Optimal Route of Tranexamic Acid Administration in Total Knee Arthroplasty: A Bayesian Network Meta-Analysis With Decision-Analytic Cost Evaluation.

Abstract

Tranexamic acid (TXA) is widely used in total knee arthroplasty (TKA) to reduce blood loss and transfusion; however, the optimal route of administration remains uncertain, particularly when considering both clinical outcomes and cost. A Bayesian network meta-analysis of randomized controlled trials was performed comparing intravenous (IV), topical, oral, combined, and no TXA in TKA. The primary outcome was total blood loss. The secondary outcomes included hemoglobin (Hb) decrease, allogeneic transfusion, and venous thromboembolism (VTE). There were 40 randomized controlled trials included. A decision-analytic cost model was constructed using transfusion as the economic endpoint, incorporating drug acquisition costs and transfusion-related hospitalization costs. All TXA routes significantly reduced total blood loss, Hb decline, and transfusion risk compared with no TXA. Combined regimens ranked highest for efficacy, demonstrating the greatest reduction in blood loss (-400 mL; 95% credible intervals (CrI) -512 to -291) and transfusion risk (relative risk (RR) 0.251; 95% CrI 0.117 to 0.468). Differences among oral, IV, and topical strategies were modest. There was no increase in VTE risk observed across TXA routes. In cost analyses, oral TXA had the lowest expected per-patient cost ($129.43), followed by IV ($185.52), topical ($227.69), and combined ($256.17). Oral TXA remained the most cost-effective strategy across all sensitivity analyses. All TXA routes effectively reduce blood loss and transfusion in TKA without increased VTE risk. Although combined regimens demonstrate the greatest efficacy, oral TXA provides the most favorable balance of efficacy, safety, cost, and ease of administration, supporting its use as a pragmatic default strategy in routine primary TKA.