Evaluating Three Routes of Tranexamic Acid Administration in Total Hip and Knee Arthroplasty: A Nationwide Database Analysis in Taiwan.

BACKGROUND

Tranexamic acid (TXA) reduces perioperative blood loss, but comparative effectiveness and safety across administration routes remain uncertain. The authors evaluated topical, IV, and oral TXA in unilateral total hip and knee arthroplasty.

METHODS

Using Taiwan's national health insurance database (2012 to 2021), the authors identified patients undergoing unilateral arthroplasty and evaluated perioperative TXA use, erythrocyte transfusion, and adverse events within 60 days after discharge. Conditional logistic regression and six propensity score-matched comparisons were conducted: topical versus none, IV versus none, oral versus none, topical versus IV, topical plus 1.0 g IV versus topical alone, and IV plus 1.0 g topical versus IV alone.

RESULTS

Compared with no TXA, all routes were associated with lower transfusion risk (topical: risk ratio [RR], 0.45; 95% CI, 0.41 to 0.48; P < 0.001; IV: RR, 0.80; 95% CI, 0.79 to 0.84; P < 0.001; oral: RR, 0.82; 95% CI, 0.73 to 0.92; P = 0.007). Topical and IV TXA were associated with similar risk (RR, 1.09; 95% CI, 0.96 to 1.24; P > 0.999), and the combined use was not associated with a different risk compared with either route alone. Topical TXA was associated with the greatest reduction in predicted transfusion risk at low dose ranging from 0 to 3.0 g (-3,087 per 10,000 [-2,886, -3,276]). Overall, TXA use was not associated with increased venous thromboembolism (VTE), infections, or wound complications. A higher VTE incidence was observed with topical TXA in patients with previous vascular disease without pharmacologic prophylaxis, but this was not significant after adjustment for confounders. TXA was not associated with renal injury overall, but high-dose IV (greater than 3.0 g) or oral (greater than 8.0 g) TXA increased predicted risk (approximately 10%) in patients with preexisting renal disease.

CONCLUSIONS

TXA use was associated with substantial transfusion reduction without an overall increase in adverse events. No administration route or combination proved superior. Caution is warranted with higher-dose IV or oral TXA in patients with renal disease, and the association between topical TXA and VTE in high-risk patients merits further investigation.