Commentary & Perspective

Commentary & Perspective on
"Tranexamic Acid Reduces Postoperative Blood Loss in Cementless Total Hip Arthroplasty"
by Satoshi Yamasaki, MD, et al.

Commentary & Perspective by
Kevin L. Garvin, MD*,
University of Nebraska Medical Center, Omaha, Nebraska

Factors that increase the patient's risk of needing allogeneic transfusion include revision hip or knee surgery, one-stage bilateral primary hip or knee replacement, an initial hemoglobin of <100 g/L, and an age greater than sixty-five years. In contrast, it is unusual for a patient to need postoperative allogeneic blood transfusion if the preoperative hemoglobin is >150 g/L or between 130 and 150 g/L, if the patient is undergoing a primary joint replacement, and if the patient is less than sixty-five years of age¹.

Unfortunately, several complications are directly attributable to allogeneic transfusion. The most common of these complications are nonhemolytic febrile allergic reactions and alloimmunization reactions, which do not generally result in serious morbidity¹. The risk of transmission of viral disease has declined appreciably over the past two decades. Hepatitis is now the most common viral disease transmitted, with hepatitis B occurring in one of 63,000 patients receiving allogeneic transfusion and hepatitis C occurring in one of 103,000. The rate of transmission of immunodeficiency virus infection is now one in 500,000². One of the most substantial risks is thought to be administrative error, which has been reported to occur once for every 19,000 units transfused³. In addition, investigators have shown that the patient who receives allogeneic blood may have an increased susceptibility to cancer and infection⁴.

In the current investigation, the authors demonstrated the effectiveness of tranexamic acid. They have controlled most variables by choosing patients who had staged bilateral total hip arthroplasty. At the time of one of the total hip arthroplasties, 1000 mg of tranexamic acid was administered intravenously five minutes before the skin incision was made, and at the time of the contralateral total hip arthroplasty, tranexamic acid was withheld. The average interval between the two procedures was sixteen months. The cumulative total blood loss in the tranexamic acid group was significantly lower than that in the control group (p < 0.01). The authors noted that the postoperative blood loss in the tranexamic acid group was significantly lower than that in the control group at all points during the first twenty-four hours (p < 0.001). Further, the greatest reduction in blood loss was observed during the first four hours after surgery in the study group (p < 0.001).

Alternative blood-preservation techniques for patients at high risk of needing allogeneic blood because of low preoperative hemoglobin or complex surgery include autologous blood donation, administration of erythropoietin, autotransfusion, the use of hypotensive anesthesia, hemodilution, and combinations of these treatment methods. When faced with many options, it becomes necessary for us to individualize treatment and to compare the risks and costs associated with each choice. Tranexamic acid prevents bleeding by its action or effectiveness in suppressing fibrinolysis. Specifically, it inhibits tissue plasminogen activator and plasmin activity. It may be given to patients at different times before or during surgery to lessen bleeding, or it may be given during the operation or, as in this case, five minutes prior to the skin incision.

Tranexamic acid has been associated with very few risks, and, in this particular study, there were no complications reported. One potential risk associated with the use of tranexamic acid is the occurrence of thromboembolism. Although thromboembolism has been reported in other studies, the authors of those studies were unable to determine whether thromboembolism resulted from the administration of tranexamic acid or other variables associated with total hip arthroplasty. Nevertheless, tranexamic acid is contraindicated in patients who have had previous thromboembolic events or who are at particularly high risk of having such an event⁵.

On the basis of the data in the study by Yamasaki et al., tranexamic acid can be safely added to the orthopaedic surgeon's armamentarium to help reduce postoperative blood loss. The issues of timing and dosage as well as the possibility of using tranexamic acid in surgical procedures that are of longer duration are areas that may be further addressed in future studies.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Hatzidakis AM, Mendlick RM, McKillip T, Reddy RL, Garvin KL. Preoperative autologous donation for total joint arthroplasty. An analysis of risk factors for allogenic transfusion. J Bone Joint Surg Am. 2000;82:89-100.
2. Cushner FD, Hawes T, Kessler D, Hill K, Scuderi GR. Orthopaedic-induced anemia: the fallacy of autologous donation programs. Clin Orthop Relat Res. 2005:431:145-9.
3. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion. 1992;32:601-6.
4. Murphy P, Heal JM, Blumberg N. Infection or suspected infection after hip replacement surgery with autologous or homologous blood transfusions. Transfusion. 1991;31:212-7.
5. Garneti N, Field J. Bone bleeding during total hip arthroplasty after administration of tranexamic acid. J Arthroplasty. 2004;19:488-92.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.