The Effect of Tranexamic Acid on Transfusion Rate in Primary Total Hip Arthroplasty

doi:10.1016/j.arth.2013.05.026

The Journal of Arthroplasty

Volume 29, Issue 2, February 2014, Pages 387-389

https://doi.org/10.1016/j.arth.2013.05.026 Get rights and content

Abstract

Total hip arthroplasty (THA) may produce blood loss requiring allogenic blood transfusion. Recently several authors have reported success decreasing their transfusion rate with tranexamic acid (TXA). We retrospectively reviewed our last 1595 primary THA in 1494 patients looking at whether the patients received TXA via IV infusion, topical application, or neither, and the need for a blood transfusion. Infusion of TXA acid produced a statistically significant difference in transfusion rate (p < 0.001) while topical TXA failed to reach statistical significance (P = 0.15). The transfusion rate without TXA was 19.86%, 4.39% with TXA infusion (odds ratio = 5.36), and 12.86% (odds ratio = 1.67) with topical TXA.

Section snippets

Materials and Methods

After IRB approval, 1595 primary total hip arthroplasties in 1494 patients performed by four fellowship trained surgeons between January 2009 and March 2013 were retrospectively reviewed. It was determined whether TXA was utilized and if so, was it given as an intravenous infusion or topically. Each patient’s chart was reviewed to determine if a blood transfusion was necessary. Table 1 displays the demographic information of the male patients in each group while Table 2 shows the demographic

Results

The average patient age in our cohort was 63.6 ± 12.2 years with a 95% CI of 62.92–64.64 years. Significant differences (P = 0.001) existed between the genders with males (60.55 ± 12.64 years) being approximately 5.45 years younger than the females (66.00 ± 11.35 years).

Among the 1595 total hip arthroplasties performed in 1494 patients over 4 years (January 2009–March 2013), there were 208 transfusions in 1047 total hips when no TXA was used, which is a transfusion rate of 19.86% (208/1047). Infusion of TXA

Discussion

There is a growing body of evidence that TXA, when used either as infusion or irrigation, has a substantial impact on blood loss and the need for post-operative transfusion following primary total hip arthroplasty. To our knowledge, this report presently is one of the largest series from a single institution.

Since the introduction of TXA into our comprehensive blood management protocol for total hip arthroplasty, we have noticed a substantial drop in the frequency of transfusions. Our goal in

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Cited by (91)

How to avoid systematic post-operative blood test after total hip arthroplasty: A new risk scoring system compared to Wu's score
2023, Revue de Chirurgie Orthopedique et Traumatologique
Une prise de sang (PDS) de routine est souvent effectuée après la mise en place d’une prothèse totale de hanche (PTH). Cependant, leur intérêt a été remis en question ces dernières années. De plus, les facteurs de risque de transfusion post-opératoire restent débattus. Récemment, un score permettant d’identifier les patients devant bénéficier une PDS a été publié par Wu et al. L’intérêt de cette étude rétrospective était de : 1) Valider le score de Wu et al., 2) identifier les facteurs de risque de transfusion postopératoire, 3) déterminer si un autre score permet de mieux identifier les patients à risque de transfusion postopératoire.
Le score de Wu et al. permet d’identifier les patients chez qui une prise de sang postopératoire est nécessaire.
Afin d’inclure 1000 patients dans l’étude, le dossier de 1693 patients ayant bénéficié d’une PTH primaire entre juin 2015 et octobre 2020 a été examiné. Une PDS pré- et post-opératoire a été effectuée chez chaque patient. Les données cliniques ainsi que le résultat des bilans biologiques ont été récoltés et analysés rétrospectivement. De manière séquentielle, une analyse descriptive suivie d’une analyse univariée et multivariée a été réalisée. Un modèle de régression logistique multiple a été utilisé pour déterminer une formule prédictive du risque de transfusion appelée THABUS pour Total Hip Arthroplasty Blood test Usefulness Score. Le score de risque publié par Wu et al. en mai 2020 a été appliqué à chaque patient et comparé au modèle prédictif THABUS.
Le taux de transfusion était de 2,3 % (23/1000). Le score publié par Wu et al. a montré qu’une PDS était nécessaire pour 60,6 % (606/1000) ; cependant, 13 % (3/23) des patients qui ont eu besoin d’une transfusion sanguine n’ont pas été identifiés par le score de Wu. Ceci lui confère une sensibilité de 86,95 % et une spécificité de 40 %. L’âge, l’hypertension artérielle, le sexe féminin, une faible hémoglobine préopératoire, le score ASA ≥ 2 et l’ostéonécrose de la tête fémorale étaient significativement associés au besoin de transfusion postopératoire. La formule THABUS peut prédire le risque de transfusion avec une sensibilité de 96,65 % et une spécificité de 75,54 %. Dans notre cohorte de 1000 patients, l’application de la formule THABUS aurait conduit à 261 PDS postopératoires et à une économie de 32,132 $. Seul un patient (4,3 %) a été manqué par notre nouveau score. La formule THABUS est significativement meilleure que le score Wu et al dans l’identification à la fois des patients qui auront besoin d’une transfusion (p < 0,01) ainsi que de ceux chez qui une PDS postopératoire n’est pas nécessaire (p < 0,001). Une intervention médicale en raison d’une anomalie de la créatinine ou des électrolytes a été nécessaire chez 0,3 % (3/1000) des patients.
Nous ne sommes pas parvenus à valider le score de Wu et al. sur notre cohorte de patients. Dans la population étudiée, la formule THABUS permet efficacement de cibler les patients à risque de transfusion. L’utilisation de la formule THABUS permet de réduire les coûts liés à l’hospitalisation sans compromettre la sécurité des patients.
III ; Étude cas-témoin.
How to avoid systematic postoperative blood test after total hip arthroplasty: A new risk scoring system compared to Wu's score
2023, Orthopaedics and Traumatology: Surgery and Research
Routine laboratory studies are often performed following total hip arthroplasty (THA). However, lately, their necessity has been challenged and risk factors for postoperative transfusion are still debated. Recently, a risk scoring system to single out patients that should have a postoperative blood test has been published by Wu et al. The purposes of this retrospective study were: (1) to validate this recently published risk scoring system to identify patients who should have a postoperative laboratory test; (2) to single out risk factors of postoperative transfusion; (3) to determine if another score can more accurately predict the need for postoperative transfusion.
Wu et al.'s risk scoring system can accurately identify patients who should have a postoperative blood test.
In all, 1693 patients who underwent primary THAs between June 2015 and October 2020 were screened for potential eligibility to include 1000 patient for analysis. Preoperative and postoperative blood tests were done for every patient. Clinical information and laboratory results were retrospectively collected and analyzed. A descriptive analysis followed by univariate and multivariate analysis were sequentially performed. A multiple logistic regression model was employed to determine a formula predicting the transfusion risk called THABUS for Total Hip Arthroplasty Blood test Usefulness Score. The risk scoring system for complete blood count published by Wu et al. in may 2020 was performed for every patient and compared to the THABUS predictive model.
The transfusion rate was 2.3% (23/1000). The risk-scoring system published by Wu and al. showed that a laboratory test was necessary for 60.6% (606/1000) however 13% (3/23) of the patients who needed a blood transfusion were missed by the risk-scoring system, giving it a sensitivity of 86.95% and a specificity of 40%. Increasing age, arterial hypertension, female gender, low preoperative hemoglobin, ASA score ≥ 2 and diagnosis of osteonecrosis of the femoral head were significantly associated with postoperative transfusion. The THABUS formula can predict the risk for transfusion with a sensibility of 96.65% and a specificity of 75.54%. In our cohort of 1000 patients, following the THABUS formula would have led to 261 postoperative blood test and cost savings of 32,132 $. Only one patient (4.3%) was missed by our new score. The THABUS formula is significantly better than Wu et al.'s complete blood count score in identifying both patient that will need a transfusion (p < 0.01) and those who shouldn’t have a postoperative blood test (p < 0.001). Medical intervention because of creatinine or electrolytes abnormality was needed in 0.3% (3/1000) of patients.
In this study Wu et al.’s recently published complete blood count risk-scoring system was not validated. However, in the studied population the THABUS formula can accurately target patients who might need a transfusion. The use of the THABUS formula could reduce hospitalization costs without compromising the patients’ safety.
III, case-control study.
Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better?
2022, Journal of Arthroplasty
To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians.
This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb.
Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P = .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01).
The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.
Tranexamic Acid Has No Effect on Postoperative Hemarthrosis or Pain Control After Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft: A Double-Blind, Randomized, Controlled Trial
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this double-blind, randomized, controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone–patellar tendon–bone (BPTB) anterior cruciate ligament reconstruction (ACLR) regarding postoperative hemarthrosis, pain, opioid consumption, and quadriceps atrophy and activation.
A controlled, randomized, double-blind trial was conducted in 110 patients who underwent ACLR with BPTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-g boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated and the volume of blood (in milliliters) was recorded. Additionally, we recorded perioperative blood loss (in milliliters); visual analog scale scores on postoperative days 1, 4, and 7 and at postoperative weeks 1, 6, and 12; postoperative opioid consumption on postoperative days 1, 4, and 7; range of motion (ROM) and ability to perform a straight leg raise at postoperative weeks 1, 6, and 12; and preoperative and postoperative thigh circumference ratio.
There was no significant difference in perioperative blood loss between the TXA and control groups (32.5 mL vs 35.6 mL, P = .47). In the TXA group, 23 knees were aspirated; in the control group, 26 knees were aspirated (P = .56). No significant difference in postoperative hemarthrosis volume was seen in patients who received IV TXA versus those who did not (26.7 mL vs 37.3 mL, P = .12). There was no significant difference in visual analog scale scores between the 2 groups (P = .15); in addition, there was no difference in postoperative opioid consumption (P = .33). No significant difference in ROM, ability to perform a straight leg raise, or postoperative thigh circumference ratio was observed (P > .05 for all).
IV TXA in patients who undergo ACLR with BPTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early postoperative recovery regarding ROM or quadriceps reactivation.
Level I, randomized controlled trial.
Use of Observation Status Versus Readmission in Elective Total Knee and Hip Arthroplasty Returns to Hospital: A Single-Institution Perspective
2019, Journal of Arthroplasty
The Affordable Care Act’s Readmission Reduction Program (RRP) and ongoing transparency efforts to promote consumer-driven competition place significant institutional focus on improving 30-day readmission rates. It remains unclear whether the reduction in readmission rates subsequent to the RRP occurred due to improved quality and/or partly due to increased use of observation status in conditions that may have been classified as readmissions prior to the RRP. We hypothesize that a significant percentage of our institution’s 30-day readmissions after elective total knee and hip arthroplasty (TKA/THA) overestimate the needs, duration, and complexity of the hospital-based intervention and inaccurately reflect the quality of service provided.
We performed a retrospective review of prospectively collected quality control data for 30-day returns to hospital after elective TKA/THA at our institution over a 2-year period. After stratification of the readmissions to under 48-hour and over 48-hour length of stay, we calculated the financial implications to our institution if the under 48-hour length of stay admissions were reclassified as an observation by applying discharge-weighted and payment-weighted analyses to the 2017 RRP report. We then calculated the out-of-pocket expenses for the under 48-hour Medicare subpopulation.
We found that 16.7% of the 30-day readmissions after elective TKA/THA required a length of stay under 48 hours. If the short length of stay TKA/THA readmissions were reclassified as observations, our institution’s 2018 RRP penalty would have been reduced to 39% or $334,512.28. However, this reclassification would result in an increase in out-of-pocket expenses by $540.25 (range $291.56-$1105.08) per patient.
A subpopulation of 30-day readmissions does not require a level of care consistent with inpatient admission services. Classification of this short length of stay subpopulation as an observation vs an admission per Centers for Medicare and Medicaid Services guidelines would have removed our institution from the TKA/THA-specific RRP penalty. However, this would result in the unintended consequence of shifting costs, particularly self-administered drug costs, to patients.
The efficacy and safety of intravenous tranexamic acid in hip fracture surgery: A systematic review and meta-analysis
2019, Journal of Orthopaedic Translation
The present meta-analysis was conducted to compare the efficacy and safety of intravenous application of tranexamic acid (TXA) with placebo in patients with hip fracture undergoing hip surgeries.
PubMed, EMBASE and Cochrane Library were searched from inception until March 2018. A combined searching strategy of subject words and random words was adopted. Only randomized clinical trials were included. The comparisons regarding transfusion rate, total blood loss, intraoperative blood loss, postoperative blood loss, postoperative haemoglobin and postoperative thromboembolic complications were conducted. The meta-analysis was performed using Review Manager 5.3, and the bias evaluation was based on the Cochrane Handbook 5.1.0.
Ten randomized controlled trials published from 2007 to 2018 were included in the meta-analysis. The results showed that there were significant differences in the two groups concerning transfusion rate of allogeneic blood [risk ratio (RR) = 0.66, 95% confidence interval (CI): 0.56 to 0.78, P = 0.003], total blood loss [mean difference (MD) = −273.00, 95% CI: −353.15 to −192.84, P < 0.00001], intraoperative blood loss (MD = −76.63, 95% CI: −139.55 to −13.71, P = 0.02), postoperative blood loss (MD = −125.29, 95% CI: −221.96 to −28.62, P = 0.01) and postoperative haemoglobin (MD = 0.80, 95% CI: 0.38 to 1.22, P = 0.0002). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 1.38, 95% CI: 0.74 to 2.55, P = 0.31).
This meta-analysis of the available evidence implies that the intravenous route of TXA shows an ability to reduce transfusion requirements and total blood loss, not increasing the incidence of thromboembolic events in patients undergoing hip surgeries.
The result of this meta-analysis shows that the utilization of intravenous TXA in patients with hip fracture undergoing hip surgeries possesses great potential in reducing blood loss and allogeneic blood transfusion safely.

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: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.05.026.

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The Effect of Tranexamic Acid on Transfusion Rate in Primary Total Hip Arthroplasty

Abstract

Section snippets

Materials and Methods

Results

Discussion

Thromb Res

J Cardiothorac Vasc Anesth

J Arthroplasty

J Arthroplasty

Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement

J Bone Joint Surg Br

Strategies for blood management in orthopaedic and trauma surgery

J Bone Joint Surg Br

Perioperative management of anemia: limits of blood transfusion and alternatives to it

Cleve Clin J Med

Perioperative blood conservation

Eur J Anaesthesiol

Activity-based costs of blood transfusions in surgical patients at four hospitals

Transfusion

An analysis of blood management in patients having a total hip or knee arthroplasty

J Bone Joint Surg Am

The effect of tranexamic acid on reducing blood loss in cementless total hip arthroplasty under epidural anesthesia

Orthopedics

Hemostatic drugs

N Engl J Med

Tranexamic acid reduces transfusion and mediastinal drainage in repeat cardiac surgery

Anesth Analg

Antifibrinolytic therapy in complex spine surgery: a case–control study comparing aprotinin and tranexamic acid

Orthopedics

Anti-fibrinolytic use for minimizing perioperative allogeneic blood transfusion

Cochrane Database Syst Rev

Comparison of the effects of aprotinin and tranexamic acid on blood loss and red blood cell transfusion requirements during the late stages of liver transplantation

Transfusion

The safety of aprotinin and lysine-derived antifibrinolytic drugs in cardiac surgery: a meta-analysis

CMAJ