Tranexamic Acid Is Safe in Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty

J Bone Joint Surg Am. 2024 Jan 3;106(1):30-38. doi: 10.2106/JBJS.23.00254. Epub 2023 Nov 15.


Background: Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not.

Methods: Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders.

Results: The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001).

Conclusions: TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients.

Level of evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

MeSH terms

  • Antifibrinolytic Agents* / adverse effects
  • Arthroplasty, Replacement, Hip* / adverse effects
  • Arthroplasty, Replacement, Knee* / adverse effects
  • Blood Loss, Surgical
  • Humans
  • Myocardial Infarction* / etiology
  • Pulmonary Embolism* / etiology
  • Retrospective Studies
  • Stroke*
  • Tranexamic Acid* / adverse effects
  • Venous Thromboembolism* / etiology
  • Venous Thromboembolism* / prevention & control


  • Tranexamic Acid
  • Antifibrinolytic Agents