Published online Jun 6, 2019. doi: 10.12998/wjcc.v7.i11.1302
Peer-review started: January 23, 2019
First decision: January 27, 2019
Revised: February 15, 2019
Accepted: March 16, 2019
Article in press: March 16, 2019
Published online: June 6, 2019
Intertrochanteric fracture is a common type of injury, and nearly 30% of intertrochanteric fracture patients die in the first 12 mo, especially the elderly with limited activity. With the improvement of surgical methods, minimal invasive surgical therapy has significantly reduced trauma with reliable efficacy. Anyway, the overall blood loss volume may be much larger than that observed. Tranexamic acid has been widely used in reducing traumatic and surgical bleeding, however, the paucity of studies regarding its use in orthopedic trauma has limited its integration into this field, which may benefit most from tranexamic acid. The safety of tranexamic acid in this group has not achieved a consensus.
Recently, the impact of tranexamic acid on intertrochanteric fracture surgery has been controversial due to several studies. For instance, some studies reported that the association between tranexamic acid and intertrochanteric fracture was significant, while others reported the opposite conclusion.
To date, although several studies focus on the use of tranexamic acid in hip fractures, the results have been controversial and limited. Thus, in order to investigate and help determine the efficacy and safety of tranexamic acid administration in reducing bleeding and transfusion in elderly intertrochanteric fracture patients, we meta-analyzed the relevant literature regarding the potential risks and benefits of tranexamic acid in intertrochanteric fracture surgery.
We searched Medline and PubMed for the publications in English (up to October 2018), that focused on the effectiveness and safety of tranexamic acid on the intertrochanteric fracture. The Consolidated Standards of Reporting Trials 2010 Statement Checklist was used to assess the methodological quality of each study. Trials without and with heterogeneity were compared by fixed-effects analysis and random-effects analysis, respectively. For each study, odds ratio (OR) and 95%CI and mean differences and 95%CI were calculated for dichotomous and continuous outcomes, respectively. The Power and Sample Size Program software was used to calculate power and sample size. Stability of the results was assessed via sensitivity analysis.
After a detailed evaluation, eight independent randomized controlled trials with cumulatively 836 patients were included in the overall meta-analysis. Tranexamic acid treatment compared with the control group significantly reduced postoperative blood loss (95%CI, -20.83 to -7.93 mL, P < 0.0001), hidden blood loss (95%CI, -213.67 to -64.43 mL, P = 0.0003), and total blood loss (95%CI, -332.49 to -23.18 mL, P = 0.02) by weighted mean differences of -14.38, -139.05, and -177.83 mL, respectively. But no significant difference was observed between groups for analysis of intraoperative blood loss. The meta-analysis also proved that the usage of tranexamic acid in intertrochanteric fractures may not significantly increase the incidence of deep vein thrombosis. Allogeneic blood transfusion data showed that significantly fewer patients in the tranexamic acid group (42%) required transfusion than the control group (95%CI, 0.36 to 0.69; P < 0.0001).
Our study suggests the use of tranexamic acid in intertrochanteric fracture surgery significantly reduced the risk of hidden blood losses as well as the need for allogeneic transfusion, without increasing other complications, especially deep vein thrombosis, particularly for intravenous use. However, larger high-quality prospective trials are required to strengthen our conclusions, define the optimal regimen, and assess the safety and cost-effectiveness of tranexamic acid before its use is recommended in intertrochanteric fracture surgery.