Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Purpose: To systematically review all available randomized controlled trials (RCTs) in the literature that examine out-comes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effec-tiveness. Methods: PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes. Results: A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded low in 4 RCTs, some concerns in 2 RCTs, and high in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I-2 = 96%, P = .14) and 12 weeks (MD -0.03, I-2 = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I-2 = 56%, P < .00001) and weeks 3-6 (MD -0.38, I-2 = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I-2 = 74%, P = .002) and weeks 4-6 (MD 6.17, I-2 = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I-2 = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I-2 = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5. Conclusions: Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early im-provements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak. Level of Evidence: Level II, systematic review of therapeutic Level I-II studies.

Automated summary

This study systematically reviewed the effectiveness of tranexamic acid (TXA) in anterior cruciate ligament reconstruction (ACLR) based on randomized controlled trials (RCTs). The results showed that the use of TXA can reduce the occurrence of aspiration, hemarthrosis, drain output, and knee swelling during the postoperative period in ACLR. Early improvements in pain and function were observed, but the clinical relevance is uncertain.