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Benefits of Tranexamic Acid Not Debatable but Leave Tourniquet Use to Surgeon’s Discretion

Commentary on an article by ZeYu Huang, MD, PhD, et al.: “Intravenous and Topical Tranexamic Acid Alone Are Superior to Tourniquet Use for Primary Total Knee Arthroplasty. A Prospective, Randomized Controlled Trial”

Boettner, Friedrich MDa; Rueckl, Kilian MD

doi: 10.2106/JBJS.17.01134
Commentary and Perspective
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Hospital for Special Surgery, New York, NY

aE-mail address for F. Boettner: boettnerf@hss.edu

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Commentary

The use of tranexamic acid has revolutionized modern total joint arthroplasty since the turn of the century1. Although the medication has not been approved by the U.S. Food and Drug Administration (FDA) for use in total joint arthroplasty, it has been shown to be a highly effective tool for reducing blood loss and transfusion requirements2. Its low risk profile and cost make it the ideal addition to every primary total joint replacement surgery. Considering that most surgeons use a tourniquet to reduce intraoperative blood loss during total knee arthroplasty, the next logical step appears to be to eliminate the intraoperative tourniquet. In their paper, ZeYu Huang et al. show that applying local and systemic tranexamic acid obviates the need for a tourniquet to reduce overall blood loss, intraoperative blood loss, hidden blood loss, and transfusion rates.

While most surgeons utilize tranexamic acid primarily to eliminate the need for autologous blood predonation and to reduce the need for allogeneic blood transfusion, ZeYu Huang et al. found that its benefits go beyond blood management3. They demonstrated that tranexamic acid has a profound impact on postoperative swelling, inflammatory biomarkers, visual analogue pain scores, range of motion at discharge, functional outcomes, and patient satisfaction. Whether, however, 5 intravenous doses in combination with topical tranexamic acid are needed to provide the added clinical benefits requires additional dose-clarifying studies4.

The conclusion of the paper suggests that we should all stop using tourniquets when performing total knee arthroplasty. In reality, the reported clinical benefits of doing that are not very impressive, and not using a tourniquet has much less impact on outcomes than the addition of tranexamic acid. There was no significant difference in the swelling ratio on postoperative day 5 (103.7% versus 102.8%), the length of the hospital stay (5.12 versus 5.12 days), or the Hospital for Special Surgery (HSS) score at 6 months (90.3 versus 91.2) between the tranexamic acid group treated with a tourniquet and the tranexamic acid group treated without a tourniquet (Table II). The reported significant difference in the range of motion on the day of discharge (105.1° versus 107.9°) was not clinically meaningful, and the difference in hidden blood loss was small compared with the massive increase in hidden blood loss when tranexamic acid was not used. In addition, not using a tourniquet for patients treated with tranexamic acid had a positive impact on patient satisfaction only during the hospital stay, not thereafter (Table III).

While we believe that the current paper provides strong evidence that adding tranexamic acid has profound benefits with respect to blood management and clinical recovery after total knee arthroplasty, we do not think that it makes a very convincing argument to discontinue the use of tourniquets.

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/E496).

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References

1. Alshryda S, Mason J, Vaghela M, Sarda P, Nargol A, Maheswaran S, Tulloch C, Anand S, Logishetty R, Stothart B, Hungin AP. Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total knee replacement: a randomized controlled trial (TRANX-K). J Bone Joint Surg Am. 2013 Nov 6;95(21):1961-8.
2. Evangelista PJ, Aversano MW, Koli E, Hutzler L, Inneh I, Bosco J, Iorio R. Effect of tranexamic acid on transfusion rates following total joint arthroplasty: a cost and comparative effectiveness analysis. Orthop Clin North Am. 2017 Apr;48(2):109-15. Epub 2017 Jan 30.
3. Kasparek MF, Faschingbauer M, Waldstein W, Boettner CS, Boettner F. Topical tranexamic acid is equivalent to targeted preoperative autologous blood donation in total hip arthroplasty. J Arthroplasty. 2017 Apr;32(4):1176-9. Epub 2016 Oct 31.
4. Lee SY, Chong S, Balasubramanian D, Na YG, Kim TK. What is the ideal route of administration of tranexamic acid in TKA? A randomized controlled trial. Clin Orthop Relat Res. 2017 Aug;475(8):1987-96. Epub 2017 Mar 10.

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