Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background: Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study. Purpose: To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures. Study Design: Meta-analysis. Methods: A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis. Results: Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, –95.51 to −27.46; P = .0004), lower hemarthrosis grade ( P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (−1.96 points; 95% CI, −2.19 to −1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced ( P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups. Conclusion: The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.

Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…The meta-analysis published by Johns et al on the same topic, concluded that TXA improves early post-op drain output, hemarthrosis, pain scores, and knee ROM, without increasing the risk of complications, while being cost-effective and clinically effective. 18 Following the additional pooling of 3 new studies in this meta-analysis 15-17 , pain and knee function score improvements J o u r n a l P r e -p r o o f failed to achieve clinical significance leaving only hemarthrosis parameters as being clinically significant. Regarding the risk of complications, findings in this study were similar in that no adverse events were reported in any of the RCTs.…”

“…Regarding the risk of complications, findings in this study were similar in that no adverse events were reported in any of the RCTs. In terms of cost-effectiveness, none of the RCTs, included in either meta-analysis, objectively studied cost-effectiveness; therefore, this conclusion cannot be made at the current time and it is unclear how Johns et al made such a claim about cost 18 . While it is believed that TXA usage in ACLR is likely cost-effective, this is not yet proven.…”

“…The recently published systematic review and meta-analysis by Johns et al on this topic, which included 4 RCTs and one abstract, concluded that TXA improves early post-operative ROM, pain, and hemarthrosis. 18 Three new RCTs, which were not reviewed by Johns et al, had differing results; with some concluding no difference in outcomes. 15,17 Moreover, no recommendations exist in recently published guidelines on the use of TXA in ACLR [19][20][21] , which compels the need for an updated study examining the new evidence.…”

The Use of Lean Six Sigma Methodology in the Reduction of Patient Length of Stay Following Anterior Cruciate Ligament Reconstruction Surgery

“…These discussions included the reduction in the length of time for which the drain will be in situ, and the use of tranexamic acid and other types of pain relief best suited to day-case procedures, with the goal of optimal pain relief and recovery for our cohort of patients. Johns et al (2021) concluded from their study that the use of tranexamic acid in ACLR surgery results in reduced joint drain output and hemarthrosis, and improved pain scores and range of motion in the initial post-operative period, without complications or thromboembolic events [69]. The changes that were introduced because of these discussions led to earlier mobilisation and physiotherapy while ensuring pain was controlled, patient satisfaction was maintained, and ultimately earlier discharge times.…”

Editorial Commentary: The Current Evidence in Support of Tranexamic Acid in Arthroscopic Surgery Is Poor

“…Ó very recently published systematic review and metaanalysis included five trials for analysis. 7 The authors demonstrated a mean reduction in drain output of 61 mL within a 24-hour window postsurgery and improved Lysholm and visual analog pain scores, which extended to 6 weeks postsurgery and reduced the need for joint aspiration. 7 Alkhatib, AINouri, Abdullah, Alzobi, Alkaramany, Sasaki and Ishibashi have added three new randomized controlled trials and performed a new meta-analysis.…”