The Journal of Arthroplasty 29 (2014) 24522456

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Topical Application of Tranexamic Acid in Primary Total Hip

Arthroplasty: A Randomized Double-Blind Controlled Trial
Chen Yue, MD, Pengde Kang, MD, Peiqing Yang, MD, Jinwei Xie, MD, Fuxing Pei, MD
Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China

a r t i c l e i n f o a b s t r a c t

Article history: So far, studies of topical tranexamic acid (TXA) in total hip arthroplasty (THA) were still lacking and
Received 10 February 2014 controversial. We conducted this randomized double-blind controlled trial which included 101 patients to
Accepted 24 March 2014 assess the effect of a high-dose 3 g topical TXA in THA. The results showed that 3 g topical TXA could
signicantly reduce transfusions from 22.4% to 5.7% (P b 0.05) without increasing the risk of deep vein
Keywords:
thrombosis (DVT), pulmonary embolism (PE) and other complications. In addition, topical TXA signicantly
topical
tranexamic acid
reduced total blood loss, reduced drain blood loss, and the drops of HB and HCT in topical TXA group were
transfusions lower than control group. We concluded that 3 g topical TXA was effective and safe in reducing bleeding and
blood loss transfusions in THA.
DVT 2014 Elsevier Inc. All rights reserved.
THA

Total hip arthroplasty (THA) is one of the most common orthopedic
operations which used for end-stage osteoarthritis and other hip
diseases such as osteonecrosis of the femoral head (ONFH). However,
THA was associated with a signicant amount of blood loss in some
cases and required allogenic blood transfusions subsequently. As
reported before, the transfusion rate of THA was 16%37% [1], which
might carry the risks of immunological reactions, volume overload,
infection, intravascular hemolysis, renal failure and even death [2,3].
Therefore, how to reduce bleeding and transfusions of THA has become
an important and urgent problem to be resolved for orthopedist.
So far, a large number of methods for controlling bleeding
transfusions were successfully used following THA, which included
autologous blood transfusion, intraoperative blood saving, hypoten-
sive anesthesia and so on [35].
As a kind of antibrinolytic agent, tranexamic acid (TXA) is a
synthetic amino acid, which is able to prevent plasminogen activation
and delay brinolysis [6,7] by blocking the lysine-binding sites of
plasminogen. It has been used successfully to reduce bleeding in
dental extraction, tonsillectomy, prostate surgery, heavy menstrual
bleeding, cardiac surgery and in patients with hemophilia [810].
For THA, although there were still controversial, numerous studies
have conrmed that intravenous tranexamic acid (IV-TXA) could
effectively reduce blood loss and transfusions in THA without
increasing the risk of DVT [1116]. However, comparing with IV-TXA,
a topical application has the advantages of easy to administer, providing
The Conict of Interest statement associated with this article can be found at
http://dx.doi.org/10.1016/j.arth.2014.03.032.
Reprint request: Fuxing Pei, MD, Department of Orthopedics, West China hospital,
Sichuan University, 37# Guoxue Road, 610041, Peoples Republic of China.
a maximum concentration of TXA at the bleeding site, and was
associated with little or no systemic absorption of the TXA [17], and so
far, there were only several studies [1720] that been reported to
evaluate the effect of topical application in THA and the high-quality
randomized controlled trials were especially lacking, the effect of
topical TXA in THA was unclear and controversial. Therefore, we
conducted this randomized double-blind controlled trial in order to
clarify the efcacy and safety of topical TXA in total hip arthroplasty.
Materials and Methods
This was a randomized, double-blind, placebo-controlled trail
which was registered and approved by the Institutional Review Board
of Sichuan University, West China Medical Center (No. 201302007).
Patients undergoing primary unilateral total hip arthroplasty for OA or
ONFH were considered appropriate for the study. The exclusion
criteria included patients who were receiving anticoagulant therapy,
patients with a history of hemophilia, deep venous thrombosis,
pulmonary embolism or ischemic heart disease and patients who
were allergic to tranexamic acid. From September 2013 to October
2013, a total of 174 patients were scheduled to have a primary
unilateral total hip arthroplasty in West China hospital, Sichuan
University. 137 were eligibility for our study after prescreening by
inclusion and exclusion criteria, but 34 patients rejected to partici-
pate. Then all the remaining 103 patients gave consent for the study
and were randomized into two study groups (52 patients in topical
TXA group and 51 patients in control group) by the method of opaque,
sealed envelopes. The patients, surgeons and nurses were blinded and
another non-related-research staff handed out the medications. Flow

http://dx.doi.org/10.1016/j.arth.2014.03.032
0883-5403/ 2014 Elsevier Inc. All rights reserved.

Downloaded for andromeda masako (andromeda72@yahoo.com) at Universitas Sumatra Utara from ClinicalKey.com by Elsevier on September 24, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 C. Yue et al. / The Journal of Arthroplasty 29 (2014) 24522456 2453

diagram of patients involved was listed in Fig. 1. (The detailed The total blood loss was calculated according to the Gross
description of withdrawals and drop-outs were listed in Result.) formula [21,22]:
All the operations were completed by one experienced orthopedic
surgeon and the whole operations were performed through the  
posterolateral approach, the prosthesis was a cementless acetabular Total blood loss PBV  Hctpre Hctpost =Hctave
cup and a cementless femoral stem. The method of anesthesia was Hctpre the initial preoperative Hct level
decided by anesthetists. We referred to and improved the methods Hctpost the Hct on the morning of the third postoperative day
described by Konig et al [20]: In topical TXA group, 3 g TXA in 150 mL Hctave the average of the Hctpre and Hctpost
saline was used at three points during the whole procedure of THA.
First, after the acetabular preparation, we used an gauze
PBV = the patient's blood volume (PBV, mL). It was assessed
(25 cm 25 cm, monolayer) which was full of 50 mL of the TXA
according to the formula of Nadler et al [23]:
solution to soak the acetabulum for three minutes, an cementless
PBV = k1 height (m) + k2 weight (kg) + k3; k1 = 0.3669,
acetabular component was then impacted. Then, after femoral canal
k2 = 0.03219, and k3 = 0.6041 for men; and k1 = 0.3561, k2 =
broach preparation, another gauze (25 cm 25 cm, monolayer) with
0.03308, and k3 = 0.1833 for women. If either reinfusion or allogenic
50 mL of the same concentration TXA was inserted in the femoral
transfusion was performed, the total blood loss is equal to the loss
canal for three minutes, and then the cementless femoral stem was
calculated from the change in Hct plus the volume transfused [22].
impacted. At last, the remaining 50 mL TXA uid was injected to the hip
We removed the drainage in the next morning after the operation,
joint after fascia closure. A drain was used and clamped for 30 minutes.
and then the postoperative blood loss in the vacuum collectors was
In the control group, the same method was used with the same dose of
recorded by nurses. Hemoglobin and hematocrit levels were tested
saline and clamped for 30 minutes too. The drainage was removed in
before the operation and on postoperative day one and day three
the next morning after the operation. All patients are given chemical
routinely. The postoperative hospitalization days and other compli-
thromboprophylaxis by low-molecular-weight heparin (LMWH) com-
cations were recorded carefully too.
bined with mechanical thromboprophylaxis by a leg pump.
The primary outcomes were the transfusion rate, the DVT and PE
Statistical Analysis
events. Blood Transfusion Protocol indicated when the hemoglobin
was less than 70 g/L or when the hemoglobin of a patient was more
All the data were analyzed by using SPSS version 19.0(SPSS Inc.
than 70 g/L but with a bad mental status, palpitation or pallor. Every
USA), Student-t test was used to analyze the normal distributed
patient was given ultrasound examination routinely for screening
numerical variable, such as total blood loss. If the numerical variable
DVT before they were discharged by senior ultrasound doctors and
was non-normal distribution or unequal variance, Wilcoxon Mann-
symptomatic DVT and PE were observed by follow-up for three
Whitney U test would be used; Pearson chi-square test or Fisher exact
months after the operation. The secondary outcomes were total blood
test was used to analyze the qualitative variable. A P-value 0.05 was
loss, drain blood loss, hemoglobin and hematocrit drop, postoperative
considered to be statistically signicant.
hospitalization days and other complications.

Results

Patients scheduled for THA From September 2013, all the 103 patients included were observed
(N=174) and followed-up, two patients in control group were out of touch and
were excluded for withdrawals and drop-outs. Thus, the data of 101
Excluded by inclusion
patients were analyzed at last. The baseline characteristics included:
and exclusion criteria
age, gender, height, weight, BMI, hip disease composition, basic
(N=37)
diseases, anesthesia method, the level of preoperative hemoglobin
and hematocrit. The baseline characteristics between the two groups
Eligible patients (N=137)
were listed in Table 1. There were no statistically signicant difference
between the two groups except the height and BMI (P b 0.05).
Rejected to participate
(N=34)
Table 1
Baseline Characteristics of the Two Groups.
Included and randomized
(N=103) Topical TXA Group Control Group P

Year 60.9 13.2 63.7 10.0 0.239

Gender(male/female) 21/31 18/31 0.707
Height (m) 1.63 0.072 1.66 0.072 0.030
Weight (kg) 64.53 9.33 63.49 9.10 0.573
BMI 24.4 3.1 23.1 2.7 0.025
Hip disease composition (OA/ONFH) 37/15 39/10 0.326
Topical TXA group (N=52) Control group (N=51) Hypertension 12/52 8/49 0.395
Diabetes mellitus 5 9 0.203
COPD 5 5 0.921
Anesthesia method (general/spinal) 43/9 44/5 0.302
Excluded for Preoperative HB(g/L) 134.27 9.26 135.47 11.16 0.557
withdrawals (N=2) Preoperative HCT (L/L) 0.400 0.033 0.410 0.038 0.378

BMI: Body mass index = Weight/Height2; OA: Osteoarthritis; ONFH: Necrosis of femoral
head; COPD: Chronic obstructive pulmonary disease; HB: Hemoglobin; HCT: Hematocrit
The value was presented as mean SD.
Analyzed (N=52) Analyzed (N=49)
Year, height, weight, BMI, preoperative HB and preoperative HCT were analyzed by
Student-t test. Gender, hip disease composition, hypertension, diabetes mellitus, COPD
and anesthesia method were analyzed by Pearson chi-square test.
Fig. 1. Flow diagram of patients involved. Signicant difference.

Downloaded for andromeda masako (andromeda72@yahoo.com) at Universitas Sumatra Utara from ClinicalKey.com by Elsevier on September 24, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
2454 C. Yue et al. / The Journal of Arthroplasty 29 (2014) 24522456

Table 2 Drain blood loss of two groups

The Primary Outcomes of Two Groups.
400
TXA Group Control Group P

Transfusions 5.7% (3/52) 22.4% (11/49) 0.021

Drain blood loss(ml)

DVT 1 0 1
300
PE 0 0 1

DVT: Deep vein thrombosis; PE: Pulmonary embolism.

Transfusions, DVT, PE were analyzed by Fishers exact test.
Signicant difference. 200

The Primary Outcomes 100

The primary outcomes including transfusion rate, DVT and PE

events. A total of 5.5 units red cells were given to three patients in 0

p
topical TXA group versus 11 patients who received 24.5 units red cells

ou

ou
gr

gr
in control group. The transfusion rate was signicantly lower in

ol
TX
topical TXA group than control group. One asymptomatic DVT was

tr
on
found by routine ultrasound examination in topical TXA group at the

third day after the operation and was cured nally, the difference
between study groups were not signicant. No symptomatic PE event
was found in both groups. The primary outcomes were showed in
Table 2.
The Secondary Outcomes
The mean total blood loss was (945.5 331.7) mL in tranexamic
acid group versus (1255.5 193.5) mL in control group, there was
statistical signicant difference between the two groups (P b 0.001).
The postoperative drain blood loss was signicantly less in the
patients who received topical TXA [(217.5 89.9) mL in TXA group
versus (296.9 109.0) mL in control group, P b 0.001]. The hemo-
globin and hematocrit drop in postoperative day one and day three
were signicantly lower in topical TXA group than in control group.
The difference of postoperative hospitalization days and other
complications between the two groups was not signicant. The
secondary outcomes were listed in Figs. 23 and Table 3.
Discussion
This was a high-quality randomized double-blind controlled trial,
the results revealed that a high-dose of 3 g topical application of TXA
could effectively reduce transfusions from 22.4% to 5.7% without
Total blood loss of two groups
1500
Total blood loss(ml)
C
Fig. 3. Drain blood loss. The histogram showed that drain blood loss in topical TXA
group was signicantly less than control group (Student-t test).
increasing the risk of DVT, PE and other complications in THA, in
addition, topical TXA was able to signicantly reduce total blood loss
by about 300 mL, reduce drain blood loss by about 80 mL and
signicantly reduce HB drop and HCT drop in postoperative day one
and day three, topical TXA was effective and safe for THA.
So far, studies on topical TXA in THA were still decient, therefore
the methods and effect of topical TXA application were unclear and
controversial. The main characteristics of current RCTs were reviewed
and listed in Table 4. We could see that 2 g of TXA application
reported by Joseph G. Martin et al [19] could improve but non-
signicant reduce the units of blood transfused compared to placebo,
however a total of 3 g topical TXA [20] could signicantly reduce
transfusions. In addition, a meta-analysis of topical TXA in total knee
arthroplasty (TKA) [24] concluded that a high dose of topical TXA
(N2 g) signicantly reduced transfusion requirements, which might
provide a reference of topical application in THA, and these were the
reasons that we used a total of 3 g topical TXA. We topically used TXA
at three different points, which was found effective in a prior study
[20] and at the same time, we also improved the method: we used
gauzes which were full of high-concentration TXA solution to soak the
acetabulum and femoral canal rather than the mentioned method of
bathing. The reason we referred to and improved this method was
that for THA, a large number of blood loss came from the steps of
acetabulum preparation and femoral canal broach preparation, and
thus this method we improved could make topical TXA be more

Table 3
1000 The Postoperative Hospitalization Days and Other Complications of the Two Groups.

TXA Group Control Group P

HB drop in postoperative day 1 (g/L) 28.29 8.85 41.5 6.39 b0.001

HB drop in postoperative day 3 (g/L) 40.02 9.74 53.27 4.79 b0.001
500
HCT drop in postoperative day 1 (L/L) 0.080 0.032 0.101 0.026 b0.001
HCT drop in postoperative day 3 (L/L) 0.112 0.031 0.144 0.019 b0.001
Supercial infection 1 0 1
Deep infection 0 0 1
Hematoma 0 0 1
0
Wound secretion 5 7 0.468
p

up

Postoperative hospitalization days 5.1 0.5 4.9 0.7 0.742

ou

ro
gr

HB: Hemoglobin; HCT: Hematocrit.

A

ol
TX

tr

HB and HCT drop in postoperative day 1 and day 3 were analyzed by Wilcoxon Mann-
on

Whitney U test. Postoperative hospitalization day was analyzed by Student-t test.

C

Wound secretion was analyzed by Pearson chi-square test. Supercial infection, deep
Fig. 2. Total blood loss. The histogram showed that total blood loss in topical TXA group infection, hematoma were analyzed by Fishers exact test.
was signicantly less than control group (Wilcoxon Mann-Whitney U test). Signicant difference.

Downloaded for andromeda masako (andromeda72@yahoo.com) at Universitas Sumatra Utara from ClinicalKey.com by Elsevier on September 24, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 C. Yue et al. / The Journal of Arthroplasty 29 (2014) 24522456
Table 4
The Main Characteristics of Related Topical TXA in THA RCTs.
Number
Author Time (TA/Control) Dose of TXA Intervention
Joseph [20] 2013 50(25/25) 2gTXA/ Intra-articular
100 mL NS injection before
joint closure
Konig [21] 2013 131(91/40) 3 g TXA/ Topically used at
100 mL NS three points
Sattar [18] 2013 161(80/81) Not Not mentioned
mentioned
targeted and make TXA play a role of anticoagulant and stopping
bleeding in acetabulum and femoral canal more sufciently and
effectively. Through our study, we could see that the effect of 3 g
topical TXA used in three points during the operation was satisfactory,
the method we used could effectively reduce bleeding by about
300 mL (24.7%) and signicantly reduce transfusions from 22.4% to
5.7%. Therefore, we could conclude that 3 g topical TXA used in three
points was effective in THA.
Comparing with application of intravenous tranexamic acid (IV-TXA)
in THA, topical TXA was considered with little or no systemic
absorption of the TXA, therefore, topical TXA could avoid the
potential complications of intravenous tranexamic acid administra-
tion [17]. However, we were not sure if topical TXA could carry the
similarly good results in reducing bleeding and transfusions with
intravenous tranexamic acid as related studies were too lacking.
Only one study reported by Wind et al [18] compared the effect
between topical TXA and IV-TXA, and they concluded that IV-TXA
was a more predictable route of administration for maximum
efcacy than topical TXA, but Winds study was retrospective, so
the strength of evidence was not satisfactory and the conclusion
might have bias. The results of this study showed that the risk
difference of transfusions was about 17%, and a high-quality meta-
analysis, which included 11 RCTs reported by Sukeik [10] showed
the risk difference of transfusions was about 20% when IV-TXA was
used in THA. So a topical dose of 3 g topical TXA might have the
similar effect with IV-TXA for transfusions. In addition, the reduction
of total blood loss was also similar between our RCT and Sukeiks
meta-analysis (about 300 mL of total blood loss reduction in our study
versus 289 mL in Sukeiks study). So these results gave us a reference
that a high-dose topical TXA might be as effective as IV-TXA in THA.
We thought the safety was very important and should be focused
on when we used TXA in THA, therefore the primary outcomes we
chose included DVT and PE events. So far TXA has been used in THA for
more than 10 years, large clinical studies [1020] and several meta-
analyses [10,28] on TXA in THA had conrmed the safety of TXA, that
TXA would not increase the risk of thrombo-embolism and mortality.
In our study, the results also showed that there were no signicant
difference of thrombo-embolism events and other complications
between topical TXA group and control group. Therefore, we trusted
that topical TXA was safe in THA. However, some potential
dangerousness of TXA may exist and just has not been claried yet,
more articles were needed to evaluate the safety of TXA.
Several studies [22,25,26] have proved that the hidden blood loss
was always huge in surgery and thus the total blood loss was always
underestimated by clinical methods of calculating blood-soaked
gauzes, suction bottles and the vacuum drain [17,26]. Therefore, we
used Gross formula to evaluate the amount of total blood loss which
was based on the hematocrit level and we thought the result we got
was more accurate than clinical methods.
The strengths of this study were obvious. First, this was a
randomized controlled trial which was designed and performed
carefully and strictly, the level of evidence was the highest Level I. So
Downloaded for andromeda masako (andromeda72@yahoo.com) at Universitas Sumatra Utara from ClinicalKey.com by Elsevier on September 24, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
2455
Drainage Blood Transfusion Protocol DVT Prophylaxis Primary Outcomes
No drains Symptomatic hypotension + Mechanical + warfarin Improve but non-signicant
HB b7 g/dL (in hospital) and aspirin reduce transfusions
(out of the hospital)
clamping Hb b8 g/L + clinical Not mentioned Transfusions decreased
for 1 h symptoms dramatically from 15% to 1%
Not HB b7 g/dL; HB b8 g/dL + Mechanical and Signicantly reduced the
mentioned tolerated anemia poorly; mechanical + LMWH risk of transfusions by 19.6%
7 g/dl b HB b 10 g/dL + when BMI N30 kg/m2
clinical symptoms
the bias was miniature. Second, the transfusion protocol was explicit
which made the primary result of transfusion rate convincing. Third,
ultrasound examination was routine for every patient, we trusted our
result of detecting DVT by using ultrasound was accurate for two
reasons: (1) So far the literatures [2931] had conrmed the accuracy
of ultrasound to detect DVT, for example Barnes et al [29] showed that
duplex scanning had an accuracy of 97% when venography was
considered as the gold standard. (2) Our hospital was the largest
medical center in West China, our ultrasound doctors were experi-
enced and all the patients in our study were detected by senior
ultrasound doctors, so the result was credible. In addition, the three-
month follow-up period was thought to be adequate to identify
known adverse events [18]. At last, we improved the method of
topical TXA application, and it was proved effective in reducing
bleeding and transfusions.
The main limitation of this study was that a large number of blood
clots formed in local area after TXA gauze was used to soak the
acetabulum whereas there were no obvious blood clots formed in
control group, this might be found by surgeon and nurses. So although
the surgeon and nurses were blinded, the strength of blinding might
weaken. In addition, our method increased the duration of surgery by
about six minutes, which might theoretically make the risk of
infection higher [27]. However, in fact, the results of our study
showed the rate of infection and other complications were very low.
We didnt think these limitations would affect the results seriously.
Conclusions
In conclusion, a dose of 3 g topical TXA could signicantly reduce
bleeding and transfusions in primary THA without increasing the risk
of DVT and PE, it was effective and safe in THA. However, as the
related reports on topical TXA in THA are still lacking and some
potential dangerousness of TXA may exist, more high-quality
randomized controlled trials are needed to establish the efcacy and
safety of topical TXA in THA.
References
1. Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of blood management in
patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81(1):2.
2. Kumar A. Perioperative management of anemia: limits of blood transfusion and
alternatives to it. Cleve Clin J Med 2009;76(4):112.
3. Cardone D, Klein AA. Perioperative blood conservation. Eur J Anaesthesiol
2009;26:722.
4. Lemaire R. Strategies for blood management in orthopaedic and trauma surgery [J].
J Bone Joint Surg (Br) 2008;90:1128.
5. Claeys MA, Vermeersch N, Haentjens P. Reduction of Blood Loss with Tranexamic
Acid in Primary Total Hip Replacement Surgery. Acta Chir Belg 2007;107:397.
6. Hoylaerts M, Lijnen HR, Collen D. Studies on the mechanism of the antibrinolytic
action of tranexamic acid. Biochim Biophys Acta 1981;673(1):75.
7. Singh J, Ballal MS, Mitchell P, et al. Effects of tranexamic acid on blood loss during
total hip arthroplasty. J Orthop Surg 2010;18(3):282.
8. Dahl OE. The role of the pulmonary circulation in the regulation of coagulation and
brinolysis in relation to major surgery. J Cardiothorac Vasc Anesth 1997;11:322.
2456 C. Yue et al. / The Journal of Arthroplasty 29 (2014) 24522456
9. Reid RW, Zimmerman AA, Laussen PC, et al. The efcacy of tranexamic acid versus
placebo in decreasing blood loss in pediatric patients undergoing repeat cardiac
surgery. Anesth Analg 1997;84:990.
10. Sukeik M, Alshryda S, Haddad FS, et al. Systematic review and meta-analysis of the
use of tranexamic acid in total hip replacement. J Bone Joint Surg 2011;21:869.
11. Benoni G, Fredin H, Knebel R, et al. Blood conservation with tranexamic acid in total
hip arthroplasty: a randomized, double-blind study in 40 primary operations. Acta
Orthop Scand 2001;72:442.
12. Husted H, Blnd L, Sonne-Holm S, et al. Tranexamic acid reduces blood loss and
blood transfusions in primary total hip arthroplasty: a prospective randomized
double-blind study in 40 patients. Acta Orthop Scand 2003;74:665.
13. Lemay E, Guay J, Ct C, et al. Tranexamic acid reduces the need for allogenic red
blood cell transfusions in patients undergoing total hip replacement. Can J Anaesth
2004;51:31.
14. Johansson T, Pettersson LG, Lisander B. Tranexamic acid in total hip arthroplasty
saves blood and money: a randomized, double-blind study in 100 patients. Acta
Orthop 2005;76:314.
15. Yamasaki S, Masuhara K, Fuji T. Tranexamic acid reduces blood loss after cementless total
hip arthroplastyprospective randomized study in 40 cases. Int Orthop 2004;28:69.
16. Ido K, Neo M, Asada Y, et al. Reduction of blood loss using tranexamic acid in total
knee and hip arthroplasties. Arch Orthop Trauma Surg 2000;120:518.
17. Alshryda S, Mason J, Sarda P, et al. Topical (Intra-Articular) Tranexamic Acid
Reduces Blood Loss and Transfusion Rates Following Total Hip Replacement A
Randomized Controlled Trial (TRANX-H). J Bone Joint Surg Am 2013;95:1969.
18. Wind TC, Bareld WR, Moskal JT. The Effect of Tranexamic Acid on Transfusion Rate
in Primary Total Hip Arthroplasty. J Arthroplasty 2014;29(2):3879.
19. Martin JG, Cassatt KB, Kincaid-Cinnamon KA, et al. Topical Administration of
Tranexamic Acid in Primary Total Hip and Total Knee Arthroplasty. J Arthroplasty
2013. http://dx.doi.org/10.1016/j.arth.2013.10.005.
Downloaded for andromeda masako (andromeda72@yahoo.com) at Universitas Sumatra Utara from ClinicalKey.com by Elsevier on September 24, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
20. 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.
21. Gross JB. Estimating allowable blood loss: corrected for dilution. Anaesthesiology
1983;58:277.
22. Liu X, Zhang X, Chen Y, et al. Hidden Blood Loss After Total Hip Arthroplasty.
J Arthroplasty 2011;26(7):11005.e.1.
23. Nadler SB, Hidalgo JU, Bloch T. Prediction of blood volume in normal human adults.
Surgery 1962;51:224.
24. Panteli M, Papakostidis C, Dahabreh Z, et al. Topical tranexamic acid in total knee
replacement: A systematic review and meta-analysis. Knee 2013;20:300.
25. Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee
arthroplasty. J Bone Joint Surg (Br) 2004;86-B:561.
26. Eipe NP, Ponniah M. Perioperative blood loss assessmenthow accurate? Indian J
Anaesth 2006;50(1):35.
27. Urguhart DM, Hanna FS, Brennan SL, et al. Incidence and risk factors for deep
surgical site infection after primary total hip arthroplasty: a systemic review.
J Arthroplasty 2010;25(8):1216.
28. Zhou XD, Tao LJ, Li J, et al. Do we really need tranexamic acid in total hip
arthroplasty? A meta-analysis of nineteen randomized controlled trials. Arch
Orthop Trauma Surg 2013;133:1017.
29. Barnes CL, Nelson CL, Nix ML, et al. Duplex scanning versus venography as a
screening examination in total hip arthroplasty patients. Clin Orthop Relat Res
1991(271):180.
30. Grady-Benson JC, Oishi CS, Hanson PB, et al. Routine postoperative duplex
ultrosonography screening and monitoring for the detection of deep vein
thrombosis. Clin Orthop Relat Res 1994;307:130.
31. Tremaine DM, Choroszy CJ, Menking SA. Deep vein thrombosis in the total hip
arthroplasty patient after hospital discharge. J Vase Tech 1992;16:23.