Does Pre-Operative Tranexamic Acid Increase the Incidence of Thromboembolism in Primary Lower
Limb Arthroplasty? 251
post operative doses but with a therapeutic plasma con-
centration of 5 mg/l still present at 18 hours after a dose
of 10 mg/kg [17] we feel a single dose is adequate.
A single pre-operative bolus dose at induction has been
used in other studies [8] while other trials have combined
a pre-operative dose with intra-operative infusions or fur-
ther post operative doses [7,20].
Ralley used one 20 mg/kg dose of TA before skin in-
cision for THA or 10 minutes before tourniquet release in
TKA [8] while Orpen used 15 mg/kg of TA given IV at
the start of cement mixing in TKA [7].
Sukeik et al. [21] analysed 11 randomised controlled
trials with pre-operative doses that ranged from 10 mg/kg
to 30 mg/kg, the biggest proportion only using a single
bolus pre- operativel y .
The use of LMWH thromboprophylaxis for all our pa-
tients follows NICE guidance and is in keeping with Su-
deik’s [21] meta-analysis in which the majority of trials
used LMWH as chemical DVT prophylaxis.
Only patients who had a clinical DVT on examination
were investigated with a duplex ultrasound Scan. Clini-
cally suspected PE was investigated with CT Pulmonary
Angiography (CTPA). Dup lex ultrasound scan has a sen-
sitivity of 97% and a specificity of 98% for the d iagnosis
of DVT [22] while CTPA remains the gold standard for
the diagnosis of PE [23].
Our results have confirmed the VTE findings in other
published data. Tanaka et al. found no difference in DVTs
between a group receiving TA and their control [10]. Lo-
zano et al. [9] studying the effectiveness and safety of
TA reported on 414 p ts who had been examined clinical-
ly and by contrast venography. They showed a lower fre-
quency of clinically evident thromboembolic complica-
tions in the cohort treated with TA compared to those
without.
Sudeik et al. found no significant differences in DVT
or PE among the randomized controlled trials included in
the meta-analysis. All studies had patients in the inter-
vention group receiving IV TA and a control group recei-
ving placebo, another antifibrinolytic or no treatment
[21]. 9 out of the 11 trials used clinical evaluation as a
screen for DVT in symptomatic post operative patien ts in
keeping with our protocols for further investigation.
Orpen et al. used duplex ultrasound as an assessment
of the proximal deep venous system for DVT on all pa-
tients five days post TKA in their prospective trial of TA.
No patient developed clinical signs or symptoms of DVT
and there was no evidence of thromboembolism on du-
plex perfor med [7].
Benoni had 4 (9.3%) confirmed DVTs in 43 TKR pa-
tients treated with TA compared with 3 (7%) DVTs and
1 PE in their placebo group of the same number [2]. Al-
though a higher percentage of VTE events the difference
between the prophylactic and placebo groups remains
nonsignificant.
5. Conclusion
In summary, our report shows that the use of pre-ope-
rative tranexamic acid in primary total knee and hip re-
placement does not increase the incidence of DVT and
PE. TA can be integrated easily into routin e practice and
it would appear that the beneficial effects of reduced blood
loss, reduced transfusion requ irements and increased hae-
moglobin levels at discharge are not accompanied with
an increase in thromboembolic complications.
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