postoperative blood loss of intertrochanteric fracture: a meta-analysis

doi:10.3969/j.issn.2095-4344.1268

Abstract

Abstract:

BACKGROUND: Tranexamic acid has been widely used in joint arthroplasty, which not only reduces perioperative blood loss, but also does not increase the risk of venous thrombus. It is reported that the use of tranexamic acid in the surgery of intertrochanteric fractures has similar effects. However, these studies are small-sample trials, and the results are still controversial. It is necessary to systematically evaluate and analyze the clinical researches about the tranexamic acid on reducing the intraoperative and postoperative blood loss of intertrochanteric fracture.

OBJECTIVE: To investigate the effectiveness and safety of tranexamic acid for reducing the intraoperative and postoperative blood loss of intertrochanteric fracture.

METHODS: PubMed, Cochrane Library, EMbase, CBM, CNKI, VIP and WanFang databases were searched for the randomized controlled trials and prospective cohort studies addressing tranexamic acid reducing intraoperative and postoperative blood loss of intertrochanteric fracture from inception to October 5, 2018. The literature selection, data extraction, and evaluation of bias risk of the studies were performed independently by two authors. Meta-analysis was conducted using RevMan 5.3 software.

RESULTS AND CONCLUSION: Thirteen studies were enrolled, including 12 randomized controlled trials and 1 prospective cohort, involving 1 353 cases of intertrochanteric fracture (676 in tranexamic acid group, and 677 in placebo group). Meta-analysis results showed that compared with the placebo group, tranexamic acid applied in the surgery of intertrochanteric fractures, could significantly reduce the intraoperative and postoperative total blood loss (MD=-228.92, 95%CI: -300.93 to -156.91, P < 0.000 01), intraoperative blood loss (MD=-23.74, 95%CI: -40.91 to -6.56, P=0.007), the hidden blood loss (MD=-153.36, 95%CI: -179.21 to -127.50, P < 0.000 01) and increase the postoperative hemoglobin (MD=6.9, 95%CI: 5.44 to 8.44, P < 0.000 01), hematocrit levels (MD=1.44, 95%CI: 0.86 to 2.03, P < 0.00001) and reduce the postoperative blood transfusion rate (OR=0.48, 95%CI: 0.36 to 0.63, P < 0.000 01). Additionally, tranexamic acid did not increase the postoperative D-dimer levels (SMD=-0.13, 95%CI: -0.58 to 0.32, P=0.57), or the incidence of venous thrombosis (OR=1.41, 95%CI: 0.79 to 2.52, P=0.24). Tranexamic acid made no effect on the operation time (MD=-0.16, 95% CI: -1.31 to 1.00, P=0.79) and postoperative mortality (OR=1.61, 95%CI: 0.78 to 1.33, P=0.2). These results indicate that it is safe and effective to use tranexamic acid for reducing intraoperative and postoperative blood loss of intertrochanteric fracture. However, multi-center large-sample randomized controlled trials are required to confirm the conclusions, because of limitations in study counts and quality.

Key words: tranexamic acid, intertrochanteric fracture, randomized controlled trials, prospective cohort study, total blood loss, intraoperative blood loss, blood transfusion, venous thrombosis, meta-analysis

CLC Number:

R459.9|R605|R318

Zhong Yanchun, Liu Lulin, Xiao Jianhua, Ouyang Xunyan, Huang Weimin, Liu Wuyang. postoperative blood loss of intertrochanteric fracture: a meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(28): 4584-4592.

Figures/Tables 7

2.3 Meta分析结果 2.3.1 术中及术后总失血量共纳入9个研究[8，10. 12-13，15-19]，包含氨甲环酸组患者412例，对照组414例。异质性检验结果显示，存在明显异质性(P < 0.000 01，I2=81%)，故采用随机效应模型进行合并。结果显示，氨甲环酸组总失血量少于对照组(MD=-228.92，95%CI：-300.93至-156.91，P < 0.000 01)，见图2。考虑到异质性明显，进行文献逐一剔除进行敏感性分析，结果显示剔除林锦秀2016年的研究文献时，异质性检验结果为(P < 0.06，I2=47%)，Meta分析结果为(MD=-243.86，95%CI：-302.12至-185.6，P < 0.000 01)。重新检查该研究的对象、干预措施、对照措施和研究结果等，未发现其他临床异质性。考虑到剔除该文献前后，Meta分析结果比较稳定，因此采用不剔除随机效应模型检验结果。 2.3.2 血栓形成发生率共纳入10个研究[7-8，11-13，15-19]，包含氨甲环酸组患者529例，发生血栓形成28例；对照组527例，发生血栓形成20例。异质性检验结果显示，无异质性(P=0.81，I2=0%)，故采用固定效应模型进行合并。结果显示，两组术后血栓形成无差异(OR=1.41，95%CI：0.79-2.52，P=0.24)，见图3。 2.3.3 术中出血量有8个研究报道了术中出血量指标[8、10、12、13、15-17、19]，氨甲环酸组患者348例，对照组352例。异质性检验结果显示，存在明显异质性(P < 0.000 1，I2=80%)，故采用随机效应模型进行合并。结果显示，氨甲环酸组术中出血量少于对照组(MD=-23.74，95%CI：-40.91至-6.56，P=0.007) ，见图4。考虑异质性较大，根据氨甲环酸给药途径不同进行亚组分析，结果显示，各小组异质性明显缩小，术前静脉给药组减少术中出血量疗效更佳(MD=-28.47，95%CI：-39.19至-17.74，P < 0.000 01)，术中局部给药组出血与对照组无显著差异(MD=1.94，95%CI：-3.50-7.38，P=0.49)，见图5。 2.3.4 隐性失血量共纳入7个研究[8，10，13，15-17，19]，包含氨甲环酸组患者315例，对照组313例。异质性检验结果显示，研究不存在明显异质性(P=0.08，I2=47%)，故采用固定效应模型进行合并。结果显示，氨甲环酸组术后隐性失血量少于对照组(MD=-153.36，95%CI：-179.21至-127.50，P < 0.000 01)，见图6。 2.3.5 输血率共纳入10个研究[7-8，11-13，15-19]，包含氨甲环酸组患者546例，对照组547例。异质性检验结果显示，无异质性(P=0.73，I2=0%)，故采用固定效应模型进行合并。结果显示，氨甲环酸组的输血率少于对照组(OR=0.48，95%CI：0.36-0.63，P < 0.000 01)，见图7。"

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