Comparison of Intravenous and Topical Tranexamic Acid in Total Joint Arthroplasty

PURPOSE OF THE STUDY To compare topical and intravenous (IV) administration of tranexamic acid (TXA) 2 g in patients undergoing total hip arthroplasty (THA), or total knee arthroplasty (TKA). MATERIAL AND METHODS In total, 452 patients undergoing THA or TKA were randomised to 3 groups: 1) the IV TXA group received 2 doses of TXA 1 g intravenously 3 hours apart; 2) the topical TXA group received TXA 2 g topically, and 3) the NO TXA - control group. Furthermore, each group was divided in two subgroups by performed surgery (THA versus TKA). The following endpoints were used for final analysis: postoperative blood loss, transfusion requirement, haemoglobin drop and postoperative complications (haematoma, surgical site infection, thromboembolism, early surgical revision). RESULTS Both topical and IV administration of TXA significantly reduced postoperative bleeding (mean +/- standard deviation) after THA and TKA (topical 504.4 +/- 281.0 ml, IV 497.3 +/- 251.7 ml, NO 863.1 +/- 326.4 ml, p<0.001). Topical use was superior to IV in reducing postoperative drainage output in THA (topical 377 +/- 213.3 ml, IV 518.1 +/- 259.0 ml, p<0.01). On the opposite, IV use was superior to topical in drainage output in TKA (topical 646.1 +/- 281.3 ml, IV 457.8 +/- 235.8 ml, p<0.01). The differences in transfusion requirement and Hb drop between these administration methods were not statistically significant (p >= 0.05), but any TXA administration was significantly better than no TXA in all endpoints of efficacy (p<0.001). The lowest complication rate was observed in the topical group (NO 24%, IV 19%, topical 7.5%). DISCUSSION Consensus on optimal TXA dosing regime in primary hip and knee arthroplasties is still missing. Use of TXA therapy in routine clinical practice is highly individualized in accordance with the current approach of personalized medicine. Topical application seems to be the safest route of TXA administration. However, precise application technique is essential. IV TXA is beneficial especially in patients with some bleeding coagulopathies undergoing TKA with a tourniquet. Repeat doses of TXA are not usually necessary after completed primary arthroplasties. CONCLUSIONS IV and topical TXA 2 g have similar effect on reduction of transfusion requirements and haemoglobin drop in THA and TKA. The IV route is superior to topical in TKA while topical TXA reduces complications in both THA and TKA.