Topical versus systemic tranexamic acid after total knee and hip arthroplasty

BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug widely used to reduce blood loss during joint replacements, including total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, there is no final consensus regarding the composition of an optimal administration of TXA regime between topical and systemic (intravenous). The purpose of our study was to compare the efficacy of topical and intravenous (IV) regimen of TXA during TKA and THA. METHODS Five relevant electronic online databases, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Chinese Biomedical Database were systematically searched in November 2015. Randomized controlled trials (RCTs) that compared topical with intravenous TXA in patients with TKA or THA were included. The search terms included "topical," "intravenous," "tranexamic acid," "knee arthroplasty" and "hip arthroplasty." Two reviewers independently extracted data and assessed the risk of bias and study quality. Data were analyzed with Review Manager 5.3 software. Grades of Recommendation Assessment, Development and Evaluation (GRADE) were used to assess the quality of evidence. RESULTS Sixteen RCTs with 1250 patients undergoing TKA and 4 RCTs involving 550 patients undergoing THA were included. There were no significant differences in total blood loss (mean difference [MD]TKA = -28.72 mL, 95% confidence interval [CI] -195.97 to 138.54 mL, P = 0.74; MDTHA = 14.03 mL, 95% CI -35.53 to 63.59 mL; P = 0.78), total drain out (MDTKA = -3.09 mL, 95% CI -39.05 to 32.88 mL; P = 0.87; MDTHA -31.00 mL, 95% CI -66.56 to 4.66 mL; P = 0.09), and transfusion rates (ORTKA = 0.90, 95% CI 0.58-1.40, P = 0.64; ORTHA = 1.19, 95% CI 0.67-2.09; P = 0.63) between topical and intravenous (IV) TXA. CONCLUSIONS The current evidence suggested that topical TXA was equally effective and safe compared with intravenous TXA in reducing blood loss and transfusion rate following TKA or THA. We recommended that either topically or systemically could be used in TKA and THA to decrease perioperative blood loss.