Intravenous versus topical tranexamic acid in primary total hip replacement: A meta-analysis

As the prevalence of total hip arthroplasty (THA) is increasing, it is usually associated with considerable blood loss. Tranexamic acid (TXA) has been reported to reduce perioperative blood loss in hip joint arthroplasty. But the best route of TXA administration continues to be controversial. So, we conducted a meta-analysis that integrated all data from the 7 included trials to compare the effectiveness and safety of topical and intravenous TXA administration in primary THA. The endpoints assessed in this meta-analysis include the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of deep vein thrombosis (DVT), pulmonary embolisms (PE), and wound infection.

Literature searches of PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature database, the CNKI database, and Wan Fang Data were performed up to August 30, 2016. Randomized controlled trials (RCTs) were included in our meta-analysis if they compared the efficiency and safety of intravenous versus topical administration of TXA in patients who underwent primary THA. The endpoints included the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of DVT, PE, and wound infection. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. The pooling of data was carried out by using RevMan 5.3, Denmark.

Seven RCTs involving 964 patients met the inclusion criteria. Our meta-analysis indicated that there were no significant differences in the 2 groups in terms of total blood loss ([mean difference (MD) = -14.74, 95% confidence interval (CI): -89.21 to 59.74, P = 0.7], transfusion rates [RD = -0.02, 95% CI: -0.05 to 0.02, P = 0.39]; no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis [DVT] [RD = 0.00, 95% CI: -0.01 to 0.01, P = 1.00], PE [RD = 0.00, 95% CI: -0.01 to 0.01, P = 0.71], or wound infection [RD = -0.01, 95% CI: -0.06 to 0.04, P = 0.66]). The pooled results showed that the intravenous groups had a lower postoperative hemoglobin decline (MD = -0.47, 95% CI: -0.74 to -0.20, P = 0.0006). It was probably due to insufficient data and the varied reporting of outcomes. There was some inherent heterogeneity due to the small sample size of each primary study.

The topical and intravenous administrations of TXA have a similar effect on the decrease of blood loss without an increased risk of complications (DVT, PE, and wound infection). Intravenous TXA administration may have a maximum efficacy. Topical TXA administration may be preferred in patients who with high risk of thromboembolic events. However, larger, high-quality RCTs are required to explore the optimal regimen, dosage, timing still in the future in order to recommend TXA widespread use in total joint arthroplasty.