SLR - May 2019 - Stephanie A. Oexeman
Reference: Nodzo SR, Pavlesen S, Ritter C, Boyle KK.Tranexamic Acid Reduces Perioperative Blood Loss and Hemarthrosis in Total Ankle Arthroplasty. Am J Orthop (Belle Mead NJ). 2018 Aug;47(8). doi: 10.12788/ajo.2018.0063Scientific Literature Review
Reviewed By: Stephanie A. Oexeman, DPM
Residency Name: CHI Franciscan Foot and Ankle Institute, Federal Way, WA
Podiatric Relevance: Perioperative patient management is crucial for decreasing postoperative complications after total ankle arthroplasty (TAA). The anterior ankle tissue is delicate, and mishandling leads to complications. Hemarthrosis causes postoperative swelling, increases pain and decreases range of motion with potential for fibrosis. Tranexamic acid (TXA) is an inexpensive antifibrinolytic drug that stabilizes clot formation, inducing a hypercoagulable state. Intravenous (IV) or topical TXA in orthopaedic procedures, such as total knee (TKA) and total hip arthroplasty (THA), is used to manage postoperative hemarthrosis; correlating to better patient outcomes, reduced complication rates and decreased hospital costs. This article looks into the use of TXA in TAA. The authors hypothesize that patients who receive TXA intraoperatively during TAA would have a decrease in postoperative blood loss, which suggests decreased hemarthrosis and therefore lower wound complication rates.
Methods: This is a level two, single institution, single surgeon, retrospective chart review comparing patients who received TAA from 2011 to 2015. Fifty patients met inclusion criteria for a TAA. Exclusion criteria were patients who had health contraindications to TXA or nonreported drain output. All patients received an anterior midline incision and Salto Talaris total ankle replacement. After inclusion and exclusion criteria, a total of 43 patients were included in the study; 22 TXA-TAA and 21 No TXA-TAA patients. A retrospective chart review was performed to evaluate demographics, perioperative hemoglobin levels, indications for surgery, adjunct surgical procedures, length of surgery, postoperative drain output, hospital length of stay, visual analog scale (VAS) for postoperative pain and complications, including minor and major wounds.
Results: The TXA-TAA group has a statistically significant decrease in postoperative drain output and significantly lower mean change in postoperative hemoglobin than the No TXA-TAA group. When calculating total blood loss, the TXA-TAA group had a significantly lower loss than the No TXA-TAA group. The authors stated that no blood transfusions were indicated in either group. There were no statistical differences in length of surgery, postoperative VAS scores, hospital length of stay or wound complications. Results for hospital length of stay could be skewed due to two patients in the TXA-TAA group requiring longer stays due to social issues. Although not significant, there was more overall complications in the No TXA-TAA group than TXA-TAA group [20 percent (5/25) vs. 8 percent (2/25)]. Both groups did not require implant removal, IV antibiotics or subsequent hospital stay. No chronic wounds developed in either group during the first 90 days.
Conclusions: Intraoperative use of TXA is an effective hemostatic agent that has shown reduced drain output and mean change in perioperative hemoglobin levels in patients who undergo TKA and THA. This study was the first to report on TXA use in TAA. Authors report a significant reduction in drain output and overall reduction in percentage of wound complications in those who receive TXA. Limitations include retrospective and small sample size to thoroughly assess significance of wound complications. In conclusion, TXA has shown to assist in postoperative blood loss, hemarthrosis and reducing postoperative wound complications.