The Use of Tranexamic Acid in Hip and Pelvic Fracture Surgeries

John D. Adams, Jr, MD, FAAOS; William A. Marshall, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(12):e576-e583. 

In This Article

Tranexamic Acid use in Hip Fractures

Zufferey et al[17] conducted one of the original randomized controlled trials investigating the use of TXA in all types of hip fractures. They demonstrated a 30% relative risk reduction in transfusion requirements for patients receiving TXA. In contrast to previous data on elective orthopaedic procedures, they found a higher incidence of vascular events among patients receiving TXA. Most events were asymptomatic deep vein thromboses and discovered via mandatory ultrasonography on all patients. It is unclear whether these deep vein thromboses were present before the initiation of the study, which may have falsely elevated the incidence of this complication. Therefore, it is difficult to make a definitive conclusion on the safety of TXA based on these results.[17] Because of this conflicting evidence for hip fracture patients, other studies were done to better define the risk-benefit profile of TXA in this patient cohort. In addition, these later studies were designed to focus on a specific type of hip fracture.

Extracapsular Hip Fractures

In 2016, two randomized-controlled trials investigated the efficacy of locally administered TXA in patients undergoing surgical treatment for an extracapsular hip fracture. Drakos et al[18] conducted the largest study, which included two-hundred patients with AO type 31A1, 31A2, and 31A3 fractures. All patients in their study underwent surgical fixation with a short intramedullary nail. Patients were randomized to receive either 3 g of TXA or normal saline injected directly adjacent to the fracture site under fluoroscopic guidance at the conclusion of the case. The control group demonstrated a larger drop in hemoglobin on postoperative day one, and 29% of patients required a transfusion compared with 22% in the treatment group. In total, an additional 21 transfusion units were required in the control group. The indication for transfusion was a hemoglobin value less than 8 g/dL, unless felt to be clinically relevant based on symptoms. Cost analysis revealed a savings of 77.8 euros per patient. Rates of thromboembolic complications were similar between treatment and control. The control group was found to have more hematomas and postoperative infections, yet the authors did not comment on the statistical significance of this.[18]

Similarly, Virani et al[19] conducted a randomized-controlled trial with local infiltration of TXA versus saline for 137 extracapsular hip fracture patients. All patients were treated with sliding hip screw fixation. Patients were randomized to 2 g of TXA or saline injected intramuscularly at the conclusion of the case. A drain was placed in each patient, and the output was recorded. Although a trend exists toward decreased blood loss, less drain output, and lower transfusion rate for patients who received TXA, it failed to reach statistical significance. Therefore, they concluded that TXA did not play a notable role in blood conservation for patients undergoing surgery for peritrochanteric fractures. In addition, similar rates exist of thromboembolism and other complications between the intervention and control groups.[19]

In contrast to local administration, investigations with intravenous (IV) administration of TXA for extracapsular hip fractures have also been done. Tengberg et al[19] conducted a double-blinded placebo-controlled trial with IV TXA versus IV saline for 72 patients treated with a short intramedullary nail. One gram of TXA or saline was administered immediately before surgery and a postoperative 24-hour infusion of 3 g of TXA or saline. The results demonstrated a statistically notable reduction in total blood loss of nearly 600 mL in the IV TXA group. In addition, a trend exists toward lower transfusion rates for patients who received TXA, despite a statistically notable higher preoperative hemoglobin level for the control group. They did not see any difference in thromboembolic events between groups. However, a trend exists toward higher 90-day mortality in patients who received TXA. The cause of death was not verified for these patients, making it difficult to ascertain the implication of this finding.[20]

A recent meta-analysis of trials investigating IV administration of TXA for extracapsular hip fractures demonstrated a reduction in overall blood loss and transfusion requirement with no additional complications.[21] Although consistency exists in fracture types, fixation methods and TXA dosing were inconsistent among the studies. Additional meta-analyses are available that include studies on both extracapsular and intracapsular hip fractures, which necessarily introduces various surgical treatments. Regardless of the variability, these studies generally support the use of TXA for blood conservation in extracapsular hip fractures.[22,23]

Intracapsular Femoral Neck Fractures

In 2017, Watts et al[23] published the only available randomized controlled trial that specifically focuses on TXA use during management of intracapsular femoral neck fractures. The trial enrolled 138 participants undergoing hemiarthroplasty or total hip arthroplasty who received either 15 mg/kg of IV TXA or saline before incision and again at closure. On all postoperative days, a statistically notable lower cumulative blood loss was noted for patients who received TXA. Although statistical significance was not reached, trend exists toward a lower transfusion rate and less total blood products required in the TXA group. Adverse events at 30 and 90 days were comparable between groups; however, the study was not powered to detect these differences. Within this study, various surgical approaches and implants were used. Most cases were done through an anterolateral approach and with a cemented implant. Although hemiarthroplasty and total hip arthroplasty were both included, equal numbers were allocated to treatment and control groups.[24]

A more recent retrospective cohort study included 226 patients who underwent hemiarthroplasty for femoral neck fracture between the years 2015 and 2017.[25] Their TXA protocol was implemented in 2016; therefore, patients treated before April 2016 did not receive TXA and those thereafter received topical TXA. As opposed to the trial by Watts et al, this study included a single surgeon with the same surgical technique and noncemented femoral implant. One gram of TXA was injected throughout the surgical site at the conclusion of the case and a vacuum drain was left in place. They found a notable reduction in calculated blood loss, drain volumes, transfusion rate, and total blood transfusion volumes for patients who received TXA. Thromboembolic events, surgical complications, and mortality were similar between cohorts, but the control group had a higher incidence of medical complications. They attributed this to a decrease in postoperative mobility secondary to the higher transfusion rate.[25]

In addition, two retrospective reviews of patients who underwent hemiarthroplasty for femoral neck fractures are available in the current literature.[26,27] Similar to the abovementioned trials, they both determined that TXA was beneficial for total blood loss and transfusion rates with no reciprocal increase in adverse events. Lee et al, who published their results of 271 patients in 2015, specifically calculated an absolute risk reduction of 12% in transfusion rate. This extrapolated to a number needed to treat of eight.[26] The study by Xie et al[27] included 609 patients and found that TXA was associated with faster mobilization and shorter hospital stays. It is important to recognize the retrospective nature of these studies, which introduces bias, and the effect on each outcome is unknown.

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