. Assuming a clinically relevant difference of 1 g/dL in postoperative decrease in hemoglobin, the equivalence margin was set as ±1 g/dL between the groups. When comparing coagulopathic and noncoagulopathic patients, total hip arthroplasty (THA) patients had no differences in hemoglobin, but had an increased reported estimated blood loss (243 versus 207 mL, P =.040) as well as an increased percent of patients requiring blood transfusions (11.8 versus 5.32%, P =.022). Total knee arthroplasty (TKA) patients had no differences in hemoglobin, estimated blood loss, or percent of patients requiring transfusion. There were no differences in medical or surgical complications for both groups for THA and TKA patients. Equivalence testing for both groups revealed statistical significance that THA and TKA coagulopathic patients receiving TXA had an equivalent risk of blood loss compared to noncoagulopathic patients receiving TXA. Coagulopathic patients receiving TXA and undergoing THA had an increased risk of receiving a transfusion; however, there were no differences in complications for both TKA and THA, as well as a normalized risk of blood loss when compared to noncoagulopathic patients. III. [ABSTRACT FROM AUTHOR]

Tranexamic acid (TXA) utilization during total joint arthroplasty (TJA) has become ubiquitous. However, concerns remain regarding the risk of thrombotic complications. The goal of this study was to examine the risk of prothrombotic complications in patients who received TXA during total knee (TKA) and total hip arthroplasty (THA). The Premier Healthcare Database was queried for patients who underwent elective TJA. TXA utilization trends were described from 2008 to 2020. Two analyses were performed using ICD-10 codes from 2016 to 2020: (1) patients who received TXA compared to patients who did not receive TXA and, (2) to account for surgeon selection bias, patients whose surgeon utilized TXA consistently (≥90% of cases) compared to patients whose surgeons used TXA infrequently (≤30% of cases). Multivariate and instrumental variable analyses (IVA) were performed to assess outcomes while accounting for confounding factors. TXA utilization increased from 0.1% of cases in 2008 to 89.2% in 2020. From 2016 to 2020, 1,120,858 TJAs were identified (62.1% TKA, 27.9% THA), of which 874,627 (78.0%) received TXA. Patients who received TXA were at lower risk of prothrombotic (adjusted Odds Ratio (aOR) 0.82, P <.001), bleeding (aOR 0.75, P <.001), and infectious complications (aOR 0.91, P < 0.001). Furthermore, patients who underwent surgery from surgeons who utilized TXA consistently were at lower risk for prothrombotic (aOR 0.90, P <.001) and bleeding (aOR 0.72, P <.001) complications. The widespread utilization of TXA during elective TJA was not associated with increased rates of prothrombotic complications. These findings persisted after accounting for surgeon selection bias. Level III. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) is a renally-excreted antifibrinolytic commonly utilized in total joint arthroplasty (TJA). This study examined whether TXA administration affected clinical outcomes and kidney function in patients who had end-stage renal disease (ESRD) undergoing TJA or hemiarthroplasty., Methods: Through a retrospective chart review, we identified 123 patients: 40 who underwent primary elective total knee arthroplasty (TKA; 65% received TXA), 34 who underwent primary elective total hip arthroplasty (THA; 52.9% TXA), and 49 who underwent nonelective THA or hemiarthroplasty (44.9% TXA) from January 2011 to February 2024. All patients had ESRD and/or were on dialysis, with no difference in percentage on dialysis between TXA groups (TKA: 65.4 versus 64.3%; THA: 55.6 versus 50.0%; nonelective/hemiarthroplasty: 86.4 versus 85.2%, P values ≥ 0.586). Demographic and perioperative characteristics, including preoperative hemoglobin, TXA administration, dose, and route of administration (ROA; intravenous, topical), were extracted. Pre- and postoperative (≤ 7 days) creatinine, perioperative transfusions, revisions, and 90-day emergency department (ED) visits, readmissions, and mortalities were recorded and compared between TXA groups., Results: In the total sample and all cohorts, change in pre- to postoperative creatinine and incidence of postoperative acute kidney injury (AKI), per Kidney Disease Improving Global Outcomes (KDIGO) guidelines, did not significantly differ based on receiving TXA (P values ≥ 0.159). Among patients receiving TXA, change in creatinine did not significantly differ by dose (P values ≥ 0.428) or ROA (P values ≥ 0.256). There were no statistically significant differences in 90-day ED visits, readmissions, or mortalities based on receiving TXA (P values ≥ 0.055). Thromboembolic events occurred in four patients (one TXA, three no TXA, P = 0.617), and perioperative transfusions occurred in two patients (one TXA, one no TXA, P = 0.882) in the nonelective/hemiarthroplasty cohort, with none in the elective cohorts., Conclusions: The administration of TXA does not portend a significant increase in complications for patients who have ESRD undergoing TJA or hemiarthroplasty for fracture, suggesting TXA should not be contraindicated in this population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Computer-assisted surgery that does not utilize femoral canal instrumentation is theorized to have less blood loss. However, there is a paucity of data on this, particularly in the era of tranexamic acid use. We sought to analyze the association of computer navigation with total calculated blood loss and transfusion rate in patients undergoing primary total knee arthroplasty (TKA).Methods: We identified 14,890 patients who underwent unilateral primary TKA at a single institution from 2016 to 2020. Computer-assisted surgery in the form of an accelerometer or robotics was utilized in 4,165 TKAs (28%). Drains were utilized in 4,860 TKAs (32%). We used multivariate logistic regression analysis to determine if computer navigation reduced the rate of blood transfusion and linear regression analysis to determine the impact of computer navigation on blood loss.Results: In total, 542 patients (3.6%) underwent a transfusion. The average change in hemoglobin (Hgb) was 2.1 g/dL (standard deviation [SD] 0.91) and average total calculated blood loss was 310 mL (SD = 154). In a multivariate regression model, computer navigation was not protective of transfusion (odds ratio [OR] 1.04, P = .73). Preoperative Hgb <10 (OR 10.5, P < .0001) and drain use (OR 2.25, P < .0001) were the most significant risk factors for transfusion. In a linear regression model, computer navigation reduced blood loss by 19 mL (SD 2.94, P < .0001) per case.Conclusion: In this large retrospective cohort analysis of contemporary TKA patients, computer-assisted surgery that eliminates intramedullary femoral canal instrumentation during primary TKA was not associated with reduced transfusion rates and had minimal differences in overall blood loss. [ABSTRACT FROM AUTHOR]

The purpose of this study was to perform a systematic review and meta-analysis to evaluate the association between tranexamic acid (TXA) use during primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA), and the risk of developing periprosthetic joint infection (PJI) after these procedures. A systematic review was carried out from inception to October 17, 2022. There were 6 studies that were ultimately included in the meta-analysis. The association between the development of PJI and TXA was analyzed using odds ratios (ORs) with 95% confidence intervals (CIs) and estimates of risk difference (RD). Subgroup analysis was performed to evaluate only studies reporting out to 90 days of follow-up versus more than 90 days of follow-up. Among 2,098,469 arthroplasties, TXA utilization was associated with an overall lower risk of PJI (OR = 0.63 [95% CI 0.42 to 0.96], P <.001) and a 0.4% lower incidence of PJI (RD = −0.0038, 95% CI [-0.005 to −0.002], P <.001). When subgrouping the studies according to length of follow-up, TXA was associated with a lower risk of PJI (OR = 0.43 [95% CI 0.35 to 0.53], P <.001) and a 1% lower incidence of PJI (RD = −0.0095 [95% CI −0.013 to −0.005], P <.001) in patients followed for more than 90 days. This meta-analysis demonstrates that TXA use is associated with a reduced risk of PJI, with our RD analysis identifying an approximately 0.4% reduction in PJI rates with TXA use. These findings provide even more data to support the routine use of TXA during primary THA and primary TKA. [ABSTRACT FROM AUTHOR]

Background: We aimed to determine the efficacy of pre-emptive antifibrinolysis with tranexamic acid (TXA) in decreasing hidden blood loss (HBL) in the elderly hip fracture patients.Methods: Ninety-six elderly hip fracture patients receiving hip arthroplasty were randomized to receive 100 mL of normal saline (group A) or 1.5 g of TXA (group B) intravenously q12 hours from postadmission day 1 (PAD1) to the day before surgery. Both groups were treated with 1.5 g of TXA q12 hours from postoperative day 1 (POD1) to POD3. HBL was calculated by formulas and recorded as the primary outcome.Results: In overall analyses, no difference was found in HBL, while the decline of hemoglobin (ΔHb), allogeneic blood transfusion (ABT) rate, fibrinogen degradation product (FDP-on PAD2, PAD3, POD1, and POD2), and d-dimer (D-D-on PAD2, PAD3, and POD1) were lower in group B. In subgroup analyses for patients receiving intervention within 72 hours of injury, group B had lower postoperative HBL, ΔHb, ABT rate, FDP, and D-D levels (on PAD2, PAD3, POD1, and POD2). For patients receiving intervention over 72 hours after injury, no difference was detected in perioperative HBL, ΔHb, and ABT rate between the 2 groups. The FDP and D-D levels were lower in group B on PAD2 and PAD3. No difference was found in coagulation parameters, wound complications, venous thromboembolism rate, and 90-day mortality in all analyses.Conclusion: Early administration (within 72 hours of injury) of multidose of TXA is effective in reducing perioperative HBL in elderly hip fracture patients. Delayed use (over 72 hours after injury) of TXA was not beneficial. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion.Methods: We identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis.Results: Twenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P < .001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb <12 had an elevated risk of transfusion at 37.5% (15/40 patients).Conclusion: With contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (<12 g/dL) had the highest risk of transfusion at 37.5%. [ABSTRACT FROM AUTHOR]

Background: The 2018 American Association of Hip and Knee Surgeons clinical practice guideline (CPG) 'tranexamic acid use in total joint arthroplasty' evaluated the efficacy and safety of tranexamic acid in primary total joint arthroplasty. The following review assessed the statistical fragility of the randomized controlled trial (RCT) outcomes on which the CPG recommendations were based using a fragility analysis., Methods: All dichotomous outcomes from the RCTs used to guide the CPG from its associated network, and direct meta-analyses were analyzed. Fragility and reverse fragility indices (FI and rFI) and quotients were calculated for each outcome. The mean indices and quotients were calculated for each guideline question, outcome category, and comparison of tranexamic dose, formulation, and administration timing., Results: This review evaluated 403 dichotomous outcomes on transfusion and complication rates associated with tranexamic acid (TXA) administration. The mean FI of significant outcomes of the CPG was 5.23, and the mean rFI of nonsignificant outcomes was 5.80. Outcomes assessing complication rates had a mean rFI of 6.48. Most outcomes on transfusion in categories comparing TXA to placebo administration had higher mean FIs than rFIs, and all outcomes comparing transfusion risk associated with different TXA formulations and doses had higher mean rFIs than FI or no associated significant outcomes., Conclusions: The rFI and FIs calculated for this CPG are comparable to or higher than mean values reported across orthopaedic literature, indicating the relative statistical stability of its included outcomes. As we learn more about fragility analyses and their potential applications, this type of statistical analysis shows promise as a useful tool to incorporate into future guidelines to assess the quality of RCTs and evaluate the strength of recommendations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Heterotopic ossification (HO) is a relatively common complication after total hip arthroplasty (THA) and can range from a radiographic observation only to severely disabling and requiring revision surgery. Prophylaxis is recommended for high-risk patients, though the ideal method and targeted population are open to debate. Tranexamic acid (TXA) is a medication increasingly being used to reduce blood loss associated with orthopaedic surgeries, including THA., Methods: A retrospective review of 357 patients undergoing THA from November 2020 through December 2023 was conducted. The patients were grouped based on whether they received intravenous TXA perioperatively or not, and their propensity score matched 2:1 TXA to no TXA on age, body mass index, sex, Charlson Comorbidity Index, and perioperative celecoxib use. Univariate and multivariate analyses were performed., Results: After propensity score matching, the only significant differences between groups were American Society of Anesthesiologists (ASA) scores and preoperative celecoxib use between groups, as the TXA group had fewer patients who had an ASA of 3 or more (38.9 versus 58.5%, P < 0.001) and more patients who had taken celecoxib preoperatively (16.3 versus 5.9%, P = 0.010). Perioperatively, patients were more likely to undergo THA using the anterior approach (74.5 versus 57.6%, P = 0.002) and were more likely to receive postoperative celecoxib prescriptions (44.8 versus 31.4%, P = 0.021), but there was no difference in other nonsteroidal anti-inflammatory drug (NSAID) usage postoperatively. Postoperatively, patients who received TXA had a lower rate of HO on the last postoperative x-ray (20.1 versus 33.9%, P = 0.007). Multivariable logistic regression, to assess predictors of HO, found that patients who had TXA were 42% less likely to have visible HO (OR [odds ratio] = 0.58, P = 0.047), while holding surgical approach, American Society of Anesthesiologists score, preoperative and postoperative celecoxib use, and postoperative other nonsteroidal anti-inflammatory drug use constant., Conclusions: The use of TXA in patients undergoing primary THA results in a decreased likelihood ofHO formation on postoperative x-rays., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: This study aimed to evaluate the safety of total knee arthroplasty (TKA) in Jehovah's Witness patients compared to non-Jehovah's Witness patients using standard perioperative TKA protocols and assess the role of tranexamic acid (TXA) in managing blood loss in this population., Methods: Patients undergoing TKA between 2011 and 2021 at 2 tertiary academic centers were retrospectively reviewed. Patient demographics, preoperative and postoperative hematologic laboratory values, intraoperative TXA use, 90-day postoperative complications, and subsequent revisions were collected. These variables were then compared between propensity score-matched cohorts at a 2:1 ratio of those who did not identify as Jehovah's Witness to those who did. Regression analysis was used to determine the effect of intraoperative TXA on hemoglobin (hgb) shift., Results: After applying exclusion criteria and matching, the TKA outcomes of 316 non-Jehovah's Witness patients and 152 Jehovah's Witness patients were analyzed. Univariate analysis suggested that non-Jehovah's Witness patients and Jehovah's Witness patients had similar preoperative and postoperative hgb, hgb shift, and hematocrit. Only 1 (0.8%) Jehovah's Witness patient reached an hgb < 8.0 mg/dL postoperatively. Multivariate logistic regression suggested that Jehovah's Witness patients did not have increased odds of reaching an hgb < 8.0 mg/dL (odds ratio = 0.99 [0.96, 1.02]; P = 0.42). Multivariate linear regression suggested that intraoperative TXA was positively correlated with hgb shift and thus a smaller decrease in hgb from pre-TKA to post-TKA (β = 0.38 [0.06, 0.69]; P = 0.02). Additionally, Jehovah's Witness patients had excellent revision-free (95% [91, 99]) and infection-free (98% [95, 100]) survival at 8 years., Conclusions: Standard perioperative TKA protocols are safe for Jehovah's Witness patients who do not have the need for transfusion, especially with appropriate preoperative hgb levels and the use of intraoperative TXA. Furthermore, these patients have excellent survivorship at 5 and 8 years of follow-up., Level of Evidence: Level III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Historically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).Methods: We retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/m2. Drains were utilized in 143 patients (30%). Mean preoperative hemoglobin (Hgb) was 13.7 g/dL. Multivariate logistic regression analysis adjusting for age ≥70 years, sex, body mass index, drain use, and preoperative Hgb of <12.5 g/dL was utilized to identify risk factors for transfusion.Results: One hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb <12.5 (OR = 3.99, P < .0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb <12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P < .001).Conclusion: Patients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb <12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) for the reduction of blood loss in orthopedic surgery is coming into greater adoption. Because TXA administration lowers the incidence of blood transfusion and of hematoma formation, risk factors for infection, we asked whether TXA use might be associated with a lower incidence of periprosthetic joint infection (PJI) following orthopedic surgery.Methods: We queried the Premier Healthcare database for ICD-9 codes corresponding to elective inpatient primary total hip replacement (THR) or total knee replacement (TKR) from 2012 to 2016, TXA administration on the day of surgery, and PJI during the hospital stay or within 90 days. We performed a multilevel multivariable logistic regression (SAS version 9.4. SAS Institute, Cary, NC) to determine if TXA administration or other covariates were a significant predictor of infection.Results: Among 914,990 total joint arthroplasty patients, 46.0% received TXA on the day of surgery. 0.13% developed PJI within 90 days. After adjusting for patient and hospital-related covariates, TXA use was associated with significantly lower odds of PJI within 90 days of surgery (OR 0.49 [0.69, 0.91]).Conclusion: Administration of TXA on the day of surgery in total knee and total hip arthroplasty was associated with a statistically significant decreased odds of PJI in the first 90 days. We therefore conclude that TXA might play an important role in our attempts to decrease PJI after joint arthroplasty. The exact mechanisms and ideal dosage by which TXA can contribute to such a reduction need further study. [ABSTRACT FROM AUTHOR]

Background: Modern surgical protocols, particularly the use of tranexamic acid (TXA), have reduced, but not eliminated, blood transfusions surrounding total hip arthroplasty (THA). Identifying patients at risk for transfusion remains important for risk reduction and to determine type and screen testing., Methods: We reviewed 6,405 patients who underwent primary, unilateral THA between January 2014 and January 2023 at a single academic institution, received TXA, and had preoperative hemoglobin (Hgb) values. We compared demographics, baseline Hgb levels, and surgical details between patients who were and were not transfused. Data were analyzed utilizing multivariate regression and receiver operating characteristic curve analysis., Results: The overall perioperative and intraoperative transfusion rates were 3.4 and 1.0%, respectively. Patients who were older, women, and American Society of Anesthesiologists class >II demonstrated an increased risk of transfusion. Risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with body mass index, and a direct correlation with age, surgical time, and estimated blood loss on multivariate analysis. The receiver operating characteristic analysis demonstrated a preoperative Hgb cutoff of 12 g/dL for predicting any transfusion. Above the threshold of 12 g/dL, total and intraoperative transfusions were rare, with rates of 1.7 and 0.3%, respectively. Total and intraoperative transfusion rates with Hgb between 11 and 12 g/dL were 14.3 and 4.6%, respectively. Below 11 g/dL, total and intraoperative transfusion rates were 27.5 and 10.1%, respectively., Conclusions: In the age of TXA, blood transfusion is rare in THA when preoperative Hgb is >12 g/dL, challenging the need for universal type and screening. Conversely, patients who have Hgb < 11.0 g/dL, remain at substantial risk for transfusion. Between Hgb 11 and 12 g/dL, patient age, sex, body mass index, American Society of Anesthesiologists classification, anticipated estimated blood loss, and surgical time may help predict transfusion risk and the need for a perioperative type and screen., Level of Evidence: III., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Advances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion.Methods: Prospectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA.Results: A total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27.Conclusion: In our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice. [ABSTRACT FROM AUTHOR]

Background: Patients with rheumatoid arthritis (RA) receive transfusions more often than patients with osteoarthritis following lower extremity total joint arthroplasty (TJA), but mitigating factors are not described. Tranexamic acid (TXA) is widely used to reduce blood loss in patients undergoing TJA, but its effect on transfusion rates in patients with RA has not been studied.Methods: We retrospectively reviewed data from a prospectively collected cohort of patients with RA undergoing TJA. Disease activity measured by Clinical Disease Activity Index, patient-reported outcome measures, and serologies was obtained. Baseline characteristics were summarized and compared. Transfusion requirements and TXA usage were obtained from chart review. Logistic regression was used to determine factors associated with transfusion in RA patients undergoing TJA.Results: The cohort included 252 patients, mostly women with longstanding RA and end-stage arthritis requiring TJA. In multivariate analysis, 1 g/dL decrease in baseline hemoglobin (odds ratio [OR] = 0.394, 95% confidence interval [CI] [0.232, 0.669], P = .001), 1-minute increase in surgical duration (OR = 1.022, 95% CI [1.008, 1.037], P = .003), and 1-point increase in Clinical Disease Activity Index (OR = 1.079, 95% CI [1.001, 1.162]) were associated with increased risk of transfusion. TXA use was not associated with decreased risk of postoperative transfusion.Conclusions: Preoperative health optimization should include assessment and treatment of anemia in RA patients before TJA, as preoperative hemoglobin level is the main risk factor for postoperative transfusion. Increased disease activity and increased surgical time were independent risk factors for postoperative transfusion but are less modifiable. While TXA did not decrease transfusion risk in this population, a prospective trial is needed to confirm this.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events.Methods: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon.Results: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77).Conclusion: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA.Level Of Evidence: Level III, Observational Cohort Study. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated preoperative anemia to be a strong risk factor for periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). Allogeneic blood transfusion can be associated with increased risk of PJI after primary and revision TJA. Tranexamic acid (TXA) is known to reduce blood loss and the need for allogeneic blood transfusion after TJA. The hypothesis of this study is that administration of intravenous TXA would result in a reduction in PJI after TJA.Methods: An institutional database was utilized to identify 6340 patients undergoing primary TJA between January 1, 2013 and June 31, 2017 with a minimum of 1-year follow-up. Patients were divided into 2 groups based on whether they received intravenous TXA prior to TJA or not. Patients who developed PJI were identified. All PJI patients met the 2018 International Consensus Meeting definition for PJI. A multivariate regression analysis was performed to identify variables independently associated with PJI.Results: Of the patients included, 3683 (58.1%) received TXA and 2657 (41.9%) did not. The overall incidence of preoperative anemia was 16%, postoperative blood transfusion 1.8%, and PJI 2.4%. Bivariate analysis showed that patients who received TXA were significantly at lower odds of infection. After adjusting for all confounding variables, multivariate regression analysis showed that TXA is associated with reduced PJI after primary TJA.Conclusion: TXA can help reduce the rate of PJI after primary TJA. This protective effect is likely interlinked to reduction in blood loss, lower need for allogeneic blood transfusion, and issues related to immunomodulation associated with blood transfusion. [ABSTRACT FROM AUTHOR]

Background: Postoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.Methods: This study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.Results: Total blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).Conclusion: CSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications. [ABSTRACT FROM AUTHOR]

Background: The use of tranexamic acid (TXA) has been proved to be effective in reducing blood loss and transfusion requirements after primary total knee arthroplasty (TKA). However, the evidence for its use in revision surgery is scant. We assessed the safety and efficacy of topical TXA in revision TKA.Methods: We retrospectively compared 76 revision TKA patients who received topical TXA (3 g before tourniquet deflation) "study group" with a historic control group of 205 revision TKA patients in which TXA was not used. Each group was further stratified into subgroups according to the type of revision. All patients were followed for a minimum of 6 weeks. Blood loss, transfusion requirements, changes in hemoglobin-hematocrit levels, Knee Society Score, and complications were recorded.Results: The mean estimated blood loss, hemoglobin drop, and transfusion rate were significantly lower in the study group than in the control group (P = .008, P < .001, P < .001, respectively). Hidden blood loss was similar between the 2 groups (P = .12). Six weeks postoperatively, the improvement in the knee-specific Knee Society Score was significantly higher in the study group than in the control group (P < .001). No significant differences were found in thromboembolic complications between the 2 groups (P = .92). In the subgroup analysis, when both components (femur and tibia) were revised, the relative risk of transfusion was significantly lower with the use of TXA (relative risk 0.227, confidence interval 0.0593-0.860, P = .004).Conclusion: Topical TXA in revision TKA is safe and effective in reducing blood loss and transfusions. This effect is enhanced when both components are revised. Additionally, the use of TXA may improve early outcomes. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) has been widely used in total knee arthroplasty (TKA) for blood loss reduction. Given limited evidence on potential relationship between the TXA and improvement of pain control and functional outcome after TKA, this study aimed at comparing the blood loss, pain scores, morphine consumption, and knee flexion across the TXA administration routes.Methods: The 228 primary TKA were randomized into no TXA use (No-TXA), intra-articular TXA (15 mg/kg) use (IA-TXA), and intravenous TXA (10 mg/kg) use (IV-TXA). A multivariate regression analysis was used for comparing perioperative blood loss (PBL), drain output, average number of units of blood transfused (ANUBT), visual analogue scales (VAS) for pain, amount of morphine consumption, and knee flexion angle.Results: The IA-TXA and IV-TXA group had 193.26 (P < .01) and 160.30 mL (P < .01) less PBL than No-TXA, respectively. No-TXA significantly required higher ANUBT than IA-TXA and IV-TXA (P = .03). The IA-TXA group had lower VAS at 6 (P = .04), 12 (P = .03), and 24 hours (P = .02) postoperative when compared to No-TXA, while IV-TXA had no effect. The IA-TXA required 18.26 mg less total morphine at 48 hours than No-TXA (P = .02), whereas IV-TXA used insignificantly (5.31 mg; P = .31) less total morphine at 48 hours than No-TXA. Both TXA routes tended to improve knee flexion, but not statistically significant.Conclusion: Both IA-TXA and IV-TXA could significantly reduce PBL and ANUBT. The IA-TXA could significantly mitigate VAS and morphine use after TKA. Hence, IA-TXA could minimize blood loss and may be considered as an adjunct to pain control following TKA. [ABSTRACT FROM AUTHOR]

Background: Routine laboratory studies are often obtained following total hip arthroplasty (THA). Moreover, laboratory studies are often continued daily until the patient is discharged regardless of medical management. The purpose of this study was to investigate the use of routine complete blood count (CBC) tests following THA. Secondarily, the purpose was to identify patient factors associated with abnormal postoperative lab values.Methods: This retrospective review identified 352 patients who underwent primary THA at a single institution from 2012 to 2014. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were used to identify factors associated with an abnormal postoperative lab and risk of transfusion.Results: Of the 352 patients, 54 patients were transfused (15.3%). Patients who underwent transfusion had a significantly lower preoperative hemoglobin (Hb; 12.0 g/dL) compared to patients who did not undergo transfusion (13.5 g/dL; P < .001). Patients who did not receive TXA were 3.7 times more likely to receive a transfusion. No patients received medical intervention based on the outcome of postoperative platelet or white blood counts. A Hb value below 11.94 g/dL for patients who are anemic preoperative or did not receive TXA predicted transfusion after postoperative day 1.Conclusion: Under value-based care models, cost containment while maintaining high-quality patient care is critical. Routine postoperative CBC tests in patients with a normal preoperative Hb who receive TXA do not contribute to actionable information. Patients who are anemic before THA or do not receive TXA should at minimum obtain a CBC on postoperative day 1. [ABSTRACT FROM AUTHOR]

Background: The most appropriate dose of tranexamic acid in total hip arthroplasty (THA) has not been decided. This study was conducted to evaluate the clinical effects of multiple-dose intravenous tranexamic acid (IV-TXA) in THA.Methods: One hundred fifty patients were randomized to receive one dose of IV-TXA before incision, followed by 2 doses of IV-TXA (group A), or 3 doses of IV-TXA (group B), or 4 doses of IV-TXA (group C) at 3-hour intervals. The primary outcome was hidden blood loss (HBL). Other outcome measurements such as total blood loss, maximum hemoglobin (Hb) drop, postoperative lowest Hb level, fibrinolysis parameter (D-dimer), inflammatory factor (interleukin-6), transfusion rate, length of stay, and complications were also compared.Results: The mean HBL, total blood loss, and maximum Hb drop were significantly lower in group C than in groups B and A. Such differences were also detected between groups B and A. The postoperative lowest Hb level was significantly higher in group C. D-dimer and interleukin-6 in group C were significantly lower than in groups B and A at 24 and 48 hours postoperatively. Such differences were also significant between groups B and A. There was no significant difference in length of stay among groups. No patient underwent blood transfusion during hospitalization. No episodes of deep venous thrombosis or pulmonary embolism occurred in all cases.Conclusion: The 5-dose IV-TXA regimen can further diminish HBL, decrease maximum Hb drop, provide additional fibrinolysis control, and ameliorate postoperative inflammatory response following THA. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) has demonstrated efficacy in reducing blood loss, reduction in hemoglobin, and blood transfusion requirements in primary total hip arthroplasty (THA). The optimal mode of TXA administration for patients undergoing primary THA is unclear. The purpose of this randomized controlled trial is to determine whether oral administration of TXA was superior to intravenous or topical routes in these patients.Methods: In this double-blinded, placebo-controlled trial, patients undergoing primary THA were randomized to oral (2 g TXA orally 2 hours preoperatively), intravenous (20 mg/kg intravenous TXA bolus 5 minutes before the incision), or topical (2 g TXA applied topically) TXA groups. The primary outcome was the reduction in hemoglobin. Secondary outcomes included blood loss, transfusion rate, cost of TXA (Chinese yuan (¥); in 2017, ¥1 = $0.147), and adverse events.Results: One hundred eighty patients were randomized into the 3 groups. Demographic characteristics were similar among the groups. The mean reduction in hemoglobin was similar among the oral, intravenous, and topical groups (3.48 ± 1.32, 3.58 ± 1.07, and 3.66 ± 1.26 g/dL, respectively). Similarly, the mean total blood loss did not differ significantly among the 3 groups. The oral group incurred the lowest TXA cost (¥480) compared with that in the intravenous (¥3329.28) and topical (¥3540) groups (P = .01). None of the patients sustained a deep venous thrombosis, pulmonary embolism, or an infection.Conclusion: The blood-sparing efficacy of oral TXA is comparable to that of the intravenous and topical forms. Oral TXA is recommended because of its cost-benefit superiority and ease of administration. [ABSTRACT FROM AUTHOR]

Background: Little data exist to evaluate an individual's pre-operative risk of blood transfusion following total knee arthroplasty (TKA). Our aim is to identify the risk factors associated with reaching the transfusion trigger of Hb <8 g/dL (TT8) following surgery and how perioperative tranexamic acid (TXA) affects that outcome.Methods: Using a retrospective cohort study design, routine, unilateral TKAs performed between 2011 and 2013 in 19 hospitals were reviewed. Patients hospitalized ≤1 day or ≥4 days were excluded. Demographic data, clinical characteristics, and potential confounders were included in statistical models. Data were abstracted from electronic clinical and utilization databases. The main outcome was the risk of reaching the TT8. The primary exposure was use of single dose intravenous TXA. Logistic regression was used to model the adjusted association between TXA usage and post-operative risk of reaching TT8.Results: A total of 10,518 TKAs met criteria; 2566 (24.3%) received TXA (+TXA). The proportion that reached the TT8 was 2.1% for + TXA and 5.3% for -TXA (P < .0001). Pre-operative Hb levels were associated with increasing odds of reaching the TT8. Increasing age was weakly associated with this outcome. The odds of reaching the TT8 were lower for patients who had received TXA, had increasing body mass index, and surgical duration in the third quartile.Conclusion: Not receiving TXA within 24 hours of TKA and pre-operative Hb levels <13 g/dL were independently associated with the odds of reaching the post-operative TT8 following a primary TKA. [ABSTRACT FROM AUTHOR]

Background: Total hip and knee arthroplasty (THA and TKA) are associated with significant blood loss and some patients require postoperative blood transfusion. While tranexamic acid has been studied extensively among this population, we tested the hypothesis that epsilon aminocaproic acid (EACA) can reduce blood loss and transfusion after joint arthroplasty.Methods: In April 2014, our Veterans Affairs Medical Center introduced a protocol to administer EACA during THA and TKA. No antifibrinolytics were used previously. We retrospectively compared blood loss and incidence of transfusion among patients who underwent primary arthroplasty in the year before standardized administration of EACA with patients having the same procedures the following year. Blood loss was measured as delta hemoglobin (preoperative hemoglobin - hemoglobin on postoperative day 1). All patients undergoing primary THA or TKA were included. Patients having revision surgery were excluded.Results: We identified 185 primary arthroplasty patients from the year before and 184 from the year after introducing the EACA protocol. There were no changes in surgical technique or attending surgeons during this period. Delta hemoglobin was significantly lower in the EACA group (2.7 ± 0.8 mg/dL) compared to the control group (3.4 ± 1.1 mg/dL) (P < .0001). The incidence of blood transfusion was also significantly lower in the EACA group (2.7%) compared to the control group (25.4%) (P < .0001). There was no difference in venous thromboembolic complications between groups.Conclusion: We demonstrated reductions in hemoglobin loss and transfusion following introduction of the EACA protocol in patients undergoing primary arthroplasty. EACA offers a lower cost alternative to TXA for reducing blood loss and transfusion in this population. [ABSTRACT FROM AUTHOR]

Background: This study aimed to examine the influence of a periarticular injection of tranexamic acid (TXA) on blood loss after a total knee arthroplasty (TKA) in patients who received an autologous blood transfusion.Methods: We retrospectively reviewed the medical charts of 82 patients (88 consecutive knees) who underwent a primary unilateral TKA with or without a periarticular TXA injection (TXA and control groups, respectively). All patients underwent an autologous blood transfusion. Perioperative parameters related to blood loss were compared between groups.Results: Compared to the control group, the decrease in hemoglobin was significantly smaller in the TXA group (1.5 ± 1.2 vs 2.5 ± 1.4 g/dL, P < .001), and blood drainage was significantly lower in the TXA group (387.2 ± 215.7 vs 582.3 ± 272.9 mL, P = .002). Moreover, the estimated blood loss, based on either hemoglobin or hematocrit, was significantly lower in the TXA group (509.8 ± 405.2 and 530.7 ± 418.5 mL, respectively) than in the control group (814.2 ± 543.8 and 809.1 ± 469.6 mL, respectively, both P < .001). No severe complications, including a venous thromboembolic event or infection, or local complications, including skin necrosis or delayed wound healing, were observed in either group. A postoperative allogeneic blood transfusion was performed in 2 cases in the control group and none in the TXA group.Conclusion: Periarticular TXA injection is effective in reducing postoperative blood loss and hemoglobin and hematocrit drops without increasing the risk of venous thrombosis or the necessity of an allogeneic blood transfusion. [ABSTRACT FROM AUTHOR]

Background: The optimal administration route of tranexamic acid (TXA) in total knee arthroplasty (TKA), and the effect of TXA on hidden blood loss and total blood loss are undetermined. The purpose of this study was to compare the effectiveness of intravenous versus intra-articular application of tranexamic acid in patients undergoing knee arthroplasty.Methods: A total of 150 patients undergoing primary unilateral total knee arthroplasty were randomly distributed to 3 groups (IV, intra-articular, and control group; each 50 patients) and administrated TXA (1 g IV and 50 mL intra-articular saline, 1 g intra-articularly and 50 mL intra-articular saline, and 0 g and 50 mL intra-articular saline, respectively). The amount of total and hidden blood loss (HBL), drainage, transfusion, changes in hemoglobin levels, and complications were recorded.Results: Intra-articular use of TXA reduced more total blood loss (P = .011) and reduced more total 48 hours drainage volume than IV use of TXA (P < .001). Two patients received transfusion in IV and control group. No deep venous thrombosis or other severe complications had occurred. The HBL volume had no significant difference among the control, IV, and intra-articular groups (708.6 ± 308.2, 651.7 ± 302.9, and 625.2 ± 252.1 mL, respectively; which was 65.6%, 70.8%, and 81.1% of the total loss).Conclusion: Intra-articular administration of TXA significantly reduced total blood loss and drainage volume to a greater degree than IV injection in total knee arthroplasty without reduction of HBL. [ABSTRACT FROM AUTHOR]

Background: Postoperative anemia following elective arthroplasty can lead to prolonged hospital stay and delays in rehabilitation and is often poorly tolerated in patients with cardiovascular disease. Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in total knee arthroplasty (TKA). However, questions over its optimal route of administration remain.Methods: A double-blinded, placebo, multicentered, randomized, controlled trial investigating the efficacy of topical and systemic routes of a single intraoperative dose (1.5 g) of TXA was conducted. Patients undergoing primary, unilateral TKA were screened for eligibility. Eligible patients were consecutively enrolled from 5 New Zealand centers between July 2014 and November 2015. Three prospective groups running in parallel (topical TXA [tTXA], systemic TXA [sTXA], and placebo) were investigated for a primary outcome of estimated perioperative blood loss. An intention-to-treat analysis was used to compare outcomes between the study groups (P value <.05).Results: One hundred and thirty-four patients across the 5 hospitals were recruited into the study. Estimated blood loss was equivalent in the 2 treatment groups, sTXA (749 mL [95% confidence interval, 637-860]) and tTXA (723 mL [620-826]). Compared to the placebo group (1090 mL [923-1257]), blood loss was significantly lower in both treatment groups (P = .001 and P = .0003, respectively). There were no significant differences in secondary outcomes, including rates of symptomatic deep vein thrombosis and pulmonary embolism (P = .759).Conclusion: In the setting of elective TKA, a single 1.5-g dose of tTXA given intraoperatively either systemically or topically effectively reduces blood loss without an increase in complications. [ABSTRACT FROM AUTHOR]

Background: Fibrin sealants are topical agents used to reduce perioperative blood loss; however, their efficacy in total hip arthroplasty (THA) remains uncertain. The purpose of this study was to determine if a fibrin sealant containing aprotinin as an antifibrinolytic agent, TISSEEL (Baxter, Deerfield, IL), reduces postoperative blood loss and transfusion during THA when compared with intravenous (IV) tranexamic acid (TXA) and control groups.Methods: Three retrospective uniform cohorts of primary THA procedures were identified, from a prospectively maintained database: 1 group who received TISSEEL, 1 group who received 1 g IV TXA, and 1 group who received neither (control). There were 80 patients in each group. Outcome measures included the lowest measured hemoglobin during postoperative hospitalization, greatest decrease in hemoglobin from preoperative to postoperative values, and blood transfusion rates.Results: The minimum postoperative hemoglobin level was significantly lower for TISSEEL patients compared with that of IV TXA patients (P = .021) and no different when compared with that of control patients (P = .134). Patients receiving fibrin sealant had a greater hemoglobin level decrease compared with that of IV TXA (P = .029) and control (P = .036). Postoperative transfusion rates were no different for the group receiving TISSEEL compared with those of control (P = .375) and were statistically greater when compared with those of IV TXA (P = .002).Conclusion: TISSEEL fibrin sealant does not reduce postoperative blood loss or transfusions; however, IV TXA reduced postoperative transfusions compared with TISSEEL and control. Therefore, TXA is recommended to reduce perioperative blood loss, while, utilization of a fibrin sealant requires further refinements before being adopted for routine use in THA. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) reduces intraoperative blood loss and transfusions in patients undergoing total knee arthroplasty. Although numerous studies demonstrate the efficacy of intravenous and topical TXA in these patients, few demonstrate the effectiveness and appropriate dosing recommendations of oral formulations.Methods: A retrospective cohort study was performed to evaluate differences in transfusion requirements in patients undergoing primary unilateral total knee arthroplasty with either no TXA (n = 866), a single-dose of oral TXA (n = 157), or both preoperative and postoperative oral TXA (n = 1049). Secondary outcomes included postoperative hemoglobin drop, total units transfused, length of stay, drain output, and cell salvage volume.Results: Transfusion rates decreased from 15.4% in the no-oral tranexamic acid (OTA) group to 9.6% in the single-dose OTA group (P < .001) and 7% in the 2-dose group (P < .001), with no difference in transfusion rates between the single- and 2-dose groups (P = .390). In addition, postoperative hemoglobin drop was reduced from 4.2 g/dL in the no-OTA group to 3.5 g/dL in the single-dose group (P < .01) and to 3.4 g/dL in the 2-dose group (P < .01), without a difference between the single- and 2-dose groups (P = .233).Conclusion: OTA reduces transfusions, with greater ease of administration and improved cost-effectiveness relative to other forms of delivery. [ABSTRACT FROM AUTHOR]

Background: The mode of administration for tranexamic acid (TXA) to significantly reduce the decrease in hemoglobin (Hb), number of transfusions, relevant costs, and side effects in patients undergoing primary unilateral total knee arthroplasty (TKA) has not been resolved.Methods: A total of 560 patients undergoing primary unilateral TKA were randomized into 4 groups: intravenous group (140 patients receiving 2 doses of 20 mg/kg intravenous TXA), topical group (140 patients administered 3.0 g topical TXA), oral group (140 patients given 2 doses of 20 mg/kg oral TXA), and a control group (140 patients not given TXA). The primary outcomes included postoperative 48-hour Hb loss and drainage volume, number of transfusions, transfusion and TXA costs, and thromboembolic complications. Secondary outcomes were postoperative inpatient time and wound healing 3 weeks after TKA.Results: Baseline data among the 4 groups were similar. The 48-hour Hb loss and drainage volume in the intravenous, topical, and oral groups were significantly less (P < .05) than those in the control group, and the latter had significantly more transfusions and transfusion costs than the other 3 groups (P < .05). The TXA cost was lowest in the oral group compared with that in the topical and intravenous groups (P < .05). No differences in thromboembolic complications, postoperative inpatient time, or wound healing were observed among the groups. However, wound dehiscence and continuous wound discharge occurred in the topical group.Conclusion: All the 3 modes of TXA administration significantly reduced postoperative Hb loss, the number of transfusions, and transfusion costs compared with those in the control group. No pulmonary embolism or infection was observed. Oral TXA is recommended because it provided a similar clinical benefit and resulted in the lowest TXA cost compared with the other 2 modes of TXA administration. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) has been associated with decreased blood loss and transfusion after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to examine both transfusion utilization and the economic impact of a Process Improvement Project implementing TXA for THA and TKA.Methods: After standardization of TXA administration in THA and TKA patients, retrospective data were compared from 12 consecutive months before (group A, n = 336 procedures) and after (group B, n = 436 procedures) project initiation.Results: TXA administration increased with project implementation (group A = 3.57%, group B = 86.01%) and was associated with reductions in perioperative hemoglobin decrement (20.2%), patients transfused (45%), and number of units transfused per patient (61.9%). Cost savings were notable per patient ($128) and annually program wide ($55,884) with the primary THA subgroup contributing the most to the savings. No increase in adverse effects was observed.Conclusion: Standardized administration of TXA is an effective and economically favorable blood-reduction strategy for patients undergoing elective THA or TKA. Although reduction in transfusions with TXA may be greater after TKA, the economic and clinical impact of transfusion reduction is more substantial in THA patients. [ABSTRACT FROM AUTHOR]

Background: This study aimed at evaluating the efficacy and safety of different regimens with a single dose and an additional postoperative dose of tranexamic acid (TA) in reducing blood loss in total knee arthroplasty (TKA).Methods: A total of 180 patients who were scheduled to undergo primary unilateral TKA in our level I trauma center were recorded and divided into groups A, B, C, and D randomly. Preoperative dose, an additional postoperative dose, and 2 postoperative additional doses of TA were infused intravenously in groups A (30 mg/kg), B (15 mg/kg), and C (10 mg/kg), respectively, and TA was not infused in group D. Blood loss (intraoperative, postoperative, and total blood loss), blood transfusion rate and volume, hemoglobin level, and incidence of deep vein thrombosis were analyzed.Results: The total blood loss and postoperative blood loss were significantly lower in groups B and C without any difference between them. As for intraoperative blood loss, there was no significant difference between groups A and B and between groups B and C with superior efficacy than group D.Conclusion: With the same total dose of TA, the preoperative dose and an additional dose of TA were superior to a single preoperative dose of TA in reducing blood loss in TKA. Besides, 1 additional dose was comparable to 2 additional doses of TA in reducing blood loss. [ABSTRACT FROM AUTHOR]

Background: We examined whether the blood conserving effect of tranexamic acid (TXA) in total hip arthroplasty using the direct anterior approach, translates to an effect on functional outcomes in the perioperative period.Methods: We conducted a single-center, randomized, double-blinded, placebo-controlled trial. One hundred one patients were randomized to receive either TXA or an equivalent volume of normal saline. The primary outcome measure was thigh swelling. Secondary outcome measures included, visual analogue pain score, timed up and go test, a 10 meter walk test, and length of stay. Blood loss and the incidence of blood transfusions were also recorded.Results: There were no statistically significant differences between the primary outcome of thigh swelling or the secondary outcome measures of postoperative pain nor mobility. There was a significant reduction in length of stay for those that received TXA 3.58 days (0.84) compared with the control group 4.27 days (0.98) (P < .001). There was significantly less intraoperative blood loss observed in the TXA group (0.460L SD 0.228) compared with the control group (0.687L SD 0.283L) (P < .001). The estimated blood loss was also significantly less in the TXA group (1.084L SD 0.440) compared with the control group (1.394 L SD 0.426).Conclusion: TXA is an effective agent in reducing blood loss in total hip arthroplasty using the anterior approach. The blood conserving effect of TXA was not associated with improved postoperative recovery across the measures of pain and mobility. Administration of TXA may have a positive effect on reducing the duration of inpatient stays. [ABSTRACT FROM AUTHOR]

Background: Topical tranexamic acid (TXA) was introduced to replace the previous targeted preoperative autologous blood donation (PABD) program. This study aims to analyze the efficacy of topical TXA compared with targeted PABD in anemic patients undergoing primary total hip arthroplasty (THA).Methods: Two thousand two hundred fifty-one patients underwent primary THA between 2009 and 2013 using targeted autologous blood donation for 280 anemic patients (12%; Hb <12.5 g/dL). One thousand nine hundred seventy-one nonanemic patients (88%; ≥12.5 Hb/dL) received no blood management intervention. Starting in 2014, 505 consecutive patients were operated using 3 grams of topical TXA and abandoning PABD. Ninety-one patients (18%) were anemic and 414 (82%) nonanemic.Results: The utilization of topical TXA in anemic patients resulted in higher hemoglobin levels on the first postoperative day (P = .014), but not on the second postoperative day (P = .198) compared with PABD. There was no difference in allogeneic transfusion rates between both groups: 12% vs 13% (P = .848). In the nonanemic group, TXA significantly increased hemoglobin levels on the first postoperative day (P = .001) as well as on the second postoperative day (P < .001), and resulted in a reduction in allogeneic transfusion rates from 8% to 1%.Conclusion: The present study suggests that topical TXA is equivalent to PABD in anemic patients and reduces transfusion rates and increases Hb-levels in nonanemic patients. [ABSTRACT FROM AUTHOR]

Background: The blood-conserving effect of intravenous (IV) tranexamic acid (TXA) is well-documented for total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, the risk of thromboembolic (TE) events after routine use of TXA is unclear and the safety profile is debated. This retrospective study investigates patient characteristics, occurrences, and predictors of TE events after routine administration of IV TXA in THA and TKA.Methods: Three thousand one hundred fifty-nine THA or TKA procedures performed from 2007-2013 at our institution were included. IV TXA, 1 g, was administered preoperatively if not contraindicated. Relevant patient characteristics and comorbidity information were extracted locally from the database. Data on TE events occurring within 90 days postoperatively came from The Danish National Patient Registry. Patient characteristics, comorbidities, and TE events were compared between TXA groups. A logistic regression model was used to evaluate predictors of TE events.Results: Of 3159 procedures, 2766 (87.6%) received TXA (TXA+ group) preoperatively, whereas 393 (12.4%) did not (TXA- group). Mean age, distributions of gender, American Society of Anesthesiologists score, anesthesia method, duration of surgery, diagnosis, and survival status were all statistically significant different (P values <.05) between TXA groups. The studied comorbidities were all significantly different (TXA+ vs TXA- group; P values ≤.002). We found 31 (1.0%) TE events out of 3159 procedures, with no significant group difference in TE events (TXA+: 27 out of 2766 = 1.0%, TXA-: 4 out of 393 = 1.0%, P value = .55 for any event). For the TXA+ group, 0.5% suffered from deep venous thrombosis, 0.3% from acute myocardial infarction, and 0.2% from a pulmonary embolism. In the TXA+ group, higher age (odds ratio [OR] = 1.06, 95% confidence interval = 1.02-1.11, P = .005) and present cardiovascular disease (OR = 4.78, 95% confidence interval = 1.72-13.28, P = .003) were associated with an increased risk of TE events.Conclusion: The findings suggest that routine use of IV TXA for TKA and THA as safe with low occurrence of TE events, although a large prospective trial should confirm this. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA.Methods: In a prospective, randomized, controlled trial, 198 patients were assigned to placebo (98 patients, normal saline injection) and study group (100 patients, 1g TXA intraoperative injection) during primary unilateral minimally invasive TKA. All patients received rivaroxaban 10 mg each day for 14 doses postoperatively. Total blood loss was calculated from the maximum hemoglobin drop after surgery plus amount of transfusion. The transfusion rate and wound complications were recorded in all patients. Deep-vein thrombosis was detected by ascending venography of the leg 15 days postoperatively.Results: The mean total blood loss was lower in the study group (1020 mL [95% confidence interval, 960-1080 mL]) compared with placebo (1202 mL [95% confidence interval, 1137-1268 mL]) (P < .001). The transfusion rate was lower in the study group compared with placebo (1% vs 8.2%, P = .018). Postoperative wound hematoma and ecchymosis were higher in placebo than the study group (P = .003). There was no symptomatic deep-vein thrombosis or pulmonary embolism in either group.Conclusion: Systemic administration of TXA can effectively reduce the postoperative blood loss which results in lower rate of transfusion requirement and wound hematoma in minimally invasive TKA patients when rivaroxaban is used for thromboprophylaxis. Rivaroxaban has a high rate of bleeding complications when used alone in TKA patients. [ABSTRACT FROM AUTHOR]

Background: The major concern with the use of tranexamic acid is that it may promote a hypercoagulable state and increase the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), particularly when chemical thromboprophylaxis is not used. The objective of this study was to ascertain whether tranexamic acid reduces blood loss and transfusion amounts and increases the prevalence of DVT and PE in the patients undergoing primary cementless total hip arthroplasty (THA) without the use of routine chemical thromboprophylaxis.Methods: There were 480 patients (582 hips) in the control group who did not receive tranexamic acid and 487 patients (584 hips) in the study group who received tranexamic acid. Mechanical compression device was applied without any chemical thromboprophylaxis. Transfusion rates and volumes were recorded. DVT was diagnosed using both sonogram and venogram at 7 or 8 days postoperatively. All patients had pre- and postoperative perfusion lung scanning to defect pulmonary embolism (PE).Results: Intraoperative (614 vs 389 mL) and postoperative blood loss (515 vs 329 mL) and transfusion volumes (3 units vs 1.5 units) were significantly lower (P < .001) in the tranexamic acid group. The prevalence of DVT was 15% (87 of 582 hips) in the control group and 18% (105 of 584 hips) in the tranexamic acid group. No fatal PE occurred in either group.Conclusion: The use of tranexamic acid reduces the volume of blood transfusion and does not increase the prevalence of DVT or PE in the patients who did not receive routine chemical thromboprophylaxis after primary cementless THA. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) is commonly used in primary total knee arthroplasty (TKA); however, the most appropriate route of administration is still debated. This study was conducted to compare the 2 most commonly used routes of TXA administration, intravenous (IV) and intra-articular (IA).Methods: This study was conducted as a double-blind, randomized, noninferiority trial and included patients undergoing primary unilateral TKA. Patients were randomized to receive IV or IA TXA and compared for postoperative fall in hemoglobin (Hb) on day 1 (primary outcome) and day 2, and blood transfusion rates, length of stay, and complications.Results: Of the 183 patients recruited, 168 were included and supplied complete data. The between-group difference in mean Hb fall at day 1 was 0.08 g/dL with the Hb fall higher in the IA group. The 95% confidence interval was -0.18 to 0.34 which did not reach the noninferiority margin of 0.5 g/dL. No significant difference was seen in the secondary outcomes.Conclusion: IA TXA is noninferior to IV TXA in terms of fall in Hb on the first postoperative day. Due to the potential for reduced serum levels and easier administration (single dose), this trial supports the use of IA TXA for primary TKA. [ABSTRACT FROM AUTHOR]

Background: This study aimed to compare the efficacy of intravenous administration of tranexamic acid for reducing blood loss in total knee arthroplasty at different dosage time.Methods: From February 2013 to December 2015, a total of 180 patients (47 in male and 133 in female) who were planned to undergo total knee arthroplasty in our trauma center were recorded. Based on dosage time of tranexamic acid administration, participants were divided into groups A, B, C, and D randomly. In groups A, B, and C, tranexamic acid (30 mg/kg) was infused intravenously 15 minutes before or after tourniquet inflation or on tourniquet deflation respectively, tranexamic acid was not applied in group D. Total blood loss (intraoperative and postoperative blood loss), blood transfusion rate and volume, hemoglobin level, and incidence of deep vein thrombosis were recorded and analyzed.Results: Compared with groups B, C, and D, there were significant reduction of blood loss, hemoglobin, and blood transfusion rate in group A (P < .05). Besides, there was no significant difference between groups B and C with superior efficacy than group D.Conclusion: Intravenous administration of tranexamic acid before tourniquet inflation was superior in terms of hemoglobin reduction, reducing blood loss and blood transfusion rate. [ABSTRACT FROM AUTHOR]

Background: In this study, we tried to assess if combined method (intravenous [IV] and topical) of tranexamic acid (TXA) administration, which has been shown to be superior in conventional arthroplasty, has similar effect in navigational arthroplasty compared to administration of drug either individually.Methods: In present randomized control trial, 200 patients were randomly divided in one of the 4 groups using computer-generated tables-control, IV, intraarticular, and combined. We studied evident loss through drain, total loss based on Gross method and hemoglobin balance method, hidden losses, hemoglobin and hematocrit drop, functional scores, and all possible complications related to TXA.Results: Evident loss in combined group was 535.55 mL, not significantly less than IV (585 mL, P = .15) and intraarticular group (514 mL, P = .74). However, these were significantly less than control group (696 mL, P = .000). Functional scores and recovery rates were, however, comparable in all 4 groups. No patients in any group developed symptomatic deep vein thrombosis.Conclusion: Tranexamic use decreases blood loss in navigation-assisted arthroplasty, however, less than that observed for conventional arthroplasty in literature. Further, combined group has no added advantage over other methods of drug administration. We believe that additional amount of TXA administered in combined regimen may not be clinically useful. Further TXA group did not have any advantage in terms of functional recovery over control group. [ABSTRACT FROM AUTHOR]

Background: While transfusion and clinically relevant anemia after elective primary total knee arthroplasty (TKA) are uncommon, there remains a question of who needs postoperative hemoglobin monitoring, especially in the setting of increasing incidence of outpatient TKA. The purpose of this study was to create predictive models for postoperative anemia and blood transfusion to guide clinical decision-making., Methods: The records of consecutive TKA patients were reviewed from February 2016 to December 2020 at a single institution. Two multivariable logistic regression models, for postoperative anemia (hemoglobin < 10 g/dL) and allogeneic blood transfusion included 8 variables: age, sex, body mass index, preoperative hemoglobin level, tranexamic acid total dose, American Society of Anesthesiologists level, operative time, and drain use. Model performance was assessed using accuracy, area under the curve (AUC), sensitivity, and specificity., Results: The records of 14,901 patients were included in this study. Patients had a mean (± standard deviation) age of 67.9 ± 9.2 years and mean body mass index of 31.3 ± 6.5 kg/m 2 . The postoperative anemia model had an accuracy of 88% (95% confidence interval [CI], 87%-89%) and AUC of 0.88 (95% CI, 0.87-0.89). The blood transfusion model had an accuracy of 97% (95% CI, 96%-97%) and AUC of 0.90 (95% CI, 0.87-0.93)., Conclusion: The postoperative anemia and blood transfusion model accurately predicted each outcome. Patients with less than a 5% probability of postoperative anemia may not benefit from a complete blood count at postoperative day 1. Application of these criteria may save the healthcare system hundreds of millions of dollars., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The optimal dosage and timing of tranexamic acid (TXA) in total knee arthroplasty (TKA) are undetermined. The purpose of this study was to explore the effect of multiple boluses of intravenous TXA on hidden blood loss (HBL), inflammatory response, and knee function after primary TKA without tourniquet.Methods: A total of 151 patients were randomly divided into 3 groups to receive single bolus of 20 mg/kg IV-TXA before skin incision (group A), or another bolus of 10 mg/kg IV-TXA 3 hours later (group B), or another 2 boluses of 10 mg/kg IV-TXA 3 hours and 6 hours later (group C). TKAs without tourniquet were operated by 1 single surgeon. The primary outcomes were HBL and maximum hemoglobin drop. Other outcome measurements such as total blood loss, transfusion rate, inflammation markers (C-reactive protein, interleukin 6), visual analog scale pain score, limb swelling ratio, Hospital for Surgery Score, range of motion, length of hospital stay (LOH), and deep venous thrombosis were also compared.Results: The mean HBL and maximum Hb drop in group C (467.6 ± 305.9 and 20.9 ± 9.3) was lower than those in group A (763.0 ± 373.3, P < .001; 28.7 ± 12.2, P < .001) and group B (637.5 ± 303.5, P = .010; 25.2 ± 8.4, P = .036). However, such differences were not detected between groups A and B (P = .058 and P = .080, respectively). The mean value of total blood loss in the groups A, B, and C were 967.2 ± 380.1, 803.7 ± 321.8, and 677.6 ± 326.0 mL, respectively, with a significant intergroup difference (P < .001). The mean serum level of C-reactive protein and interleukin 6 in group C were lower than those in group A and group B on postoperative days 1 and 2. The visual analog scale pain score and swelling ratio were also lower in group C than in the other 2 groups with statistical significance on POD 1-3. Moreover, the Hospital for Surgery Score, range of motion, and LOH were better in group C. No episodes of transfusion or deep venous thrombosis had occurred.Conclusion: Multiple boluses of IV-TXA can effectively reduce HBL after primary TKA without tourniquet. What is the most important is that, by adding another bolus of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammatory response, less pain, less knee swelling, better knee function, and shorter LOH. [ABSTRACT FROM AUTHOR]

Background: Simultaneous bilateral total knee arthroplasty (TKA) can lead to greater blood loss and higher risk of venous thromboembolism. The effectiveness and safety of tranexamic acid (TXA) in simultaneous bilateral TKAs have not been clearly defined. We presumed that a fixed dose of TXA may be a preferable alternative for ease of administration in patients undergoing simultaneous bilateral TKAs.Methods: We prospectively randomized 120 primary simultaneous bilateral TKAs to a fixed dose of TXA or equivalent volume of normal saline intravenously. The primary outcome measure was total blood loss. The secondary outcome measures were blood transfusion rate, transfusion units, intraoperative blood loss, drainage volumes, hidden blood loss, maximum decline of hemoglobin, and postoperative suprapatellar girth increment.Results: There were statistically significant lower total blood loss, blood transfusion rate, drainage volumes, transfusion units, and maximum decline of hemoglobin in the TXA group than in the control group (P < .05), without increasing incidence of asymptomatic and symptomatic venous thromboembolism. However, TXA did not significantly reduce the hidden blood loss (P = .123). No differences were observed in suprapatellar girth increments between both groups on postoperative day 5 and week 6 (P = .251 and .299).Conclusion: Fixed dose of TXA for patients undergoing simultaneous bilateral TKAs was effective and safe in reducing total blood loss and allogeneic blood transfusion needs without any additional thromboembolic risk. However, TXA administered intravenously did not significantly reduce the hidden blood loss. [ABSTRACT FROM AUTHOR]

Background: Use of tranexamic acid (TXA) is effective and safe in reducing the blood loss in total knee arthroplasty (TKR) performed using a tourniquet, but, data in TKR performed without tourniquet are limited, and there is no study comparing the topical (T) with intravenous (IV) TXA administration. Our aim was to compare the topical (T) with intravenous (IV) TXA administration in TKR performed without tourniquet.Material and Methods: A total of 120 patients undergoing unilateral TKR for knee osteoarthritis were included in a prospective randomized study. Operations were performed under spinal anesthesia, no tourniquet was used, and the postoperative regime was the same for all patients. Patients were divided into 3 groups; in group C (control), 40 patients received no TXA, in group IV, 40 patients received 1 g of TXA intravenously, and in group L, 1 g of TXA was applied locally to 40 patients. The primary outcome measures included the calculated blood loss, the transfusion rate, and quantity of allogeneic blood units, whereas secondary outcome measures were complications.Results: There was no statistically significant difference in patient's demographics and perioperative results. Calculated blood loss, allogeneic blood transfusion rate, and quantity in group C were significantly higher compared with those of TXA groups (P < .001). There was no significant difference in complications rate between the 3 groups.Conclusions: According to the results of this study, IV or T administration of 1-g TXA significantly reduced the blood loss and the need for allogeneic blood transfusion in patients undergoing TKR without a tourniquet (with no significant difference between the 2 routes of administration). [ABSTRACT FROM AUTHOR]