Paper of the Week: Tranexamic acid is associated with reduced periprosthetic joint infection after primary total joint arthroplasty

Paper of the Week: Tranexamic acid is associated with reduced periprosthetic joint infection after primary total joint arthroplasty

ICM Philly September 29, 2020

Hamidreza Yazdi, Mitchell R Klement, Mohammed Hammad, Daisuke Inoue, Chi Xu, Karan Goswami, Javad Parvizi

The Journal of Arthroplasty 35.3 (2020): 840-844
DOI: 10.1016/j.arth.2019.10.029

Summary by: Christian Ong, B.A.

Periprosthetic joint infections (PJI) have an incidence rate of 1-2% following total joint arthroplasties (TJA) and are a costly and dangerous complication [1,2]. Considering that an estimated four million TJA’s will be performed annually in the United States by the year 2030, the number of patients who will, and are currently impacted by PJI is immense [3]. Indeed, PJI is one the primary motivators for TJA revisional surgeries, which will cost the US healthcare system an estimated $13 billion dollars in 2030 [4,5,6]. Two known risk factors for PJI include preoperative anemia and perioperative bleeding leading to allogenic blood transfusion [7,8]. Previous studies have found the antifibrinolytic drug tranexamic acid (TXA) to reduce incidences of these two risk factors [9,10].

In this study, Yazdi et al sought to investigate if TXA could successfully reduce incidences of PJI following primary TJA. Between January 2013 and June 2017, a total of 6,340 patients were identified who had undergone primary THA or TKA, who had at least 1 year follow-up data. This population was 46.2% males, had a mean age of 64.7 years, and mean follow-up time of 26.3 months. The cohort was split into two separate groups, 3,683 patients who had received intravenous single dose TXA 20-30 minutes prior to incision, and another 2,657 who did not. Over 90% of subjects were prescribed low dose aspirin for 4 weeks following surgery as an antithrombotic.

Unadjusted logistic bivariate analyses indicated the presence of rheumatoid arthritis, increased BMI, higher CCI, male gender, renal disease, liver disease, coagulopathies, longer hospital stays, longer surgical duration, and anemia to be risk factors for PJI. These same findings also found IV single-dose TXA, neuraxial anesthesia and simultaneous bilateral surgery to reduce PJI likelihood. Further, adjusted multivariate analyses confirmed that preoperative TXA was associated with lower incidences of PJI (OR=0.68, p=0.04), especially in nonanemic patients undergoing primary total hip arthroplasty.

This study found TXA to be effective in reducing rates of PJI following primary TJA. While mechanism of prevention is unknown, authors speculate linkage to lowered perioperative bleeding, and thus reduced need for allogenic transfusion with immunomodulation. However, as a retrospective study it is likely that the data was incomplete. Further limitations include the fact that subjects were not matched, and health records were sourced from a tertiary referral center that performed a low volume of TJA, preventing complete generalizability to other facilities. Future confirmational studies are potentially needed to supplement these findings.


  1. Kurtz, Steven M., et al. “Economic burden of periprosthetic joint infection in the United States.” The Journal of arthroplasty27.8 (2012): 61-65.
  2. Kurtz, Steven M., et al. “Prosthetic joint infection risk after TKA in the Medicare population.” Clinical Orthopaedics and Related Research® 468.1 (2010): 52-56.
  3. Kurtz, Steven, et al. “Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.” Jbjs 89.4 (2007): 780-785.
  4. Bozic, Kevin J., et al. “The epidemiology of revision total knee arthroplasty in the United States.” Clinical Orthopaedics and Related Research® 468.1 (2010): 45-51.
  5. Kurtz, Steven M., et al. “Reasons for revision of first-generation highly cross-linked polyethylenes.” The Journal of arthroplasty 25.6 (2010): 67-74.
  6. Bhandari, Mohit, et al. “Clinical and economic burden of revision knee arthroplasty.” Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 5 (2012): CMAMD-S10859.
  7. Akonjom, Mandus, et al. “General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections.” The Journal of arthroplasty 34.2S (2019): S147.
  8. Greenky, Max, et al. “Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection?.” Clinical Orthopaedics and Related Research®470.10 (2012): 2695-2701.
  9. Benoni, Goran, et al. “Does tranexamic acid reduce blood loss in knee arthroplasty?.” The American journal of knee surgery8.3 (1995): 88.
  10. Yang, Zhi-Gao, Wei-Ping Chen, and Li-Dong Wu. “Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis.” JBJS 94.13 (2012): 1153-1159.
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