The Effect of Tranexamic Acid on the Outcome of Total Ankle Replacement 

SLR - March 2023 - Lee Tiberi, PGY1 

Title: The Effect of Tranexamic Acid on the Outcome of Total Ankle Replacement 

Reference: Ali M, Hassan A, Shah S, Rashid A, Naguib A. The Effect of Tranexamic Acid on the Outcome of Total Ankle Replacement. Cureus. 2022 Jul 9;14(7):e26706. doi: 10.7759/cureus.26706. PMID: 35959184; PMCID: PMC9360626. 

Level of Evidence: III 

Reviewed by: Lee Tiberi, PGY1 

Residency Program: Kent Hospital, Warwick, RI 

Podiatric Relevance: Total Ankle Replacement (TAR) is a rapidly developing facet of foot and ankle surgery with ever-expanding technological advancements and widening breadth of indications. With patient demand reacting accordingly, it is becoming increasingly important for foot and ankle surgeons to familiarize themselves with the most up-to-date methods of intra- and peri-operative management in order to optimize patient outcomes. While tranexamic acid (TXA) is typically used to prevent traumatic exsanguination, there is a growing body of evidence to support its use in elective orthopedic procedures. Further research into application for TAR may improve hemostasis and post-operative edema control thus decreasing risk of potential dehiscence complications.   

Methods: This is a retrospective study on 69 patients who underwent TAR with Integra and Cadence prosthetics (26 and 43, respectively) between September 2014 and December 2019. All procedures were performed by two foot and ankle surgeons from a single institution through an anterior approach. 33 patients received TXA prior to tourniquet inflation. No surgical drains were used. Primary outcome measures include pre- and post-operative hemoglobin levels, wound complications, and MOXFQ functional outcome scores.  

Results: Average pre- and post-operative hemoglobin levels for the non-TXA cohort were 13.8 and 12.7, respectively. Average pre- and post-operative hemoglobin levels for the TXA cohort were 13.8 and 12.8, respectively. No patients required post-operative transfusion. 8/36 patients in the non-TXA group developed wound complications: three cases of delayed healing, one case of deep infection requiring washout, two superficial infections which responded to oral antibiotics, and two cases of wound dehiscence (one requiring NPWT). 3/33 patients in the TXA group developed wound complications: two being wound dehiscence (one requiring NPWT) and one being superficial infection (resolved on oral antibiotics). There was a significant difference in post-op MOXFQ scores (13.96 and 21.98 for TXA and non-TXA groups, respectively) 

Conclusions: Data from this study demonstrated that there was no significant difference in intra-operative blood loss, however the TXA group had less reported wound complications with better MOXFQ functional outcome scores. The ankle joint is less accommodating to volume expansion given small intra-articular capacity and limited soft tissue coverage. Tourniquets provide adequate intra-operative hemostasis but the joint is subject to internal bleeding and hemarthrosis after it is deflated. Adding TXA may be an effective adjunctive therapy for maintaining post-operative hemostasis and ultimately controlling edema which, when unchecked, can often negatively impact soft tissue healing following TAR procedures.