{'fraction_non_alphanumeric': 0.029605263157894735, 'fraction_numerical': 0.003837719298245614, 'mean_word_length': 5.50445632798574, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Letter to the Editor: Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial.

To the Editor, Amid the burgeoning number of TKAs, surgeons are now focusing on decreasing patients’ morbidity and mortality. In particular, there is enthusiasm for blood-sparing strategies, most notably tranexamic acid (TXA). Although several clinical trials and metaanalyses have demonstrated its utility for providing a safety valve against blood loss and decreasing allogenic blood transfusion in TKA surgery [1, 5], a concrete guideline as to its dose, route, timing, and frequency of administration has not been developed. The twomost commonly used routes of TXA administration in TKA are intravenous (IV) and intra-articular [1, 9], and investigators like Meshram and colleagues [6] are now exploring whether combined (that is, IV plus intraarticular) administration results in reduced blood loss compared with single-route administration (such as IV or intraarticular alone) without any additional harmful effects. Indeed, an additional dose of TXA must be balanced against the added untoward risk. Meshram and colleagues [6] found no difference between intraarticular alone and combined TXA administration in bilateral (simultaneous or staged) TKAs, and further advised against using combined TXA for routine TKAs. Their seminal research deserves applause for its well-designed randomized trial with large sample size, and for focusing on bilateral TKAs. However, I believe that the claim “... future studies may not be needed to ascertain the ideal route of TXA administration in patients undergoing bilateral TKA” [6] needs further examination. Recently conducted meta-analyses have reported conflicting results regarding the best route of TXA administration for primary TKA [7, 11]. While Wang and colleagues [11] alignedwith the present study and stated no differences between combined TXA and intraarticular TXA regarding blood transfusion, total blood loss, and hemoglobin drop, another metaanalysis [7] found differences in total blood loss and blood volume of drainage when compared to combine TXA with single use (IV/ intraarticular) TXA. However, none of the studies have shown any additional risk of thromboembolism with combined administration. When interpreting these findings, we must also acknowledge the inherent risks of metaanalyses like publication bias and heterogeneity of included trials arising from methodological limitations, small sample size, dose and timing of TXA administration, different transfusion criteria, tourniquet use, surgical time, and method of blood loss measurement—any or all of these factors could potentially skew study results. Most studies have excluded high-risk patients with coagulopathy, bleeding risks, hepatic or renal impairment, and past history of ischemic events or stents. As such, we still do not know which TXA regimen is worth considering for high-risk patients. One metaanalysis [2] evaluated the safety of TXA in total joint arthroplasty and did not find an increased risk of thromboembolic risk among patients administered with TXA, even in The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons.