Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. There are several Cochrane reviews relevant to hip or knee replacement surgery, covering a variety of interventions. In this podcast, Parag Raval, a trauma and orthopaedic surgeon, talks with Naomi Gibbs from the Systematic Review Initiative at NHS Blood and Transplant in Oxford, UK, who is one of the authors of the January 2024 review looking at the best medication to stop bleeding in people having this surgery.

Parag: Hello Naomi, first of all, could you tell us about the need for medication to prevent bleeding in people having a hip or knee replacement

Naomi: Hello Parag. Thanks. Well, hip or knee replacement surgery can cause significant blood loss so it's important to control this bleeding when having such major surgery. It can lead to many post-surgery patients developing anaemia, which makes them feel fatigued, weak, short of breath and in some cases may even be life-threatening. One way to manage this is to give the patient a blood transfusion, but this carries its own risk of complications. So, using medications to prevent blood loss during surgery might be a better option and has been shown to improve patient outcomes, decrease healthcare costs and preserve limited supplies of donated blood.

Parag: Ok, so what medications currently exist to prevent bleeding?

Naomi: There are several available and some have been more studied than others. We covered a whole range in the review, including antifibrinolytics, like tranexamic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non‐fibrin sealants. We also looked at studies comparing different doses, methods of administration and times of use, either before, during or after an operation. This was to help us find out whether any of the drugs could reduce blood loss and blood transfusions, and their optimal dose, route and timing.

Parag: Did you find the evidence you needed?

Naomi: Well, we found 102 randomised trials which matched our eligibility criteria. Of these, 90 studies reported the number of included participants, which totaled a little over 8400 people. The studies were from around the world, with the highest number coming from Europe and Asia. Most studies had tested tranexamic acid, administered intravenously, orally or topically, or using a combination of routes.

Parag: This sounds like one of the larger Cochrane reviews; what does all this evidence tell us and how confident are you in the results?

Naomi: Mainly, tranexamic acid was the most effective of the medications tested for controlling bleeding, and adults having hip or knee replacement surgery required fewer blood transfusions if they were given it.
However, we were not able to definitively draw conclusions on the best dose, route or timing and we're not confident about the evidence for some of the outcomes. Having said that, though, tranexamic acid given in higher doses using multiple methods of administration, such as orally and injected into the joint during surgery, may be more likely to prevent bleeding, and taking tranexamic acid orally is probably as effective at preventing a blood transfusion as injecting it straight into a vein.

Parag: What about any safety aspects? Are there any potential harms?

Naomi: Reassuringly, no. We didn't find evidence of any harms, even when tranexamic acid was used in higher doses.

Parag: Overall, what's your take-home message?

Naomi: Surgeons doing hip or knee replacements should consider using tranexamic acid, via multiple routes of administration, in higher doses or using oral tranexamic acid to prevent bleeding.

Parag: Thank you, Naomi. If people would like to read the review, how can they get hold of it?

Naomi: Thanks Parag. The review's available free online. If listeners go to Cochrane Library dot com and type 'medications to stop bleeding in hip or knee surgery' in the search box, they will see our review at the top of the list.