Topical Tranexamic Acid in Total Knee Arthroplasty: Does It Augment the Effect of the Intravenous Administration in Patients with Moderate-to-High Risk of Bleeding? A Randomized Clinical Trial

2020 ◽  
Author(s):  
Ahmed A. Abdallah ◽  
Asser A. Sallam ◽  
Mohamed S. Arafa ◽  
Ayman T. Henawy
Keyword(s):  
High Risk ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Total Blood Loss ◽  
Transfusion Rate ◽  
Total Blood ◽  
Risk Of Bleeding ◽  
Hidden Blood Loss ◽  
Total Knee ◽  
Topical Tranexamic Acid

AbstractThis study aimed to compare the superimposed clinical value of topical tranexamic acid (TXA) application when it is simultaneously combined with intravenous (IV) administration versus the use of either IV TXA alone or IA TXA alone during primary total knee arthroplasty (TKA) in patients with moderate-to-high risk of bleeding. We hypothesized that the combined administration approach will result in a more adequate reduction in the perioperative blood loss and blood transfusion rate. Ninety-four patients undergoing primary TKA were randomly allocated into intra-articular (IA) alone, IV alone, and combined group. We used 2 g of IV TXA in the IV TXA alone and combined groups 10 minutes before tourniquet deflation. However, we applied 1.5 g TXA in 100 mL isotonic saline half topically before arthrotomy closure and half retrogradely after wound closure through the drain. Follow-up period was 6 weeks. The primary outcome measures included the drainage blood volume, total blood loss, hidden blood loss, intraoperative blood loss, and the allogenic transfusion rate. Secondary outcomes included postoperative hemoglobin drop, amount of transfused blood units, thromboembolism, and wound complications. Combined administration of TXA provided significantly better results in terms of blood volume collected by the drain, total blood loss, and hidden blood loss (p < 0.01). Contrarily, the intraoperative blood loss, the allogeneic transfusion rate, and the number of transfused units were similar in all groups (p > 0.05). The subgroup analysis revealed that a combined IA and IV TXA administration significantly reduced the total blood loss in patients with either moderate or high risk of bleeding. Moreover, the degree of hemoglobin drop was significantly lesser with the combined approach. No thromboembolic complications or wound infection occurred. In conclusion, the combined use of topical and IV tranexamic acid resulted in a significant reduction in postoperative blood loss and hemoglobin level following TKA but did not influence the rate of allogeneic blood transfusion. This is a Level I, therapeutic study.

scholarly journals Multimodal Peri-articular Injection with Tranexamic Acid can reduce postoperative blood loss versus Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Trial

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Hui-ming Peng ◽  
Wei Wang ◽  
Jin Lin ◽  
Xi-sheng Weng ◽  
Wen-wei Qian ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Knee Arthroplasty ◽  
Total Blood Loss ◽  
Postoperative Blood Loss ◽  
Total Blood ◽  
Randomized Controlled ◽  
Hidden Blood Loss ◽  
Total Knee

Abstract Background Tranexamic acid (TXA) has shown significant reductions in blood loss and transfusion rates in total knee arthroplasty (TKA). However, the optimal administration route continues to be debated. The aim of this trial was to compare the effectiveness of intravenous (IV) versus peri-articular injection (PAI) application of tranexamic acid in patients undergoing total knee arthroplasty. Methods We conducted a randomized controlled, double-blinded study. A total of 93 patients undergoing primary unilateral TKA were randomly distributed between 2 groups: the IV group (47 cases; 1 g TXA IV) and the PAI group (46 cases; 1 g TXA injected peri-articularly). The amount of total and hidden blood loss (HBL), drainage, transfusion rate, hemoglobin and hematocrit drift, and complications were recorded. Results Peri-articular injection of TXA reduced total blood loss (P < 0.001) and HBL more than IV use of TXA (P < 0.001). No patients in either group received a transfusion. No symptomatic deep venous thrombosis or other severe complications occurred. Conclusion Peri-articular injection of TXA significantly reduced total blood loss and hidden blood loss to a greater degree than IV injection in total knee arthroplasty without reduction of drainage volume. Trial registration Chinese Clinical Trial Registry, ChiCTR-INR-16010270. Date of registration: December 27, 2016.

scholarly journals The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty

2020 ◽  
Vol 9 (6) ◽  
pp. 322-332 ◽  
Author(s):  
Hai-Yan Zhao ◽  
Releken Yeersheng ◽  
Xue-Wen Kang ◽  
Ya-Yi Xia ◽  
Peng-De Kang ◽  
...  
Keyword(s):  
Blood Loss ◽  
Tranexamic Acid ◽  
Primary Total Knee Arthroplasty ◽  
Quadriceps Strength ◽  
Total Blood Loss ◽  
Total Blood ◽  
Hidden Blood Loss ◽  
Straight Leg Raising ◽  
Total Knee ◽  
No Tourniquet

Aims The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. Methods This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay. Conclusion Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA. Cite this article: Bone Joint Res 2020;9(6):322–332.

scholarly journals Lower total blood loss in total knee arthroplasty with a low-pressure tourniquet than without

2021 ◽  
Vol 87 (3) ◽  
pp. 461-468
Author(s):  
Simon Joufflineau ◽  
Emmanuel Thienpont
Keyword(s):  
Total Knee Arthroplasty ◽  
Blood Loss ◽  
Knee Arthroplasty ◽  
Low Pressure ◽  
Total Blood Loss ◽  
Transfusion Rate ◽  
Total Blood ◽  
Hidden Blood Loss ◽  
Total Knee ◽  
No Tourniquet

Tourniquet-use has been described in litera- ture as a surgical factor leading to increased post-operative hidden blood loss in total knee arthroplasty (TKA). The hypothesis for this retro- spective study was that low-pressure tourniquet TKA would offer the benefits of tourniquet surgery without the potential negative effects on late blood loss after the procedure. Therefore, this study evaluated total (TBL) and hidden blood loss (HBL) in TKA with or without a tourniquet. We retrospectively compared two groups : one group (n= 54) undergoing TKA without a tourniquet and one group with a low-pressure tourniquet (n= 110). The outcomes compared were hemoglobin levels 2 weeks before surgery and at days 2 and 4 after surgery to calculate total and hidden blood loss, transfusion rate, and functional outcome. A higher total blood loss was observed in the no tourniquet group with a mean loss of 1073 mL against 890 mL in the tourniquet group (p-value = 0,003). Hidden blood loss values between both groups were statistically not significant : in the no-tourniquet group, Hb drop between D2 and D4 was 0.5 g/dL against 0.4 g/ dL in the low-pressure tourniquet group. The tourniquet-less group did not present with better functional scores. This study showed that low- pressure tourniquet use reduces TBL without increasing HBL in TKA.

scholarly journals Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials

BMJ Open ◽  
2019 ◽  
Vol 9 (1) ◽  
pp. e024350 ◽  
Author(s):  
Qi Sun ◽  
Jinyu Li ◽  
Jiang Chen ◽  
Chenying Zheng ◽  
Chuyin Liu ◽  
...  
Keyword(s):  
Blood Loss ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Total Blood Loss ◽  
Controlled Trials ◽  
Transfusion Rate ◽  
Total Blood ◽  
Total Knee ◽  
Randomised Controlled ◽  
Blood Loss Volume

ObjectiveThis study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).DesignThis was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE).SettingWe searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration.ParticipantsPatients undergoing TKA or THA.InterventionsIntravenous, topical or combined intravenous and topical TXA.ResultsTwenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=−34.53, p=0.50), postoperative Hb levels (WMD=−0.01, p=0.96), Hb decline (WMD=−0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles.ConclusionsThe combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.

scholarly journals Hemostatic effect of tourniquet combined with tranexamic acid in total knee arthroplasty: a network meta-analysis

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Yimin Zhang ◽  
Bao Lang ◽  
Guifeng Zhao ◽  
Fengming Wang
Keyword(s):  
Total Knee Arthroplasty ◽  
Blood Transfusion ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Knee Arthroplasty ◽  
Meta Analysis ◽  
Total Blood Loss ◽  
Total Blood ◽  
Study Results ◽  
Total Knee

Abstract Background There are various techniques to reduce blood loss in total knee arthroplasty (TKA), including the use of a tourniquet and tranexamic acid (TXA). In this study, we studied the combined effect of TXA with a tourniquet on blood loss in the setting of primary TKA. Methods Randomized controlled trials (RCTs) of nine treatment methods were included (placebo, intravenous [i.v.] TXA, topical TXA, i.v.-combined topical TXA, oral TXA, placebo + tourniquet, i.v. TXA +tourniquet, topical TXA + tourniquet, and i.v.-combined topical TXA + tourniquet). The patients were divided into eight groups according to the different treatment strategies, with 30 cases per group. The differences in the total blood volume, the number of patients transfused, the hemoglobin before and after the operation, and complications after the operation were compared. Results Totally 15 RCTs meeting our inclusion criteria were collected in this study. Compared with the placebo + tourniquet group, the i.v. TXA + tourniquet group displayed lower hemoglobin reduction value, pulmonary embolism (PE) incidence, total blood loss, and blood transfusion risk; the topical TXA + tourniquet group showed reduced PE incidence, total blood loss, and blood transfusion risk, and the i.v.-combined topical TXA and i.v.-combined topical TXA + tourniquet groups showed decreased total blood loss and lower blood transfusion risk. Retrospective clinical study results also demonstrated that the efficacy of i.v.-combined topical TXA was the best. Conclusions Our meta-analysis indicates that i.v.-combined topical TXA provides a low total blood loss without increasing the blood transfusion risk in patients undergoing total knee replacement surgery.

One step closer to sparing total blood loss and transfusion rate in total knee arthroplasty: a meta-analysis of different methods of tranexamic acid administration

2015 ◽  
Vol 135 (4) ◽  
pp. 573-588 ◽  
Author(s):  
Hamidreza Shemshaki ◽  
Sayed Mohammad Amin Nourian ◽  
Niloofaralsadat Nourian ◽  
Masoudhatef Dehghani ◽  
Masoud Mokhtari ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Knee Arthroplasty ◽  
Meta Analysis ◽  
Transfusion Rate ◽  
Total Blood ◽  
One Step ◽  
Total Knee ◽  
Acid Administration

scholarly journals A randomized, non-crossover, parallel-group analysis of tranexamic acid in minimizing blood loss and transfusions in total knee arthroplasty

2021 ◽  
Vol 0 ◽  
pp. 1-4
Author(s):  
Nikhil Mudgalkar
Keyword(s):  
Total Knee Arthroplasty ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Knee Arthroplasty ◽  
Acid Group ◽  
Total Blood Loss ◽  
Blood Transfusions ◽  
Total Blood ◽  
Parallel Group ◽  
Total Knee

Objectives: Total knee arthroplasty is associated with significant blood loss, necessitating blood transfusions. Due to the obvious risks and costs of allogeneic blood transfusions, techniques to minimize blood loss in surgery are needed. The objective of this study was to assess the efficacy of tranexamic acid treatment in reducing blood loss and blood transfusion requirements during total knee arthroplasty. Materials and Methods: A prospective, randomized, double-blind, parallel-group, non-crossover trial was carried out in Prathima Hospital, Karimnagar. The trial involved 28 ASA I and II patients undergoing unilateral knee arthroplasty, 14 in each of the control and study groups. In the study group, a 10 mg/kg bolus of tranexamic acid was administered slowly IV 30 min before tourniquet deflation, followed by a 1 mg/kg/hr infusion for 12 h, compared to the standard medical treatment in the control group. Total blood loss during and after surgery was compared between the two classes. We also compared the hemoglobin drop after surgery, the number of people who needed blood transfusions, and the number of units needed between the two classes. Any complications were also reported. Results: Total blood loss in the tranexamic acid group was 543.3 ± 184.85 versus 685.83 ± 176.74, a statistically significant difference (P < 0.05). Intraoperative blood loss was comparable, but post-operative blood loss was significantly lower in the tranexamic acid group (389.16 ± 174 ml vs. 514.36 ± 143.89 ml), indicating that it was statistically significant (P < 0.05). There were no complications reported from any of the groups. Conclusion: Tranexamic acid is an effective strategy for minimizing overall blood loss and blood transfusions in patients undergoing total knee arthroplasty.

scholarly journals Effects of Tranexamic Acid on Hemorrhage Control and Deep Venous Thrombosis Rate After Total Knee Arthroplasty: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

2021 ◽  
Vol 12 ◽  
Author(s):  
Tao Ling ◽  
Zhihu Zhao ◽  
Wenwen Xu ◽  
Weihong Ge ◽  
Lingli Huang
Keyword(s):  
Total Knee Arthroplasty ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Meta Analysis ◽  
Total Blood Loss ◽  
Controlled Trials ◽  
Hemorrhage Control ◽  
Total Blood ◽  
Randomized Controlled ◽  
Total Knee

Background: Total knee arthroplasty (TKA) surgery has a lot of complications, especially hemorrhage, which can be controlled via tranexamic acid (TXA). The guidelines endorse the integration of TXA interventions in the management of TKA-induced complications. However, uncertainty surrounds the effects of different TXA therapies. This frequentist model network meta-analysis (NMA) aims to compare hemorrhage control and deep venous thrombosis (DVT) rate of different TXA therapies in TKA.Methods: Articles were searched with the PubMed, Embase, Cochrane Library, and Web of Science from 1966 to October 2020. Randomized controlled trials (RCTs) comparing different TXA therapies, or with placebo in patients with TKA were included. Two investigators independently conducted article retrievals and data collection. The outcome was total blood loss and DVT rate. Effect size measures were mean differences (MDs), or odds ratios (ORs) with 95% confidence intervals (CIs). We conducted a random-effects NMA using a frequentist approach to estimate relative effects for all comparisons and rank treatments according to the mean rank and surface under the cumulative ranking curve values. All analyses were performed in Stata software or R software. The study protocol was registered with PROSPERO, number CRD42020202404.Results: We identified 1 754 citations and included 81 studies with data for 9 987 patients with TKA. Overall, all TXA therapies were superior to placebo for total blood loss in TKA. Of all TXA therapies, M therapy (IV/IV infusion + oral TXA &gt; 3g) was most effective for total blood loss (MD=−688.48, −1084.04–−328.93), followed by F therapy (IV TXA ≥ 15 mg/kg or 1 g three times). TXA therapies in this study are not associated with the increase of DVT risk.Conclusions: TXA therapies in this study are effective and safe for the treatment of TKA-induced complications. M therapy (IV/IV infusion + oral TXA &gt; 3 g) may be the most effective TXA therapy for hemorrhage control. TXA therapies in this study do not increase DVT risk. Considering hemorrhage control and DVT rate simultaneously, F therapy (IV TXA ≥ 15 mg/kg or 1 g three times) may be suggested to apply for TKA, and this study may provide a crucial clue to future TXA use.

scholarly journals A non-randomized prospective study of the blood sparing effect of tranexamic acid in total knee replacement

2016 ◽  
Vol 3 (1) ◽  
pp. 12
Author(s):  
Anand Gupta ◽  
Ashok Nagla ◽  
Vinay Tantuway ◽  
Rishi Gupta ◽  
Vivek Patel ◽  
...  
Keyword(s):  
Blood Loss ◽  
Total Knee Replacement ◽  
Tranexamic Acid ◽  
Knee Replacement ◽  
Subcutaneous Tissue ◽  
Skin Incision ◽  
Total Blood Loss ◽  
Postoperative Blood Loss ◽  
Total Blood ◽  
Total Knee

<p class="abstract"><strong>Background:</strong> Several techniques are available to minimize the likelihood of blood transfusion following total knee arthroplasty. Tranexamic acid, an inhibitor of fibrinolysis that blocks the lysine-binding site of plasminogen to fibrin has been reported to reduce intraoperative and postoperative blood loss in patients undergoing total hip and total knee arthroplasties with or without cement. The objective of this study was to assess the efficacy of antifibrinolytic treatment along with other measures like saline adrenaline infusion, no drain, no tourniquet and hypotensive anaesthesia in reducing perioperative blood loss during total knee replacement<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> Between January 2011 to January 2016,  seventy five consecutive patients who had given written informed consent, undergoing a TKR received tranexamic acid 15 mg/kg body weight intravenous 5 minutes before the skin incision and two doses afterwards (3 and 6 hours after the first dose respectively). TKR was performed in a routine fashion without tourniquet. The saline adrenaline (1:200000) was infiltrated into the skin subcutaneous tissue and capsule before skin incision. A routine closure was carried out without drain. Total blood loss including the hidden blood loss was calculated. All patients were monitored for anemia and postoperative thromboembolic complications.<strong></strong></p><p class="abstract"><strong>Results:</strong> The average total blood loss in study group is 433 ± 148 ml. This is much lesser than what other studies have reported. Mean reduction in hemoglobin levels (gm/dl) between preoperative and postoperative readings is 1.6 gm/dl. One patient had a postoperative DVT which was treated with rivaroxaban 20 mg OD for 6 weeks (oral anticoagulant)<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> Antifibrinolytic agents like tranexamic acid used along with other measures reported in this study produces a significant decrease in blood loss in patients undergoing total knee replacement<span lang="EN-IN">.</span></p>

scholarly journals Intravenous Tranexamic Acid Has Benefit for Reducing Blood Loss after Open-Wedge High Tibial Osteotomy: A Randomized Controlled Trial

2021 ◽  
Vol 10 (15) ◽  
pp. 3272
Author(s):  
Man-Soo Kim ◽  
In-Jun Koh ◽  
Yong-Gyu Sung ◽  
Dong-Chul Park ◽  
Won-Jun Ha ◽  
...  
Keyword(s):  
Blood Loss ◽  
Tranexamic Acid ◽  
High Tibial Osteotomy ◽  
Total Blood Loss ◽  
Wound Complications ◽  
Control Group ◽  
Transfusion Rate ◽  
Tibial Osteotomy ◽  
Total Blood ◽  
Wedge High Tibial Osteotomy

(1) Background: the purpose of this study was to investigate the efficacy and safety of intravenous (IV) administration of tranexamic acid (TXA) in patients undergoing medial opening wedge high tibial osteotomy (MOWHTO). (2) Methods: a total of 73 patients were randomly allocated into two groups (TXA group and control group). The primary outcome was total perioperative calculated blood loss after MOWHTO. Secondary outcomes included self-reported pain severity using a 10-point visual analog scale (VAS) and the EuroQol-5 Dimension (EQ-5D) questionnaire. The postoperative allogeneic transfusion rate and wound complications were compared. Deep vein thrombosis (DVT) incidence was compared by conducting DVT computed tomography imaging. (3) Results: the total blood loss after surgery was 470.9 mL in the TXA group and 739.3 mL in the control group, showing a significant difference (p < 0.001). There were no differences in pain VAS scores between the two groups (all p > 0.05). No difference in preoperative EQ-5D scores for any items existed between the two groups. No transfusion was performed in either group. There was no difference in DVT incidence or the rate of wound complications between the two groups. (4) Conclusion: in patients undergoing MOWHTO, IV TXA reduces total blood loss and drainage amount. However, no additional benefits in clinical outcomes, transfusion rate, or wound complications were apparent, with similar DVT incidence rates.

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