Hemostatic effect of tourniquet combined with tranexamic acid in total knee arthroplasty: a network meta-analysis

BACKGROUND: There are various techniques to reduce blood loss in total knee arthroplasty (TKA), including the use of a tourniquet and tranexamic acid (TXA). In this study, we studied the combined effect of TXA with a tourniquet on blood loss in the setting of primary TKA. METHODS: Randomized controlled trials (RCTs) of nine treatment methods were included (placebo, intravenous [i.v.] TXA, topical TXA, i.v.-combined topical TXA, oral TXA, placebo + tourniquet, i.v. TXA +tourniquet, topical TXA + tourniquet, and i.v.-combined topical TXA + tourniquet). The patients were divided into eight groups according to the different treatment strategies, with 30 cases per group. The differences in the total blood volume, the number of patients transfused, the hemoglobin before and after the operation, and complications after the operation were compared. RESULTS: Totally 15 RCTs meeting our inclusion criteria were collected in this study. Compared with the placebo + tourniquet group, the i.v. TXA + tourniquet group displayed lower hemoglobin reduction value, pulmonary embolism (PE) incidence, total blood loss, and blood transfusion risk; the topical TXA + tourniquet group showed reduced PE incidence, total blood loss, and blood transfusion risk, and the i.v.-combined topical TXA and i.v.-combined topical TXA + tourniquet groups showed decreased total blood loss and lower blood transfusion risk. Retrospective clinical study results also demonstrated that the efficacy of i.v.-combined topical TXA was the best. CONCLUSIONS: Our meta-analysis indicates that i.v.-combined topical TXA provides a low total blood loss without increasing the blood transfusion risk in patients undergoing total knee replacement surgery.