The Efficacy and Safety of Tranexamic Acid in Foot and Ankle Surgery: A Systematic Review and Meta- Analysis

Abstract

Category: Basic Sciences/Biologics; Other Introduction/Purpose: Tranexamic acid (TXA) use is increasing in Orthopedic practice specially among arthroplasty surgeons. It was proven to decrease the estimated blood loss and need for blood transfusion in hip, knee and shoulder arthroplasty as well as pelvis and acetabulum surgery. There was no reported increase risk of thromboembolic events with the use of TXA in orthopedic practice. This systematic review and meta analysis aimed on reporting on the available evidence on the use of TXA in foot and ankle surgery. Methods: The current meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electronic-based search on MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases to November 2021. Clinical studies on tranexamic acid use in foot and ankle surgeries reporting at least one of the desired outcomes; estimated blood loss (EBL), Hemoglobin difference between pre- and post-op, or complications were included. To assess risk of bias, the Joanna Briggs institute critical appraisal tool was used for case series and the Newcastle Ottawa scale for comparetive studies. The level of evidence was assigned according to the Cochrane Book Review Group. Results: A total of 718 foot and ankle procedures were included. Out of those, 491 (68.38%) procedures received tranexamic acid while 221 (31.64%) served as controls and did not receive tranexamic acid. In the TXA group, 34 (6.92%) procedures received local TXA injection in one study, while the remaining majority of 457 (93.08%) procedures received intravenous (IV) TXA. Among the control group, saline was used a placebo in 113 (51.13%) controls in 3 studies, while no placebo was used in the remaining 108 (48.87%) controls. The pooled mean EBL for the TXA group was 57.75 mL [95% CI: 44.80 to 70.70, I2 = 98.31%] while the pooled mean EBL for the control group was 299.26 mL [95% CI: 212.43 to 386.09, I2= 98.96%] with statistical significance Figure 1. No significant difference was found between the two groups in terms of change of hemoglobin and risk of thromboembolic events and other complications. Figure 2,3 Conclusion: This systematic review and metaanalysis showed that the use of TXA in foot and ankle surgery was safe with no increased risk in thromboembolic events. The lower risk of bleeding using TXA despite being stastically significant, did not reach clinical significance and did not affect the post operative hemoglobin level. TXA can be considered in foot and ankle surgery in special cases with higher risk of bleeding or in cases where the use of tourniquet is contraindicated.