Topical TXA in Total Joint Replacement Lowers Blood Transfusion Use
Orthopedic surgeons from The Miriam Hospital in Providence RI, affiliated with Brown University, have conducted a cost-benefit analysis of topical tranexamic acid (TXA) in primary total hip and knee arthroplasty patients that revealed a 12 percent transfusion rate reduction – from 17.5 percent to 5.5 percent – with no significant difference in complication rates. In addition to reducing the risk for postoperative bleeding and transfusion following total joint replacement, use of topical TXA enabled approximately 9.3 percent more patients to be discharged to home rather than to a skilled nursing facility. The study and its findings were published in March 2015 in The Journal of Arthroplasty.
A release from Lifespan Hospitals quotes John Froehlich, M.D., program director of the Total Joint Center at The Miriam Hospital and a principal investigator on the study, as saying, “Historically, with hip or knee replacement, there was a 25 to 30 percent chance of a blood transfusion. We realized that this high frequency of transfusions was associated with longer hospital stays and a higher risk of infections, which we are always working to avoid. Tranexamic acid has been around for 30 years, but because there was concern about the danger of administering it intravenously, we opted to inject it in the joints. We found it to be effective in reducing ongoing blood loss and the subsequent need for transfusion, and we have now standardized the practice.”
The reduction of perioperative blood transfusions in total joint arthroplasty has been an ongoing goal in the effort to deliver more efficient and effective health care. According to several studies, blood transfusions may add a 3 to 20 percent risk of postoperative infection. Perioperative transfusion adds both cost to the procedure and risk to the patient, including joint infection, allergic reaction and viral transmission, which led to The Miriam’s analysis of topical TXA in primary hip and knee arthroplasty.
Tranexamic acid is a synthetic derivative of the amino acid lysine, and produces antifibrinolytic activity by competitively inhibiting lysine binding sites on plasminogen molecules. Through this process, TXA is able to help the body stabilize blood clot formation and thereby reduce bleeding at surgical sites. Most protocols of TXA in total joint arthroplasty have involved intravenous delivery of TXA. However, a theoretical concern for the possibility of causing new blood clots in veins may be why intravenous TXA implementation has been slow to progress. A growing number of studies have indicated that intraarticular, or topical, injection administration may provide advantages. These include potentially reduced costs with a single injection, surgeon control, and localization and concentration of the drug more precisely at the surgical site.