Efficacy and Safety of Intraosseous Regional Versus Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Trial
In brief
Intraosseous tranexamic acid cut calculated blood loss by 143 mL after knee replacement
In this 98-patient randomized trial, intraosseous tranexamic acid reduced calculated blood loss by about 143 mL compared with intravenous dosing and preserved hemoglobin better on postoperative days 2 and 3; no patient needed a transfusion. Deep vein thrombosis was detected in 10% versus none, a possible safety signal that larger trials must clarify.
- Journal
- JB & JS open access (Q1)
- Published
- 15 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Shuaifei Tian, Baochao Ji, Yicheng Li, Xiaogang Zhang, Guoqing Li, Boyong Xu, et al.
- PMID
- 42857797
- DOI
- 10.2106/JBJS.OA.26.00282
Why clinicians should know about it
- Picked for Orthopedics and Sports Medicine (top studies of the week, 1 November 2026): Intraosseous TXA reduced perioperative blood loss
Abstract
BACKGROUND: Tranexamic acid (TXA) reduces perioperative blood loss in total knee arthroplasty (TKA); however, evidence for intraosseous regional administration (IORA) remains limited. We evaluated the efficacy and safety of IORA-TXA versus intravenous TXA (IV-TXA) in TKA. METHODS: In this prospective, randomized, single-center trial, 98 patients undergoing primary TKA were randomized 1:1 to IORA-TXA or IV-TXA (49 per group) at a uniform dose of 20 mg/kg. The primary outcome was calculated perioperative blood loss. Secondary efficacy outcomes included calculated hidden blood loss, postoperative hemoglobin (Hb) levels, and transfusion rate. Safety outcomes included deep vein thrombosis (DVT), muscular calf vein thrombosis, pulmonary embolism (PE), and wound-related complications. RESULTS: Compared with IV-TXA, IORA-TXA reduced calculated perioperative blood loss (674.8 ± 335.0 vs. 817.5 ± 357.2 mL; mean difference, 142.6 mL; 95% CI, 7.4-277.8; p = 0.038) and calculated hidden blood loss (644.8 ± 335.5 vs. 790.9 ± 339.0 mL; mean difference, 146.1 mL; 95% CI, 10.9-281.3; p = 0.035). Postoperative Hb was similar on POD1 (134.0 ± 9.8 vs. 130.1 ± 11.1 g/L; p = 0.067) but was higher with IORA-TXA on POD2 (119.8 ± 8.3 vs. 113.8 ± 11.5 g/L; mean difference 6.0 g/L; 95% CI 2.0-10.0; p = 0.005) and POD3 (114.8 ± 7.9 vs. 109.8 ± 12.6 g/L; mean difference 5.0 g/L; 95% CI 0.8-9.2; p = 0.020). No patient required blood transfusion. DVT detected by routine postoperative Doppler occurred numerically more often with IORA-TXA than with IV-TXA: 10.2% (95% CI, 3.4%-22.2%) versus 0.0% (95% CI, 0.0%-7.3%); p = 0.056. CONCLUSIONS: IORA-TXA reduced calculated perioperative and hidden blood loss and improved early postoperative Hb preservation compared with IV-TXA. However, DVT incidence was numerically higher with IORA-TXA, indicating a potential thromboembolic safety signal that warrants confirmation in larger, adequately powered trials. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.