Deniz GULABİ, Yücel YÜCE, Kutlu Hakan ERKAL, NECDET SAĞLAM, Savaş ÇAMUR

The combined administration of systemic and topical tranexamic acid for total hip arthroplasty: Is it better than systemic?

Obective: The aim of this study was to evaluate the effect of combined intravenous and topical use of tranexamic acid (TXA) on total blood loss and transfusion rate in total hip arthroplasty. Methods: This prospective randomized study included 57 patients who had undergone total hip arthroplasty between September 2016 and September 2017. The IV administration group (Group 1) consisted of 26 patients (mean age: 63.73 ± 10.29 years), while the IV and topical administiration group (Group 2) consisted of 22 patients (62.82 ± 8.31 years). Demographic data and outcomes were obtained through a review of individual medical records. Medical comorbidities, body mass index (BMI), ASA and CCI, preoperative and postoperative hemoglobin levels, postoperative transfusion records and 90-day joint-related (implant subsidence, dislocation, postoperative anemia, deep infection, hematoma and/or wound problem, postoperative periprosthetic fracture) readmission rate and complication rate were compared between the groups. Results: No signiﬁcant differences were observed between the 2 groups in terms of age, gender, height, weight, body mass index (BMI), the level of preoperative Hb values, and the American Society of Anesthesiologists (ASA) and Charleson Comorbidty Index (CCI) rating (p > 0.05). The mean postoperative Hgb in the group 2 was higher by a small amount compared to the group 1. No statistically signiﬁcant difference was determined between the groups in respect of the Hgb values (p¼0.562). Hgb Delta in the group 2 was lower than that of the group 1. The difference between the groups in the Hgb Delta values was not statistically signiﬁcant (p ¼ 0.268). The mean total blood loss was lower in the group 2 than in the group 1 but the difference was not statistically signiﬁcant (p ¼ 0.788). There was no signiﬁcant difference observed in terms of any adverse complications among the 2 groups (p > 0.05). Conclusion: The combined administration of IV and topical TXA compared with IV alone can decrease total blood loss and the number of blood transfusions required without increasing the risk of DVTor/and PE in total hip arthroplasty. But the statistical analysis and clinical relevance is not signiﬁcant.

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Oremus K. Tranexamic acid for the reduction of blood loss in total knee arthroplasty. Ann Transl Med. 2015;3(Suppl 1):S40eS44. https://doi.org/ 10.3978/j.issn.2305-5839.2015.03.35.

Wu YG, Zeng Y, Yang T, Si H, Cao F, Shen B. The efﬁcacy and safety of combination of intravenous and topical tranexamic acid in revision hip arthroplasty: a randomized, controlled trial. J Arthroplasty. 2016;31:2438e2453. https:// doi.org/10.1016/j.arth.2016.03.059.

Lemos MJ, Healy WL. Blood transfusion in orthopaedic operations. J Bone Joint Surg Am. 1996;78(8):1260e1270.

Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks ofallogeneic blood transfusion and the available strategies for theirprevention. Blood. 2009;113(15):3406e3417. https://doi.org/10.1182/blood-2008-10167643.

Hawi N, Kendoff DO, Hessling U, et al. Effectiveness of an autologous transfusion system following cemented and non-cemented revisions of total hip arthroplasty. Int Orthop. 2014;38:1603e1608. https://doi.org/10.1007/s00264014-2359-1.

Niemi TT, Pitkanen M, Syrjala M, et al. Comparison of hypotensive epidural anaesthesia and spinal anaesthesia on blood loss and coagulation during and after total hip arthroplasty. Acta Anaesthesiol Scand. 2000;44(4):457e464. https://doi.org/10.1034/j.1399-6576.2000.440418.x.

Paul JE, Ling E, Lalonde C, et al. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials. Can J Anaesth. 2007;54(10):799e810. https://doi.org/ 10.1007/BF03021707.

Atik OS. Does tranexamic acid reduce blood loss and blood transfusion requirementinkneearthroplasty?EklemHastalikCerrahisi.2012;23(3):166e167.

Yamasaki S, Masuhara K, Fuji T. Tranexamic acid reduces blood loss after cementlesstotal hiparthroplasty-prospective randomizedstudy in40 cases. Int Orthop. 2004;28:69e73. https://doi.org/10.1007/s00264-003-0511-4.

Wei W, Wei B. Comparison of topical and intravenous tranexamic acid on blood loss and transfusion rates in total hip arthroplasty. J Arthroplasty. 2014;29:2113e2116. https://doi.org/10.1016/j.arth.2014.07.019.

Wind TC, Barﬁeld WR, Moskal JT. The effect of tranexamic acid on transfusion rate in primary total hip arthroplasty. J Arthroplasty. 2014;29:387e389. https:// doi.org/10.1016/j.arth.2013.05.026.

Alshryda S, Sukeik M, Sarda P, et al. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J. 2014;96-B(8):1005e1015. https://doi.org/10.1302/0301620X.96B8.33745.

HuangZ,Ma J, Shen B, etal. Combinationof intravenousandtopical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty. 2014;29:2342e2346. https://doi.org/ 10.1016/j.arth.2014.05.026.

Loftus TJ, Spratling L, Stone BA, et al. A patient blood management program in prosthetic joint arthroplasty decreases blood use and improves outcomes. J Arthroplasty. 2016;31:11e14. https://doi.org/10.1016/j.arth.2015.07.040.

Phillips SJ, Chavan R, Porter ML, et al. Does salvage and tranexamic acid reduce the need for blood transfusion in revision hip surgery? J Bone Joint Surg Br. 2006;88:1141e1142. https://doi.org/10.1302/0301-620x.88B9.17605.

Kwong LM. Rivaroxaban, an oral, direct factor Xa inhibitor: a new option for thromboprophylaxis. Orthopaedics. 2012;35. https://doi.org/10.3928/ 01477447-20121101-17, 919e9.

GrossJB. Estimating allowableblood loss: corrected for dilution. Anesthesiology. 1983;58:277e280.

Konig G, Hamlin BR, Waters JH. Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty. J Arthroplasty. 2013;28:1473e1476. https://doi.org/10.1016/j.arth.2013.06.011.

Alshryda S, Mason J, Sarda P, et al. Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement a randomized controlled trial (TRANX-H). J Bone Joint Surg Am. 2013;95: 1969e1974. https://doi.org/10.2106/JBJS.L.00908.

Yue C, Kang P, Yang P, et al. Topical application of tranexamic acid in primary total hip arthroplasty: a randomized double-blind controlled trial. J Arthroplasty. 2014;29:2452e2456. https://doi.org/10.1016/j.arth.2014.03.032.

Akgul T,BugetM,SalduzA,etal.Efﬁcacyofpreoperativeadministrationofsingle high dose intravenous tranexamic acid in reducing blood loss in total knee arthroplasty: a prospective clinical study. Acta Orthop Traumatol Turc. 2016;50: 429e431. https://doi.org/10.1016/j.aott.2016.06.007.

Gillette BP, DeSimone LJ, Trousdale RT, et al. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res. 2013;471:150e154. https://doi.org/10.1007/ s11999-012-2488-z.

Iwai T, Tsuji S, Tomita T, et al. Repeat-dose intravenous tranexamic acid further decreases blood loss in total knee arthroplasty. Int Orthop. 2013;37:441e445. https://doi.org/10.1007/s00264-013-1787-7.

Husted H, Blond L, Sonne-Holm S, et al. Tranexamic acid reduces blood loss and blood transfusions in primary total hip arthroplasty: a prospective randomized double-blind study in 40 patients. Acta Orthop Scand. 2003;74:665e669.

Niskanen RO, Kokala OL. Tranexamic acid reduces blood loss in cemented hip arthroplasty: a randomized, double-blind study of 39 patients with osteoarthritis. Acta Orthop. 2006;76:829e832. https://doi.org/10.1080/ 17453670510045444.

Singh J, Ballal MS, Mitchell P, et al. Effects of tranexamic acid on blood loss during total hip arthroplasty. J Orthop Surg. 2010;18(3):282e286. https:// doi.org/10.1177/230949901001800305.