Inclusion and exclusion criteria
Inclusion criteria: The inclusion criteria were as follows: 1. Preoperative HB, PLT, PT, and APTT were normal; 2.Preoperative imaging (X-ray and CT) suggested a diagnosis of acetabular fracture; and 3. Only one acetabular operation was performed, which was for a fracture.
Exclusion criteria: The exclusion criteria included the following: 1. Abnormal preoperative coagulation function and PT and APTT values; 2. Previous deep vein thrombosis (including history of intramuscular venous thrombosis), cerebral embolism, and cerebral infarction; 3. Clear TXA allergy and contraindications for TXA use; 4. High risk with regard to thrombosis, as in patients with atrial fibrillation, post-cardiac pacemakers, and stent implantations. 5. Severe liver and kidney dysfunction; and 6. Simultaneous acetabular fractures and other operations.
Clinical data
This study was retrospective in nature. From January 2016 to October 2019, 85 patients with acetabular fractures were enrolled in our study. They were divided into three groups according to different dosages of TXA. In the single treatment group, patients received intravenous infusion of TXA (15 mg/kg) 20 min before surgery (n = 33), in the repeated treatment group, patients received intravenous infusion of TXA (15 mg/kg) 20 min before surgery and intravenous infusion of TXA (10 mg/kg at 3 h (n = 26), and in multiple treatment group, patients received intravenous infusion of TXA (15 mg/kg) 20 min before surgery and intravenous infusion of TXA (10 mg/kg) at 3 and 6 h (n = 26); the basic data of the three patient groups, including the age, sex ratio, fracture type, and preoperative hemoglobin, are shown in Table 1. There was no significant difference in PLT, PT, and APTT between groups (P>0.05). The study was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University, and all selected patients signed informed consent forms.
Surgical methods and perioperative management
The surgical method used for the three groups was the same. The fracture types were divided into two categories according to the Letournel–Judet classification. Simple fractures (anterior wall, anterior column, posterior wall, posterior column, and transverse type) and complex fractures (posterior wall with posterior wall column, transverse type with posterior wall, double column, T-type, and anterior with posterior half-horizontal type). Simple and complex fractures in a single treatment group, repeated treatment group, multiple treatment group were found in 18 and 15, 14 and 12, and 13 and 13 cases, respectively. There were no significant differences in fracture types among groups (χ2 = 0.133, P = 0.936). All patients underwent general anesthesia, during which an anesthesiologist controlled their blood pressure to maintain it at 90/60 mmHg.
A drainage tube was routinely placed in the three groups of patients, and the drainage was recorded. The drainage tube was generally removed 24 h after surgery. No patient showed bleeding after surgery, and on the next day. According to the guidelines for the prevention of venous thromboembolism in major orthopedic surgery in China, low molecular heparin was combined with physical methods for anticoagulation. In cases where there was more drainage after surgery, the hemoglobin level progressively decreased; the hemoglobin level should be stabilized in such cases before anticoagulation. Ultrasound examination of both lower extremities was performed five days after surgery to confirm whether there was thrombosis. If there was swelling of the lower extremities accompanied by pain and to determine whether there is thrombosis, ultrasound examinations of both lower extremities were required to be performed. Pulmonary embolism was judged based on clinical manifestations.
The patient decided whether to sit up depending on the type of fracture and the degree of fixation stability during the operation. The lower extremities could perform quadriceps functional exercise and sputum pump exercise on the second day. Postoperative ultrasound could exclude thrombus formation and the extremities could be treated with lower extremity air pump.
Surgery-related blood transfusion rate: blood transfusion index: Hb < 70 g/L or Hb ≥ 70 g/L, the patient develops dizziness, paleness, weakness, and other discomfort. During the operation, depending on the bleeding of the patient, it is up to the anesthesiologist and the clinician to decide whether blood transfusion is needed. Three categories of surgery-related blood transfusion rates were recorded. The blood transfusion rate in each category was calculated as number of patients requiring intraoperative blood transfusion + number of patients requiring postoperative transfusion / total number of patients.
Statistical analysis
Statistical analysis was performed using SPSS 23.0 (SPSS, USA) statistical software. The data are expressed as one-way analysis of variance for the normal distribution and Tukey method for comparison between groups. Categorical variables were analyzed via chi-square test or Fisher’s exact test. P < 0.05 was considered statistically significant.