Tranexamic Acid Is Effective in Reducing Blood Loss in Revision TKA
The orthopaedic literature generally supports the use of tranexamic acid (TXA) in reducing blood loss and decreasing the need for transfusion after primary total hip and total knee arthroplasty, although the optimal route of administration and dose remain in question. 
What about in revision procedures, which typically involve greater blood loss than primary surgery? Is TXA effective for these patients as well?
The data are more limited in this area, but the findings of a study presented at the 2018 American Association of Hip and Knee Surgeons Annual Meeting suggest that TXA is also beneficial in reducing blood loss in revision total knee arthroplasty (TKA).
This multicenter, randomized trial sought to determine the optimal dosing regimen of TXA to maximize its blood-sparing properties in patients undergoing revision TKA. The researchers randomized 233 TKA patients scheduled for revision surgery for septic and aseptic causes to receive 1 of the following TXA regimens:
- 1 gram of intravenous (IV) TXA pre-incision
- 1 gram of IV TXA pre- and post-incision
- 1 gram of IV TXA pre-incision and 1 gram of topical TXA intraoperatively
- 3 oral doses of TXA (1950 mg each) given 2 hours preoperatively, 6 hours postoperatively, and the morning of POD1
The researchers included 196 patients in the analysis, which had a primary outcome of reduced hemoglobin level. Of the original group of 233 patients, 1 withdrew from the study, 3 did not undergo revision TKA, 16 were screen failures, and 17 did not receive the treatment they were assigned.
No significant difference was seen in reduction in hemoglobin among the groups (P=0.48):
- 2.79g/dL for the single dose of IV TXA
- 2.58g/dL for the double dose of IV TXA
- 2.59g/dL for the combined IV and topical doses of TXA
- 2.88g/dL for the oral doses of TXA
Calculated blood loss (P=0.63) and transfusions (P=0.78) were also similar among the treatment groups.
The researchers concluded that given the study findings, surgeons should “consider using the lowest effective dose and the least costly regimen for TXA use in revision TKA.”
Fillingham YA Darrith B, Calkins TE, Abdel MP, Malkani AL, Schwarzkopf R, Padgett DE, Sershon RA Bini SA, Della Valle CJ. A Multi-Center Randomized Clinical Trial of Tranexamic Acid in Revision Total Knee Arthroplasty: Does the Dosage Regimen Matter? (Paper #33). Presented at the 2018 Annual Meeting of the American Association of Hip & Knee Surgeons, November 1-4, 2018, Dallas, Texas.
- Fillingham YA, Ramkumar DB, Jevsevar DS, et al. Tranexamic acid use in total joint arthroplasty: the clinical practice guidelines endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2018 Oct;33(10):3065-3069. doi: 10.1016/j.arth.2018.08.002. Epub 2018 Aug 7.