Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials

Objective This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). Design This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/ or occurrence of venous thromboembolism (VTE). Setting We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration. Participants Patients undergoing TKA or THA. Interventions Intravenous, topical or combined intravenous and topical TXA. Results Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD= 30.92, p= 0.31), drain blood loss (WMD=-34.53, p= 0.50), postoperative Hb levels (WMD=-0.01, p= 0.96), Hb decline (WMD=-0.39, p= 0.08), LOS (WMD= 0.15, p= 0.38), transfusion rate (RR= 1.08, p= 0.75) and VTE occurrence (RR= 1.89, p= 0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD= 198.07, p< 0.05), greater Hb decline (WMD= 0.56, p< 0.05) and higher transfusion rates (RR= 2.51, p< 0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles. Conclusions The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.