Comparison Of Different Routes Of Administration Of Tranexamic Acid In Total Hip Arthroplasty: A Network Meta-analysis

Background:Total hip arthroplasty(THA)is often accompanied by massive blood loss,which may result in anemia and blood transfusion.Currently,tranexamic acid(TXA),as an effective antifibrinolytic drug,is widely used to reduce perioperative blood loss.Although many studies have demonstrated that the application of TXA in different routes of administration in primary THA is effective in reducing blood loss and transfusion rate,and does not increase the risk of thrombotic events.However,in the existing research,there is a lack of sufficient and strong evidence to prove which route of administration is the most effective and safest.Purpose:The purpose of this study was to specifically review the role of different routes of administration of TXA in THA,in order to better explore the efficacy and safety of TXA in primary THA,as well as the most effective and safe medication regimen.Materials and Methods:Searches were conducted through Pub Med,Embase,and Cochrane Library databases,and publications were published until October 2021.Included studies were randomized controlled trials(RCTs)comparing different routes of TXA administration or placebo prophylaxis in THA patients.Two researchers independently conducted article searches,screening,and data collection.Included outcome measures were total blood loss,transfusion rate,incidence of deep vein thrombosis(DVT),and incidence of pulmonary embolism(PE).We performed a pooled analysis of the data using a combination of traditional direct comparisons and network meta-analysis.The effect size of the continuous variable(total blood loss)was calculated as the mean ± standard deviation(SD),and the weighted mean difference(WMD)and 95%confidence interval(CI)were analyzed;Calculation of effect sizes for categorical variable(transfusion rate,DVT incidence,PE incidence),hazard ratios(RR)and 95% confidence intervals(CI)were analyzed.We performed a random-effects network meta-analysis using a frequentist approach,using cumulative ranking curves(SUCRA),draw a ranking probability map,rank the effects of each intervention according to the surface area under the corresponding curve,and find the best intervention.Quality assessment of each study was carried out using the Cochrane Collaboration tool.All data analyses were performed using Stata16.0 software or Review Manager 5.3 software.Result:A preliminary search identified 814 articles,and 44 RCTs were finally included,involving a total of4506 patients.Regarding the effectiveness of TXA,all routes of TXA administration can effectively reduce total blood loss and transfusion rate compared with placebo;Regarding the safety of TXA,there were no statistically significant differences in the incidence of DVT and PE between all routes of administration of TXA compared with placebo.Therefore,the use of TXA does not present any significant safety concerns through this study.For the exploration of the best medication regimen for TXA,intravenous combined topical medication ranked first in terms of reducing total blood loss(MD=-416.36,95 % CI:[-501.57,-331.15])and reducing blood transfusion rate(RR=0.11,95%CI:[0.05,0.26]),with SUCRA values of98.5% and 98.7%,respectively;Topical medication was significantly associated with the incidence of DVT(RR=0.89,95%CI: [0.41,1.93])and PE(RR=1.03,95%CI: [0.4,2.62]),except for placebo,safety ranked first relative to other interventions,with SUCRA values of 70.6% and 54.3%,respectively.Conclusion:In primary THA,any route of TXA administration was effective in reducing total blood loss and transfusion rates without increasing the risk of thrombotic events.Regarding the optimal route of administration of TXA,intravenous combined with topical drug is the most effective drug regimen in reducing total blood loss and transfusion rate;Topical alone is the safest regimen in terms of the incidence of DVT and PE,and we recommend it for patients at higher risk of thrombosis.