Utility Of Tranexamic Acid (TXA) In Foot And Ankle Surgery

By Jeffrey E. McAlister, DPM, FACFAS and Usman Urooj, DPM

The following is information on a drug I now utilize in complex hindfoot and ankle surgery, in particular total ankle arthroplasty, calcaneal fractures, pilon fractures and complex cartilage repair of the ankle.  My experience with this drug spans over 100 cases without complication. Read on to learn more about tranexamic acid and see if it could help your patients, as well.

What is Tranexamic Acid?

Tranexamic acid (TXA), available in oral, topical and IV forms, is a drug that belongs to the antifibronyltics drug class. It is used to treat or prevent excessive blood loss. TXA can be utilized to prevent prolonged bleeding in situations including, but not limited to: major trauma; postpartum bleeding; dental work; heavy menstruation; or surgery.¹

Clotting Cascade:

For your review, a helpful graphic outlining the clotting cascade is available here.

Degradation Pathway

plasminogen --> plasmin (activated by plasminogen)

fibrin -->  fibrin degradation products (activated by plasmin)

Mechanisms Of Action

Tranexamic acid is a synthetic analog of the amino acid lysine. It reversibly binds to lysine receptor sites on plasminogen, decreasing the conversion of plasminogen to plasmin. This then prevents fibrin breakdown, preserving Fibrin’s matrix structure, causing the blood clot to not dissolve. Thus, TXA prevents blood loss.¹

Facts About TXA

• Reaches peak plasma concentration one hour after IV injection, excreted renally with a half-life between 80 and 120 minutes.^2,3
• Blocks the body’s natural ability to dissolve blood clots and theoretically should increase potential for unwanted blood clot formation, possibly leading to pulmonary embolism (PE).
• However, the literature does not show that use of TXA in orthopedic surgery consistently elevates risk of deep vein thrombosis or PE.^4-7

Contraindications^4-7

• Seizure history, severe renal disease (Cr less than 30m/min), bleeding disorders
• Early pregnancy
• Major bleed in the upper urinary tract
• Acute conditions such as: DVT; PE; myocardial infarction and cardiovascular accident.

Why Is This Important In Foot And Ankle Surgery?

Use of TXA in foot and ankle surgery, especially in total joint arthroplasty, significantly reduces incidents of perioperative blood loss, need for blood transfusion and hospitals stays. In studies, these positive outcomes occurred without increased risk of DVT or PE.^5,8 Hemarthrosis following total ankle replacement can result in significantly elevated postop pain and reduced ankle range of motion. Use of TXA in orthopedic surgeries decreases postoperative drain output and resulted in significantly less postoperative hemarthrosis.^4-7 Less hemarthrosis resulted in better pain control.4-7 TXA use can also lead to decreased tourniquet time, which can in turn reduce tourniquet-associated postoperative pain.^4-7

Nodzo and colleagues in 2018 published their retrospective cross sectional study studying patients who underwent total ankle replacement with or without TXA administration.⁹ The group with TXA treatment had less drain output, less wound complications, and less mean change in preoperative to postoperative hemoglobin levels. They concluded that TXA may be an effective hemostatic agent when used in ankle arthroplasties and can aid in reducing perioperative blood loss, hemarthrosis and risk of wound complications.⁹

In 2015, Xie and team concluded that preoperative TXA may effectively reduce postoperative blood loss and wound complications in patients who underwent calcaneal fracture ORIF without added clinically significant side effects compared with a control group.¹⁰

Meta-analysis of studies on the use of TXA failed to show any significant increase in the risk of stroke, MI, PE, or DVT from its use.¹¹

In Conclusion

Intra- and postoperative hemostasis success tactics likely change over the course of one’s training, such as in my experience from drains, to wound or incisional negative pressure wound therapy (NPWT). I find that for these larger cases, where blood pooling postoperatively may present an issue with pain and possible hemarthrosis, infection, etc., TXA may assist in improving outcomes. My most common procedures where I use TXA include: total ankle arthroplasty; ankle fusion; subtalar joint fusion; tibiotalocalcaneal fusions; medial double arthrodesis; midfoot fusions; and any ankle and hindfoot trauma, especially calcaneal fractures. I will have anesthesia administer one gram of TXA prior to tourniquet elevation and one gram at the end of the case. Alternatively, I also found success when, instead of the second IV dose, I poured or placed it into the surgical wound directly. My experience has been nothing but positive and I have seen no adverse events or side effects. I have used it in conjunction with incisional NPWT or drains and haven’t seen a difference there. I do think there is utility to the use of this inexpensive and simple tactic in hindfoot and ankle cases.

Dr. McAlister is a fellowship-trained foot and ankle surgeon. He is in private practice and is the founder of the Phoenix Foot and Ankle Institute. (www.phoenixfai.com) One can reach Dr. McAlister at jeff.mcalister@phoenixfai.com.

Dr. Usman Urooj is a third-year resident program at the Carl T. Hayden Medical Center Podiatric Medicine and Surgery residency program, in Phoenix, Ariz.

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.

References

1. Johns WL, Walley KC, Jackson III B, Gonzales TA. Tranexamic acid and foot and ankle surgery. Foot Ankle Spec. 2021. Available at: https://doi.org/10.1177/1938640020983639 . Published January 6, 2021. Accessed April 30, 2021.

2. Andersson L, Nilsson IM, Niléhn JE, Hedner U, Granstrand B, Melander B. Experimental and clinical studies on AMCA, the antifibrinolytically active isomer of p-aminomethyl cyclohexane carboxylic acid. Scand J Haematol. 1965;2:230-247.

3. Eriksson O, Kjellman H, Pilbrant A, Schannong M. Pharmacokinetics of tranexamic acid after intravenous administration to normal volunteers. Eur J Clin Pharmacol. 1974;7:375-380.

4. Elwatidy S, Jamjoom Z, Elgamal E, Zakaria A, Turkistani A, El-Dawlatly A. Efficacy and safety of prophylactic large dose of tranexamic acid in spine surgery: a prospective, randomized, double-blind, placebo-controlled study. Spine (Phila Pa 1976). 2008;33:2577-2580.

5. Yang ZG, Chen WP, Wu LD. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty:a meta-analysis. J Bone Joint Surg Am. 2012;94:1153-1159.

6. Lozano M, Basora M, Peidro L, et al. Effectiveness and safety of tranexamic acid administration during total knee arthroplasty. Vox Sang. 2008;95:39-44.

7. Johns W, Patel N, Langstaff R, Vedi V. Tourniquet and tranexamic acid use in total knee arthroplasty. Orthop Proc. 2020;102-B

8. Konig G, Hamlin BR, Waters JH. Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty. J Arthroplasty. 2013;28:1473-1476.

9. Nodzo SR, Pavlesen S, Ritter C, Boyle KK. Tranexamic acid reduces perioperativ blood loss and hemarthrosis in total ankle arthroplasty. Am J Orthop (Belle Mead NJ). 2018;47(8). doi:10.12788/ajo.2018.0063

10. Xie B, Tian J, Zhou D. Administration of tranexamic acid reduces postoperative blood loss in calcaneal fractures: a randomized controlled trial. J Foot Ankle Surg. 2015;54:1106-1110.

11. Chornenki N, Um K, Mendoza P, et al. Risk of venous and arterial thrombosis in non surgical patients receiving systemic tranexamic acid: A systemic review and meta-analysis. Thrombosis Res. 2019;179:81-86.

12. Karaaslan F, Karaoğlu S, Yurdakul E. Reducing intra-articular hemarthrosis after arthroscopic anterior cruciate ligament reconstruction by the administration of intravenous tranexamic acid. Am J Sports Med. 2015;43:2720-2726.

13. Preis M, Bailey T, Jacxsens M, Barg A. Total ankle replacement in patients with haemophilic arthropathy: primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty. Haemophilia. 2017;23:e301-e309.

14. Liu W, Yang C, Huang X, Liu R. Tranexamic acid reduces occult blood loss, blood transfusion, and improves recovery of knee function after total knee arthroplasty: a comparative study. J Knee Surg. 2018;31:239-246.