Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials

Tranexamic Acid Causes Chondral Injury Through Chondrocytes Apoptosis Induced by Activating Endoplasmic Reticulum Stress

PURPOSE

To investigate whether tranexamic acid (TXA) is cytotoxic in chondrocyte and cartilage tissues, as well as explore the mechanisms behind the possible toxicity in detail.

METHODS

We detected the cell viability of chondrocytes in vitro and the change of morphology and specific in vivo contents of cartilage after TXA treatment. Furthermore, we detected apoptosis in cartilage. We used apoptosis-specific staining, reactive oxygen species detection, mitochondrial membrane potential detection, flow cytometry, and western blot for apoptosis detection. Finally, we detected the activation of endoplasmic reticulum stress (ERS) in TXA-treated chondrocytes to clarify the mechanism behind chondrocyte apoptosis.

RESULTS

TXA presented an increasing toxic effect with increasing concentrations, especially in the 100 mg/mL group. In addition, we found that 50 mg/mL and 100 mg/mL TXA significantly increased apoptosis in cartilage and subchondral bone. TXA could induce chondrocyte apoptosis in cell and protein levels with reactive oxygen species generation and mitochondrial membrane depolarization. An apoptosis inhibitor could inhibit the induced apoptosis. Next, TXA induced calcium overload in chondrocytes and increased ERS-specific protein expression, whereas ERS inhibitor blocked ERS activation and further inhibited chondrocyte apoptosis.

CONCLUSIONS

We concluded that TXA had a toxic effect on chondrocytes by inducing apoptosis through ERS activation, especially in 50 mg/mL and 100 mg/mL groups. We recommend TXA concentrations of less than 50 mg/mL in joint surgeries.

CLINICAL RELEVANCE

It is still unclear whether TXA has a toxic effect on cartilage when topically used in joint surgeries. The concentration also varies. This study provides additional evidence that TXA at high concentrations will cause cartilage damage, which will help to provide a new understanding of the clinical administration of TXA.

Does tranexamic acid diminish hemorrhage and pain in open elbow arthrolysis? a systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Effective hemostasis has the potential to reduce inflammation and pain, leading to potential benefits in the early rehabilitation of patients who undergo elbow arthrolysis. In the present study, we aim to assesse the effects of tranexamic acid (TXA) on elbow arthrolysis postoperative blood loss, patients' pain perception according to the visual analog scale (VAS), elbow range of motion (ROM), and complications.

METHODS

We systematically searched PubMed, Web of Science, SCOPUS, and Cochrane Library. We included controlled trials, either randomized (RCT) or non-randomized studies of intervention (NRSI) comparing the effects of intravenous tranexamic acid (TXA) treatment with placebo/no treatment on postoperative blood loss, pain VAS score, elbow ROM, and complications, in patients who underwent open or closed elbow arthrolysis surgery.

RESULTS

One RCT, and three NRSIs met eligibility criteria. The meta-analysis determined that tranexamic acid application reduced drain output 34 mm on average (WMD: -34.00; 95% CI: -49.45, -18.55). There was a discrepancy among included articles in terms of intra-operative blood loss; although the study with the largest sample size (291 and 296 patients in the case and control groups, respectively) reported reduced intra-operative blood loss in patients who received TXA. The pooled estimation for the pain VAS score on the first day post-operatively indicates a reduction in pain among patients in the TXA group (WMD: -0.82; 95% CI: -1.36, -0.28). Results for ROM, and complications' rate such as hematoma and ulnar nerve palsy were not different between the two groups.

CONCLUSION

TXA may be beneficial to reduce elbow arthrolysis bleeding volume. However, it dose not seem to affect final elbow ROM and patients' pain score. Further high-quality clinical trials are needed to draw a robust conclusion on this topic.

Tranexamic acid is safe with respect to the risk of deep venous thrombosis in patients with hemophilic arthritis undergoing total knee arthroplasty without chemoprophylaxis: A prospective study

BACKGROUND

Pharmacologic thromboprophylaxis is controversial for hemophiliacs who undergo total joint replacements. The purpose of this study was to assess the safety of tranexamic acid (TXA) utilization with respect to the incidence of deep venous thrombosis (DVT) in hemophiliacs undergoing total knee arthroplasty (TKA).

METHODS

A total of 104 patients with hemophilic arthritis were included in the study. The patients were randomly divided into two groups of 52 subjects. All patients received a modified coagulation factor substitution regimen. In the TXA group, 1 g of TXA was injected intravenously 15 min before incision and 2 g of TXA was intra-articularly injected in the surgical area. A routine mechanical prophylaxis was administered to all patients under a standardized postoperative protocol. Thromboembolic complications in both groups were followed up for 2 years.

RESULTS

All patients were male and underwent 146 arthroplasties. There was a mean age of 33.2 ± 8.8 years and a mean body mass index of 22.2 ± 5.1 kg/m2. A 100% compliance rate was observed with mechanical prophylaxis. No asymptomatic DVT was detected on postoperative ultrasound in all patients. We also failed to find any proof of clinical venous thromboembolism in our patients during a 2-year follow up. Only two cases in the TXA group underwent blood transfusions (4.0%), while 29.2% of the patients in the non-TXA group needed transfusion.

CONCLUSIONS

This prospective study showed that TXA could be safely utilized in patients with hemophilic arthritis who underwent TKA without increasing the incidence of DVT and routine chemoprophylaxis may not be necessary.

Efficacy of perioperative cryotherapy combined with intra-articular injection of tranexamic acid in total knee arthroplasty

OBJECTIVE

To evaluate the efficacy and safety of perioperative cryotherapy combined with intra-articular injection of tranexamic acid (TXA) in total knee arthroplasty (TKA) and explore a new strategy of enhanced recovery after TKA.

METHODS

We randomly divided 200 patients into 4 groups: normal saline (10 mL) by drainage (Group A, placebo); intra-articular injection of TXA (1 g, 10 mL, Group B); normal saline (10 mL) and continuous cryotherapy postoperatively (Group C) and intra-articular injection of TXA (1 g, 10 mL) and continuous cryotherapy postoperatively (Group D). Primary outcomes were blood loss volume, postoperative pain and circumference variation. We also recorded consumption of analgesics, postoperative length of stay (p-LOS), range of motion (ROM), function score (Hospital for Special Surgery) and severe complications.

RESULTS

There were statistically significant differences in postoperative drainage volume, total blood loss, hidden blood loss, and visual analogue scale at rest and walking on postoperative day 1 (POD1), POD2, POD3, ROM (POD3, 7, discharge, postoperative month), circumference variation (POD3, 7), p-LOS, Hospital for Special Surgery score (discharge) and drop of hemoglobin on POD3 (P < .05) among 4 groups, but there were no significant differences in intraoperative blood loss, postoperative prothrombin, activated partial thromboplastin time, overall number of patients or total consumption of oxycodone and perioperative complications (e.g., incidence of surgical site infection, deep venous thrombosis, and cold injury) among them (P > .05).

CONCLUSION

Continuous cryotherapy combined with intra-articular injection of TXA provides short-term advantages in reducing blood loss, pain, postoperative swelling, p-LOS and increasing ROM and joint function in the early postoperative period after TKA without increasing any severe complications.

Efficacy and Safety of Tranexamic Acid in Shoulder Arthroscopic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Visual clarity during shoulder arthroscopy can ensure an efficient and effective performance of the procedure, and it is highly related to bleeding without a tourniquet. Tranexamic acid (TXA) is widely used in adult reconstruction procedures; however, its use in shoulder arthroscopic operations is a relatively novel topic.

PURPOSE

To analyze the available literature on visual clarity, blood loss, pain control, functional outcomes, and complications after the administration of tranexamic acid in shoulder arthroscopic surgery.

METHODS

A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of shoulder arthroscopic surgery. The literature search included the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The primary outcomes included visual clarity, blood loss, and visual analog scale scores for pain. Secondary outcomes were operative time, irrigation amount used, postoperative shoulder swelling, the need for pressure increase, mean arterial pressure (MAP), functional outcomes, postoperative adverse effects such as deep venous thrombosis, and pulmonary embolism. The outcomes were pooled to perform a meta-analysis.

RESULTS

Seven prospective randomized controlled trials met the inclusion criteria for analysis. All of the included studies performed arthroscopic rotator cuff repair. No significant difference in visual clarity was observed (SMD (standardized mean difference), 0.45 [95% CI(confidence interval), -0.68, 1.59]; p = 0.44) nor in pain score (MD (mean difference), -0.46 [95% CI, -0.97, 0.05]; p = 0.08) between the TXA group and the control group. Two studies found no significant difference in blood loss between the TXA group and the control group. The meta-analysis from five studies demonstrated no significant difference between the TXA and control groups in operative time (MD, -3.51 [95% CI, -15.82, 8.80]; p = 0.58) or irrigation amount used (MD, -2.53 [95% CI, -5.93, 0.87]; p = 0.14). Two trials reported different statistical results in postoperative shoulder swelling. No significant differences regarding the need for pressure increase and MAP were reported between groups. No wound complications or infections or cardiac, thrombotic, or thromboembolic complications were recorded in either group.

CONCLUSION

The use of intravenous or local TXA in shoulder arthroscopic surgery did not increase complications or thromboembolic events, but TXA had no obviously effect of reducing bleeding to obtain a clear visual field or pain release in patients undergoing shoulder arthroscopic surgery.