Intertrochanteric fracture is a major type of hip fracture which incurs substantial blood loss because much muscles insertion involved around this region, great bone surface area is available for blood loss in the extracapsular fractures[15]. Especially for elderly and frail patients who receive surgical treatment (most of these patients associated with anemia), massive blood loss usually result in blood transfusion and a high risk of perioperative morbidity and mortality[16, 17]. TXA has been reported to reduce surgical blood loss effectively and safely[18], improve perioperative care for patients undergoing hip arthroplasty[11]. However, the data regarding its use in intertrochanteric fracture with PFNA, especially topical applications, is limited. Therefore, in the present study, we sought to determine whether topical application of TXA would reduce perioperative blood loss effectively and safely.
TXA, a synthetic amino acid analogue that can reduce the need for blood loss and transfusion for its characteristic of plasminogen inhibition[11, 12]. In selective knee and hip arthroplasty, the efficacy of TXA in reducing blood loss is generally accepted[19]. Some study has focused on intravenous TXA for bleeding management in intertrochanteric fracture patients with PFNA. It indicated that intravenous use of TXA perioperatively can reduce total and hidden blood loss[20]. We first reported the effects of topical application of TXA in intertrochanteric fracture patients with PFNA. Our data showed that the TBL reduce 30% (from 813 reduce to 566 mL) and the HBL reduce 31% (from 652 reduce to 447 mL) after treated with TXA topically during operation. Moreover, we also confirmed a obvious reduction in IBL (28%, from 168 reduce to 121 mL) and drainage (45%, from 202 reduce to 112 mL) in the study group. Our data indicated that topical application of TXA has equivalent or even better effects of controlling perioperative bleeding than intravenous TXA in intertrochanteric fracture patients with PFNA.
Only two literatures reported the effects of topical application of TXA in intertrochanteric fracture patients with short cephalomedullary nail, dynamic hip screw and barrel plate, but not PFNA. Drakos et al reported a randomized prospective trial in 200 intertrochanteric fractures treated with a short cephalomedullary nail[21]. The patients received 3 g of TXA in the subfascial plane and around the fracture site before wound closure. Their data showed a 43% reduction in transfusion requirements in the TXA group. Virani SR et al reported a randomized prospective trial in 137 intertrochanteric fractures treated with dynamic hip screw and barrel plate[22]. The patients received subfascial and intramuscular infiltration of 2 g TXA before wound closure. However, they found no significant differences of transfusion between the TXA and control group. These differences could be due to the different internal fixation methods, mode of application and the dosage of TXA. Our results is similar to Drakos et al report[21] and showed a 42.6% reduction in transfusion requirements in the study group. In consideration of administration before wound closure does not reduce intraoperative bleeding, we soaked TXA in the wound for 5 min after greater trochanter exposure and before wound closure. We confirmed a obvious reduction in IBL (28%, from 168 reduce to 121 mL). We found the similar approach was used recently in bleeding control of acetabular fractures and it was confirmed to reduce IBL effectively[23].
The potential increased risk of thromboembolic events was the primary concern when administering TXA because TXA promotes thrombosis by inhibiting fibrinolysis and increases thrombus mass[24]. Topical application has little or no systemic exposure of TXA and it can potentially avoid the complications of intravenous TXA. Our data showed that there were no significant differences in deep venous thrombosis, pulmonary embolism, myocardial infarction and cerebrovascular accident. These results were consistent with recent studies on the topical application of TXA in hip fractures[21, 22, 25]. Coagulation function was also evaluated and perioperative PT, INR, APTT and D-dimer were no significant difference between two groups in this study. There was one patient in each group was readmitted in one month after discharge for wound infection, and cured with antibiotics and dressing changes. We also found that topical use of TXA did not increase the risk of wound complications and mortality.
To our knowledge, this is the first study of topical application of TXA in intertrochanteric fracture patients with PFNA and propensity score matching was used to minimize selection bias. However, this was a retrospective study with a small number of patients. In addition, the optimal dosing and timing of TXA administration
is still controversial. Therefore, further prospective randomized controlled trial including larger sample sizes and different dosing and timing of TXA administration are warranted to confirm our findings.