Efficacy and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

Total knee arthroplasty (TKA) often leads to substantial perioperative blood loss and postoperative hemoglobin decline, frequently requiring allogeneic transfusions. Tranexamic acid (TXA) effectively reduces bleeding, but debate persists regarding whether topical or intravenous (IV) administration provides superior clinical outcomes.This systematic review and meta-analysis evaluated the efficacy and safety of topical versus IV TXA in primary TKA using pooled data from randomized controlled trials (RCTs).

PubMed was searched for parallel-group RCTs comparing topical and IV TXA. Random-effects models analyzed continuous outcomes via standardized mean differences (SMDs) and dichotomous outcomes via relative risks (RRs) with 95% confidence intervals (CIs).

Eleven RCTs were included. Pooled analysis demonstrated no statistically significant differences between topical and IV TXA across all metrics. Postoperative hemoglobin drop (9 studies, 815 patients; SMD = -0.292, 95% CI: -0.748 to 0.163, P = 0.208), total blood loss (5 studies, 418 patients; SMD = 0.356, 95% CI: -0.297 to 1.009, P = 0.284), drainage volume (5 studies, 357 patients; SMD = 0.721, 95% CI: -0.394 to 1.836, P = 0.204), and transfusion rate (10 studies, 914 patients; RR = 0.644, 95% CI: 0.343 to 1.209, P = 0.171). Safety data were limited, as usable deep vein thrombosis (DVT) data were reported in only seven studies (with four studies not reporting or not stating thromboembolic/adverse event), and only a single DVT event was reported in the IV group.