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Replacement Registry (CJRR). 2004 report: total hip and total knee replacements in Canada. 2004. 6. Australian Orthopaedic Association. National Joint Replacement Registry annual report 2005. 2005. 7. Frankowski JJ, Watkins-Castillo S. Primary total knee and hip arthroplasty projections for the U.S. population to the year 2030. 2002. http://www.aaos.org/ wordhtml/research/stats/TJR_projections.pdf. Accessed 2004 Feb 20. 8. Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2003;85:27-32. 9. Bozic KJ, Katz P, Cisternas M, Ono L, Ries MD, Showstack J. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am. 2005;87:570-6. 10. Agency for Healthcare Research and Quality. NIS technical documentation. Rockville, MD: Agency for Healthcare Tranexamic Acid in Total Joint Arthroplasty: The Endorsed Clinical Practice Guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, The Hip Society, and The Knee Society Fillingham YA1 , Ramkumar DB2 , Jevsevar DS2 , Yates AJ3 , Sayeed SA4 , Sah AP5 , Bini SA6 , Clarke HD7 , Schemitsch E8 , Johnson RL9 , Memtsoudis S10, Della Valle CJ1 1 Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA 2 Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA 3 Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA 4 South Texas Bone and Joint Institute, San Antonio, TX, USA 5 Institute for Joint Restoration, Fremont, CA, USA 6 Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA 7 Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA 8 Department of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada 9 Department of Anesthesia, Mayo Clinic, Rochester, MN, USA 10Department of Anesthesia, Hospital for Special Surgery, New York, NY, USA Introduction Hip and knee arthroplasties are routine orthopaedic procedures commonly associated with acute postoperative anemia, and in many cases requires an allogeneic or autologous blood transfusion. Several techniques have been used to limit postoperative blood loss and risk of transfusion. Tranexamic acid (TXA) is an antifibrinolytic agent that has fundamentally changed blood management in total joint arthroplasty (TJA) by making transfusion an infrequent event. Although TXA is widely used in total hip arthroplasty (THA) and total knee arthroplasty (TKA), it has not yet become the standard of care. A significant body of literature has been compiled on the use of TXA in hip and knee arthroplasty but a comprehensive review and analysis of the existing evidence to provide clinical guidance is lacking. Therefore, The American Association of Hip and Knee Surgeons (AAHKS), The American Academy of Orthopaedic Surgeons (AAOS), The Hip Society (THS), The Knee Society (TKS) and The American Society of Regional Anesthesia and Pain Medicine (ASRA) have worked together to develop evidence-based guidelines on the use of TXA in primary TJA. The purpose of these guidelines is to improve the treatment of orthopaedic surgical patients and reduce practice variation by promoting a multidisciplinary evidence-based approach on the use of TXA. The combined clinical practice guidelines are meant to address common and important questions related to the efficacy and safety of TXA in primary TJA. Utilizing the AAOS Clinical Practice Guidelines and Systematic Review Methodology, the committee members completed a series of direct meta-analyses and network metaanalyses to support the clinical practice guidelines.1 For each question, we have provided a recommendation, assessed the strength of the recommendation, and elaborated on the rationale of the recommendation, which should be interpreted in accordance with the AAOS Clinical Practice Guidelines and Systematic Review Methodology. 1 The current clinical practice guidelines were based on the available evidence, so future updates may become necessary as additional literature becomes available with future research. Guideline Question 1: For patients undergoing primary TJA, what method of administration of TXA, compared to placebo, reduces the risk of transfusion and/or reduces blood loss? Response/Recommendation: Administration of intravenous (IV), topical, and oral TXA as well as combinations of individual formulations of TXA are all effective strategies when compared to placebo for reducing calculated blood loss and the need for transfusion during the perioperative episode of a primary TJA. Strength of Recommendation: Strong Rationale: The direct meta-analysis of one moderate quality and 82 high quality studies provided significant evidence for the ability of TXA to reduce the risk of blood loss and need for transfusion during the perioperative episode of primary hip and knee arthroplasties. 2, 3 Subsequent network meta-analysis supported the blood-sparing properties of TXA. 2, 3 Total Hip Arthroplasty Intravenous and topical TXA have been shown with limited
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