|

The Efficacy and Safety of Tranexamic

Acid Treatment in Orthopaedic
Trauma Surgery
Cody R. Perskin, BA Abstract
» Tranexamic acid (TXA) is a drug used to control hemorrhage by
Connor P. Littlefield, BA
preventing the breakdown of fibrin.
Charles Wang, MD
» TXA is a cost-effective treatment for trauma patients across a variety
Uchenna Umeh, MD of economic settings.
Kenneth A. Egol, MD
» Concerns of TXA causing thromboembolic events (TEEs) in ortho-
paedic trauma patients are not supported by evidence.
Investigation performed at NYU » TXA has been shown to reduce blood loss in hip fracture surgery.
Langone Orthopedic Hospital, New
York, NY

T
rauma accounts for a sub-
stantial annual global mor-
tality and economic burden.
It is estimated that hemor-
rhage accounts for approximately 30% to
40% of traumatic mortality1. Acute hem-
orrhage is a major complication in trauma
patients and the second leading cause of
death in a traumatic setting, after central
nervous system injuries1. To prevent mas-
sive blood loss, subsequent hypovolemic
shock, and the need for transfusion, anti-
fibrinolytic drugs can be utilized to treat the
patient, including aprotinin, epsilon-
aminocaproic acid, aminomethylbenzoic
acid, and tranexamic acid (TXA), among
others2. These medications encourage the
natural clotting cascade initiated by the body
to preserve a homeostatic blood volume
during events of substantial blood loss. In the
antifibrinolytic drug class, TXA has gained
popularity as a result of its efficacy in
reducing blood loss in a variety of medical
specialties3-5 at a reasonable cost6-9.
TXA is a lysine derivative10 that can be
inhaled, applied topically, or given by
intravenous (IV) administration3,11 in
order to systemically manage patient hem-
orrhage. Depending on the specific case,
dosing recommendations have ranged from
administering TXA at a dose of 15 mg/kg of
body weight12 to administering a bolus
ranging from 1 to 4 g of TXA13,14. Some
studies have experimented with providing
multiple doses of TXA but have generally
found similar outcomes between single and
multiple-dose groups15. Common contra-
indications include a known allergy to TXA,
intracranial hemorrhage, renal dysfunction,
and history of thrombosis16,17. Additionally,
clinicians should be cognizant that TXA
has been associated rarely with induced
seizures18,19; however, studies have demon-
strated that with careful decision-making,
proper timing of anesthetics, and proper
dosing, these risks are appropriately miti-
gated19. Literature across a variety of medical
specialties has demonstrated excellent patient
outcomes, minimal complications, and a
reduced rate of hemorrhage and need for
transfusion in patients that receive TXA4,20.
The purpose of this article is to review the
TXA mechanism of action and highlight
patient outcomes associated with TXA treat-
ment in an orthopaedic trauma setting.
Clotting Pathophysiology and
Basic Science
Following any traumatic event that induces
vascular injury, blood must be converted

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JBJS REVIEWS 2021;9(7):e20.00292 · http://dx.doi.org/10.2106/JBJS.RVW.20.00292 1

 | T h e E f f i c a c y a n d S a f e t y o f Tr a n e x a m i c A c i d Tr e a t m e n t i n O r t h o p a e d i c Tr a u m a S u r g e r y

Fig. 1
The coagulation cascade.

into a clot to seal the hole in the endo-
thelial wall and mitigate further blood
loss21. Clot formation occurs as a result
of the coagulation cascade (Fig. 1),
which can follow 2 different pathways:
intrinsic or extrinsic. The intrinsic
pathway triggers blood clotting when
plasma comes into contact with artificial
surfaces, such as a glass test tube21,22.
This pathway is not required for physi-
ologic hemostasis but is thought to play a
role in thrombotic disorders21. Con-
versely, the extrinsic pathway is essential
for hemostasis and is initiated when
disruption of the endothelial wall
exposes the integral membrane receptor
tissue factor (TF) to plasma factor VII/
VIIa (FVIIa)21. Other proteins, such as
von Willebrand factor further facilitate
the binding of platelets to the injured
wall during this process. The TF/FVIIa
complex is the main activator of a pro-
tease cascade23 that activates factor IX
(FIX) to FIXa and factor X (FX) to
FXa24. The prothrombinase complex
(FVa [factor Va]/FXa) is the first aspect
of the common pathway and activates
the conversion of prothrombin to
thrombin24. Next, thrombin cleaves
fibrinogen into fibrin monomers while
simultaneously activating FXIII to
FXIIIa, a protein that cross-links fibrin
monomers to form the fibrin matrix of a
clot24.
The mechanism of action for
TXA on the clotting cascade has been
described as multimodal because of its
dual blockade preventing fibrinolysis
(Fig. 2)25. First, TXA acts as a reversible

Fig. 2
The mechanism of tranexamic acid (TXA) is
depicted. TXA inhibits activation of plasmino-
gen to plasmin as well as the binding of
plasmin to fibrin. tPA 5 tissue plasminogen
activator. (Reproduced from: Tzatzairis TK,
Drosos GI, Kotsios SE, Ververidis AN, Vogiatzaki
TD, Kazakos KI. Intravenous vs Topical Tra-
nexamic Acid in Total Knee Arthroplasty
Without Tourniquet Application: A Random-
ized Controlled Study, J Arthroplasty. 2016
Nov;31[11]:2465-70, with permission from
Elsevier.)

2 JULY 2021 · VOLUME 9, ISSUE 7 · e 20.00292

 T h e E f f i c a c y a n d S a f e t y o f Tr a n e x a m i c A c i d Tr e a t m e n t i n O r t h o p a e d i c Tr a u m a S u r g e r y
competitive inhibitor to the 5-lysine
binding motif present on the surface of
plasminogen10,16,26, which disrupts
plasminogen activation to plasmin.
Ultimately, this prevents downstream
fibrinolysis and preserves existing clots.
TXA also acts as a potent inhibitor
of plasmin and its association with
fibrin by binding to lysine residues on
plasmin to inhibit plasmin-catalyzed
fibrinolysis16,25. Specifically, TXA is
believed to insert into the primary
specificity pocket (S1)27. Together,
these actions of TXA suggest that this
medication prevents the breakdown of
existing fibrin complexes rather than
promotes the formation of new clots25.
This fact is pivotal in understanding the
efficacy and safety of TXA as it stabilizes
blood loss while avoiding hyper-
coagulation events.
Recent studies have suggested that
in addition to reducing blood loss, TXA
administration may be especially bene-
ficial to orthopaedic trauma patients for
its potential role in augmenting bone-
healing. One study28 found that topical
TXA improved bone-healing, radio-
graphic scores, and bone mineralization
at 2 and 4 weeks after TXA administra-
tion in rats, despite positing that sys-
temic TXA application may delay
fracture-healing by preventing fracture
hematoma formation during early heal-
ing stages. Çevik et al.28 attributed the
fracture-healing benefits of TXA treat-
ment to the extended duration of fibrin
matrices present in hematomas sur-
rounding fracture sites. Another study29
on TXA reported similar results showing
that TXA improves radiographic scores
and accelerates fracture-healing com-
pared with a control group in rat models.
This additional benefit of TXA may be
the result of fracture microstabilization
to the developing fibrin-collagen scaf-
fold in the early stages of fracture-heal-
ing30. Previous examination of other
antifibrinolytic drugs31 has yielded
similar results of improved osseous callus
compared with a control group. Balkanlı
et al.32 found no significant difference in
fracture-healing or time to healing
JULY 2021 · VOLUME 9, ISSUE 7 · e20.00292
between a TXA treatment group and the
control group.
Anesthetic Considerations
There are several concerns for the anes-
thesiologist when considering TXA
administration in a patient presenting
with urgent or emergency orthopaedic
trauma. Patients with a history of renal
disease, cancer, vascular stents, current
anticoagulant use, and existing throm-
boembolic events (TEEs), such as
venous thromboembolism, myocardial
infarction, cerebrovascular accident,
and transient ischemic attack, are of
particular concern. Traditionally, these
patients have been labeled as high risk
and were excluded from receiving TXA
in the perioperative setting.
Based on its mechanism of action,
TXA has always been considered to be
associated with a high risk of the devel-
opment of TEEs. Current literature
lacks high-level evidence to support the
use of TXA in patients with a history of a
TEE. However, recent studies have not
shown a higher rate of TEEs in these
higher-risk patients who received TXA.
It appears the increased risk of throm-
boembolic complications in this patient
population after TXA administration is
theoretical.
Orthopaedic trauma patients may
present for surgery while they are on
anticoagulant or antiplatelet medica-
tions. Examples of these medications are
warfarin; rivaroxaban; apixaban for atrial
fibrillation, current deep vein throm-
bosis (DVT), or pulmonary embolism;
and clopidogrel (Plavix) for patients
with cardiac or vascular stents. The
concern that TXA may induce a hyper-
coagulable state in these patients has
generally precluded its use in patients on
concurrent anticoagulant or antiplatelet
therapy. Traditionally, these patients
have received no TXA at the time of
surgery if they are on anticoagulants.
Some surgeons have chosen to inject
topical TXA in this patient population,
but there are limited studies on IV TXA
and its safety in this subgroup of
patients.
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Lastly, renal insufficiency or renal
failure is a concern for TXA adminis-
tration. TXA is primarily cleared
(.90%) unchanged by glomerular fil-
tration with a half-life of 1.5 to 2
hours33. TXA blood levels are elevated in
proportion to the severity of renal disease
and the reduction in renal clearance.
Clinicians should make note of ortho-
paedic trauma patients presenting with
severe renal disease. Higher doses of
serum TXA resulted in seizures in
patients with Stage-3, 4, or 5 chronic
renal disease who received TXA for car-
diac surgery33. Although the dose of
TXA used in cardiac surgery is higher
than that used in orthopaedic trauma
patients, more studies are needed to
determine the optimal dose of TXA in
patients with a history of renal disease
who are seen with acute orthopaedic
trauma.
Clinical Outcomes
Hip Fractures
The majority of TXA research in
orthopaedic trauma has been in hip
fracture surgery. Ample evidence sup-
ports the use of TXA in elective hip
arthroplasty to reduce blood loss and the
need for transfusion, which has led to its
endorsement by the American Associa-
tion of Hip and Knee Surgeons and the
American Academy of Orthopaedic
Surgeons34. Since anemia and the need
for blood transfusions in the elderly are
associated with morbidity and mortality,
blood conservation is essential in this
population. Many surgeons refuse to use
TXA in the sick elderly population who
are more susceptible to TEEs, so vali-
dating its safety in this group is crucial.
In a randomized controlled trial
(RCT) of 138 subjects, Watts et al.35
studied IV TXA in patients with femoral
neck fractures treated with hemiarthro-
plasty (HHA) or total hip arthroplasty
(THA). Patients in the TXA group were
administered 15 mg/kg of IV TXA just
prior to incision and a second dose
during wound closure. The control
group received normal saline solution.
This study attempted to include higher-
risk patients who had historically
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been excluded from TXA studies. By
measuring changes in postoperative
hemoglobin levels and converting
hemoglobin declines to volumetric
blood loss using the hemoglobin balance
method36, the authors found that TXA
decreased cumulative blood loss on
postoperative day 3 by a mean of 305 mL
compared with the control group. The
TXA and control groups had transfusion
rates of 17% and 26%, respectively,
although this difference was not signifi-
cant. Despite 32% of the patients having
a history of a TEE, there was no differ-
ence in the TEE rate at 90 days between
groups. Of note, patients did not
undergo surveillance for TEEs and only
underwent testing for TEEs if they pre-
sented with acute symptoms. Although
these data support the use of TXA in
more frail orthopaedic patients, the lit-
erature on this population remains
sparse. Contrary to these data, there is
some evidence from retrospective stud-
ies that has suggested that TXA sub-
stantially decreases postoperative
transfusions in HHA patients, with
1 study even showing a 2.7% reduction
in 30-day mortality37-39.
The literature concerning TXA in
intertrochanteric (IT) fracture surgery is
also limited to smaller RCTs. The largest
study consisted of 100 patients with IT
fractures who underwent treatment with
an intramedullary nail40. Half of the
cohort received 1 g of IV TXA, and half
received placebo prior to surgery. Total
blood loss was calculated using a formula
that accounted for the difference
between the preoperative and postop-
erative hematocrit. The results demon-
strated that the TXA group had
substantially less total blood loss than
the placebo group (564 versus 819 mL).
Additionally, they observed only 5
transfusions in the TXA group com-
pared with 27 in the control group.
Similar findings have been replicated by
the other small RCTs, which have
shown that TXA administration results
in absolute risk reductions in the trans-
fusion rate, ranging from 18% to
28%41-43. None of those studies dem-
onstrated an increase in complication
4 JULY 2021
rates with TXA; however, it is important
to note that sicker patients or individuals
with prior TEEs were excluded in many
cases. In another RCT studying local
administration of TXA in IT hip fracture
surgery, the 100 patients in the TXA
group were injected with 3 g of TXA
subfascially around the fracture site
under radiographic guidance at the end
of the surgery44. The authors concluded
that topical TXA resulted in a mean
reduction of 43% in transfusion
requirements postoperatively, with a
total of 27 packed red-blood-cell
(pRBC) units administered to the TXA
group and a total of 48 pRBC units
administered to the control group. In
most studies, subjects had a workup for
TEEs only when clinically indicated.
Schiavone et al.41 monitored asymp-
tomatic subjects with ultrasound sur-
veillance and did not report an increased
risk of TEE after IV TXA at a dose of 15
mg/kg. Given the lack of safety data in
higher-risk groups, strong consideration
should be given for IV TXA during hip
fracture surgery, specifically for patients
who are at an increased risk for intra-
operative and postoperative blood loss.
Other Lower Extremity Fractures
Because of the relatively small blood loss
associated with surgery of a distal frac-
ture of the lower extremity, there has
been little research on TXA application
in the lower extremity for indications
other than hip fractures. One group
studied the effect of TXA on blood loss
and postoperative complications in an
RCT of 90 patients undergoing opera-
tive repair of calcaneal fractures45.
Patients received either IV TXA at a dose
of 15 mg/kg or normal saline solution
preoperatively. They measured postop-
erative blood loss with drain bags and
found that the TXA group had less
postoperative blood loss. The TXA
group did not have an increased risk of a
TEE, which was assessed in both
symptomatic and asymptomatic indi-
viduals with ultrasound surveillance.
Interestingly, the TXA group had a
lower rate of wound complications
compared with the control group (7.3%
versus 23.8%).
These findings are further sup-
ported by results reported by Ding et al.,
who demonstrated that less postopera-
tive blood loss following calcaneal frac-
ture surgery is associated with a lower
risk of wound complications46. This
may be because, with decreased post-
operative blood loss, patients experience
less wound drainage and smaller hema-
toma volumes under the tenuous
skin flap, which in turn leads to fewer
wound infections and decreased pres-
sure beneath the flap. Xie et al.45 also
postulated that the TXA’s inhibition
of plasmin, which is an activator of
various proinflammatory pathways,
could play a role in decreasing wound
complications47,48. If future studies are
able to demonstrate a therapeutic effect
of TXA on wound complications, there
would be strong evidence to make it the
standard of care in all patients under-
going fracture repair in anatomic sites
susceptible to wound complications.
TXA is not commonly used in
tibial fracture surgery, and as far as we
know only 1 small study has investigated
its use for this indication. An RCT of 70
patients with tibial shaft fractures as-
sessed whether there was any benefit in
using IV TXA at a dose of 10 mg/kg
during tibial intramedullary (IM) nail-
ing49. They found that patients who
received TXA had higher hemoglobin
levels at the 24-hour and 48-hour post-
operative time points. Zero patients in
the TXA group and 2 patients in the
control group required a transfusion.
DVT status was monitored with Dop-
pler ultrasound at 4-week follow-up
visits, which did not reveal a DVT in
either cohort.
Upper Extremity Fractures
Most studies relating to TXA use in
upper extremity fractures are restricted
to proximal humeral fractures, which is
likely because surgeons do not have the
option of using a tourniquet when re-
pairing these fractures. Cuff et al.50
studied 101 patients undergoing shoul-
der arthroplasty or open reduction and
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internal fixation (ORIF) for the treat-
ment of proximal humeral fractures.
Patients were randomized and received
1 g of IV TXA or normal saline solution
preoperatively. The study compared
preoperative and postoperative hemo-
globin levels and assessed intraoperative
blood loss and 24-hour postoperative
drain output. The authors found that
preoperative administration of TXA re-
sulted in a smaller postoperative decrease
in hemoglobin level and decreased blood
loss in both arthroplasty and ORIF.
Similarly, many studies have evaluated
TXA in elective total shoulder arthro-
plasty (TSA) and reverse total shoulder
arthroplasty (RTSA) for indications
such as degenerative joint disease and
rotator cuff arthropathy. Those studies
have offered evidence that TXA may
decrease blood loss and transfusion rates
in elective TSA and RTSA51-53.
Yang et al.54 evaluated the use of
TXA in proximal humeral fractures
treated with a locking plate. In their
RCT of 67 patients with 3 or 4-part
proximal humeral fractures, half of the
subjects received IV TXA at a dose of 15
mg/kg preoperatively and half received
normal saline solution preoperatively.
They observed less total blood loss as
measured by drainage bags in the TXA
group in the 24-hour postoperative
period. Larger-scale prospective trials are
required before definitive conclusions
can be drawn. The literature search did
not yield any studies evaluating TXA
application for distal upper extremity
trauma such as elbow or forearm frac-
tures. Surgeries for these fractures typi-
cally involve less blood loss. In addition,
surgeons have the option to use tourni-
quets during these procedures to reduce
blood loss, so there is less need for TXA.
Pelvic and Acetabular Fractures
Three recent RCTs have explored the
use of TXA in pelvic and acetabular
trauma. Spitler et al.55 randomized 93
patients with pelvic, acetabular, and
proximal femoral fractures into a
TXA group and a control group.
The TXA group received 15 mg/kg of IV
TXA immediately prior to surgery and 3
JULY 2021 · VOLUME 9, ISSUE 7 · e20.00292
hours after the initial dose. The primary
outcomes assessed were total blood loss,
change in hemoglobin level, and units of
blood transfused. Total blood loss was
calculated using a formula that considers
changes in hemoglobin levels. The
authors found that there was signifi-
cantly less total blood loss in the TXA
group than in the control group (952
versus 1,325 mL). Additionally, the
TXA group had a smaller hematocrit
decrease on postoperative days 1 and 2,
which was replicated in another RCT of
patients with a pelvic fracture56. The
Spitler study also showed that there was
no significant difference in postopera-
tive transfusion rates and units trans-
fused in the TXA group. Lastly, patients
were monitored for clinical signs of
DVT for a minimum of 30 days, which
did not reveal any differences in DVT
rate between the 2 groups.
While the study did not stratify by
fracture location, 84% of the study
population had pelvic and acetabular
fractures, so it is likely that the results
would be similar if the authors had
studied this subgroup separately. Since
the study did not show a difference in
transfusion rate, the clinical importance
of its effect on blood loss is limited. If the
TXA group received fewer transfusions,
the argument can be made that TXA
helps to avoid the risks associated with
blood transfusion such as immunologi-
cal reactions, anaphylaxis, infection, and
acute lung injury57,58. A few retrospec-
tive studies have shown lower transfu-
sion rates when this patient population
received TXA perioperatively59,60.
Another recent RCT investigating
TXA use in acetabular fracture surgery
found no benefit from TXA adminis-
tration61. In that study, 88 patients with
acetabular fractures received either 10
mg/kg of TXA preoperatively followed
by a 10 mg/kg infusion over 4 hours or
equivalent doses of normal saline solu-
tion. The outcomes assessed by the
study included the rate of blood trans-
fusion, number of pRBC units trans-
fused, and rate of symptomatic TEEs.
The study found no significant differ-
ence between the TXA group and the
|
control group for any of these outcomes,
which is consistent with those seen in the
Spitler study.
The findings presented in the pel-
vic and acetabular fracture studies are
encouraging as many showed decreased
blood loss with TXA administration and
similar rates of TEEs. Unfortunately,
neither of the RCTs were able to detect a
difference in transfusion patterns
between TXA and control groups. It
seems that larger and higher-quality
studies on the use of TXA in pelvic and
acetabular fracture fixation are required
to assess its effect on perioperative and
postoperative complications.
Topical Tranexamic Acid
The evidence supporting topical TXA
for hip fracture surgery is also limited to
several small RCTs. In 1 study of 144
patients undergoing an HHA, half of the
patients received topical administration
of 1 g of TXA during surgery just prior to
wound closure62. The transfusion rate
in the TXA group was significantly
lower than in the control group (36.1%
versus 65.2%). Interestingly, the study
observed a significantly decreased rate of
postoperative medical complications in
the TXA group (31.9% versus 56.9%).
Another RCT comparing 1 g of topical
TXA and 10 mL of fibrin sealant (FS) in
158 patients with a femoral neck fracture
demonstrated a trend toward decreased
postoperative blood loss and transfusion
requirements in the TXA group com-
pared with the FS and control groups;
however, a significant difference was not
detected63. None of these studies
described an increased rate of sympto-
matic TEE in the topical TXA group,
and they did not assess for asymptomatic
TEE. These studies suggest that topical
TXA is a viable option for use in hip
fracture patients.
Cost Analysis
Given the rising cost of health care in the
United States, it is important for clini-
cians to consider the cost-effectiveness
of medications such as TXA before
administering them to their patients. A
large multicenter randomized trial of
5
 | T h e E f f i c a c y a n d S a f e t y o f Tr a n e x a m i c A c i d Tr e a t m e n t i n O r t h o p a e d i c Tr a u m a S u r g e r y
.20,000 patients, known as the Clinical
Randomisation of an Antifibrinolytic in
Significant Head Injury-2 (CRASH-2)
trial, studied the efficacy and cost-
effectiveness of administering TXA to
trauma patients at risk for substantial
bleeding64. The study estimated that the
cost of giving TXA to 1,000 patients was
approximately $30,830. In addition,
they reported that the administration of
TXA within 3 hours of injury saved 755
life-years per 1,000 trauma patients,
with an incremental cost per life-year
gained of $6464. Another economic
evaluation of the CRASH-2 trial assess-
ing TXA’s cost-effectiveness in lower
and middle-income countries, such as
Tanzania and India, concluded that
TXA is cost-effective across all economic
settings65. The authors found that
administering TXA to bleeding trauma
patients within 3 hours of injury resulted
in an incremental cost per life-year
gained of $48 and $66 in Tanzania and
India, respectively. In conclusion, TXA
has proven to be a cost-effective option,
even in lower-resource settings, for
trauma patients at risk for substantial
bleeding.
While TXA’s cost-effectiveness has
not been well studied specifically in
fracture surgery, studies in other ortho-
paedic subspecialties have shown that
TXA treatment leads to substantial cost
savings. In a study of patients undergo-
ing elective total joint arthroplasty
(TJA), the use of IV TXA resulted in
significantly lower postoperative trans-
fusion rates following total hip arthro-
plasty (THA) and total knee
arthroplasty (TKA), which in turn
reduced average direct hospital costs by
$3,083 and $2,582 for THA and TKA,
respectively6. Similar cost savings were
replicated in a large retrospective study
showing that TXA use during TKA re-
sulted in average cost savings of $1,500
per patient, which was driven largely by
decreased blood bank costs and length of
stay in the TXA group66. Another study
by Phan et al.67 compared the cost-
effectiveness of intraoperative TXA and
preoperative iron supplementation (FE)
and erythropoietin (EPO) in anemic
6 JULY 2021
patients undergoing total joint arthro-
plasty. The authors concluded that
treating anemic patients preoperatively
with FE or EPO is 2 to 17 times more
expensive than using intraoperative
TXA, which resulted in a postoperative
transfusion rate of only 6.7%. Given
TXA’s proven cost-effectiveness in
arthroplasty surgery, future studies
should investigate whether its use gen-
erates substantial cost savings in fracture
surgery as well.
Overview
There are several limitations to the ex-
isting literature pertaining to the use of
TXA in orthopaedic trauma. First, most
data published are from single-center
trials with varying transfusion protocols,
making differences in transfusion rates
less likely to be detected in studies with
lower hemoglobin transfusion thresh-
olds. Second, there is heterogeneity in
dosing regimens among studies, which
can range from 1 dose of IV TXA at 10
mg/kg to 2 doses of IV TXA at 15 mg/
kg, or in some cases a single 1-g bolus of
IV TXA not adjusted for the weight of
the patient. Furthermore, since these
studies take place all over the world, the
findings from a trial in 1 geographic
region may not be generalizable to a
patient population in another region.
Additionally, many of the above-
mentioned studies excluded patients
with certain comorbidities or history of
TEEs, which further limits their gener-
alizability to higher-risk patient groups.
Lastly, it is important to note that post
hoc analysis from the CRASH-2 trial
demonstrated an increased mortality
risk due to bleeding when TXA was
administered .3 hours after injury
in trauma patients68. The literature
currently lacks studies assessing when it
is safest to administer TXA between 3
and 24 hours after injury, which is rele-
vant to orthopaedic trauma patients who
often undergo surgery early in their
admission.
In the studies we reviewed, there
were conflicting data on the ability of
TXA to limit the need for blood trans-
fusions. Without clear evidence that
TXA can reduce the likelihood that a
patient will require a transfusion, it is
currently difficult to make a case for its
clinical utility across all fracture surgery.
However, given its limited side-effect
profile and ability to considerably reduce
costs, the use of TXA should be strongly
considered in patients with an expected
large intraoperative and postoperative
blood loss. In this review, we identified
strong evidence that both IV and topical
TXA reduce postoperative transfusion
requirements specifically in hip fracture
surgery. Additionally, it should be noted
that we failed to identify a single study
that demonstrated a higher TEE risk in
the TXA group, but this concern should
continue to be investigated in higher-
powered studies. Current literature
supports the use of TXA in select
orthopaedic trauma patients and has
paved the way for large multicenter trials
to provide more insight into the role of
TXA in orthopaedic trauma.
Source of Funding
No external funds were received in
support of this study.
Cody R. Perskin, BA1,
Connor P. Littlefield, BA1,
Charles Wang, MD1,
Uchenna Umeh, MD1,
Kenneth A. Egol, MD1
1NYU Langone Orthopedic Hospital, New
York, NY
Email for corresponding author:
Kenneth.Egol@nyumc.org
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