Tranexamic acid lowers transfusions and readmissions in high-risk total knee arthroplasty patients, but neurologic risks remain in patients with seizures or visual disturbances.

PURPOSE: Tranexamic acid (TXA) is widely used in total knee arthroplasty (TKA) to reduce perioperative blood loss and transfusions. However, its safety in high-risk patients remains uncertain. This study evaluates TXA's safety and efficacy in TKA patients with a history of (1) thromboembolic events, (2) renal failure, (3) atrial fibrillation, (4) seizures and (5) visual disturbances.

METHODS

A retrospective analysis of the US Collaborative Network within TriNetX examined TKA patients from 2017 to 2023 (n = 59,057). High-risk patients were categorised by preexisting risk factors and propensity-score matched into TXA and non-TXA groups. Postoperative outcomes, including thromboembolic events, transfusions, renal failure, seizures, visual disturbances, infections, revisions, readmissions and mortality, were compared using odds ratios (OR) with 95% confidence intervals (CIs).

RESULTS

TXA was associated with lower transfusion rates, revisions, readmissions and emergency visits across multiple risk groups. No increased risk of deep vein thrombosis (DVT) or (PE) was observed in patients with prior thrombosis, renal failure, or atrial fibrillation, though ischaemic stroke/transient ischaemic attack (TIA) was higher in those with prior thrombosis (5.6% vs. 3.9%, OR: 1.44, 95% CI: 1.24-1.68). Patients with seizures had higher rates of postoperative seizures (10.4% vs. 7.1%, OR: 1.53, 95% CI: 1.18-1.99) and pulmonary embolism (1.9% vs. 1.0%, OR: 2.02, 95% CI: 1.06-3.85). In those with visual disturbances, TXA was linked to increased postoperative seizures (0.9% vs. 0.4%, OR: 1.97, 95% CI: 1.21-3.19) and visual disturbances (4.2% vs. 3.3%, OR: 1.29, 95% CI: 1.07-1.57).

CONCLUSIONS

TXA reduced transfusions, readmissions and revisions in high-risk TKA patients without increasing DVT or PE risk, though there was a modest increase in stroke/TIA for patients with prior thromboembolism. However, higher postoperative neurologic complications in patients with seizures or visual disturbances warrant further investigation. While TXA can provide benefits across several outcomes, discretion is advised in patients with neurological risk factors to optimise safety.

LEVEL OF EVIDENCE: Level III retrospective cohort study.