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Wang HY, Wang L, Luo ZY, Wang D, Tang X, Zhou ZK, Pei FX. Intravenous and subsequent long-term oral tranexamic acid in enhanced-recovery primary total knee arthroplasty without the application of a tourniquet: a randomized placebo-controlled trial. BMC Musculoskelet Disord 2019; 20:478. [PMID: 31653221 PMCID: PMC6814971 DOI: 10.1186/s12891-019-2885-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 10/10/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To assess the efficacy and safety of intravenous and subsequent long-term oral tranexamic acid (TXA) following total knee arthroplasty (TKA) without a tourniquet. METHODS In this double-blinded trial, 118 patients undergoing primary TKA were randomized into two groups: the patients in group A received intravenous TXA at 20-mg/kg 10 min before the surgery and 3 h postoperatively, and then oral 1 g TXA from postoperative day (POD) 1 to POD 14, and the patients in group B received intravenous TXA at 20-mg/kg 10 min before surgery and 3 h postoperatively, and then oral 1 g placebo from postoperative day (POD) 1 to POD 14. The primary outcome was total blood loss. Secondary outcomes included ecchymosis area and morbidity, postoperative transfusion, postoperative laboratory values, postoperative knee function and length of hospital stay. Complications, and patient satisfaction were also recorded. RESULTS The mean total blood loss was lower in Group A than in Group B (671.7 ml vs 915.8 ml, P = 0.001). There was no significant difference in the transfusion rate between the two groups. Group A had a higher hemoglobin than Group B on POD 3 (106.0 g/L vs 99.7 g/L, P = 0.001). However, no significant difference was found for Hb or hematocrit on POD 1 or POD 14 between the two groups. Patients in Group A had less ecchymosis morbidity (7 vs 38, P = 0.001), smaller ecchymosis area (1.6 vs 3.0, P = 0.001) than Group B. The blood coagulation level as measured by fibrinolysis (D-Dimer) was lower in Group A than in Group B on POD 1 and POD 3 (4.6 mg/L vs. 8.4 mg/L, respectively, P = 0.001; 1.5 mg/L vs. 3.3 mg/L, respectively, P = 0.001). However, there was no significant difference on POD 14, and the fibrin degradation products showed the same trend. Patients in Group A had less swelling than those in Group B on POD 3 and POD 14. The circumference of the knee was 43.1 cm vs. 46.1 cm (POD 3, P = 0.001) and 41.4 cm vs. 44.9 cm (POD 14, P = 0.001) in Group A vs Group B, respectively. Nevertheless, the circumference of the knee in the two groups was similar on POD 1 and POD 3 M. No significant differences were identified in knee function, pain score, or hospital stay. No significant differences were identified in thromboembolic complications, infection, hematoma, wound healing and patients satisfaction between the two groups. CONCLUSION Intravenous and subsequent long-term oral TXA produced less blood loss and less swelling and ecchymosis compared with short-term TXA without increasing the risk of complications. TRIAL REGISTRATION The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17012264 ).
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Affiliation(s)
- Hao-Yang Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, People's Republic of China
| | - Liu Wang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, Sichuan University, Chengdu, 610041, People's Republic of China.,Department of Cariology and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ze-Yu Luo
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, People's Republic of China
| | - Duan Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, People's Republic of China
| | - Xin Tang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, People's Republic of China.
| | - Zong-Ke Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, People's Republic of China.
| | - Fu-Xing Pei
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, People's Republic of China
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Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Reducing red blood cell transfusion in orthopedic and cardiac surgeries with Antifibrinolytics: A laboratory medicine best practice systematic review and meta-analysis. Clin Biochem 2019; 71:1-13. [DOI: 10.1016/j.clinbiochem.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/02/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
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Local Pro- and Anti-Coagulation Therapy in the Plastic Surgical Patient: A Literature Review of the Evidence and Clinical Applications. MEDICINA-LITHUANIA 2019; 55:medicina55050208. [PMID: 31137735 PMCID: PMC6572131 DOI: 10.3390/medicina55050208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/23/2019] [Accepted: 05/22/2019] [Indexed: 11/17/2022]
Abstract
The risks of systemic anti-coagulation or its reversal are well known but accepted as necessary under certain circumstances. However, particularly in the plastic surgical patient, systemic alteration to hemostasis is often unnecessary when local therapy could provide the needed adjustments. The aim of this review was to provide a summarized overview of the clinical applications of topical anti- and pro-coagulant therapy in plastic and reconstructive surgery. While not a robust field as of yet, local tranexamic acid (TXA) has shown promise in achieving hemostasis under various circumstances, hemostats are widely used to halt bleeding, and local anticoagulants such as heparin can improve flap survival. The main challenge to the advancement of local therapy is drug delivery. However, with increasingly promising innovations underway, the field will hopefully expand to the betterment of patient care.
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Zhang YM, Yang B, Sun XD, Zhang Z. Combined intravenous and intra-articular tranexamic acid administration in total knee arthroplasty for preventing blood loss and hyperfibrinolysis: A randomized controlled trial. Medicine (Baltimore) 2019; 98:e14458. [PMID: 30762760 PMCID: PMC6408055 DOI: 10.1097/md.0000000000014458] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 01/09/2019] [Accepted: 01/13/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability. However, blood loss and fibrinolytic activity, accounting for a poor prognosis following TKA operation, were relieved by fibrinolytic inhibitor tranexamic acid (TXA). For a better application of TXA function, we explored the effect of intravenous injection (IV) of TXA combined with intra-articular injection (IA) of TXA in patients after TKA. METHODS Patients admitted from Weifang People's Hospital from January 2015 to December 2016 who received TKA were injected with 20 mg/kg TXA by IV before TKA (n = 50), 3.0 g TXA by IA after TKA (n = 50), or combination of 20 mg/kg TXA by IV before TKA and 3.0 g TXA by IA after TKA (n = 50). Knee function was assessed using HSS, KSS, NASS, and ROM. In addition, the total blood loss (TBL), hidden blood loss (HBL), maximum hemoglobin (Hb) drop, fibrinolytic activity, as well as incidence of thromboembolism were measured. The patients were followed up for 6 months. The deadline for follow-up was June 2017 and the incidence of thromboembolism events within 6 months after operation was counted. RESULTS HSS, KSS, NASS scores, and ROM were elevated after patients receiving TKA. Patients received IV plus IA TXA has decreased TBL, HBL, and maximum Hb drop than those received IV TXA-alone and IA TXA-alone, with reductions in FDP and D-dimer, indicating that IV plus IA TXA injection is superior to prevent blood loss and hyperfibrinolysis during TKA. Age, sex, type of femoral prosthesis, and the injection method of TXA were risk factors for HBL of patients after receiving TKA. CONCLUSIONS The aforementioned results demonstrate that TKA is an effective surgery, and IV plus IA TXA injection functions more effectively in reducing blood loss and fibrinolytic activity in patients, which is a clinical factor of occult hemorrhage.
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The best cited articles of the European Journal of Orthopaedic Surgery and Traumatology (EJOST): a bibliometric analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:533-544. [DOI: 10.1007/s00590-018-2147-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 12/19/2022]
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Harper RA, Sucher MG, Giordani M, Nedopil AJ. Topically Applied Epsilon-Aminocaproic Acid Reduces Blood Loss and Length of Hospital Stay After Total Knee Arthroplasty. Orthopedics 2017; 40:e1044-e1049. [PMID: 28968480 DOI: 10.3928/01477447-20170925-07] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 08/14/2017] [Indexed: 02/03/2023]
Abstract
Perioperative blood loss after total knee arthroplasty (TKA) affects postoperative recovery. Tranexamic acid is safe and efficient in reducing blood loss without increasing thromboembolic events. Epsilon-aminocaproic acid (ε-ACA) is less expensive than and as safe as tranexamic acid. Its efficiency when locally applied in TKA is unknown. The authors retrospectively followed 240 consecutive patients treated by 1 surgeon with TKA from January 2012 to August 2016. From January 2013 to May 2015, the authors topically applied 5 g of ε-ACA to the open wound after tourniquet release and before closure (ε-ACA-after-tourniquet-release group). From August 2015 to August 2016, the authors topically applied 5 g of ε-ACA intraoperatively to the open wound 3 minutes before tourniquet release (ε-ACA-before-tourniquet-release group). The last 80 patients not receiving ε-ACA (control group), the 80 patients in the ε-ACA-after-tourniquet-release group, and the 80 patients in the ε-ACA-before-tourniquet-release group were compared regarding blood loss, treatment costs, and thromboembolic complications. The mean±SD calculated blood loss was 1478.8±367.1 mL for the control group, 1424.0±249.3 mL for the ε-ACA-after-tourniquet-release group, and 1052.3±419.1 mL for the ε-ACA-before-tourniquet-release group (P<.05). Using ε-ACA before tourniquet release reduced the length of hospital stay by 0.7 days (P<.05) compared with not using ε-ACA, leading to cost savings of $1547.37 per patient. One patient in the ε-ACA-before-tourniquet-release group and 1 patient in the control group developed a venous thromboembolism in the postoperative period. Epsilon-aminocaproic acid significantly reduces blood loss after TKA when topically applied before tourniquet release. Its application reduced costs by decreasing the length of hospital stay and did not increase thromboembolic events. [Orthopedics. 2017; 40(6):e1044-e1049.].
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Nielsen CS, Gromov K, Jans Ø, Troelsen A, Husted H. No Effect of a Bipolar Sealer on Total Blood Loss or Blood Transfusion in Nonseptic Revision Knee Arthroplasty-A Prospective Study With Matched Retrospective Controls. J Arthroplasty 2017; 32:177-182. [PMID: 27554781 DOI: 10.1016/j.arth.2016.06.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Postoperative anemia is frequent after revision of total knee arthroplasty (TKA) with reported transfusion rates up to 83%. Despite increased efforts of reducing blood loss and enhancing fast recovery within the fast-track setup, a considerable transfusion rate is still evident. The aim of this study was therefore to evaluate the effect of a bipolar sealer on blood loss and transfusion in revision TKA. METHODS In this single-center prospective cohort study with retrospective controls, 51 patients were enrolled in a fast-track setup for revision TKA without the use of a tourniquet. Twenty-five prospectively enrolled patients received treatment with both a bipolar sealer and electrocautery, whereas 26 patients had received treatment with a conventional electrocautery only in the retrospective group. RESULTS No significant differences were found neither for calculated blood loss, with 1397 (standard deviation, ± 452) mL in the bipolar sealer group vs 1452 (SD, ± 530) mL in the control group (P = .66), nor for blood transfusion rates of 53% and 46% (P = .89), respectively. Four controls were readmitted within 90 days follow-up. CONCLUSION The use of a bipolar sealer in a TKA revision setting without the use of a tourniquet did not reduce blood loss or blood transfusion rates.
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Affiliation(s)
- Christian Skovgaard Nielsen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark; Orthopedic Department, Harris Orthopedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Øivind Jans
- Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark
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Balasubramanian N, Natarajan GB, Prakasam S. Prospective Study to compare Intra-articular versus Intravenous Tranexemic Acid in reducing Post-operative Blood Loss in staged bilateral Total Knee Arthroplasty. Malays Orthop J 2016; 10:7-11. [PMID: 28553440 PMCID: PMC5333676 DOI: 10.5704/moj.1611.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The number of total knee arthroplasties (TKA) performed is around two million annually worldwide and this number is expected to increase fivefold by 2025. The most common indication is osteoarthritis of the knee. Blood loss is significant during the post-operative period and blood transfusion when necessary has its own drawbacks. The use of intravenous tranexamic acid has significantly reduced blood loss. We analysed 35 patients who underwent staged bilateral TKA between August 2013 and February 2016 and had administered intra-articular tranexamic acid for one knee and intravenous tranexamic acid for the other knee. The results were analysed based on post-operative blood loss, change in haemoglobin (Hb) level and haematocrit (PCV) and the need for blood transfusion. The average postoperative blood loss was 129.57 ml and 277.71 ml for intra articular group and intravenous group respectively. A control group (no drug or placebo group) with age matched patients (n= 21) was chosen from medical records. The average blood loss in the control group was 493.81 ml. The fall in Hb level and PCV was 0.72 gm/dl and 2.62 % (Intra-articular Group), 1.36 gm/dl and 4.34 % (Intravenous Group) and 2.62 gm/dl and 5.52 % (Control). The number of transfusions were two (Intra-articular Group), five (Intravenous Group) and nine (Control). We conclude that when compared with intravenous route, intra-articular administration has significantly reduced blood loss, Hb level and PCV fall and the rate of blood transfusion.
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Affiliation(s)
- N Balasubramanian
- Department of Orthopaedic Surgery, Saveetha Medical College & University, Chennai, India
| | - G B Natarajan
- Department of Orthopaedic Surgery, Saveetha Medical College & University, Chennai, India
| | - S Prakasam
- Department of Orthopaedic Surgery, Saveetha Medical College & University, Chennai, India
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Gao F, Sun W, Guo W, Li Z, Wang W, Cheng L. Topical Administration of Tranexamic Acid Plus Diluted-Epinephrine in Primary Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Trial. J Arthroplasty 2015; 30:1354-8. [PMID: 25817183 DOI: 10.1016/j.arth.2015.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/03/2015] [Accepted: 03/09/2015] [Indexed: 02/01/2023] Open
Abstract
The aim of this trial was to evaluate the efficacy and safety of intra-articular administration of tranexamic acid (TXA) plus diluted-epinephrine (DEP) on perioperative blood loss and transfusion in primary unilateral total knee arthroplasty (TKA) without drainage. One hundred patients scheduled to undergo TKA were randomized into two groups: 50 patients received intra-articular 3g TXA plus 0.25mg DEP (1:200,000), and 50 patients received 3g topical TXA alone. The results showed that topical combined administration significantly reduced total blood loss (P=0.006), hidden blood loss (P=0.000) and transfusion rate (0% vs. 4%), without increasing the risk of thromboembolic and hemodynamic complications (P>0.05). Therefore, topical TXA plus DEP was effective and safe in reducing blood loss and transfusion following TKA, without substantial complications.
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Affiliation(s)
- Fuqiang Gao
- Osteonecrosis and Joint-Preserving and Reconstruction Center, Beijing, China; Department of Orthopedic Surgery, Beijing, China; Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Beijing, China; China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Wei Sun
- Osteonecrosis and Joint-Preserving and Reconstruction Center, Beijing, China; Department of Orthopedic Surgery, Beijing, China; Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Beijing, China; China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Wanshou Guo
- Osteonecrosis and Joint-Preserving and Reconstruction Center, Beijing, China; Department of Orthopedic Surgery, Beijing, China; Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Beijing, China; China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Zirong Li
- Osteonecrosis and Joint-Preserving and Reconstruction Center, Beijing, China; Department of Orthopedic Surgery, Beijing, China; Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Beijing, China; China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Weiguo Wang
- Osteonecrosis and Joint-Preserving and Reconstruction Center, Beijing, China; Department of Orthopedic Surgery, Beijing, China; Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Beijing, China; China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Liming Cheng
- Osteonecrosis and Joint-Preserving and Reconstruction Center, Beijing, China; Department of Orthopedic Surgery, Beijing, China; Beijing Key Laboratory of Arthritic and Rheumatic Diseases, Beijing, China; China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
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Wang CG, Sun ZH, Liu J, Cao JG, Li ZJ. Safety and efficacy of intra-articular tranexamic acid injection without drainage on blood loss in total knee arthroplasty: A randomized clinical trial. Int J Surg 2015; 20:1-7. [DOI: 10.1016/j.ijsu.2015.05.045] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/10/2015] [Accepted: 05/18/2015] [Indexed: 11/29/2022]
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Digas G, Koutsogiannis I, Meletiadis G, Antonopoulou E, Karamoulas V, Bikos C. Intra-articular injection of tranexamic acid reduce blood loss in cemented total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1181-8. [PMID: 26169991 DOI: 10.1007/s00590-015-1664-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/16/2015] [Indexed: 12/19/2022]
Abstract
The purpose of this study was to compare the efficacy of intravenous and topical tranexamic acid (TXA) versus control group for reduction in blood loss following primary total knee arthroplasty (TKA). A total of 90 patients were prospectively allocated to each of three groups (control, intravenous IV and intra-articular) and underwent unilateral total knee arthroplasty. In the IV group, patients received one dose of TXA of 15 mg/kg before deflation of the tourniquet, while in the intra-articular group patients received 2 g TXA via the drain retrogradely after closure of the wound. The mean drained blood loss in control, IV and intra-articular groups was 415 ± 24, 192 ± 21 and 121 ± 17 ml, respectively. About 43 % (control), 23 % (IV) and 17 % (intra-articular) of each group required transfusion, and the mean transfusion was 338, 168 and 79 ml, respectively. Preoperative hemoglobin values decreased at 24 h by 2.80 ± 0.14, 2.24 ± 0.17 and 2.26 ± 0.18 mg/dl, respectively. TXA reduced blood loss and transfusion requirement. Compared with one-dose intravenous administration, intra-articular administration of TXA seems to be more effective in terms of reducing drained blood loss and transfusion frequency. We recommend administration of topical TXA in primary TKA in healthy patients to decrease perioperative blood loss.
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Affiliation(s)
- G Digas
- Orthopaedic department, General Hospital Xanthi, Xanthi, Greece.
| | - I Koutsogiannis
- Orthopaedic department, General Hospital Xanthi, Xanthi, Greece
| | - G Meletiadis
- Orthopaedic department, General Hospital Xanthi, Xanthi, Greece
| | - E Antonopoulou
- Orthopaedic department, General Hospital Xanthi, Xanthi, Greece
| | - V Karamoulas
- Orthopaedic department, General Hospital Xanthi, Xanthi, Greece
| | - Ch Bikos
- Orthopaedic department, General Hospital Xanthi, Xanthi, Greece
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Sabatini L, Atzori F. Topical intra-articular and intravenous tranexamic acid to reduce blood loss in total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:S18. [PMID: 26046063 DOI: 10.3978/j.issn.2305-5839.2015.02.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/06/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Luigi Sabatini
- Unit of Orthopaedics and Traumatology, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043 Orbassano, Torino, Italy
| | - Francesco Atzori
- Unit of Orthopaedics and Traumatology, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043 Orbassano, Torino, Italy
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Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Pérez-Chrzanowska H, Figueredo-Zalve R. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am 2014; 96:1937-44. [PMID: 25471907 DOI: 10.2106/jbjs.n.00060] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Abundant literature regarding the use of intravenous tranexamic acid (TXA) in primary total knee replacement is available. Randomized controlled trials have confirmed the efficacy of topical TXA compared with placebo, but the comparison between topical and intravenous TXA is unclear. The present study was designed to verify noninferior efficacy and safety of topical intra-articular TXA compared with intravenous TXA in primary total knee replacement with cemented implants. METHODS A Phase-III, single-center, double-blind, randomized, controlled clinical trial was performed to compare topical intra-articular TXA (3 g of TXA in 100 mL of physiological saline solution) with two intravenous doses of TXA (15 mg/kg in 100 mL of physiological saline solution, one dose before tourniquet release and another three hours after surgery) in a multimodal protocol for blood loss prevention. The primary outcome was the blood transfusion rate, and the secondary outcomes included visible blood loss (as measured in the drain) at twenty-four hours postoperatively and invisible blood loss (as estimated from the Nadler formula) at forty-eight hours postoperatively. The sample size of seventy-eight patients was calculated to give a statistical power of 99% for demonstrating noninferiority. Thirty-nine patients each were allocated to receive topical intra-articular TXA (the experimental group) and intravenous TXA (the control group); there were no significant differences in demographics or preoperative laboratory values between the groups. Noninferiority was estimated by comparing the confidence intervals with a delta of 10%. Student t and Mann-Whitney tests were used to assess the significance of any differences. RESULTS The transfusion rate was zero in both groups; thus, noninferiority was demonstrated for the primary efficacy end point, suggesting equivalence. Noninferiority was also demonstrated for the secondary efficacy end points. Drain blood loss at twenty-four hours was 315.6 mL (95% confidence interval [CI], 248.5 to 382.7 mL) in the experimental group and 308.1 mL (95% CI, 247.6 to 368.5 mL) in the control group (p = 0.948, Mann-Whitney). Also, estimated blood loss at forty-eight hours was 1259.0 mL (95% CI, 1115.6 to 1402.3 mL) in the experimental group and 1317.9 mL (95% CI, 1175.4 to 1460.4 mL) in the control group (p = 0.837, Mann-Whitney). No significant safety differences were seen between groups. CONCLUSIONS Topical administration of TXA according to the described protocol demonstrated noninferiority compared with intravenous TXA, with no safety concerns. This randomized controlled trial supports the topical intra-articular administration of TXA in primary total knee replacement with cemented implants. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Enrique Gomez-Barrena
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario "La Paz"-IdiPAZ-UAM, Traumatología 1ª planta, Paseo de la Castellana 261, 28046 Madrid, Spain. E-mail address for E. Gomez-Barrena: ,
| | - Miguel Ortega-Andreu
- Departments of Orthopaedic Surgery and Traumatology (M.O.-A.) and Anaesthesiology (H.P.-C. and R.F.-Z.), Hospital La Paz-Cantoblanco, Carretera de Colmenar Viejo Km 14, 28049 Madrid, Spain
| | - Norma G Padilla-Eguiluz
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario "La Paz"-IdiPAZ-UAM, Traumatología 1ª planta, Paseo de la Castellana 261, 28046 Madrid, Spain. E-mail address for E. Gomez-Barrena: ,
| | - Hanna Pérez-Chrzanowska
- Departments of Orthopaedic Surgery and Traumatology (M.O.-A.) and Anaesthesiology (H.P.-C. and R.F.-Z.), Hospital La Paz-Cantoblanco, Carretera de Colmenar Viejo Km 14, 28049 Madrid, Spain
| | - Reyes Figueredo-Zalve
- Departments of Orthopaedic Surgery and Traumatology (M.O.-A.) and Anaesthesiology (H.P.-C. and R.F.-Z.), Hospital La Paz-Cantoblanco, Carretera de Colmenar Viejo Km 14, 28049 Madrid, Spain
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