More Evidence That TXA May Reduce the PJI Risk in Joint Replacement Patients
Research from The Rothman Institute has shown an association between the use of tranexamic acid (TXA) and a reduced risk of periprosthetic joint infection (PJI) following total joint arthroplasty, with the study authors noting that, “[t]his protective effect [of TXA] is likely interlinked to reduction in blood loss, lower need for allogeneic blood transfusion, and issues related to immunomodulation associated with blood transfusion.” 
Although the Rothman study included more than 6300 patients, it was a single-institution investigation. Would a broader study, using data from a national database, show the same results, or would the Rothman findings be an anomaly related to the practice’s focus on reducing PJIs, not the use of TXA?
According to a retrospective cohort study from Hospital for Special Surgery (HSS) – recently presented at the virtual 2020 American Society of Anesthesiologists Annual Meeting – it could be the TXA: The HSS researchers also found that administration of TXA during total joint arthroplasty appears to reduce the risk of PJI in the 90 days after surgery.
Tranexamic acid is widely used to minimize blood loss during total joint arthroplasty, thus reducing the need for blood transfusion after the procedure. “There is evidence suggesting that bleeding, the formation of hematomas, and the need for blood transfusions [are] associated with infections,” said HSS anesthesiologist Stavros G. Memtsoudis, MD, PhD, MBA, lead author of the study. “Therefore, we evaluated [whether] the use of TXA, which has been shown to reduce bleeding, actually relates to decreased infection risk.”
To validate the findings of the study from The Rothman Institute, Dr. Memtsoudis and his HSS colleagues identified 931,692 patients in the Premier Healthcare database – a large population-based database – who had undergone elective inpatient total hip or total knee arthroplasty between 2012 and 2016. Nearly half (45.2%) had received TXA on the day of surgery.
The overall incidence of PJI was 0.14% (n=1269). After adjusting for various patient and hospital-related factors – including hematoma formation; patient age, gender, and race; comorbidities; anesthesia type; insurance type; year of procedure, and hospital size, location, and teaching status – the HSS researchers found that the use of TXA was associated with 40% lower odds of a developing a PJI within 90 days of surgery (OR 0.60 CI 0.53, 0.68). In addition, the odds of developing a PJI within 90 days of surgery was approximately 8 times higher with hematoma formation (OR 8.08 CI 5.59, 11.68).
The researchers also compared PJI rates in patients who did and who did not receive TXA during each study year. Patients in the TXA groups had a significantly lower PJI rate than patients who did not receive TXA each year, with the exception of 2012 and 2014. In those years, the difference in the PJI rates between groups was not significant.
Although the incidence of PJIs in total joint arthroplasty patients is already relatively low, administration of TXA during the procedure appears to have a further protective effect. The researchers said this is likely due to TXA’s ability to prevent hematomas, which have been associated with significantly increased odds of PJI.
The researchers concluded that, “patients who are considered to be at high risk of postoperative [PJI] may benefit from administration of TXA.”
Wilson L, Zhong H, Poeran J, Liu J, Memtsoudis SG. Tranexamic Acid Use During Total Joint Arthroplasty Is Associated with Reduced Odds of Periprosthetic Infection. Abstract A3070. Presented at: 2020 American Society of Anesthesiologists Annual Meeting, October 2-5, 2020; virtual meeting.
- Yazdi H, Klement MR, Hammad M, et al. Tranexamic acid is associated with reduced of periprosthetic infection after primary total joint arthroplasty. J Arthroplasty. 2020;35(3):840-844.