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Tomasz Poboży

Tranexamic acid in total knee arthroplasty: intra-articular or peri-articular administration?

Autor:

Tomasz Poboży

Polish version: Kwas traneksamowy w endoprotezoplastyce kolana — podanie dostawowe czy okołostawowe?

A randomized trial conducted in Thailand suggests that a fixed 3 g intra-articular dose of tranexamic acid (TXA) may improve some bleeding outcomes compared with 10 mg/kg administered peri-articularly during primary total knee arthroplasty. The findings concern two specific local regimens and do not establish the best TXA strategy overall.

Why this study matters

TXA is widely used in knee arthroplasty, but protocols vary in route, dose and timing. Comparing a high fixed intra-articular dose with a weight-based peri-articular dose addresses a practical question: both can be administered during surgery, and a difference in transfusion requirements could be clinically relevant.

Study design

This prospective, assessor-blinded randomized trial allocated 80 patients undergoing primary unilateral total knee arthroplasty 1:1 to 3 g intra-articular TXA or 10 mg/kg peri-articular TXA. The co-primary outcomes were transfusion-adjusted calculated blood loss at 72 hours and red blood cell transfusion. Analysis followed the intention-to-treat principle.

Main results

  • Transfusion-adjusted calculated blood loss was lower with intra-articular administration: 537 ± 282 mL versus 754 ± 476 mL; mean difference 218 mL, 95% CI 43–393 mL; P = 0.019.
  • Transfusion was required in 3/40 patients (7.5%) in the intra-articular group and 11/40 (27.5%) in the peri-articular group. The relative risk for peri-articular versus intra-articular administration was 3.67 (95% CI 1.11–12.16; P = 0.037).
  • Unadjusted calculated blood loss, haematocrit decline and drain output were similar between groups.
  • The abstract reported no symptomatic deep vein thrombosis or pulmonary embolism.

Clinical interpretation for an orthopaedic surgeon

The most practical finding is the lower transfusion rate with 3 g intra-articular TXA. Several other bleeding measures did not differ, however, so the results were not uniformly favourable. They support further standardisation of local protocols rather than a universal preference for one administration route.

Limitations

  • With only 80 patients, the trial cannot reliably assess rare thromboembolic complications.
  • Two specific doses and local administration techniques were compared. The findings cannot be directly extrapolated to intravenous TXA, combined regimens or other doses.
  • The relatively high transfusion rate in the peri-articular group may also reflect local transfusion thresholds and population characteristics, which cannot be fully assessed from the public abstract.
  • The full text was not freely and legally available when the original summary was prepared.

Implications for practice

Local administration technique and dose deserve consideration within the overall blood conservation protocol for knee arthroplasty. This study does not show that 3 g intra-articular TXA should replace every other strategy or that it is safer regarding thromboembolic events; the trial was too small to answer the latter question.

References

1. Konarski W, Derczyński M, Poboży K, Domańska-Poboża J, Poboży T. Tranexamic Acid Use in Total Hip Arthroplasty for Avascular Necrosis: A Single-Center Experience. Journal of Clinical Medicine. 2025;14(10):3399. DOI: 10.3390/jcm14103399. 2. Plangsiri K, Phimolthares S, Kasemkijwattana C, Kongmalai P. High-dose intra-articular versus weight-based peri-articular tranexamic acid in primary total knee arthroplasty: a randomized controlled trial. The Knee. Published online 18 August 2026. DOI: 10.1016/j.knee.2026.104605. PMID: 42617482.

This summary is based on the publicly available abstract and publication metadata.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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