Is There a Synergistic Effect of Topical Plus Intravenous Tranexamic Acid Versus Intravenous Administration Alone on Blood Loss and Transfusions in Primary Total Hip and Knee Arthroplasties?

Background: The optimal route and dosing regimen of tranexamic acid (TXA) in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unclear. As such, we sought to analyze if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and transfusions.Methods: We retrospectively analyzed 6720 primary TKAs and 6559 THAs performed from February 1, 2016 to December 31, 2019 at a single institution in patients who received a double IV dose (6159 TKAs and 6276 THAs) compared with a combined single IV and topical dose (561 TKAs and 283 THAs) of TXA. Multivariate logistic regression models, adjusting for age, body mass index, American Society of Anesthesiologists class, preoperative hemoglobin, and TXA administration, were performed for significant variables from a univariate analysis.Results: In the TKA cohort, the mean total blood loss was statistically similar for double IV (305 mL, 95% confidence interval [CI] = 301-310 mL) TXA compared with combined TXA (310 mL, 95% CI = 299-321 mL) (P = .43). Furthermore, there was no difference in the rate of transfusion (odds ratio = 1.23, 95% CI = 0.57-2.67, P = .598). In the THA cohort, there was statistically higher blood loss with double IV (328 mL, 95% CI = 323-333 mL) TXA than in the combined group (295 mL, 95% CI = 280-310 mL) (P < .001). The rate of transfusion was statistically similar at-2% (P = .970).Conclusions: A double IV TXA dose and a combined single IV and topical TXA dose were equally effective in minimizing blood transfusions (-2%) at primary TKA and THA. We did not find a synergistic effect when combining a systemic IV TXA with a topical TXA.Level of Evidence: Level III.(c) 2020 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).