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

Shortcomings of the Literature

Interest in the use of TXA as an antifibrinolytic drug has heightened over the past decade. Although its use for elective orthopaedic procedures such as total joint arthroplasty is widely accepted, there does not seem to be a clear consensus regarding its use in fracture surgery. As such, we should be critical while reviewing the available literature on this topic.

The literature on TXA use for orthopaedic trauma is centered around hip and pelvic fracture surgery. This represents a largely heterogenous group of injuries. Many of the current studies fail to narrow their focus on an isolated injury pattern or type of surgery.[17,30] This introduces a number of confounding variables, which potentially obscures outcomes. Therefore, this review attempted to focus on studies that emphasized a specific fracture pattern and fixation strategy to reduce the inherent variability in surgical times, blood loss, and complications. In addition, it is important to recognize the difficulty in controlling for the range of fracture severity or displacement, which may influence results.

To date, no standardized regimen has been found for TXA administration. This introduces a wide variety of routes, dosages, and timing (Table 2). Local infiltration during hip fracture surgery has been done in various ways. For example, Drakos et al[18] injected 3 g of TXA at the fracture site, whereas Virani et al[19] injected 2 g of TXA intramuscularly. This could certainly make an impact, especially if most blood loss is from the fracture site during reduction and at the trochanteric entry for an intramedullary device. IV administration of TXA also varies. Some studies provide a single preoperative bolus, whereas others provide multiple doses. The second dose varies based on the timing and duration of infusion. It is unknown how these variables affect the efficacy of the drug.

Several primary outcome variables are used in the current literature, including blood loss, hemoglobin values, and transfusion requirements. It is difficult to know which of these is most suitable to gauge efficacy of TXA. In addition, each of these variables has inherent weaknesses that should be discussed. Blood loss calculations include intraoperative, hidden, and/or total blood loss. One should be cautious when using blood loss as a surrogate for efficacy. Estimating intraoperative blood loss is most often done by a visual assessment and has been shown to be highly unreliable.[31,32] Alternate methods such as gravimetric and photometric analysis are error prone, laborious, and costly.[33,34] Outside the surgical suite, a plethora of methods exist to determine blood loss. These calculations use an estimated total blood volume that can be swayed by erroneous data such as hydration status, height, and weight. Each equation has unique features, some are quite cumbersome, and accuracies vary.[35,36] In some instances, such as in the study by Virani et al,[19] drain output is used as a measure of postoperative blood loss. Drain placement is not universally accepted, and output may be affected by technical errors in placement and clotting within the line. All of these methods, prone to inaccuracies, may have notable ramifications on the conclusions of a study. Hemoglobin values, although more objective, have the potential to be misinterpreted. For example, Drakos et al[18] concluded that TXA reduced blood loss and improved hemoglobin values based on a difference of 0.5 g/dL. Although this was statistically notable, it does not necessarily translate to clinical relevance. Regarding transfusions, various thresholds exist in the reviewed literature, ranging from 7 to 10 g/L, which makes interpretation challenging. To complicate matters further, some studies allow for a more subjective transfusion trigger such as tachycardia or hypotension, which may be explained by pain or certain physiologic traits.[19]

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