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Metoki Y, Iwase D, Kusumoto Y, Aikawa J, Mukai M, Fukushima K, Inoue G, Takaso M. The necessity of suction drainage when intra-articular injection of tranexamic acid is used during primary total knee arthroplasty: a retrospective study. BMC Musculoskelet Disord 2024; 25:475. [PMID: 38890633 PMCID: PMC11184754 DOI: 10.1186/s12891-024-07604-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Suction drainages are commonly used after total knee arthroplasty (TKA) procedures; however, their use is somewhat controversial. Recently, some reports have claimed that the administration of tranexamic acid (TXA) may prevent postoperative bleeding following TKAs. Although numerous studies have reported regarding different dosages, timings of administration, or drain clamping times for intravenous and intra-articular TXA injections (IA-TXAs), few have examined whether suction drainage is necessary when TXA is administered. In this study, we compared using suction drainage without TXA administration and IA-TXA without suction drainage and aimed to examine the need for suction drainage during IA-TXA. METHODS This retrospective study was conducted on 217 patients who had received TKA for osteoarthritis; 104 were placed on suction drainage after TKA without TXA (Group A), whereas the remaining 113 received IA-TXA immediately after surgery without suction drainage (Group B). Our clinical evaluation included assessments of the need for transfusion, presence of postoperative complications, incidence of deep vein thrombosis (DVT), and changes in hemoglobin (Hb), hematocrit (Hct), and D-dimer levels. RESULTS No significant differences were observed in terms of postoperative complications and preoperative Hb, Hct, or D-dimer levels between the two groups. Although the prevalence of DVT was significantly higher in Group B (p < 0.05), all cases were asymptomatic. Hb and Hct levels were significantly lower in Group A than in Group B at 1, 3, 7, and 14 days postoperatively (p < 0.05), although none of the cases required blood transfusions. D-dimer levels were significantly higher in Group A than in Group B at 1 and 3 days postoperatively (p < 0.05). CONCLUSION Suction drainage might not be necessary when IA-TXA is administered after TKA procedures.
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Affiliation(s)
- Yukie Metoki
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Dai Iwase
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan.
| | - Yasuaki Kusumoto
- Department of Physical Therapy, Fukushima Medical University School of Health Sciences, 10-6 Sakaemachi, Fukushima City, Fukushima, 960-8516, Japan
| | - Jun Aikawa
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Manabu Mukai
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Kensuke Fukushima
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Gen Inoue
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara City, Kanagawa, 252-0374, Japan
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Samborski SA, Morris SC, Leary S, Geiger K, Hlas A, Westermann R, Banffy M. Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy. Arthroscopy 2024:S0749-8063(24)00300-1. [PMID: 38703922 DOI: 10.1016/j.arthro.2024.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. METHODS This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. RESULTS A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n = 45; primary, n = 404) than in the group that did not receive TXA (n = 25; primary, n = 388) (P = .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P = .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P = .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5 minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n = 27) than in the group that did (n = 10) (P = .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P = .24). CONCLUSIONS There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. LEVEL OF EVIDENCE Level III, retrospective multicenter consecutive series.
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Affiliation(s)
| | - S Craig Morris
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, U.S.A
| | | | | | - Armen Hlas
- University of Iowa, Iowa City, Iowa, U.S.A
| | | | - Michael Banffy
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, U.S.A
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Gibbs VN, Champaneria R, Sandercock J, Welton NJ, Geneen LJ, Brunskill SJ, Dorée C, Kimber C, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD013295. [PMID: 38226724 PMCID: PMC10790339 DOI: 10.1002/14651858.cd013295.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. OBJECTIVES To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology. SEARCH METHODS We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants. DATA COLLECTION AND ANALYSIS We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. MAIN RESULTS We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). AUTHORS' CONCLUSIONS We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Nicky J Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Pimenta FS, de Oliveira Campos TV, de Abreu E Silva GM, Buzelin MA, Nunes CB, de Andrade MAP. Chondrotoxic effects of tranexamic acid and povidone-iodine on the articular cartilage of rabbits. INTERNATIONAL ORTHOPAEDICS 2023; 47:2429-2437. [PMID: 37099167 DOI: 10.1007/s00264-023-05820-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/18/2023] [Indexed: 04/27/2023]
Abstract
PURPOSE To evaluate the chondrotoxic effects of intra-articular use of TXA 20 mg/kg and/or 0.35% PVPI on knee joint cartilage in an experimental model of rabbits. METHODS Forty-four male New Zealand adult rabbits were randomly assigned to four groups (control, tranexamic acid (TXA), povidone-iodine (PVPI), and PVPI + TXA). The knee joint cartilage was accessed through an arthrotomy and exposed to physiological saline SF 0.9% (control group), TXA, PVPI, and PVPI followed by TXA. Sixty days after surgical procedure, the animals were sacrificed and osteochondral specimens of the distal femur were obtained. Histological sections of cartilage from this area were stained with hematoxylin/eosin and toluidine blue. The following cartilage parameters were evaluated by the Mankin histological/histochemical grading system: structure, cellularity, glycosaminoglycan content in the extracellular matrix, and integrity of the tidemark. RESULTS The isolated use of PVPI causes statistically significant changes in cartilage cellularity (p-value = 0.005) and decrease glycosaminoglycan content (p = 0.001), whereas the isolated use of TXA decreased significantly the glycosaminoglycan content (p = 0.031). The sequential use of PVPI + TXA causes more pronounced alterations in the structure (p = 0.039) and cellularity (p = 0.002) and decreased content of glycosaminoglycans (p < 0.001) all with statistical significance. CONCLUSION Data suggest that intra-articular use of tranexamic acid 20 mg/kg and intraoperative lavage with 0.35% povidone-iodine solution for three min are toxic to the articular cartilage of the knee in an experimental in vivo study in rabbits.
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Affiliation(s)
- Frederico Silva Pimenta
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil.
| | - Túlio Vinícius de Oliveira Campos
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Guilherme Moreira de Abreu E Silva
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Marcelo Araújo Buzelin
- Institute of Education and Research Santa Casa, Ave dos Andradas 2688, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Cristiana Buzelin Nunes
- Pathologic Anatomy Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Marco Antônio Percope de Andrade
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
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Tan TK, Lee JY, Tay A, Kuster M. Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:709-738. [PMID: 35377071 DOI: 10.1007/s00590-022-03241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
AIM The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | | | - Aaron Tay
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Markus Kuster
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
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Guler O, Çarkcı E, Çerci MH, Gümüşsuyu G, Öztürk Ç. Comparison of weight-based versus standard dosing of tranexamic acid for blood loss and transfusion amount in knee arthroplasty without tourniquet. Acta Orthop Belg 2022; 88:53-60. [PMID: 35512155 DOI: 10.52628/88.1.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of the study is to compare weight-based versus standard dosing of intravenous (IV) tranexamic acid (TXA) for blood loss and transfusion amount in total knee arthroplasty (TKA) without a tourniquet. A total of 99 patients were divided into two groups: Group 1 (standard): 1 g of IV TXA 30 min before skin incision, and 1 g at postoperative 30 min and 3 h. Group 2 (weight-based): 10 mg/kg IV TXA 30 min before the skin incision, and 10 mg/kg at postoperative 30 min, and 3 h. Hemoglobin levels, before, and 1, and 2 days after the operation, postoperative amount of decrease in hemoglobin levels, and amount of erythrocyte transfusion were recorded. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Society Score (KSS) were applied in the evaluation of TKA results preoperatively, and at 1., 3., 6., and 12. months, postoperatively. In both study groups, hemoglobin levels in male patients dropped significantly more deeply than female patients. Also, in both study groups, hemo- globin levels were significantly lower in patients with comorbid illnesses. A statistically significant difference was not detected between both groups in terms of pre- and postoperative WOMAC scores, KSS knee scores, and KSS function scores. Our study showed that standard and weight-based dosing of IV TXA treatments were similar in efficacy and safety. Both treatments reduce blood loss and the need for transfusion. Also, there was no significant difference in terms of reliability between two groups.
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Singh H, Agarwal KK, Tyagi S, Makadia P, Oza B, Jain P, Patel M. Peroperative Intra-Articular Infiltration of Tranexamic Acid and Ropivacaine Cocktail in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial. Cureus 2022; 14:e23091. [PMID: 35464570 PMCID: PMC8996435 DOI: 10.7759/cureus.23091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Total knee arthroplasty (TKA) is a procedure that has improved the quality of life of patients with knee arthritis. Postoperative pain and blood loss are the two major drawbacks of TKA which affect patient satisfaction and delay recovery and rehabilitation. Local infiltration analgesia has shown better results in controlling immediate postoperative pain, thus enabling early rehabilitation and mobilization, while local infiltration of antifibrinolytic agents has shown impressive results in controlling blood loss. In this study, we evaluate the effect of a combination of intra-articular infiltration of ropivacaine cocktail along with intra-articular instillation of tranexamic acid in reducing patient-reported postoperative pain and the level of blood loss control after TKA. Methodology Patients presenting with high-grade osteoarthritis and undergoing TKA were included and randomly allocated to two groups: one receiving the intra-articular infiltration (group A), and the other not receiving any infiltration (group B). Postoperative pain was measured through the Visual Analog Scale (VAS) every three hours for the first 24 hours, and then at 48 hours and 72 hours postoperatively. The need for additional analgesia, in the form of a slow epidural infusion, in patients experiencing severe postoperative pain was evaluated in both groups. Postoperative blood loss was assessed by measuring total drain output (in mL) and by comparing preoperative and postoperative (at 24 hours) hemoglobin, hematocrit drift, and blood transfusion rates. The duration of the postoperative hospital stay and the time taken to start postoperative knee mobilization exercises and weight-bearing were noted to assess the recovery and rehabilitation of the patients in the two groups. Results The study included 42 patients (group A, 22 patients; group B, 20 patients) with 28 knees in each group. Patients with intra-articular infiltration using ropivacaine cocktail with tranexamic acid showed excellent pain control compared to the non-infiltrated patients in the early 48 hours postoperatively. There was a significant drop in postoperative hemoglobin and hematocrit values in the non-infiltrated patients compared to the other group. Further, the intra-articular infiltration-instillation significantly reduced blood loss through the drain, the requirement of postoperative blood transfusions, and the duration of hospital stay. Conclusions It can be safely concluded that ropivacaine cocktail and tranexamic acid instillation postoperatively in knee arthroplasty patients is a very useful and effective technique to reduce postoperative pain and blood loss.
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Affiliation(s)
- Harpreet Singh
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Kamal Kumar Agarwal
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Sangam Tyagi
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Prashant Makadia
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Bineet Oza
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Pranjal Jain
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Meet Patel
- Department of Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
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Cawthorne DP, Castillo TE, Sivakumar BS. Effect of commonly used surgical solutions on the tensile strength of absorbable sutures: an in-vitro study. ANZ J Surg 2021; 91:1451-1454. [PMID: 33928746 DOI: 10.1111/ans.16908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Within recent decades the use of various surgical solutions to prevent bleeding, ward off infection or decrease post-operative pain has become common-place in orthopaedic procedures. However, little work has been done to determine the effects that these solutions have on the tensile strength of various sutures, particularly those that are used for deep closures, which are often absorbable in nature. Whilst numerous authors have attempted to reach conclusions regarding the nature of these effects, a consensus has yet to be reached and this paper is designed with the aim to contribute to the current literature on the subject and improve surgical practice. METHODS This in-vitro study incubated three different surgical sutures in five commonly used surgical solutions at 37°C for 30 min, prior to applying a constant increase in force to determine the effects these solutions have on tensile strength. A control set was included. RESULTS No significant difference was found in the tensile strength of Vicryl and PDS-II sutures, whilst Monocryl incubated in chlorhexidine exhibited a borderline significant increase in tensile strength. CONCLUSIONS Common surgical solutions used on orthopaedic procedures can impact on the tensile strength of suture materials; however, further research is required on the subject.
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Affiliation(s)
- Donald P Cawthorne
- Department of Orthopaedic Surgery, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Tiana E Castillo
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia.,Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Taeuber I, Weibel S, Herrmann E, Neef V, Schlesinger T, Kranke P, Messroghli L, Zacharowski K, Choorapoikayil S, Meybohm P. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surg 2021; 156:e210884. [PMID: 33851983 PMCID: PMC8047805 DOI: 10.1001/jamasurg.2021.0884] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use. OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines. DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020. STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded. DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality. RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53). CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.
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Affiliation(s)
- Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Leila Messroghli
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Li S, Chen B, Hua Z, Shao Y, Yin H, Wang J. Comparative efficacy and safety of topical hemostatic agents in primary total knee arthroplasty: A network meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e25087. [PMID: 33761670 PMCID: PMC9282116 DOI: 10.1097/md.0000000000025087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 02/17/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Topical hemostatic agents are commonly used for reducing perioperative blood loss and transfusion requirement in primary total knee arthroplasty (TKA), although the optimal option has yet to be defined. This study aimed to evaluate the efficacy and safety of topical hemostatic agents and rank the best intervention using the network meta-analysis (NMA) method. METHODS We searched Web of science, PubMed, and Cochrane Library database up to April 2020, for randomized controlled trials (RCTs) on topical hemostatic agents in primary TKA. The quality of included studies was assessed using the Cochrane "risk of bias" tool. Direct and indirect comparisons were performed for the result of network meta-analysis followed by consistency test. RESULTS Thirty seven RCTs with 3792 patients were included in this NMA and the pooled results indicated that tranexamic acid plus diluted epinephrine (TXA+DEP) displayed the highest efficacy in reducing total blood loss, hemoglobin drop and transfusion requirement. None of the included treatments was found to increase risk of thromboembolic events compared to placebo. According to the results of ranking probabilities, TXA+DEP had the highest possibility to be the best topical hemostatic agent with regard to the greatest comparative efficacy and a relatively high safety level. CONCLUSION Current evidence supports that administration of TXA+DEP may be the optimal topical hemostatic agent to decrease blood loss and transfusion requirement in primary TKA. More direct studies that focused on the topical application of TXA+DEP versus other treatments are needed in the future.
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Affiliation(s)
- Shaoshuo Li
- Laboratory for New Techniques of Restoration & Reconstruction of Orthopedics and Traumatology, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Traumatology & Orthopedics, Wuxi Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi, China
| | - Baixing Chen
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Zhen Hua
- Department of Traumatology & Orthopedics, Wuxi Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi, China
| | - Yang Shao
- Department of Traumatology & Orthopedics, Wuxi Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi, China
| | - Heng Yin
- Department of Traumatology & Orthopedics, Wuxi Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi, China
| | - Jianwei Wang
- Department of Traumatology & Orthopedics, Wuxi Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi, China
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Morales-Avalos R, Ramos-Morales T, Espinoza-Galindo AM, Garay-Mendoza D, Peña-Martínez VM, Marfil-Rivera LJ, Garza-Ocañas L, Acosta-Olivo C, Cerda-Barbosa JK, Valdés-González NL, Vílchez-Cavazos F. First Comparative Study of the Effectiveness of the Use of Tranexamic Acid against ε-Aminocapróic Acid via the Oral Route for the Reduction of Postoperative Bleeding in TKA: A Clinical Trial. J Knee Surg 2021; 34:383-405. [PMID: 31491796 DOI: 10.1055/s-0039-1696722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total primary knee replacement results in significant postoperative bleeding. There are reports that 20 to 50% of the patients require a blood transfusion, which has been related to many complications, resulting in the search for strategies to reduce bleeding. The use of oral antifibrinolytics is becoming a low cost and safe way of achieving this goal. The hypothesis of this study was that the use of oral aminocaproic acid could provide similar results to the use of oral tranexamic acid (TXA). The purpose was to compare the effects of oral aminocaproic acid as a hemostatic agent versus the use of oral TXA administered in multiple doses pre and postsurgery in patients undergoing total primary knee replacement. We enrolled 92 patients that were randomly divided into two groups: received three doses of aminocaproic acid (2,000 mg per dose) or three doses of oral TXA (1,300 mg per dose). The drugs were administered according to the following schedule: 2 hours before surgery and 6 and 12 hours after surgery. The variables that were analyzed to compare the effectiveness of the hemostatic agents were total blood loss; hidden blood loss; external blood loss; transfusion rate; intraoperative blood loss; decreases in hemoglobin and hematocrit values; surgical drainage output; visual analogue scale; and surgical complications. There were no significant differences between any of the study variables for the group receiving oral aminocaproic acid and the group receiving oral TXA (p > 0.05), with the exception of patients who received TXA, who presented with more adverse events (p = 0.04). Our study showed that the use of oral aminocaproic acid was similar to its counterpart TXA regarding the evaluated parameters. Although patients who received TXA presented an average of 140 mL less blood loss than patients in the ε-ACA group, the difference did not appear to be clinically important, the transfusion rate was very low, and there were no between-group differences in postoperative complications.
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Affiliation(s)
- Rodolfo Morales-Avalos
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Tomas Ramos-Morales
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Ana María Espinoza-Galindo
- Department of Anesthesiology, University Hospital "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Domingo Garay-Mendoza
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Víctor M Peña-Martínez
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Luis Javier Marfil-Rivera
- Department of Hemaotology, University Hospital "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Lourdes Garza-Ocañas
- Department of Pharmacology and Toxicology, Faculty of Medicine, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Carlos Acosta-Olivo
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Jessica K Cerda-Barbosa
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Nancy L Valdés-González
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Félix Vílchez-Cavazos
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
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12
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Zhao Y, Xi C, Xu W, Yan J. Role of tranexamic acid in blood loss control and blood transfusion management of patients undergoing multilevel spine surgery: A meta-analysis. Medicine (Baltimore) 2021; 100:e24678. [PMID: 33607807 PMCID: PMC7899852 DOI: 10.1097/md.0000000000024678] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/21/2020] [Accepted: 01/16/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This study aimed to explore the role of tranexamic acid (TXA) in blood loss control and blood transfusion management of patients undergoing multilevel spine surgery. METHODS In this meta-analysis, a comprehensive search of literatures was performed from PubMed, Embase, Cochrane Library, and Web of Science from inception to June 23rd, 2020. Weighed mean difference (WMD) was used as the effect size for measurement data, and risk ratio for enumeration data. Publication bias was assessed by Begg test. RESULTS Totally 23 studies (11 randomized controlled trials and 12 cohort studies) involving 1621 participants were enrolled in this meta-analysis. The results showed that the administration of TXA can significantly decrease the intraoperative [WMD: -215.655, 95%CI: (-307.462, -123.847), P < .001], postoperative [WMD: -69.213, 95%CI: (-104.443, -33.983), P = .001] and total [WMD: -284.388, 95%CI: (-437.66, -131.116), P < .001] volumes of blood loss of patients undergoing multilevel spine surgery. It can also significantly reduce the intraoperative [WMD: -333.775, 95%CI: (-540.45, -127.099), P = .002] and postoperative [WMD: -114.661, 95%CI: (-219.58, -9.742), P = .032] volumes of transfusion. In addition, TXA was found to significantly increase the preoperative [WMD: 0.213, 95%CI: (0.037, 0.389), P = .018] and postoperative [WMD: 0.433, 95%CI: (0.244, 0.622), P < .001] hemoglobin levels as well as the preoperative platelet count [WMD: 14.069, 95%CI: (0.122, 28.015), P = .048]. CONCLUSION The administration of TXA can effectively reduce blood loss and transfusion, and improve hemoglobin levels and preoperative platelet count in patients undergoing multilevel spine surgery.
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Reale D, Andriolo L, Gursoy S, Bozkurt M, Filardo G, Zaffagnini S. Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6961540. [PMID: 33532495 PMCID: PMC7834786 DOI: 10.1155/2021/6961540] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. DESIGN A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. RESULTS A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. CONCLUSIONS There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.
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Affiliation(s)
- Davide Reale
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Safa Gursoy
- Department of Orthopaedics and Traumatology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Murat Bozkurt
- Department of Orthopaedics and Traumatology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Li J, Liu R, Rai S, Ze R, Tang X, Hong P. Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty. J Orthop Surg Res 2020; 15:581. [PMID: 33267906 PMCID: PMC7709322 DOI: 10.1186/s13018-020-02119-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal dosage and administration approach of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains controversial. In light of recently published 14 randomized controlled trials (RCTs), the study aims to incorporate the newly found evidence and compare the efficacy and safety of intra-articular (IA) vs. intravenous (IV) application of TXA in primary TKA. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for RCTs comparing IA with IV TXA for primary TKA. Primary outcomes included total blood loss (TBL) and drain output. Secondary outcomes included hidden blood loss (HBL), hemoglobin (Hb) fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time. RESULT In all, 34 RCTs involving 3867 patients were included in our meta-analysis. Significant advantages of IA were shown on TBL (MD = 33.38, 95% CI = 19.24 to 47.51, P < 0.001), drain output (MD = 28.44, 95% CI = 2.61 to 54.27, P = 0.03), and postoperative day (POD) 3+ Hb fall (MD = 0.24, 95% CI = 0.09 to 0.39, P = 0.001) compared with IV. There existed no significant difference on HBL, POD1 and POD2 Hb fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time between IA and IV. CONCLUSION Intra-articular administration of TXA is superior to intravenous in primary TKA patients regarding the performance on TBL, drain output, and POD3+ Hb fall, without increased risk of perioperative complications. Therefore, intra-articular administration is the recommended approach in clinical practice for primary TKA.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Renhao Ze
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Higher doses of topical tranexamic acid safely improves immediate functional outcomes and reduces transfusion requirement in total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:2071-2075. [PMID: 32862267 DOI: 10.1007/s00402-020-03591-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/16/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Topical administration of tranexamic acid (TXA) in patients undergoing total knee arthroplasty (TKA) is increasingly popular as it avoids the risks related with systemic absorption of the medication. Previous studies have established the efficacy of TXA in TKA, however here are limited direct comparison studies available and the dosing regimens vary. Hence, there is no consensus on an optimal dose. Our objective is to compare blood loss, transfusion requirement and immediate post-operative function between high (2 g) and low (1 g) dose tranexamic acid in patients undergoing TKA. METHODS This is a retrospective cohort study of 104 patients undergoing total knee arthroplasty in a single institution under a single surgeon. In total, 61 and 43 patients receiving 1 g and 2 g of topical TXA respectively. Blood loss as estimated from the difference in haemoglobin (Hb) and haematocrit (HCT) levels post-surgery and number of blood transfusions required were compared between groups. Immediate post-operative function and complications were also measured. RESULTS Patient characteristics were mostly similar between groups. The transfusion requirements were higher in 1 g group compared to the 2 g group (0.11 vs 0.00, p = 0.034). The mean post op day 1 (POD1) range of motion higher in the 1 g group vs 2 g group (72.1 vs 63.7, p = 0.035). The 2 g group had a lower POD1 pain score compared to the 1 g group (4.02 vs 5.43, p < 0.01). There was no statistically significant difference in complications that were related to the administration of TXA between the two groups. CONCLUSION Higher dose of topical TXA is safe, helps improve immediate post-operative functional outcomes and reduces transfusion requirements.
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Rodriguez-Merchan EC, Encinas-Ullan CA, Gomez-Cardero P. Intra-articular Tranexamic Acid in Primary Total Knee Arthroplasty Decreases the Rate of Post-operative Blood Transfusions in People with Hemophilia: A Retrospective Case-Control Study. HSS J 2020; 16:218-221. [PMID: 33088236 PMCID: PMC7534883 DOI: 10.1007/s11420-019-09711-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Blood transfusion rates after total knee arthroplasty (TKA) in patients without hemophilia have diminished with the use of a standardized multimodal blood loss prevention method (MBLPM) that includes intra-articular tranexamic acid (TXA) (MBLPM-TXA). However, the topic has not been addressed in people with hemophilia. QUESTIONS/PURPOSES Our aim was to investigate whether the MBLPM-TXA prevents blood loss in patients with hemophilia A who undergo TKA, thereby decreasing the need for post-operative blood transfusion. METHODS This retrospective case-control comparative study involved 30 TKA patients who had a severe degree of hemophilia A without inhibitions: one group treated with the MBLPM-TXA (n = 15) and a second group treated without it (n = 15). In all cases, the pre-operative hemoglobin level was greater than 13 g/dL. RESULTS The MBLPM-TXA group had a transfusion rate of zero, whereas 46.6% of the patients (seven of 15) in the non-MBLPM-TXA group needed transfusion. CONCLUSION This retrospective case-control study showed that the use of an MBLPM-TXA in patients with hemophilia A who underwent TKA was effective in reducing rates of transfusion. We recommend its use.
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Affiliation(s)
- E. Carlos Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital–IdiPaz, Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Carlos A. Encinas-Ullan
- Department of Orthopaedic Surgery, La Paz University Hospital–IdiPaz, Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Primitivo Gomez-Cardero
- Department of Orthopaedic Surgery, La Paz University Hospital–IdiPaz, Paseo de la Castellana 261, 28046 Madrid, Spain
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Amin MS, Habib MK, Rehman AU. Comparison of blood loss between intra-articular and intra-venous administration of tranexamic acid in primary total knee arthroplasty. SICOT J 2020; 6:20. [PMID: 32553103 PMCID: PMC7301632 DOI: 10.1051/sicotj/2020017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/27/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To compare the blood loss between intra-articular and intra-venous administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty. DESIGN OF STUDY It was a randomized controlled trial. Study duration and settings: This study was carried out at the Orthopedic Departments of Combined Military Hospital Lahore and Rawalpindi from Jan 2016 to March 2018. METHODOLOGY Patients of both the genders were involved this study who had age in the rage of 40-80 years undergoing primary unilateral total knee arthroplasty for degenerative conditions like osteoarthritis and rheumatoid arthritis. These patients were randomly divided into two treatment groups. Patients in IA group received intra-articular tranexamic acid while those in IV group received intravenous tranexamic acid. From all the patients, a written signed consent was taken. FINDINGS Females were predominant with male-to-female ratio of 1:3.7. The mean age of the patients was 67.3 ± 8.2 years while the mean BMI was 30.9 ± 2.9 Kg/m2. Majority (n = 191, 95.5%) of the patients had osteoarthritis while remaining 9 (4.5%) patients had rheumatoid arthritis. There was no statistically significant difference between intra-articular and intra-venous administration of tranexamic acid in terms of mean post-operative hemoglobin (9.93 ± 1.14 vs. 9.87 ± 1.26 g/dL; p-value = 0.724), mean post-operative hematocrit (34.8 ± 1.66 vs. 34.73 ± 1.27%; p-value = 0.594), and mean fall in hemoglobin (2.27 ± 0.34 vs. 2.25 ± 0.30 g/dL; p-value = 0.587) and hematocrit (2.34 ± 0.94 vs. 2.46 ± 0.28%; p-value = 0.216). CONCLUSION Intra-articular administration of tranexamic acid was found to be as effective and safe as intra-venous administration in reducing blood loss in primary total knee arthroplasty. Due to convenience, the use of intra-articular administration of tranexamic acid after primary TKA may be considered in future practice.
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Affiliation(s)
- Muhammad Suhail Amin
- Professor Orthopedic, CMH Hospital Rawalpindi and CMH Lahore Orthopedic ward, CMH Hospital Rawalpindi, Pakistan
| | - Muhammad Khurram Habib
- Assistant Professor Orthopedics, DHQ Hospital Faisalabad, Clinical Fellow, CMH Lahore, DHQ Hospital Faisalabad Orthopedics ward, Pakistan
| | - Aziz Ur Rehman
- Clinical fellow CMH Hospital Rawalpindi and CMH Lahore, Pakistan
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Effect of tranexamic acid on blood loss after reverse total shoulder arthroplasty according to the administration method: a prospective, multicenter, randomized, controlled study. J Shoulder Elbow Surg 2020; 29:1087-1095. [PMID: 32423576 DOI: 10.1016/j.jse.2020.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/16/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ideal method of administering tranexamic acid (TXA) for reverse total shoulder arthroplasty (RTSA) remains unknown. We aimed to evaluate TXA efficacy according to 3 administration methods after RTSA. METHODS Overall, 102 patients who underwent RTSA using a single implant between September 2016 and November 2018 were randomized to the following groups according to the TXA administration method: intravenous (n = 34; 1 g + 0.9% normal saline 100 mL), topical (n = 33; 2 g + 0.9% normal saline 50 mL), and combined groups (n = 34). Patients were enrolled in 4 tertial referral hospitals for prospective multicenter studies. The primary outcome was a hemoglobin decrease in 24 hours postoperatively; secondary outcomes were total drain volume, transfusion rate, and calculated total blood loss. RESULTS Demographic data, including preoperative hemoglobin levels, were not different among the 3 groups, but the average age was higher in the combined group (P = .038). Hemoglobin decrease (1.8 ± 1.1 vs. 1.8 ± 1.0 vs. 2.0 ± 1.1 g/dL, P = .769), total drain volume (209.2 ± 147.6 vs. 167.2 ± 102.0 vs. 166.0 ± 118.7, P = .270), and total blood loss (701.1 ± 352.3 vs. 656.5 ± 285.6 vs. 699.0 ± 248.7 mL, P = .810) were not significantly different among the 3 groups (all P > .05). The transfusion rate was higher in the intravenous group (n = 4), whereas only 1 patient had transfusion in the topical group and none in the combined group, although the difference was not statistically significant (P = .084). CONCLUSION Blood loss did not differ among TXA administration methods after RTSA. However, considering the risk of complication in intravenous TXA, topical TXA after RTSA may be safer, even for patients with normal risk for venous thromboembolic complication.
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Results after the application of tranexamic acid intravenous or intra-articular in the control of postsurgical bleeding after total hip arthroplasty: a randomized controlled trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1221-1230. [PMID: 32372118 DOI: 10.1007/s00590-020-02688-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION A frequent complication after total hip arthroplasty is bleeding; to reduce it, intravenous or intra-articular tranexamic acid (TXA) is used. There is no evidence yet on which route of administration is better. MATERIALS AND METHOD This was a prospective, controlled, randomized study in 2 arms between February 2017 and February 2019. In group A, 15 mg/kg intravenous TXA was administered and in group B 2 g intra-articular TXA. Haemoglobin and haematocrit values were evaluated at 24-72 h, also volume of drained blood, volume of blood lost, transfusions and complications. RESULTS A total of 195 patients were included: 110 in group A and 85 group B. Haemoglobin dropped 3.10 ± 1.32 g/dl in 24 h and 3.63 ± 1.41 g/dl at 72 h in group A; the haematocrit dropped 8.38 ± 4.67% in 24 h and 15.40 ± 4.39% in 72 h. In group B, haemoglobin dropped 3.09 ± 1.40 g/dl in 24 h and 3.34 ± 1.23 g/dl in 72 h and haematocrit 9.75 ± 3.95% and 10.40 ± 3.72% in 24 and 72 h. No significant differences were found for haemoglobin values at 24 and 72 h and haematocrit at 24 h (p > 0.05); we did not obtain statistically significant differences in drainage, blood loss between groups or in the proportion of transfused. When stratifying the results by age, we obtained significant differences in the decrease in haemoglobin (p = 0.021) and haematocrit (p = 0.025) in patients > 65 years. CONCLUSIONS The different routes of administration of TXA in PTC have a similar effect in reducing post-operative bleeding without evidencing an increase in complications. LEVEL OF EVIDENCE I.
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Gianakos AL, Hurley ET, Haring RS, Yoon RS, Liporace FA. Reduction of Blood Loss by Tranexamic Acid Following Total Hip and Knee Arthroplasty: A Meta-Analysis. JBJS Rev 2019; 6:e1. [PMID: 29738409 DOI: 10.2106/jbjs.rvw.17.00103] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND This study involved a meta-analysis of 36 published studies to examine the efficacy of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss, drain output, thromboembolic complications, and hospital stay following total hip and total knee arthroplasty. This study also evaluated whether treatment with a combination of both IA and IV TXA has an effect on these outcomes. Lastly, this study attempted to analyze the method and technique of TXA administration in order to establish a best practice for its use in reducing overall blood loss in arthroplasty procedures. METHODS MEDLINE, Embase, and the Cochrane Library database were screened. Studies comparing IV TXA with IA TXA or with combined IV and IA TXA were included. Data including total blood loss, drain output, thromboembolic complications, and hospital stay, where available, were analyzed using meta-analysis with fixed effects. Results are presented as the standardized mean difference (SMD), and meta-regression was employed to explore plausible demographic contributions to heterogeneity. RESULTS Twenty-eight randomized controlled trials, 3 prospective cohort studies, and 5 retrospective cohort studies with 5,499 patients were included in this review. IA administration during total knee arthroplasty showed a significant advantage in terms of total blood loss (SMD = -0.14, 95% confidence interval [CI] = -0.027 to -0.02, I = 78.2%) and drain output (SMD = -0.30, 95% CI = -0.43 to -0.18). There was no significant difference between IV and IA administration in total hip arthroplasty. Combined IA plus IV TXA was associated with a significant reduction in blood loss versus IV TXA alone in both total knee arthroplasty and total hip arthroplasty. IV TXA dosing varied, as 14 (39%) of the studies used a weight-based approach while 22 (61%) used a standard dose. Twenty-seven (96%) of 28 studies of IA administration used standard dosing while 1 study followed a weight-based protocol. There was no difference in symptomatic thromboembolic complications, with overall rates in total knee arthroplasty and total hip arthroplasty of 1.0% and 1.0% for IV administration and 1.1% and 0.3% for IA administration, respectively. There was no difference in length of hospital stay for IV versus IA TXA administration. CONCLUSIONS IA TXA, either alone or in conjunction with IV TXA, reduces total blood loss and/or drain output in total knee arthroplasty and total hip arthroplasty. Optimal methodology remains to be clarified; however, there are substantial economic benefits of utilizing either IV or IA TXA, with greater cost benefits when using IA TXA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arianna L Gianakos
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
| | | | - R Sterling Haring
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
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Jia J. Combined use of intravenous and topical tranexamic acid in patients aged over 70 years old undergoing total hip arthroplasty. J Orthop Surg Res 2019; 14:345. [PMID: 31699131 PMCID: PMC6836663 DOI: 10.1186/s13018-019-1384-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 09/20/2019] [Indexed: 12/11/2022] Open
Abstract
Purpose The present study was designed to evaluate the efficacy and safety of combined use of intravenous (IV) TXA administration and topical intraarticular tranexamic acid (TXA) strategy in patients aged over 70 undergoing total hip arthroplasty (THA). Methods One hundred eighty patients were randomized into three groups, including an IV group, a local group, and a combined group. Patients were administrated with 15 mg/kg of IV-TXA in the IV group, 2 g TXA in the topical group, or 15 mg/kg IV-TXA combined with 2 g TXA in the combined group. Total blood loss (TBL), maximum hemoglobin drop, the transfusion rate and the number of allogeneic blood units, and the incidence of deep venous thrombosis (DVT), and pulmonary embolism (PE) were recorded and analyzed. Results TBL was 757.75 ± 188.95 mL in the combined group, which was significantly lower than in the IV group (892.75 ± 218.47) or the topical group (1015.75 ± 288.71) (p = 0.015, p = 0.001 respectively). The mean values of maximum hemoglobin drop in the combined, IV, and topical groups were 2.67 ± 0.42, 3.28 ± 0.52, and 3.75 ± 0.62 g/dL, respectively, with a significant intergroup difference (p < 0.001 for all). PE was not detected within 1 month after the surgery. Asymptomatic DVT was reported in 1 patient of the IV group, and in 2 patients from the combined group, while the difference was not statistically significant. Conclusions Compared to intravenous or topical use of TXA, the combined therapy effectively decreased total blood loss and reduced the transfusion rate, simultaneously possessed the same degree of safety in primary THA patients aged over 70.
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Affiliation(s)
- Junqing Jia
- Department of Orthopedics, Shanxi Great hospital, Taiyuan, 030032, Shanxi Province, China.
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Gómez Barbero P, Gómez Aparicio M, Blas Dobón J, Pelayo de Tomás J, Morales Suárez-Varela M, Rodrigo Pérez J. Which route of administration of acid tranexamic, intravenous or intra-articular, is more effective in the control of post-surgical bleeding after a total hip arthroplasty? A prospective, controlled and randomized study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Sun Q, Li J, Chen J, Zheng C, Liu C, Jia Y. 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; 9:e024350. [PMID: 30696680 PMCID: PMC6352808 DOI: 10.1136/bmjopen-2018-024350] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE This 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). DESIGN This 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). SETTING We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration. PARTICIPANTS Patients undergoing TKA or THA. INTERVENTIONS Intravenous, topical or combined intravenous and topical TXA. RESULTS Twenty-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. CONCLUSIONS The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.
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Affiliation(s)
- Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jinyu Li
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiang Chen
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chenying Zheng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chuyin Liu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yusong Jia
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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Gómez Barbero P, Gómez Aparicio MS, Blas Dobón JA, Pelayo de Tomás JM, Morales Suárez-Varela M, Rodrigo Pérez JL. Which route of administration of acid tranexamic, intravenous or intra-articular, is more effective in the control of post-surgical bleeding after a total hip arthroplasty? A prospective, controlled and randomized study. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:138-145. [PMID: 30683523 DOI: 10.1016/j.recot.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/22/2018] [Accepted: 05/03/2018] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION One of the most frequent complications after a total hip arthroplasty (THA) is bleeding, intravenous tranexamic acid (TXA) is used to reduce it. We considered it necessary to carry out a study to clarify which administration route is superior. MATERIAL AND METHOD Prospective, controlled and randomized study in 2 arms carried out between February 2017 and February 2018. 15mg/kg of intravenous TXA were administered in group-A and 2gr of intra-articular TXA in group-B. The values of haemoglobin and haematocrit were evaluated at 24h-72h, blood loss volume, drained blood volume, transfusions and complications. RESULTS 78 patients were included, 31 with intravenous treatment and 47 with intra-articular. The decrease of haemoglobin in the intravenous group was 3.15±1.64g/dl in 24h and 3.75±1.56g/dl in 72h, the haematocrit decreased by 10.4±4.17% in 24h and 11.85±4.15% in 72h. In the intra-articular group there was a haemoglobin fall of 3.03±1.30g/dl in 24h and 3.22±1.2g/dl in 72h and the haematocrit fell by 10.66±3.6% and 12,11±3.29% in 24 and 72h (P>.05). The mean drainage in 24h was 195.80ml in group-A versus 253.93ml in group-B (P>.05) and in 48h it was 225.33ml in group-A and 328.19ml in group-B (P=.009). The intravenous group lost an average of 1,505ml of blood compared to the 11,280ml of the intra-articular group. In 5.1% of the cases, transfusions were necessary. We had no secondary complications. CONCLUSIONS The different routes of administration of TXA in THA have a similar effect in the reduction of postoperative bleeding. There was no evidence of an increase in complications.
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Affiliation(s)
- P Gómez Barbero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doctor Peset, Valencia, España.
| | - M S Gómez Aparicio
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doctor Peset, Valencia, España
| | - J A Blas Dobón
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doctor Peset, Valencia, España
| | - J M Pelayo de Tomás
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doctor Peset, Valencia, España
| | - M Morales Suárez-Varela
- Área de Medicina Preventiva y Salud Pública, Epidemiología, Universidad de Valencia, Valencia, España
| | - J L Rodrigo Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Doctor Peset, Valencia, España
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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. [PMID: 30579365 PMCID: PMC6303980 DOI: 10.1186/s13018-018-1038-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 12/11/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Total knee arthroplasty is regarded as the most effective treatment for severe knee osteoarthritis. The influential factors of blood loss in total knee arthroplasty remain controversial. The study aims to explore the influential factors of blood loss in total knee arthroplasty comprehensively. MATERIAL AND METHODS Three hundred and four osteoarthritis patients undergoing unilateral primary total knee arthroplasty were enrolled. Demographic characteristics, laboratory results, surgical protocol, and hemostatic and anticoagulation drugs were collected. Estimation of blood loss was calculated using the Gross equation. Multivariable stepwise linear regression analysis was performed to find out the influential factors. RESULTS Total blood loss reached the biggest volume (1346 ± 671 mL) in the post-operative third day. Hidden blood loss reached 465 ± 358 mL. Gender, tranexamic acid, prosthesis type, and drainage were proven to be positively correlated with the total blood loss (all P < 0.05). Male appeared to suffer more surgical blood loss than female. Posterior cruciate stabilizing prosthesis might lead to more surgical blood loss than posterior cruciate retaining prosthesis. Tranexamic acid could effectively reduce total blood loss while drainage might increase bleeding. Gender and anticoagulation drugs were correlated with hidden blood loss (both P < 0.05). Low molecular weight heparin resulted in less hidden blood loss than rivaroxaban. CONCLUSIONS Posterior cruciate retaining prosthesis and topical use of tranexamic acid were preferred to reduce total blood loss. Drainage was not recommended due to the risk of increasing bleeding. Low molecular weight heparin was recommended to prevent venous thrombosis.
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Affiliation(s)
- Yong Hu
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
| | - Qiang Li
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
- Department of Orthopaedic Surgery, Chinese Traditional Medicine Hospital of Huaihua City, Huaihua, 418000 Hunan Province China
| | - Bao-Gang Wei
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
- Department of Orthopaedic Surgery, Inner Mongolia People’s Hospital, Hohhot, 100017 Inner Mongolia China
| | - Xian-Sen Zhang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
- Department of Orthopedic Surgery, The Third People’s Hospital of Dongguan City, Dongguan, 523326 Guangdong Province China
| | | | - Jun Xiao
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
| | - Zhan-Jun Shi
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
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Yates J, Perelman I, Khair S, Taylor J, Lampron J, Tinmouth A, Saidenberg E. Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis. Transfusion 2018; 59:806-824. [PMID: 30516835 DOI: 10.1111/trf.15030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.
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Affiliation(s)
- Jeffrey Yates
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simonne Khair
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
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The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis. J Arthroplasty 2018; 33:3090-3098.e1. [PMID: 29805106 DOI: 10.1016/j.arth.2018.04.043] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty. METHODS We searched Ovid MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases for publications before July 2017 on TXA in primary total joint arthroplasty. All included studies underwent qualitative and quantitative homogeneity testing. Direct and indirect comparisons were performed as a network meta-analysis, and results were tested for consistency. RESULTS After critical appraisal of the available 2113 publications, 67 articles were identified as representing the best available evidence. Topical, intravenous (IV), and oral TXA formulations were all superior to placebo in terms of decreasing blood loss and risk of transfusion, while no formulation was clearly superior. Use of repeat IV and oral TXA dosing and higher doses of IV and topical TXA did not significantly reduce blood loss or risk of transfusion. Preincision administration of IV TXA had inconsistent findings with a reduced risk of transfusion but no effect on volume of blood loss. CONCLUSIONS Strong evidence supports the efficacy of TXA to decrease blood loss and the risk of transfusion after primary TKA. No TXA formulation, dosage, or number of doses provided clearly improved blood-sparing properties for TKA. Moderate evidence supports preincision administration of IV TXA to improve efficacy.
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The Safety of Tranexamic Acid in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2018; 33:3070-3082.e1. [PMID: 29699826 DOI: 10.1016/j.arth.2018.03.031] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/12/2018] [Accepted: 03/15/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is effective in reducing blood loss in total joint arthroplasty (TJA), but concerns still remain regarding the drug's safety. The purpose of this direct meta-analysis was to evaluate and establish a basis for the safety recommendations of the combined clinical practice guidelines on the use of TXA in primary TJA. METHODS A search was completed for studies published before July 2017 on TXA in primary TJA. We performed qualitative and quantitative homogeneity testing and a direct comparison meta-analysis. We used the American Society of Anesthesiologists (ASA) score of 3 or greater as a proxy for patients at higher risk for complications in general and performed a meta-regression analysis to investigate the influence of comorbidity burden on the risk of arterial thromboembolic event and venous thromboembolic event (VTE). RESULTS Topical, intravenous, and oral TXA were not associated with an increased risk of VTE after TJA. In addition, meta-regression demonstrated that TXA use in patients with an ASA status of 3 or greater was not associated with an increased risk of VTE after total knee arthroplasty. CONCLUSION Although most studies included in our analysis excluded patients with a history of prior thromboembolic events, our findings support the lack of evidence of harm from TXA administration in patients undergoing TJA. Moderate evidence supports the safety of TXA in patients undergoing total knee arthroplasty with an ASA score of 3 or greater. The benefits of using TXA appear to outweigh the potential risks of thromboembolic events even in patients with a higher comorbidity.
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Karampinas PK, Megaloikonomos PD, Lampropoulou-Adamidou K, Papadelis EG, Mavrogenis AF, Vlamis JA, Pneumaticos SG. Similar thromboprophylaxis with rivaroxaban and low molecular weight heparin but fewer hemorrhagic complications with combined intra-articular and intravenous tranexamic acid in total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:455-460. [PMID: 30221330 DOI: 10.1007/s00590-018-2307-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate the efficacy of the combined intravenous and intra-articular administration of tranexamic acid (TXA) to control the collateral effects and complications of rivaroxaban (RIV) after total knee arthroplasty (TKA) and to compare thromboprophylaxis schemes with and without TXA, RIV and low molecular weight heparin (LMWH). MATERIALS AND METHODS We prospectively studied 158 TKA patients from 2014 to 2018. The patients were randomly assigned into three groups. Group A (46 patients) was administered intravenous and intra-articular TXA and RIV postoperatively; group B (58 patients) was administered TXA as in group A and LMWH postoperatively; and group C (54 patients) was administered saline as in group A and RIV postoperatively. We evaluated blood loss, transfusion requirements and hemorrhagic complications. RESULTS Hct and Hb values significantly decreased in group C compared to groups A and B, without any difference between groups A and B. Suction drain blood volume output was significantly higher in group C compared to group A and B, without any difference between group A and B. Hemorrhagic complications were more common in group C. No patient experienced clinical findings of VTE. CONCLUSION Combined intravenous and intra-articular administration of TXA is safe and effective in TKA, with fewer hemorrhagic complications compared to placebo. Thromboprophylaxis with RIV and LMWH is similar.
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Affiliation(s)
- Panayiotis K Karampinas
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
| | | | - Eleftherios G Papadelis
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece.
| | - John A Vlamis
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Spyros G Pneumaticos
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Sukur E, Kucukdurmaz F. Comparison of Cytotoxic Effects of Intra-Articular Use of Tranexamic Acid versus Epinephrine on Rat Cartilage. Med Sci Monit 2018; 24:1166-1170. [PMID: 29478074 PMCID: PMC5836540 DOI: 10.12659/msm.908560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Adequate visualization is known to be essential to perform arthroscopic procedures effectively and efficiently. We hypothesized that tranexamic acid may be considered as an alternative agent to reduce intra-articular bleeding during arthroscopic procedures, after comparing its potential chondrotoxicity with that of epinephrine. Material/Methods Seventy-two rats were randomized into 3 groups with 24 rats each. The injections were performed in the right knees, as follows: Group 1: 0.25 mL of tranexamic acid solution, Group 2: 0.25 mL of epinephrine solution, and Group 3: 0.25 mL of 0.9% saline, serving as control. One week after the injections, the animals were euthanized. Samples were evaluated histologically based on the Osteoarthritis Research Society International (OARSI) Histopathology Grading and Staging System and the “live/dead” staining technique to determine chondrocyte viability. Results Comparison of epinephrine and tranexamic acid revealed significantly higher OARSI scores in the epinephrine group (epinephrine: 3.42±1.31, TA: 0.92±0.90; P<0.001). The most significant difference between the 2 groups was in the number of joints diagnosed with OARSI grade III. The percentage of viability was significantly higher in the tranexamic acid group when compared with the epinephrine group (tranexamic acid: 79.74±3.343; epinephrine: 63.81±1.914; P<0.05). Conclusions Based on the histologic parameters and chondrocyte viability, tranexamic acid is less cytotoxic than epinephrine in rat chondrocytes at the doses typically used in irrigation fluid, and may be a good alternative to epinephrine in arthroscopic surgery.
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Affiliation(s)
- Erhan Sukur
- Department of Orthopedics and Traumatology, Sakarya Research and Training Hospital, Sakarya, Turkey
| | - Fatih Kucukdurmaz
- Department of Orthopedics and Traumatology, Bezmialem Vakif University, Istanbul, Turkey
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Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, Tinmouth A, Lavallée LT, Fergusson DA, Breau RH. The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis. Transfus Med Rev 2018; 32:S0887-7963(17)30151-7. [PMID: 29567052 DOI: 10.1016/j.tmrv.2018.02.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 12/21/2022]
Abstract
Tranexamic acid (TXA) is an effective hemostatic agent used for the reduction of blood loss and transfusion. However, the safety profile of TXA remains in question due to a potential increased risk of venous thromboembolism. By applying TXA topically as opposed to intravenously, systemic absorption may be reduced and unwanted side-effects mitigated. The objective of our review is to investigate the efficacy and safety of topically applied tranexamic acid compared to both placebo, and the intravenous administration. Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ISI Web of Science, PubMed, and Clinicaltrials.gov were searched from inception to November, 2016. We included randomized controlled trials that compared topical tranexamic acid to either placebo (or standard care) or intravenous administration, in adult patients. Surgical and non-surgical trials were included. Abstract, full-text selection, data extraction and risk of bias assessment were all performed in duplicate. In total, 67 studies involving 6,034 patients met inclusion criteria. The majority of trials evaluated orthopedic procedures. Compared to placebo, the administration of topical TXA significantly reduced the odds of receiving a blood transfusion (pooled OR 0.28, 95% CI 0.20 to 0.38; P < 0.001) and significantly reduced mean blood loss (WMD -276.6, 95% CI -327.8 to -225.4; P < 0.0001). When compared to the intravenous administration, there was no difference between the two groups in terms of transfusion requirements (pooled OR 1.03, 95% CI 0.72 to 1.46; P=0.88) or blood loss (WMD -21.95, 95% CI -66.61 to 27.71; P=0.34). There was no difference in the odds of developing a venous thromboembolic complication between the topical TXA and control groups (pooled OR=0.78, 95% CI 0.47 to 1.29; P=0.33) or the topical and intravenous groups (pooled OR=0.75, 95% CI 0.39 to 1.46; P=0.40). The topical application of TXA effectively reduces both transfusion risk and blood loss compared to placebo, without increasing thromboembolic risks. There were no major differences between topical and intravenous tranexamic acid with respect to safety and efficacy, and both were superior to placebo with regards to blood loss and transfusion requirements. Further study of the topical application is required outside of the field of orthopedics.
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Affiliation(s)
- Joshua Montroy
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada
| | - Preveshen Moodley
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nicholas A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Luke T Lavallée
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
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Subramanyam KN, Khanchandani P, Tulajaprasad PV, Jaipuria J, Mundargi AV. Efficacy and safety of intra-articular versus intravenous tranexamic acid in reducing perioperative blood loss in total knee arthroplasty: a prospective randomized double-blind equivalence trial. Bone Joint J 2018; 100-B:152-160. [PMID: 29437056 DOI: 10.1302/0301-620x.100b2.bjj-2017-0907.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIMS The aims of this study were to compare the efficacy and safety of intra-articular and intravenous (IV) tranexamic acid (TXA) in controlling perioperative blood loss in total knee arthroplasty (TKA) using a randomized, double-blinded equivalence trial. PATIENTS AND METHODS A total of 182 patients aged between 45 and 75 years undergoing unilateral TKA at a tertiary centre were randomized to receive TXA, either 1.5 g intra-articularly after closure of the wound (n = 91) or two doses of 10 mg/kg IV (n = 91). The primary outcome measure was the reduction in the level of haemoglobin (Hb) in the blood on the fifth postoperative day. Secondary outcome measures were the total, visible, and hidden blood losses (TBL, VBL, HBL). We assumed equivalence of the primary outcome in both routes with a margin of ± 0.35gm/dl. Block randomization using computer-generated random numbers was used. The patients and the assessor of outcome were blinded. RESULTS All patients completed the study. The mean difference in the reduction of the level of Hb between the two groups was -0.0055 gm/dl, with two-sided 95% confidence interval (CI) being -0.29 to 0.27, well within the predefined equivalence margin of ± 0.35gm/dl. The groups were comparable with regard to TBL, VBL, HBL, and complications. No patient needed a blood transfusion. CONCLUSION A single intra-articular dose and two IV doses of TXA give equivalent efficacy and safety in the management of blood loss at TKA. Cite this article: Bone Joint J 2018;100-B:152-60.
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Affiliation(s)
- K N Subramanyam
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - P Khanchandani
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - P V Tulajaprasad
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - J Jaipuria
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - A V Mundargi
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
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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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Ou Y, Wei J, Li R, Liang B, Qiu D, Wei M, Mu X, Li Z. Clinical Research of Combined Intravenous Administration and Topical Application of Tranexamic Acid to a Surgical Wound During Posterior Lumbar Fusion. Surg Innov 2018; 25:128-135. [PMID: 29303065 DOI: 10.1177/1553350617751449] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yufu Ou
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Jianxun Wei
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Rongzhu Li
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Bin Liang
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Dezan Qiu
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Minke Wei
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Xiaoping Mu
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Zhuhai Li
- The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Xu R, Shi D, Ge W, Jiang Q. Quantitative efficacy of topical administration of tranexamic acid on postoperative bleeding in total knee arthroplasty. Br J Clin Pharmacol 2017; 83:2485-2493. [PMID: 28707406 DOI: 10.1111/bcp.13374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 06/28/2017] [Accepted: 07/11/2017] [Indexed: 01/09/2023] Open
Abstract
AIMS Topical tranexamic acid (TXA) is used in patients undergoing total knee arthroplasty to reduce perioperative blood loss. However, the optimal dosing regimen remains undetermined. The aim of the present study was to quantitatively evaluate the effect of topical TXA on the reduction of postoperative drainage, and identify the dosing regimen factors affecting the efficacy of topical TXA. METHODS Model-based meta-analysis was used to evaluate the efficacy of topical TXA and the dosing regimen factors influencing clinical efficacy. Data from a systemic literature search was identified and used to build a time-effect model for placebo and TXA in treating perioperative blood loss. RESULTS Fourteen studies containing 16 TXA-control groups of drainage volume data were included for MBMA modelling. The model described the postoperative drainage-time profiles adequately. According to the model estimation, TXA can finally reduce the postoperative drainage by about 41.7%, and 10.9 h was needed to reach 50% of the maximal drainage volume. Covariate analysis indicated that both dose and contact time alone did not correlate well with clinical efficacy. However, when considered together, they can dramatically improve fitting of the data. Simulation showed that increasing dose or contact time extensively would produce a plateau-like effect: 2-3 g TXA with contact time of 1-2 h would yield >60% reduction in the drainage volume. CONCLUSIONS Dose and contact time together determined the efficacy of TXA. Extensively large dose or long contact time seems unnecessary. These findings may further guide the clinical practice on the topical TXA regimen optimization.
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Affiliation(s)
- Ruijuan Xu
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Dongquan Shi
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Weihong Ge
- Department of Pharmacy, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
| | - Qing Jiang
- Department of Sports Medicine and Adult Reconstructive Surgery, Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, China
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Sridharan K, Sivaramakrishnan G. Tranexamic Acid in Total Knee Arthroplasty: Mixed Treatment Comparisons and Recursive Cumulative Meta-Analysis of Randomized, Controlled Trials and Cohort Studies. Basic Clin Pharmacol Toxicol 2017; 122:111-119. [DOI: 10.1111/bcpt.12847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/04/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Kannan Sridharan
- Pharmacology; School of Health Sciences; College of Medicine, Nursing and Health Sciences; Fiji National University; Suva Fiji Islands
| | - Gowri Sivaramakrishnan
- Prosthodontics; School of Oral Health; College of Medicine, Nursing and Health Sciences; Fiji National University; Suva Fiji Islands
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Mi B, Liu G, Zhou W, Lv H, Liu Y, Zha K, Wu Q, Liu J. Intra-articular versus intravenous tranexamic acid application in total knee arthroplasty: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2017; 137:997-1009. [PMID: 28378211 DOI: 10.1007/s00402-017-2683-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of this meta-analysis was to compare the blood loss and complications of intra-articular (IA) with intravenous (IV) tranexamic acid (TXA) for total knee arthroplasty (TKA). METHODS A comprehensive search of studies was conducted to identify related articles in Pubmed, Embase, Cochrane central Register of Controlled Trials, springerLink, OVID and the Research published from January 1980 to September 2016. All studies that compared IA TXA with IV TXA application on TKA were included. Main outcomes of the two methods were collected and analyzed by using Review Manager 5.3. RESULTS There were 16 randomized controlled trials with 1308 cases met the criteria. Compared with IV TXA, IA TXA had similar blood volume of drainage, hidden blood loss, transfusion rate and complications (P > 0.05). IA TXA had lower total blood loss than IV TXA, and there was significant difference (P < 0.05). Subgroup analysis of total blood loss based on times of IV TXA administration showed that repeat dose of IV TXA had a higher total blood loss and postoperative hemoglobin drop (P < 0.05) than IA TXA. However, single dose of IV TXA had a similar efficacy on total blood loss and postoperative hemoglobin drop (P > 0.05) when compared with IA TXA. CONCLUSIONS Both IA TXA and single dose of IV TXA are effective in reducing total blood loss and postoperative hemoglobin drop without increasing complications of DVT or PE. The current meta-analysis suggests that 1.5 g TXA by IA administration or 1 g TXA by IV administration 10 min before tourniquet deflation is effective and safe in patients undergoing TKA.
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Affiliation(s)
- Bobin Mi
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China.
| | - Wu Zhou
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Huijuan Lv
- Deparetment of Rheumatology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yi Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Kun Zha
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Qipeng Wu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Jing Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
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Yang L, Du S, Sun Y. Is combined topical and intravenous tranexamic acid superior to single use of tranexamic acid in total joint arthroplasty?: A meta-analysis from randomized controlled trials. Medicine (Baltimore) 2017; 96:e7609. [PMID: 28746213 PMCID: PMC5627839 DOI: 10.1097/md.0000000000007609] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To compare the efficacy and safety of the combined application of both intravenous and topical tranexamic acid (TXA) versus the single use of either application in patients with total knee and hip arthroplasty (TKA and THA). METHODS Potentially relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect, and the Cochrane Library. Randomized control trials (RCTs) of patients prepared for total joint arthroplasty that compared combined TXA with placebo were retrieved. The primary endpoint was hemoglobin decline or postoperative hemoglobin level, blood loss, drainage volume, transfusion requirements. The secondary outcomes were length of stay (LOS), and operation time as well as surgery-related adverse effects, such as wound infection, deep vein thrombosis (DVT), and pulmonary embolism (PE). After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary. RESULTS Five RCTs that included 604 patients met the inclusion criteria. The present meta-analysis indicated significant differences existed in the total blood loss (mean difference [MD] = -134.65, 95% CI: -191.66 to -77.64, P < .0001), postoperative hemoglobin level (MD = 0.74, 95% CI: 0.39-1.10, P < .0001), drainage volume (MD = -47.44, 95% CI: -64.55 to -30.33, P < .00001), and transfusion rate (risk difference [RD] = -0.06, 95% CI: -0.10 to -0.02, P = .006) between groups. CONCLUSION Combined administration of TXA in TKA and THA was associated with significantly reduced total blood loss, postoperative hemoglobin decline, drainage volume, and transfusion requirements. Well-designed, high-quality RCTs with long-term follow-up are still required.
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Peng Zhang MM, Jifeng Li MM, Xiao Wang MM. Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg 2017; 43:171-180. [PMID: 28602763 DOI: 10.1016/j.ijsu.2017.05.065] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/07/2017] [Accepted: 05/29/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of the combined application of both intravenous and topical tranexamic acid versus the single use of either application in patients with total knee and hip arthroplasty. METHODS Potentially relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect and the Cochrane Library. Patients undergoing primary total knee and hip arthroplasty were included in our studies, with an experimental group that received combined intravenous and topical application of tranexamic acid and a control group that received a single application of tranexamic acid or normal saline. The primary outcomes were total blood loss, hemoglobin decline and transfusion requirements. The secondary outcomes were length of stay, operation time and tranexamic acid-related adverse effects, such as superficial infection, deep vein thrombosis or pulmonary embolism. Modified Jadad scores were used to assess the quality of the included randomized controlled trials (RCTs). The data was pooled using RevMan 5.3. After testing for heterogeneity across studies, the data were aggregated using random-effects modeling when appropriate. We have registered the trial at http://www.researchregistry.com. RESULTS Six RCTs that included 704 patients met the inclusion criteria. The present meta-analysis indicated significant differences existed in the total blood loss (MD = -134.65, 95% CI: -191.66 to -77.64, P < 0.0001), postoperative hemoglobin level (MD = 0.74, 95% CI: 0.39 to 1.10, P < 0.0001), drainage volume (MD = -40.19, 95% CI: -55.95 to -24.43, P < 0.00001) and transfusion rate (RD = -0.07, 95% CI: -0.11 to -0.03, P = 0.0004) between groups. CONCLUSION Combined administration of tranexamic acid in total knee and hip arthroplasty was associated with significantly reduced total blood loss, postoperative hemoglobin decline, drainage volume, and transfusion requirements. Based on the limitations of current meta-analysis, well-designed, high-quality RCTs with long-term follow-up are still required.
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Affiliation(s)
- M M Peng Zhang
- Department of Orthopedics, Huaihe Hospital, Henan University, Henan, China
| | - M M Jifeng Li
- Department of Orthopedics, Huaihe Hospital, Henan University, Henan, China
| | - M M Xiao Wang
- Department of Orthopedics, Huaihe Hospital, Henan University, Henan, China.
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Xie J, Hu Q, Huang Q, Ma J, Lei Y, Pei F. Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis. Thromb Res 2017; 153:28-36. [PMID: 28319822 DOI: 10.1016/j.thromres.2017.03.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/26/2017] [Accepted: 03/09/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The appropriate route for administering tranexamic acid in primary total hip (THA) and knee arthroplasty (TKA) remains controversial. The purpose of this meta-analysis was to compare the efficacy and safety of topical or intravenous tranexamic acid. METHODS PubMed, EMBASE, and the Cochrane Library databases were systematically searched for randomized controlled trials (RCTs) comparing topical and intravenous tranexamic acid following primary THA or TKA. Primary outcomes were transfusion frequency and maximum drop in hemoglobin. Other parameters included total blood loss (TBL), hidden blood loss, drainage volume, hemoglobin level on postoperative day 1 (POD 1), deep vein thrombosis (DVT), pulmonary embolism (PE), wound complications and other adverse events. Data were analyzed using Rev Man 5.2. RESULTS A total of 18 RCTs involving TKA and 4 RCTs involving THA, corresponding to approximately 2260 patients, were included in the meta-analysis. No significant difference between topical and intravenous tranexamic acid was found in transfusion requirement (RR 1.14, 95%CI 0.87 to 1.50, p=0.35). The maximum drop in hemoglobin was significantly smaller in the intravenous group than in the topical group (MD 0.33g/dL, 95%CI 0.07 to 0.58, p=0.01); similar results were observed for the subset of studies involving THA (MD 0.49g/dL, 95%CI 0.28 to 0.70, p<0.001) and the subset involving TKA (MD 0.30g/dL, 95%CI 0.02 to 0.59, p=0.04). The topical and intravenous groups did not differ significantly in TBL, drainage volume, hemoglobin level on POD 1, DVT, PE, wound complications or other adverse events. CONCLUSION The available evidence indicates similar transfusion requirements and safety for topical and intravenous tranexamic acid in THA and TKA. However, intravenous injection seems to be associated with a smaller maximum drop in hemoglobin.
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Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Qinsheng Hu
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Qiang Huang
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Jun Ma
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Yiting Lei
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Fuxing Pei
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
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Chen TP, Chen YM, Jiao JB, Wang YF, Qian LG, Guo Z, Ma Z, Han CY, Shi TH. Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2017; 12:11. [PMID: 28103911 PMCID: PMC5244538 DOI: 10.1186/s13018-017-0512-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/08/2017] [Indexed: 02/03/2023] Open
Abstract
Background This study aims to compare the effectiveness and safety of topical versus intravenous tranexamic acid (TXA) in reducing blood loss in primary total knee arthroplasty (TKA). Methods PubMed, Embase, the Cochrane Library, Web of Science, Chinese Biomedicine Literature (CBM), Wanfang Database and China National Knowledge Infrastructure (CNKI), and Google Scholar were searched for randomized controlled studies (RCTs) that compared topical versus intravenous TXA in terms of reducing blood loss during TKA from their inception to September 2015. This systematic review and meta-analysis was performed according to PRISMA criteria. Results Twelve studies reporting 12 RCTs comprising 1130 patients were included. Compared with the intravenous administration of TXA, the topical administration of TXA showed no significant differences in total blood loss (MD 2.08, 95% CI −68.43 to 72.60, P = 0.95), blood loss in drainage (MD 18.49, 95% CI −40.01 to 76.98, P = 0.54), hidden blood loss (MD 4.75, 95% CI −337.94 to 347.44, P = 0.99), need for transfusion (RR = 0.92, 95% CI 0.67~1.25, P = 0.58), hemoglobin (Hb) decline (MD −0.42, 95% CI −0.89 to 0.05, P = 0.08), and DVT occurrence (RR = 1.17, 95% CI 0.55~2.50, P = 0.68). Conclusions Compared with intravenous administration TXA, topical administration TXA exhibits comparable effectiveness and safety in terms of reducing blood loss during TKA. Due to the poor quality of the included studies, more high-quality RCTs are needed to identify the optimal method and dose of TXA after TKA.
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Affiliation(s)
- Tao-Ping Chen
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Yu-Min Chen
- Hebei University, Yuhua Dong Road, 342, Yuhua District, Baoding, Hebei Province, 071000, China.
| | - Jian-Bao Jiao
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Yun-Fei Wang
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Li-Gang Qian
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Zhao Guo
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Zheng Ma
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Cui-Yu Han
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Tong-Huan Shi
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
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Meena S, Benazzo F, Dwivedi S, Ghiara M. Topical versus intravenous tranexamic acid in total knee arthroplasty. J Orthop Surg (Hong Kong) 2017; 25:2309499016684300. [PMID: 28176605 DOI: 10.1177/2309499016684300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The aim of this meta-analysis is to examine the efficacy and safety of intra-articular tranexamic acid (TXA) when compared to intravenous (IV) route. METHODS The literature search was conducted using PubMed, Cochrane Library, MEDLINE, EMBASE and China National Knowledge Infrastructure (CNKI). All randomized controlled trials evaluating the effectiveness of topical route and IV route of TXA administration were included. RESULTS Eight randomized clinical trials comprising of 857 patients were included in this analysis. We found no statistically significant difference in terms of total blood loss, drain output, transfusion requirement, thromboembolic complication, tourniquet time and surgical duration. CONCLUSION Topical TXA has a similar efficacy to IV-TXA in reducing total blood loss, drain output, transfusion rate and haemoglobin drop without any increase in thromboembolic complications.
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Affiliation(s)
- Sanjay Meena
- 1 Department of Orthopaedics, Lady Hardinge Medical College and Associated Hospitals, Connaught Place, New Delhi, India
| | - Francesco Benazzo
- 2 Clinica Ortopedica e Traumatologica, Universita degli Studi di Pavia, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi, Pavia, Italy
| | - Saumitra Dwivedi
- 3 Department of Orthopaedics, Adichunchanagiri Institute of Medical Sciences, Mandya, Karnataka, India
| | - Matteo Ghiara
- 2 Clinica Ortopedica e Traumatologica, Universita degli Studi di Pavia, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi, Pavia, Italy
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Fu Y, Shi Z, Han B, Ye Y, You T, Jing J, Li J. Comparing efficacy and safety of 2 methods of tranexamic acid administration in reducing blood loss following total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2016; 95:e5583. [PMID: 27977593 PMCID: PMC5268039 DOI: 10.1097/md.0000000000005583] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) were to gather data to evaluate the efficacy and safety of topical tranexamic acid (TXA) versus intravenous (IV) TXA for blood loss after a total knee arthroplasty (TKA). METHODS Electronic databases: Pubmed, Web of Science, Cochrane library, and Embase from inception to June 2016 were searched. RCTs that comparing topical with IV TXA for blood loss control in patients prepared for TKA were included in this meta-analysis. The Cochrane risk of bias tool was used to appraise risk of bias. The primary outcomes were needed for transfusion, total blood loss, and blood loss in drainage. Secondary outcomes are hemoglobin (Hb) value at 24-hour post TKA and complication (deep venous thrombosis [DVT] and infection). The efficacy of blood loss was tested by total blood loss, drainage volume, Hb drop, and the Hb value at 24 hours after TKA. The safety was measured by the occurrence of DVT and infection. Continuous outcomes were expressed as the mean difference with the respective 95% confidence intervals (CIs). Discontinuous outcomes were expressed as the relative risk with 95% CIs. Stata 12.0 software (Stata Corp., College Station, TX) was used for the meta-analysis. RESULTS A total of 14 articles involving 1390 patients were finally included for this meta-analysis. The pooled results revealed that there were no significant difference between the need for transfusion, total blood loss, blood loss in drainage, Hb value at 24-hour post TKA, the occurrence of complications (infection and DVT) between topical administration of TXA and IV TXA. CONCLUSION Topical TXA has similar efficacy for blood loss control to IV TXA without sacrificing safety in TKA. However, the dose of topical TXA and IV TXA is different, thus, optimal timing and dose of TXA are still needed to explore the maximum effect of TXA.
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Affiliation(s)
- Yu Fu
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Zhigang Shi
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Bing Han
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Yong Ye
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Tao You
- Department of Orthopaedics, The First Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Juehua Jing
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Jun Li
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
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Wang S, Gao X, An Y. Topical versus intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials. INTERNATIONAL ORTHOPAEDICS 2016; 41:739-748. [PMID: 27837327 DOI: 10.1007/s00264-016-3296-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/15/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug used widely to prevent bleeding in total knee arthroplasty (TKA). However, there is no consensus regarding the administration routes of TXA. This meta-analysis aimed to investigate the efficacy of topical (intra-articular) versus intravenous TXA in reducing blood loss and transfusion rate in patients who underwent TKA. METHOD We conducted a Pubmed, EMBASE, Cochrane Library, and Web of Science search for randomized controlled trials (RCTs) comparing topical versus intravenous TXA in TKA. Two authors conducted selection of studies, data extraction, and assessment of risk of bias independently. A pooled meta-analysis was performed using RevMan 5.3 software. RESULT Sixteen RCTs with a total of 1330 patients were included. Current meta-analysis indicated that there were no significant differences in total blood loss (MD = -41.64 ml; 95 % CI: -163.43 ml to 80.18 ml; P = 0.50), drain output (MD = 22.44, 95 % CI: -11.18 to 56.06, P = 0.19), transfusion rate (RR = 0.89, 95 % CI: 0.62 to 1.27, P = 0.52), the drop of Hb level at post-operative day 1 (MD = 0.26, 95 % CI -0.03 to 0.55, P = 0.03), day 2 (MD = -0.08, 95 % CI -0.76 to 0.59, P = 0.81), day 3 (MD = -0.20, 95 % CI -0.77 to 0.37, P = 0.49), and length of stay (MD = -0.10; 95 % CI: -0.17 to -0.02; P = 0.02) between the topical group and intravenous group. In addition, no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis (RR = 1.08, 95 % CI: 0.48 to 2.40, P = 0.86), pulmonary embolism (RR = 0.56, 95 % CI: 0.05 to 5.99, P = 0.63), wound complications (RR = 0.56, 95 % CI: 0.05 to 5.99, P = 0.63), and infection (RR = 0.74, 95 % CI: 0.30 to 1.85, P = 0.52) between the two groups. CONCLUSION Our meta-analysis of 16 RCTs revealed that both topical TXA and intravenous TXA are effective in reducing blood loss and transfusion rates in patients who underwent TKA.
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Affiliation(s)
- Shangquan Wang
- Department of Comprehensive Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No. 6 Zhonghuan South Road, Beijing, 100102, China
| | - Xinxia Gao
- Department of Comprehensive Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No. 6 Zhonghuan South Road, Beijing, 100102, China
| | - Yan An
- Department of Comprehensive Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No. 6 Zhonghuan South Road, Beijing, 100102, China.
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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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Hatz D, Anoushiravani AA, Chambers MC, El-Othmani MM, Saleh KJ. Approach to Decrease Infection Following Total Joint Arthroplasty. Orthop Clin North Am 2016; 47:661-71. [PMID: 27637652 DOI: 10.1016/j.ocl.2016.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical site infection in total joint arthroplasty is a challenging complication that warrants discussion with regard to prevention and management. Limiting postoperative infection rate is a paramount quest in the orthopedic community. Several preoperative risk factors have been identified in orthopedic literature with regards to likelihood of developing postoperative infection. This article evaluates several factors that predispose total joint arthroplasty patients to infection. Methods of patient surgical preparation designed to decrease postoperative infection, decreasing intraoperative traffic during procedural settings, and elaborate intraoperative prophylactic advancements are assessed. Approaches to decrease postoperative infection by discussing means of lowering rates of postoperative transfusion, wound drainage, and hematoma formation are analyzed.
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Affiliation(s)
- Daniel Hatz
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Afshin A Anoushiravani
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Monique C Chambers
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Mouhanad M El-Othmani
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Khaled J Saleh
- Department of Orthopaedic and Sports Medicine, Detroit Medical Center, 311 Mack Avenue, 5th Floor, Detroit, MI 48201, USA.
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Chen Y, Chen Z, Cui S, Li Z, Yuan Z. Topical versus systemic tranexamic acid after total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2016; 95:e4656. [PMID: 27741100 PMCID: PMC5072927 DOI: 10.1097/md.0000000000004656] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug widely used to reduce blood loss during joint replacements, including total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, there is no final consensus regarding the composition of an optimal administration of TXA regime between topical and systemic (intravenous). The purpose of our study was to compare the efficacy of topical and intravenous (IV) regimen of TXA during TKA and THA. METHODS Five relevant electronic online databases, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Chinese Biomedical Database were systematically searched in November 2015. Randomized controlled trials (RCTs) that compared topical with intravenous TXA in patients with TKA or THA were included. The search terms included "topical," "intravenous," "tranexamic acid," "knee arthroplasty" and "hip arthroplasty." Two reviewers independently extracted data and assessed the risk of bias and study quality. Data were analyzed with Review Manager 5.3 software. Grades of Recommendation Assessment, Development and Evaluation (GRADE) were used to assess the quality of evidence. RESULTS Sixteen RCTs with 1250 patients undergoing TKA and 4 RCTs involving 550 patients undergoing THA were included. There were no significant differences in total blood loss (mean difference [MD]TKA = -28.72 mL, 95% confidence interval [CI] -195.97 to 138.54 mL, P = 0.74; MDTHA = 14.03 mL, 95% CI -35.53 to 63.59 mL; P = 0.78), total drain out (MDTKA = -3.09 mL, 95% CI -39.05 to 32.88 mL; P = 0.87; MDTHA -31.00 mL, 95% CI -66.56 to 4.66 mL; P = 0.09), and transfusion rates (ORTKA = 0.90, 95% CI 0.58-1.40, P = 0.64; ORTHA = 1.19, 95% CI 0.67-2.09; P = 0.63) between topical and intravenous (IV) TXA. CONCLUSIONS The current evidence suggested that topical TXA was equally effective and safe compared with intravenous TXA in reducing blood loss and transfusion rate following TKA or THA. We recommended that either topically or systemically could be used in TKA and THA to decrease perioperative blood loss.
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Affiliation(s)
- Yongcai Chen
- Department of Microsurgery, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology
- Correspondence: Yongcai Chen, No.24 Jinghua Road, Jianxi District, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang 471003, Henan, China (e-mail: )
| | - Zhuo Chen
- Medical College of Henan University of Science and Technology, Luoyang, Henan, China
| | - Shuo Cui
- Department of Microsurgery, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology
| | - Zhiyang Li
- Department of Microsurgery, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology
| | - Zhengjiang Yuan
- Department of Microsurgery, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology
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Rodriguez-Merchan EC, Romero-Garrido JA, Gomez-Cardero P. Multimodal blood loss prevention approach including intra-articular tranexamic acid in primary total knee arthroplasty for patients with severe haemophilia A. Haemophilia 2016; 22:e318-20. [PMID: 27227798 DOI: 10.1111/hae.12942] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | - J A Romero-Garrido
- Department of Pharmacy, La Paz University Hospital-IdiPaz, Madrid, Spain
| | - P Gomez-Cardero
- Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain
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50
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Duymus TM, Aydogmus S. Letter to the Editor: Intra-articular tranexamic acid wash during bilateral total knee arthroplasty. J Orthop Surg (Hong Kong) 2016; 24:134. [PMID: 27122531 DOI: 10.1177/230949901602400132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- T M Duymus
- Department of Orthopedic Surgery and Traumatology, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
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