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

Acetabular and Pelvic Fractures

Although an abundance of literature tends to support the use of TXA in hip fracture surgery, less available and less convincing data exist for pelvic trauma. Spitler et al[28] randomized a total of 93 patients undergoing open reduction and internal fixation for high-energy proximal femur fractures, pelvic ring injuries, and acetabular fractures to receive either IV TXA or placebo. At the time of incision, the treatment group received 15 mg/kg of TXA, followed by a second dose 3 hours later. Most cases (84%) were pelvic ring and acetabular fractures, followed by proximal femur fractures (16%). Any patient with open fracture, additional injury that contraindicated immediate VTE prophylaxis use, and patients undergoing other urgent procedures such as exploratory laparotomy were excluded. Notable findings included lower total blood loss and smaller postoperative hematocrit changes in the TXA group. Postoperatively, 17% of patients who received TXA were transfused compared with 30% of patients in the control group. Although these results are promising, several factors need to be considered. A higher intraoperative transfusion rate and higher intraoperative blood loss was noted in the TXA group, which may have introduced selection bias. Furthermore, the TXA group had a lower preoperative hematocrit, potentially predisposing them to the aggressive intraoperative resuscitation efforts directed by the anesthesia team. Other confounders include a heterogeneous group of injuries and highly variable surgical times (2 to 12.5 hours). In addition, the use of intraoperative intraoperative cell salvage was not controlled.[28]

A randomized controlled trial focused solely on IV TXA use in acetabular fractures was published by Lack et al in 2017.[29] Given the known strong effect of preoperative anemia on transfusion rates, randomization was stratified based on preoperative hemoglobin levels. A total of 88 patients were included. The TXA group received 10 mg/kg 30 minutes before incision and 10 mg/kg infusion over 4 hours during surgery. The control group received an equal volume of normal saline. The primary outcome measure was incidence of transfusion. Secondary outcomes were number of units transfused, estimated blood loss, and incidence of VTE. Contrary to expected results, a trend exists toward inferiority in the TXA group in all outcome measures. The TXA group demonstrated a higher transfusion rate, average estimated blood loss, and received more transfusion units than the control group. One incidence of venous thromboembolism was also noted in a patient who received TXA. Although none of these findings reached statistical significance, a decision was made to preemptively terminate enrollment. Analysis of the available data demonstrated that a preoperative hemoglobin <11 g/dL, complex acetabular fracture patterns, and surgical time >4.5 hours were notable risk factors for transfusion. As a conglomerate, these factors were even more tightly associated with transfusion. Overall, more complex fracture patterns and longer surgical times were observed in the TXA cohort, which may have introduced bias. The authors concluded that these risk factors, along with the variability in fracture severity, likely overwhelmed any effect of TXA (Table 1).[29]

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