Abstract
Tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) are antifibrinolytic agents
commonly used to reduce blood loss in total knee arthroplasty (TKA). Although TXA
is widely adopted, EACA offers a potentially more economical alternative. However,
head-to-head comparisons using paired designs remain limited. The present randomized
controlled trial included 294 patients undergoing bilateral TKA. Each patient received
topical TXA in one knee and topical EACA in the contralateral knee in a randomized
sequence. Primary outcomes included total perioperative blood loss and total drain
output over 3 days. Secondary outcomes included transfusion requirement, postoperative
complications, and cost-effectiveness. The statistical analyses included paired t -tests, linear mixed-effects models for effect modification, logistic regression for
transfusion and complications, and cost-effectiveness analysis comparing drug costs
against blood loss reduction. Data from 294 patients (588 knees) were analyzed. TXA
was associated with a statistically significant but modest reduction in total blood
loss compared with EACA (mean difference: 10.03 mL, p < 0.001), well below the predefined non-inferiority margin of 200 mL. Similarly,
drain output was also found to be lower in TXA-treated knees (mean difference: 10.07 mL;
p = 0.0001), but the difference was not considered clinically significant. The rates
of transfusion and postoperative complications were low (2.72 and 3.74% respectively).
Cost-effectiveness analysis revealed EACA to be more cost effective as compared with
TXA. Topical EACA was found to be non-inferior to TXA in reducing perioperative blood
loss in TKA, with equivalent clinical outcomes and greater cost-effectiveness. These
findings support the use of EACA as a cost-saving alternative to TXA, particularly
in resource-limited settings.
Keywords total knee arthroplasty - tranexamic acid - aminocaproic acid - blood loss - cost-effectiveness
