Efficacy and safety of tranexamic acid in unilateral major revision total hip arthroplasty

Background: The risk of blood loss differs among subtypes of revision total hip arthroplasty (THA), and different tranexamic acid (TXA) protocols have rarely been studied in those conditions. The present study aimed to evaluate the efficacy and safety of intravenous and intravenous plus topical TXA in a subtype of revision THA. Methods: We retrospectively reviewed 91 patients who underwent unilateral major revision THA from 2010 to 2018. The major revision was defined as a subtype of revision THA, which included concomitant femoral and acetabular components revision, revision for periprosthetic femoral fracture (PFF), and one-stage revision for periprosthetic joint infection (PJI). In the intravenous group, 23 patients received intravenously 1 g of TXA 30 minutes before the incision with the second dose 3 hours later. In the combined group, 20 patients received intravenously 1 g of TXA 30 minutes before the incision with the second dose 3 hours later, and 2 g of TXA was topically injected around the joint capsule when the fascia layer was closed. Forty-eight patients who underwent revision procedures without TXA constituted the control group. Within the three groups, we compared demographic variables, operation-related data, transfusion volume, transfusion rate, calculated blood loss, postoperative drainage volume, and venous thromboembolism (VTE) risk. Results: Compared with the control group, both intravenous and combined TXA significantly reduced intraoperative transfusion volume (3.43 +/- 2.32 vs. 4.68 +/- 2.63 units, P=0.044; 2.78 +/- 1.91 vs. 4.68 +/- 2.63 units, P=0.004; respectively) and total transfusion volume (4.16 +/- 2.73 vs. 5.73 +/- 3.05 units, P=0.036; 3.50 +/- 2.74 vs. 5.73 +/- 3.05 units, P=0.005; respectively), and there were significant reductions of postoperative drainage volume (250.87 +/- 204.54 vs. 455.73 +/- 303.93 mL, P=0.003; 285.00 +/- 218.14 vs. 455.73 +/- 303.93 mL, P=0.017; respectively) and calculated blood loss (1,322.49 +/- 656.13 vs. 1,698.66 +/- 728.39 mL, P=0.031; 1,237.13 +/- 545.32 vs. 1,698.66 +/- 728.39 mL, P=0.012; respectively). One patient had a symptomatic pulmonary embolism, and two patients had calf muscular vein thrombosis in the control group. There were two patients and one patient with calf muscular vein thrombosis in the intravenous group and the combined group, respectively. Perioperative transfusion volume, transfusion rate, and calculated blood loss were comparable between the intravenous group and the combined group. Conclusions: Both intravenous TXA and combined TXA significantly reduced perioperative transfusion volume and calculated blood loss in unilateral major revision THA with comparable perioperative transfusion rate and risk of VTE. More researches are required to explore the optimal TXA administration protocol in subtypes of revision THA.