CORR Insights®: Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial.

Abstract

Taking blood conservation measures for patients undergoing TKA is important because blood transfusions after surgery can increase the risk of serious complications, including prosthetic joint infection and death. Post-operative anemia also is associated with prolonged hospital stay and delayed rehabilitation; these risks are especially severe in patients with other comorbidities [18]. The best current evidence now favors use of tranexamic acid (TXA) [5]. This drug has been a game-changer for arthroplasty patients who previously had been treated with a host of interventions to try to mitigate blood loss and reduce transfusion after TKA, including preoperative autologous blood donation, pre-operative stimulation of erythropoiesis, controlled hypotension, hemodilution, intra-operative or post-operative blood salvage, tourniquet use and timing of deflation, thermal energy, fibrin spray, peri-articular injections, continuous passive motion versus splinting, intra-operative and post-operative knee positioning, and cryotherapy [9, 10]. Introduced in 1962 as a treatment to reduce the severity of post-partum hemorrhage [20], TXA was first approved by the US Food and Drug Administration in 1986 to reduce bleeding in patients with hemophilia undergoing tooth extraction [4]. Despite increasing evidence supporting TXA use in multiple medical disciplines, and its inclusion on the World Health Organization’s list of essential medicines [21], the FDA has only expanded its use to include treating heavy cyclic menstrual bleeding [11]. Despite the fact that any use of TXA in patients undergoing TKA is considered offlabel by the FDA, its use in TKA now is widespread and well supported by randomized trials [6, 12, 17] and numerous meta-analyses [3, 8, 22, 23]. Being an anti-fibrinolytic, TXA has the theoretical risk of harmful vascular thrombosis, and thus empirically, caution has been used in orthopedic studies by excluding patients with previous history (or increased risk) of thromboembolic events, including patients who have had or are at risk for deep vein thrombosis/pulmonary embolism, stroke, myocardial infarction, history of cardiac stents or bypass surgery, or who have thrombophilia [12, 17]. However, these theoretical risks have not been confirmed in multiple large studies [13]. The current randomized, doubleblind trial by Meshram and colleagues [14] found no “clinically significant difference” in both the primary and secondary outcome variables between the IA only and combined IA and IV groups in both the simultaneous and This CORR Insights is a commentary on the article “Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial” by Meshram and colleagues available at: DOI: 10. 1097/CORR.0000000000000942. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. M. J. Grecula MD (✉), University of Texas Medical Branch, Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Route 0165, Galveston, TX 77555 USA, Email: mgrecula@utmb.edu