| Part Ⅰ Quantifying perioperative hidden blood loss and investigating its influencing factors in elderly patients with intertrochanteric fracture treated with PFNA:A prospective studyObjective:We aimed to quantify perioperative hidden blood loss and investigate its influencing factors in elderly patients with intertrochanteric fractures undergoing proximal femoral nail antirotation(PFNA)fixation surgery.Methods:We prospectively collected the clinical data of 200 elderly patients with intertrochanteric fractures treated with PFNA systems in our hospital between December 1,2014 and August 31,2018.The intraoperative visible blood loss,blood transfusion rate,and pre-and postoperative hemoglobin levels as well as the general characteristics of the enrolled patients were recorded.A multiple linear regression analysis model(stepwise)was used to identify independent factors affecting perioperative hidden blood loss.Results:The mean perioperative hidden blood loss was 614.72± 368.14 mL,which accounted for 84.05%of the mean total perioperative blood loss(731.37±391.50 mL).The mean preoperative hidden blood loss was 368.33± 325.57 mL,which accounted for 50.36%of the mean total perioperative blood loss.Multiple linear regression analysis revealed that fracture types AO/OTA 31-A2.2 to A3.3,male sex,right-sided injury,and operation time>60 min were independently associated with increased pernoperative hidden blood loss.Tranexamic acid treatment was negatively correlated with perioperative hidden blood loss.Conclusion:Intertrochanteric fractures in elderly patients undergoing PFNA fixation surgery was associated with significant pernoperative hidden blood loss and anemia.Furthermore,there was persistent hidden blood loss before and after the surgery.Fracture types AO/OTA 31-A2.2 to A3.3,male sex,operation time>60 min were independently associated with increased perioperative hidden blood loss.Surgeons should carefully monitor hemoglobin levels both pre-and postoperatively and take measures timely to avoid anemia,and thereby improve surgical safety and postoperative rehabilitation.Shortening preoperative time may helps to reduce preoperative blood loss.Part Ⅱ Efficacy and safety of tranexamic acid for controlling bleeding during surgical treatment of intertrochanteric fracture in the elderly with PFNA:A randomized controlled trialObjective:The purpose of the present study was to evaluate the efficacy and safety of tranexamic acid in reducing blood loss in intertrochanteric fracture in the elderly undergoing PFNA fixation surgery.Methods:Consecutive eligible patients were recruited and randomly assigned to a tranexamic acid group or a control group.The tranexamic acid group received 15 mg/kg body weight of tranexamic acid intravenously 15 minutes before incision and the same dose 3 hours later.The control group received 100 mL of saline intravenously 15 minutes before incision.The efficacy outcomes included the total perioperative blood loss,postoperative transfusion rate,postoperative hemoglobin level,and length of hospital stay.The safety outcomes were the incidence of thrombotic events and the mortality rate within 6 weeks after surgery.Results:We had 44 patients in the tranexamic acid group and 46 patients in the control group for the final analysis.The tranexamic acid group had significantly lower total perioperative blood loss than the control group(384.5 ± 366.3 mL vs.566.2 ± 361.5 mL;P<0.020).Postoperative transfusion rate was 15.9%in the tranexamic acid group vs.36.9%in the control group(P = 0.024).Each group had 1 patients with postoperative deep venous thrombosis.In the control group,3 patients had cerebral infarction,and 1 patient died within 6 weeks after operation.Conclusion:Intravenous tranexamic acid is effective for reducing total perioperative blood loss and transfusion rate in intertrochanteric fracture in the elderly undergoing PFNA fixation surgery.No increased risk of thrombotic events was observed with the use of tranexamic acid;however,this study was underpowered for detecting this outcome.Further research is necessary before tranexamic acid can be recommended in high-risk patients.Part Ⅲ Efficacy and safety of tranexamic acid for reducing blood loss in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery:A meta-analysisObjectives:The aim of this study was to evaluate the efficacy and safety of tranexamic acid for reduce blood loss in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery.Methods:We searched MEDLINE,the Cochrane Library and EMBASE for published randomized clinical trials relevant to use of TXA in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery.Meta-analysis was performed according to the guidelines of the Cochrane Reviewer’s Hand book.Results:The pooled results showed that the mean total blood loss in tranexamic group was significant lower than that in the control group(mean difference-172.83 P<0.00001).The intra-and postoperative transfusion rate for the tranexamic group was 34.4%(91/264)and for the control group was 49.24%(136/276),with significant difference(P<0.03).The overall incidence of thrombotic events was 4.26%(7/164)in the intravenous tranexamic group group,and 5.71%(10/175)in the control group,with no significant difference(P = 0.56).Conclusion:The present evidence shows that TXA can significantly reduce total and hidden blood loss,transfusion rate,and do not increase the risk of thrombotic events in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery.However,the impact of TXA on thrombotic events needs to be researched in more high-quality,large-sample randomized clinical trials. |
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