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A randomized, double‐blind, placebo‐controlled trial on the efficacy of tranexamic acid combined with rivaroxaban thromboprophylaxis in reducing blood loss after primary cementless total hip arthroplasty

Aims Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three‐hour two‐dose (short‐TXA) and 11‐hour four‐dose (long‐TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non‐inferiority of the reduction of blood loss of the short protocol versus the long protocol. Patients and Methods A multicentre, prospective, randomized, double‐blind, placebo‐controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short‐ and long‐TXA protocols in the reduction of perioperative RBL was compared with a placebo group. Results TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short‐TXA vs placebo) and 550.1 ml (long‐TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre‐specified margin of non‐inferiority (p = 0.027). Conclusion In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short‐ and long‐TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non‐inferiority of a short‐ versus a long‐TXA protocol in reducing perioperative RBL was supported in a secondary analysis.