Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty
These authors point out that revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. They hypothesized that the administration of tranexamic acid (TXA) during revision arthroplasty is protective against subsequent PJI.
They identified 1,731 patients who underwent aseptic revision; of these patients, 83 (4.8%) developed
PJI.
Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%.
In their multivariate analysis,
(1) preoperative anemia was independently associated with over a 2-fold increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003).
(2) antibiotic administration was independently associated with a reduced risk of PJI (OR, 0.25 [95% confidence interval (CI), 0.07 to 1.02]; p = 0.034).
(3) female sex was independently associated with a reduced risk of PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016).
(4) TXA administration was independently associated with a reduced risk of PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030).
Comment: It has not been suggested that tranexamic acid has antibiotic properties; instead the authors suggest, "It would stand to reason that, if one could limit blood loss and avoid the need for allogeneic blood transfusion, a reduction in infection may be possible." The question that remains to be answered is whether - in addition to the presence of preoperative anemia - blood loss and/or transfusion are indeed major risk factors for PJI.
There are some data that may be missing from the univariate analysis table as indicated below, especially the data related to blood loss and units of blood received (see yellow highlights).
If the data show that blood loss (rather than the use or non-use of TXA) drives the rate of periprosthetic infection, it may be the case that other anti-blood-loss steps (topical thrombin, careful coagulation, controlling intraoperative blood pressure) may be comparably effective in reducing PJI. Further studies are need to determine: (1) is PJI related to the amount of blood loss into the wound, to the amount of external blood loss (drains and soaked dressing), or to the resulting drop in the number of circulating red blood cells? (2) which has the stronger association with PJI, the estimated blood loss or the units of blood received? (3) should antibiotics be routinely administered in apparently "aseptic" revisions? and (4) is management of preoperative anemia effective in reducing PJI?
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