- Letter to the Editor
- Open Access
In reply to the letter to the editor regarding “The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis”
Journal of Orthopaedic Surgery and Research volume 16, Article number: 505 (2021)
We appreciate all of the reviewers for their thought-provoking comments about our recent meta-analysis published in the journal . Our answers to these questions raised are as follows:
Firstly, although the heterogeneity of total blood loss is high, we use the random effects model that allows reliable pooled results; this heterogeneity might be attributed to different surgical procedures. At present, there is no conclusion about the data-base to be searched. Many meta-analyses also searched only two or three databases [2,3,4,5,6,7,8,9,10,11]. The three databases we searched (PubMed, Embase and Cochrane Library) can find most of the literatures. The article on Ma  cannot be included in the above three databases. Also, it was published later than our deadline for retrieval.
It is well known that the prevalence of knee osteoarthritis is much higher in female. Meta-regression analysis for gender as an item does not make much sense. We do not think it is appropriate to conclude that female might benefit more than male on blood management from tranexamic acid (TXA) by dividing them into three subgroups based on gender. From their results, it can only be concluded that no matter what the proportion of female is, TXA can benefit. Moreover, gender difference could affect total blood loss, with greater amount in men compared with women [13,14,15].
Secondly, we agree with the hypothesis that intraoperative TXA had a short-time effect, but it might benefit patients for a relatively long time. This is consistent with the results of our meta-analysis, which is also in agreement with previous studies [16, 17].
Finally, most of the studies included in this meta-analysis are cohort studies, which cannot be as consistent as randomized controlled trials (RCTs). And we choose random-effect model to make the results tend to be conservative. Moreover, the results were consistent even with the fixed-effect model (Figs. 1 and 2). The Stata 15.0 software (StataCorp, College Station, TX, USA) was performed to evaluate the publication bias. The results of the funnel plot “Egger test” (P = 0.247) indicated a low risk of publication bias. However, as this meta-analysis did not include enough studies, the reliability of these assessments was not very strong. Strictly speaking, publication bias in this study is not necessary.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Randomized controlled trials
Ma J, Lu H, Chen X, Wang D, Wang Q. The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis. J Orthop Surg Res. 2021;16:373.
Gay F, Jackson G, Rosiñol L, Holstein SA, Moreau P, Spada S, Davies F, Lahuerta JJ, Leleu X, Bringhen S, Evangelista A, Hulin C, Panzani U, Cairns DA, Di Raimondo F, Macro M, Liberati AM, Pawlyn C, Offidani M, Spencer A, Hájek R, Terpos E, Morgan GJ, Bladé J, Sonneveld P, San-Miguel J, McCarthy PL, Ludwig H, Boccadoro M, Mateos MV, Attal M. Maintenance treatment and survival in patients with myeloma: a systematic review and network meta-analysis. JAMA Oncol. 2018;4:1389–97.
Boulos MI, Jairam T, Kendzerska T, Im J, Mekhael A, Murray BJ. Normal polysomnography parameters in healthy adults: a systematic review and meta-analysis. Lancet Respir Med. 2019;7:533–43.
Clarke MA, Long BJ, Del Mar MA, Arbyn M, Bakkum-Gamez JN, Wentzensen N. Association of endometrial cancer risk with postmenopausal bleeding in women: a systematic review and meta-analysis. JAMA Intern Med. 2018;178:1210–22.
Scott ML, Baldwin KD, Mistovich RJ. Operative versus nonoperative treatment of pediatric and adolescent clavicular fractures: a systematic review and critical analysis. JBJS Rev. 2019;7:e5.
Yaghmour KM, Hossain FS, Konan S. Clinical and health-care cost analysis of negative pressure dressing in primary and revisiontotal knee arthroplasty: a systematic review and meta-analysis. J Bone Joint Surg Am. 2020;103:541–8.
Bram JT, Magee LC, Mehta NN, Patel NM, Ganley TJ. Anterior cruciate ligament injury incidence in adolescent athletes: a systematic review and meta-analysis. Am J Sports Med. 2021;49:1962–72.
Chan XHS, Win YN, Mawer LJ, Tan JY, Brugada J, White NJ. Risk of sudden unexplained death after use of dihydroartemisinin-piperaquine for malaria: a systematic review and Bayesian meta-analysis. Lancet Infect Dis. 2018;18:913–23.
Ekelund U, Steene-Johannessen J, Brown WJ, Fagerland MW, Owen N, Powell KE, Bauman A, Lee IM. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet. 2016;388:1302–10.
Zheng Z, Luo J. The therapeutic effect to eldecalcitol + bisphosphonate is superior to bisphosphonate alone in the treatment of osteoporosis: a meta-analysis. J Orthop Surg Res. 2020;15:390.
Fan Y, Li Z, Zhang H, Hong G, Wu Z, Li W, Chen L, Wu Y, Wei Q, He W, Chen Z. Valgus knee bracing may have no long-term effect on pain improvement and functional activity in patients with knee osteoarthritis: a meta-analysis of randomized trials. J Orthop Surg Res. 2020;15:373.
Zhong ZMDLXWW. Safety evaluation of tranexamic acid in reducing perioperative blood loss in high tibial osteotomy. Chin J Tissue Eng Res. 2021;25:1847–52.
Guerin S, Collins C, Kapoor H, McClean I, Collins D. Blood transfusion requirement prediction in patients undergoing primary total hip and knee arthroplasty. Transfus Med. 2007;17:37–43.
Mähringer-Kunz A, Efe T, Fuchs-Winkelmann S, Schüttler KF, Paletta JR, Heyse TJ. Bleeding in TKA: posterior stabilized vs. cruciate retaining. Arch Orthop Trauma Surg. 2015;135:867–70.
Hu Y, Li Q, Wei BG, Zhang XS, Torsha TT, Xiao J, Shi ZJ. Blood loss of total knee arthroplasty in osteoarthritis: an analysis of influential factors. J Orthop Surg Res. 2018;13:325.
Kim KI, Kim HJ, Kim GB, Bae SH. Tranexamic acid is effective for blood management in open-wedge high tibial osteotomy. Orthop Traumatol Surg Res. 2018;104:1003–7.
Ni J, Liu J, Zhang J, Jiang J, Dang X, Shi Z. Tranexamic acid is beneficial for blood management of high tibial osteotomy: a randomized controlled study. Arch Orthop Trauma Surg. 2020. https://doi.org/10.1007/s00402-020-03558-5.
This study was supported by the Key Project of University Humanities and Social Science Research in Anhui Province (SK2016A0963).
Ethics approval and consent to participate
Consent for publication
The authors declare that there are no conflicts of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Ma, J., Lu, H., Chen, X. et al. In reply to the letter to the editor regarding “The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis”. J Orthop Surg Res 16, 505 (2021). https://doi.org/10.1186/s13018-021-02628-7
- Blood loss
- Hemoglobin decrease
- Drain output
- High tibial osteotomy
- Tranexamic acid