Mitchell R. Klement, MD, Fortunato G. Padua, MD, William T. Li, BS, Max Detweiler, BS, and Javad Parvizi, MD, FRCS

The Journal of Bone and Joint Surgery. American Volume.
DOI 10.2106/JBJS.19.00925

Summary by Ahna J. Donahue, BA

Revision total joint arthroplasty (TJA) is common in the United states [1]. A frequent complication resulting from TJA is the occurrence of a periprosthetic joint infection (PJI) [2,3].  Infection complications are costly and increase the risk of morbidity. As such, surgical protocols that reduce the risk of PJI are essential. One proposed approach is the administration of Tranexamic Acid (TXA). Previous studies demonstrate that this blood clotting promoter limits blood loss during aseptic revision TJA, thus lowering the incidence of required postoperative blood transfusions [4,5]. Although blood transfusions are associated with increased risk of PJI, the effect of TXA treatment on PJI has not been evaluated. The present study by Klement et. al. sought to determine if the administration of TXA could effectively protect against the occurrence of postoperative PJI in patients undergoing aseptic revision arthroplasty.

The researchers identified 1,731 patients that underwent aseptic revision total hip arthroplasty or total knee arthroplasty between 2009 to 2018 at a single institute. Procedures were identified as aseptic if patients did not meet the Musculoskeletal Infection Society (MSIS) criteria for PJI. In addition, patients with a history of joint infection before revision were excluded from the study.  For analysis, the cohort was divided into two groups: those that received TXA (n=666 patients) and those who did not (n=1,065).  Patients that received TXA were given a single 1-g dose intravenously prior to incision.  Patients were also risk-stratified to receive chemoprophylaxis for venous thromboembolism and anticoagulated appropriately. 

In the combined cohort, 4.8% of patients were diagnosed with PJI after aseptic revision.  Pre-operative anemia was reported in 28.1% of patients.  The incidence of PJI in the group of patients who received TXA was 3.30%, which was significantly lower than the 5.73% (p=0.029) rate of PJI in the group  that did not receive TXA.  After controlling for confounding variables using multivariate regression, TXA remained an independent factor associated with a decreased risk of PJI (p=0.030).  Preoperative anemia was the only factor that increased the risk of PJI after revision TJA (p=0.003). However, the protective effect of TXA against PJI was observed across the entire range of measured pre-operative hemoglobin levels.

There is support for preoperative anemia as an identifiable risk factor for infection in primary and revision TJA [6]. However, TXA has consistently demonstrated the ability to limit blood loss and the need for allogenic blood transfusion [7,8].  In the present study, TXA was associated with a reduced risk of PJI within 90 days post-operatively after controlling for confounding variables.  Limitations of the study include its retrospective design and possible selection bias in TXA administration. In addition, the minimum follow-up for inclusion was 90 days and all patients came from a single institute. Blood management and its impact on PJI should be further studied across different practice settings with longer follow-up to confirm that the administration of TXA effectively reduces the occurrence of PJI after aseptic revision arthroplasty.

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