Potential to decrease transfusion rates following arthroplasty…..

Published on: 15 April, 2014

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Perioperative bleeding is always a major concern in orthopaedics, particularly in major joint replacement surgery. It not only poses major risks to the patients, but also leads to additional costs.

Antifibrinolytics (agents that inhibit degradation of fibrin clots) have long been used to reduce perioperative bleeding in other areas such as cardiac and spine surgery. Early studies in orthopaedics did not produce solid conclusions about overall efficacy. A 2006 meta-analysis found that tranexamic acid (TXA)was associated with fewer postoperative transfusions and identified a dose-dependant effect. A recent retrospective study of more than 2,000 primary arthroplasty patients reported no increase in the rate of symptomatic thrombotic events when used for deep vein thrombosis (DVT).

Tranexamic acid has been used extensively in total knee arthroplasty, both topically and intravenously. With respect to transfusion, a randomized, placebo-controlled trial pointed to reduced transfusion rates with higher doses but a larger study is required to produce a significant reduction.

A paper recently presented at the American Academy of Orthopaedic Surgeons Annual Meeting in New Orleans provided some promising data that may lead to a decrease in transfusion rates.

Scott A. Wingerter, MD, PhD, presented these results at the recent meeting in March for patients undergoing either primary or revision hip or knee arthroplasty. “Transexamic acid continues to support a decreased transfusion rate following both primary and revision hip and knee surgery without any increase in thromboembolic events.”

Wingerter and colleagues at Washington University School of Medicine performed a database search of all primary and revision hip and knee replacement surgeries to compare transfusion rates. Overall the study included 1,320 hip cases and 886 knee cases. They found no significant difference in demographic data between pre-TXA and post-TXA groups. The investigators found the transfusion ate for all hip cases combined was 41.7% pre-TXA, which decreased to 13% after TXA. The rate from knee cases decreased from 25% to 7%.

For the rate of thromboembolic events (VTE’s), “there was no significant difference in the incidence of at 4 weeks to 6 weeks or at 6 months. There was an absolute lower percentage in our patient group that was receiving TXA.” Wingerter said.

The interest in the importance of this type of therapy has certainly increased in recent years. Future well designed studies documenting reduced transfusions, costs and longer-term mortality data are needed to determine optimal admistration regimes, but this is certainly encouraging data not only for patients undergoing joint replacement surgery, but also for healthcare professionals and adminstrators alike.

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