This paper revealed a rapid uptake in the use of tranexamic acid in primary TKA into routine clinical orthopaedic practice. Previous research into the time lag to clinical implementation of evidence-based medicine is limited. In comparison to the reported average 15.6 years by Balas and Boren, this study suggests 18 months to reach > 50% clinical uptake of TXA from time of landmark paper publication [9]. A more recent study purported a 16-year time lag from research publication to > 90% clinical use of medical therapies in acute coronary syndrome [10]. However, our paper revealed a far shorter 3.5 years to achieve > 90% TXA use in TKA from time of landmark paper publication.

The time of publication of these papers must be considered. The former was published in 2000 and investigated the uptake of clinical practices described in literature dating back to 1966. It must therefore be considered that in that time the dissemination of new research took longer than in the current day, and this may have influenced their results. However, the latter paper [11] was published more recently in 2015 and investigated papers and practices between 1990 to 2012. Over those years, the distribution of research and information is more comparable to today’s standards as electronic means of circulation were more readily available.

While it may be that the modern surgical community more effectively circulates new research or that members themselves are more active in remaining up to date and instigating new findings, this is difficult to prove definitively. Rather, as this research was collected at a non-specialised and regional orthopaedic centre it would be interesting to compare these results with a similar study at a specialised, urban centre. Improving the time lag from research to clinical practice will serve to improve patient outcomes with more efficient and higher quality care.

This paper reinforces the knowledge that use of TXA in primary TKA reduces the rate of post-operative blood transfusion. Allogenic blood transfusion following TKA is associated with complications inherent to transfusion as well as poorer post-operative outcomes. In comparison to TKA patients not requiring blood transfusion after surgery, those receiving allogenic transfusion have a higher mortality rate, greater LOS and increased risk of post-operative infection [14, 15]. In addition to this, these patients are more likely to be discharged to an extended care facility and have a greater hospital admission cost [14, 15]. The authors recognise that transfusion practices have evolved in the past two decades with a focus on restrictive transfusion policies supported by a randomised control trial published in 1999 and Cochrane review from 2010 [16, 17]. The authors recognize that the studied hospital did not have a formal transfusion protocol for post-operative TKA during the data collection period. However, as this study took place well after the aforementioned publications regarding restrictive transfusion protocols, we have no evidence to suggest that transfusion practices would confound our analyses.

Our study affirms that the use of TXA reduces in-hospital length of stay. While this could be attributed, in part, to the reduction in post-operative blood transfusions, our analysis showed a reduced LOS even after controlling for post-operative blood transfusion. There are confounding factors that may have influenced the length of stay outcome. For example, in recent years there have been moves to standardise peri-operative TKA care, with particular focus on early mobilisation, which may have had an effect in reducing length of stay. However, the centre at which this study took place did not implement a formal rapid recovery protocol for its knee arthroplasties during the study period. Additionally, the centre did not have a standardized post operative analgesia protocol for TKA patients, nor were these details included in the documentation collected on the surgeries in this study. Whilst the authors have no reason to believe that the post-operative analgesia protocol is correlated with TXA use, this is a factor unaccounted for in the analysis. Analysis indicated a significant negative association between TXA and haemoglobin. Maintaining higher haemoglobin levels may play an important role in improving patients’ post-operative exercise capacity and rehabilitation, thereby ultimately reducing their length of stay [18,19,20].

The interpretations in this study are limited to TXA use in primary TKA at a single, regional hospital and can therefore only be considered a generic reflection of improvements in the translational process in medical and surgical fields. Also, this study was limited to quantitative analyses and has therefore not investigated the more complex reasons for why time lags to common clinical practice remain.

The authors recognise that a significant proportion of operations were performed by a single surgeon, however our methodology accounted for this potential bias by fitting all regressions as mixed effects models with random effects for surgeon. We also recognise that the practice in TXA use of one surgeon may have influenced the practice of other surgeons at this hospital. While some may argue that this confounds the effect of time to uptake, we feel that it is more logical to consider these effects as the same thing. Uptake time is in many ways a measure of the speed of process of collaboration and interaction that goes on between medical practitioners to ultimately influence their behaviour.