Use of Topical Tranexamic Acid in Primary THA
The authors conducted a retrospective cohort study to determine which total hip arthroplasty patients would be most likely to benefit from tranexamic acid.
Walter A. Anazonwu, BS; John R. Tuttle, MD; and Lee E. Rubin, MD
The authors have no disclosures relevant to this article.
Editor’s Note: This article is excerpted from Subgroup Analysis of Topical Tranexamic Acid in Primary Total Hip Arthroplasty, published in the March 2015 issue of Reconstructive Review.
Intraarticular, or “topical,” tranexamic acid (TXA) has increasingly received attention for reducing blood loss following total joint arthroplasty [1,3,6,8,14]. Although our institution has seen transfusion rates drop from 17.5% to 5.5% after administration of topical TXA in total joint replacement, it is still not known which patients will benefit most from TXA administration .
Patients undergoing total hip arthroplasty (THA) at our institution continue to have a higher allogeneic transfusion rate compared with patients undergoing total knee arthroplasty (TKA). Although THA patients respond to topical TXA, the question remains: Which specific subset of THA patients might benefit most from administration of topical TXA?
To answer this question we performed a retrospective cohort study that involved 123 THA patients who received topical TXA and 111 control patients who did not receive TXA treatment. Patients were subdivided into groups based on gender, age, BMI, preoperative hemoglobin, and surgical approach.
Our goal was to identify characteristics that will more accurately justify the use of topical TXA in THA. Preoperative identification of patients who would most likely benefit from topical TXA administration would allow for more targeted use of the drug, ideally reducing cost and unnecessary exposure.
Protocol and Results
Patients in the study group received 1 gram of TXA, which was injected intraarticularly following iliotibial band closure or into the pericapsular and deep tissue spaces, depending on the surgeon’s preference. No other changes were made to each surgeon’s individual surgical or postoperative protocol between the control and study groups. Transfusion was triggered by hemoglobin (Hgb) of less than 8 g/dL or symptomatic anemia.
Analyzing the results of 224 THA patients, we found that topical TXA consistently reduced transfusion rates, increased postoperative Hgb levels, and decreased the change in Hgb levels. However, further analysis of the subgroups revealed that these effects were not evenly distributed.
- Males and females had a significant difference in their postoperative Hgb and delta Hgb, but only females experienced a significant reduction in transfusion rate (38.6% without TXA to 11.3% with TXA; P = 0.0003).
- In males, the transfusion rate decreased from 3.7% to 1.9%, which was not significant (P = 0.5805).
- One possible explanation for the difference in transfusion rates between men and women could be the increased risk for transfusion normally seen in women who undergo THA .
- As seen in the control group of this study, women generally have a lower average Hgb than men (13.2 g/dL compared with 14.6 g/dL), which results in women having lower postoperative Hgb (8.4 g/dL compared with 9.9 g/dL).
Body Mass Index
All patients, regardless of BMI, experienced significant differences in their delta Hgb, postoperative Hgb, and transfusion rate.
- Patients younger than age 50 years experienced no significant changes in delta Hgb, postoperative Hgb, or transfusion rate.
- Patients over age 65 years and patients between age 50 and 65 years had a significant difference in delta Hgb and postoperative Hgb:
- Patients over age 65 years experienced a significant reduction in transfusion rate (26.1% to 9.8% after administration of TXA, P = 0.0261).
- Patients between 50 and 65 years experienced a transfusion reduction rate from 20% to 6.5% after administration of TXA, p = 0.0538.
- After TXA administration, patients with preoperative Hgb < 12 g/dL saw significant reductions in the rate of transfusion (100% to 30%, P = 0.0063).
- After TXA administration, patients with a preoperative Hgb of > 12 g/dL experienced a significant reduction in the rate of transfusion (17.4% to 4.3%, P =0.0038) and a significant change in delta Hgb (4.9 +/- 1.1 to 4.1 +/- 1.0, P = 0.0001).
Surgical Approach to the Hip
After administration with TXA, patients who underwent either the direct anterior approach or anterior-lateral approach experienced significant differences in their postoperative Hgb, delta Hgb, and transfusion rates.
Although perioperative administration of TXA is being more widely used in total joint replacement surgery, the method/route of TXA administration and the exact patient population that stands to benefit the most from TXA utilization in THA have yet to be established in the literature. The goal of this study was to retrospectively determine which patients undergoing THA had a significant response to topical TXA.
The greatest weakness of this study was its retrospective design. Patients were followed for 30 days postoperatively in the electronic database, and, therefore, long-term complications or complications managed at a different healthcare facility were not recorded in this study.
Some subgroups may be underpowered to determine a significant difference in our outcome variables. For example, no significant differences were found in the <50 age group; this may be a false negative, or younger patients may truly not benefit from topical TXA in THA.
This study is consistent with the current literature by revealing significant differences in transfusion rate reduction, delta Hgb, and postoperative Hgb with topical TXA [7,12,13,15].
In concordance with Judge et al’s paper, our study concludes that BMI has no bearing in primary hip replacement surgery despite TXA treatment . The two BMI subgroups in our study showed no significant change in complication rates, and both subgroups experienced significant differences in their delta Hgb, postoperative Hgb, and transfusion rate after administration with TXA.
Surgical approach had no effect on the outcomes in THA despite TXA use. There was no significant change in complication rates in the direct anterior approach group or the anterolateral approach group. In addition, both subgroups experienced significant differences in their delta Hgb, postoperative Hgb, and transfusion rate after administration with TXA.
Patients who are normally at risk for transfusions in THA appear to benefit the most with TXA treatment: Women experienced a significant reduction in transfusion rate after TXA treatment. One explanation could be the increased risk for transfusion normally seen in women who undergo THA.
According to Morrison et al, the clinical significance of TXA is strongest in patients who have the highest anticipated blood loss . Danninger et al and Saleh et al concluded that women are at an increased risk for transfusion in THA.
Our data are consistent with these findings, showing a higher transfusion rate in women (38.6% compared with 3.7% for men) [2,11].
Also, women had a relatively greater clinical response to TXA (with transfusion rate reduction from 38.6% to 11.3% in women compared with a transfusion rate reduction from 3.7% to 1.9% in men).
According to Saleh et al, a risk factor for transfusion after THA is increased age .
Our study shows that the rate of transfusion was highest in patients more than 65 years old (26% compared with 20% in patients between 50 and 65 years old, and 13.3% in patients less than 50 years old). While the subgroup may be underpowered, patients less than 50 years of age do not appear to benefit from TXA use. This may be due to their ability to compensate for relative anemia compared to the older cohorts. Patients over the age of 65 consistently benefit from TXA use.
Our study is consistent with the conclusion that low preoperative Hgb is associated with an increased risk of transfusion during admission for THA [4, 11].
All patients in our study who had a Hgb < 12.0 g/dL received a transfusion prior to TXA administration, while 17.4% of patients with Hgb >12.0 g/dL received a transfusion prior to TXA administration. Only patients with Hgb > 12.0 g/dL experienced a significant change in delta and postoperative Hgb after TXA administration. There are two likely possibilities for this difference:
- Patients with a low preoperative Hgb are more likely to receive an intraoperative transfusion, which would alter both delta Hgb and postoperative Hgb.
- The number of patients in the < 12 Hgb group may be too low to detect these differences.
TXA appears to be effective despite preoperative Hgb status.
According to Mayr et al, when compared to the traditional anterior-lateral approach, patients who undergo THA by the direct anterior approachb experience a faster return to normal function . Our results do not indicate a significant difference between the 2 approaches for THA with regard to short-term outcomes, with similar blood product utilization in both groups. Patients undergoing either approach stand to benefit from TXA administration.
According to this study, there are no restrictions on the use of topical TXA in THA, but not all patients should be expected to benefit equally.
A preoperative Hgb >12 is protective against perioperative transfusions, especially in combination with TXA. However, TXA significantly reduces transfusion rates regardless of preoperative Hgb status. Female patients and those over 65 years of age appear to have the most reliable and consistent response to topical TXA use in THA.
Walter A. Anazonwu, BS; John R. Tuttle, MD; and Lee E. Rubin, MD, are from the Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Anazonwu WA, Tuttle JR, Rubin LE. Subgroup analysis of topical tranexamic acid in primary total hip arthroplasty. Reconstructive Review 2015;5(1):13-17. http://reconstructivereview.org/ojs/index.php/rr/article/view/80/117 Copyright (c) 2015 All published articles are the shared property of its authors and Reconstructive Review. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. JISRF gives permission for reproduction of articles as long as notification and recognition is provided.
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