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Sawant S, Deshpande SV, Wamborikar H, Jadawala VH, Suneja A, Goel S, Patel V. The Impact of Tranexamic Acid on Blood Loss Management in Primary Total Knee Arthroplasty: A Comprehensive Review. Cureus 2024; 16:e65386. [PMID: 39184800 PMCID: PMC11344607 DOI: 10.7759/cureus.65386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 07/25/2024] [Indexed: 08/27/2024] Open
Abstract
Total knee arthroplasty (TKA) is a widely performed surgical procedure to restore function and relieve pain in patients with advanced knee arthritis. One of the key challenges in TKA is managing perioperative blood loss, which can lead to complications such as postoperative anemia and the need for blood transfusions. Tranexamic acid (TXA), an antifibrinolytic agent, has shown promising results in reducing blood loss and transfusion requirements in various surgical settings, including TKA. This comprehensive review synthesizes current evidence regarding the efficacy and safety profile of TXA in primary TKA. Mechanistically, TXA functions by inhibiting the breakdown of fibrin clots, promoting hemostasis, and minimizing blood loss. Clinical studies evaluating TXA in TKA have consistently demonstrated significant reductions in blood loss parameters, including total blood loss, postoperative drain output, and transfusion rates. Key findings highlight the efficacy of TXA across different dosing regimens and administration routes, with minimal associated risks of thromboembolic events or adverse effects. Comparative analyses with other blood conservation strategies underscore TXA's superiority in reducing transfusion requirements and its cost-effectiveness in clinical practice. The review also discusses current clinical guidelines and recommendations for TXA use in TKA, emphasizing optimal dosing strategies and patient selection criteria. Future research directions include exploring the long-term outcomes of TXA administration and its impact on functional recovery, and refining protocols to enhance its efficacy and safety further. In conclusion, TXA represents a valuable adjunct in blood loss management during primary TKA, offering substantial benefits in patient outcomes, healthcare resource utilization, and cost-effectiveness. Continued research efforts are warranted to optimize its use and expand its applicability in orthopedic surgery.
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Affiliation(s)
- Sharad Sawant
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanjay V Deshpande
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Hitendra Wamborikar
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek H Jadawala
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anmol Suneja
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sachin Goel
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vatsal Patel
- Department of Orthopedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Bayrak HC, Adiguzel IF, Demir M, Tarlacık AO. Tranexamic Acid and Tourniquet: Which Combination Reduces Blood Loss Most Effectively? Niger J Clin Pract 2024; 27:521-527. [PMID: 38679776 DOI: 10.4103/njcp.njcp_3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 02/27/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Blood loss during and after total knee arthroplasty (TKA) can lead to substantial morbidity and the need for blood transfusions. There are several methods to minimize blood loss and decrease transfusion rates in patients undergoing TKA. Tranexamic acid, an antifibrinolytic agent with known efficacy for achieving these goals, is combined with tourniquets to reduce bleeding in arthroplasty surgeries. Our study investigated the effects of various combinations of tranexamic acid and tourniquet use on bleeding in knee arthroplasty in 558 patients. AIM We aimed to determine the method that would provide the least blood loss and transfusion need in knee arthroplasty surgery. METHODS Between January 2018 and December 2022, 558 patients aged between 55 and 85 years underwent TKA surgery for grade 4 gonarthrosis in our clinic, and their decrease in hemoglobin value and whether they were transfused or not were analyzed. The patients were divided into four groups based on use of tranexamic acid and tourniquet. Demographic variables and patient data (body mass index, INR values, and preoperative hemoglobin values) were recorded. RESULTS There were 558 patients with a mean age of 68.19 (67 ± 6.949) years. In group 1, tranexamic acid was not used in 128 patients and tourniquet was used only during cementation; in group 2, in 132 patients, tranexamic acid was not used and tourniquet was used throughout the surgery; in group 3, in 158 patients, tranexamic acid was used and tourniquet was used throughout the surgery; in group 4, in 140 patients, tranexamic acid was used and tourniquet was used only during cementation. The decrease in hemoglobin value and transfusion rate was lowest in group 3 and highest in group 1. Besides, there was a greater decrease in hemoglobin value in group 2 than in group 4 and the transfusion rate was similar. CONCLUSIONS This clinical study showed that using tranexamic acid and a tourniquet throughout surgery significantly reduced the decrease in hemoglobin value and the need for transfusion.
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Affiliation(s)
- H C Bayrak
- Department of Orthopaedics and Traumatology, Eskisehir Yunus Emre State Hospital, Eskisehir, Turkey
| | - I F Adiguzel
- Department of Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - M Demir
- Department of Orthopaedics and Traumatology, Tokat Zile State Hospital, Tokat, Turkey
| | - A O Tarlacık
- Department of Orthopaedics and Traumatology, Eskisehir City Hospital, Eskişehir, Turkey
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Ketelaar EN, Wagner M, Lorenzo A, Comrie R, Restini C, Brannan GD, Corvasce R, Mohammad S. The Effect of Tranexamic Acid With or Without Tourniquet on Blood Loss in Total Knee Arthroplasty at a Community Hospital. Cureus 2024; 16:e54835. [PMID: 38533141 PMCID: PMC10963136 DOI: 10.7759/cureus.54835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2024] [Indexed: 03/28/2024] Open
Abstract
Tourniquets have long been used in total knee arthroplasty due to the theoretical improvement of bleeding control, integration of cement-bone interface, visibility, and efficiency of the overall surgery. However, this has become increasingly disputed. Comparative studies in total knee arthroplasty employing chemical prophylaxis, i.e., tranexamic acid, have been conducted. This retrospective cohort study evaluated the effect of tranexamic with or without a tourniquet on mean blood loss, hemoglobin, and length of stay in total knee arthroplasty patients. A total of 153 patients' records met the inclusion criteria, 95 patients (62%) were in the tranexamic acid-only group while 58 patients (38%) were in the tranexamic acid plus tourniquet group. Based on mean blood loss in mL (827.5 without vs. 810.1 with the tourniquet, p=0.805), hemoglobin counts in g/dL (12.6 without vs. 12.5 with the tourniquet, p=0.598), and length of stay in days (1.0 days without vs. 1.1 with the tourniquet, p=0.204), there was no statistical difference between the tranexamic alone vs. tranexamic plus tourniquet groups. There were no statistical differences in the mean BMI between groups (32.3 without vs. 32.4 with tourniquets, p=0.901). The patient population had more women (64.1%) than men (35.9%) (p=0.001), but no significant difference in gender based on tourniquet use (p=0.521). The tourniquet group averaged three years younger than the tranexamic alone group (age mean 68.2 without vs 65.3 with tranexamic, p=0.029). This study found no identifiable difference in the three observed variables, indicating that tourniquet provides limited to no additional benefit in reducing blood loss over tranexamic alone in total knee arthroplasty, while tranexamic alone has no deleterious decrease in mean hemoglobin or increase in length of stay.
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Affiliation(s)
| | - Michael Wagner
- Orthopedic Surgery, McLaren Macomb Hospital, Mount Clemens, USA
| | - Adam Lorenzo
- Anesthesiology, University of Buffalo, Buffalo, USA
| | - Robert Comrie
- Orthopedic Surgery, McLaren Macomb Hospital, Mount Clemens, USA
| | - Carolina Restini
- Pharmacology, Michigan State University College of Osteopathic Medicine, Macomb, USA
| | - Grace D Brannan
- Orthopedic Surgery, McLaren Macomb Hospital, Mount Clemens, USA
| | - Roger Corvasce
- Orthopedic Surgery, McLaren Macomb Hospital, Mount Clemens, USA
| | - Saad Mohammad
- Orthopedic Surgery, Mclaren Macomb Hospital, Mount Clemens, USA
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Chen S, Luo F, Lin Y, Yu G, Luo J, Xu J. Effect of intravenous low-dose norepinephrine on blood loss in non-tourniquet total knee arthroplasty under general anesthesia: a randomized, double-blind, controlled, single-center trial. J Orthop Surg Res 2023; 18:933. [PMID: 38057870 DOI: 10.1186/s13018-023-04360-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/08/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE This prospective trial aimed to evaluate the effects of low-dose intravenous norepinephrine (NE) on intraoperative blood loss and bleeding from osteotomy sites during non-tourniquet total knee arthroplasty (TKA) under general anesthesia. METHODS A total of 120 patients who underwent TKA between December 2020 and May 2022 were enrolled and randomly assigned to the intravenous low-dose NE Group (NE Group) or the control group (C Group). During surgery, NE Group received 0.05-0.1 μg/(kg min) of NE intravenously to raise and maintain the patient's mean arterial pressure (MAP). C Group received the same dose of saline as placebo. Intraoperative blood loss, bleeding score at osteotomy sites, Δlactate levels (Lac), postoperative complications, and transfusion rate during hospitalization were compared between groups. RESULTS Intraoperative and osteotomy blood loss was significantly lower in the NE Group than in the C Group (P < 0.001). No significant difference was observed in ΔLac between groups (P > 0.05). There was no significant difference in complications between the groups 3 days after surgery (P > 0.05). In addition, there was no significant difference in blood transfusion rates between the two groups during hospitalization (P > 0.05). CONCLUSION In non-tourniquet TKA under general anesthesia, low-dose intravenous NE safely and effectively reduced intraoperative blood loss and provided a satisfactory osteotomy site while maintaining a higher MAP.
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Affiliation(s)
- Shijie Chen
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Fenqi Luo
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Yuan Lin
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Guoyu Yu
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Jun Luo
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China
| | - Jie Xu
- Shengli Clinical College of Fujian Medical University, No. 134 East Street, Fuzhou, Fujian, China.
- Department of Orthopedic, Fujian Provincial Hospital, No. 134 East Street, Fuzhou, Fujian, China.
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Wang M, Lan Y, Wang H, Chen C, Mei Z, Tao Q. Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial. BMC Musculoskelet Disord 2023; 24:893. [PMID: 37978365 PMCID: PMC10655351 DOI: 10.1186/s12891-023-07036-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 11/12/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients. METHODS In this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction. RESULTS No statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.). CONCLUSION TXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.
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Affiliation(s)
- Mingyou Wang
- Department of Orthopaedics, Panzhihua Central Hospital, 34# Yikang road, Panzhihua, Sichuan, 617000, People's Republic of China
| | - Yuping Lan
- Department of Orthopaedics, Panzhihua Central Hospital, 34# Yikang road, Panzhihua, Sichuan, 617000, People's Republic of China
| | - Hongping Wang
- Department of Orthopaedics, Panzhihua Central Hospital, 34# Yikang road, Panzhihua, Sichuan, 617000, People's Republic of China
| | - Chunyu Chen
- Department of Orthopaedics, Panzhihua Central Hospital, 34# Yikang road, Panzhihua, Sichuan, 617000, People's Republic of China
| | - Zhu Mei
- Department of Orthopaedics, Panzhihua Central Hospital, 34# Yikang road, Panzhihua, Sichuan, 617000, People's Republic of China
| | - Qifeng Tao
- Department of Orthopaedics, Panzhihua Central Hospital, 34# Yikang road, Panzhihua, Sichuan, 617000, People's Republic of China.
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Bai X, Bai F, Wang Z, Zhang Y, Liu F, Wang Q. Clinical efficacy of intra-articular infusion of cocktail combined with tranexamic acid in the treatment of middle-age and older patients with frozen shoulder following arthroscopic capsular release. Front Surg 2023; 10:1035054. [PMID: 37206349 PMCID: PMC10189014 DOI: 10.3389/fsurg.2023.1035054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/30/2023] [Indexed: 05/21/2023] Open
Abstract
Objective To investigate the clinical efficacy of arthroscopic capsular release and postoperative intra-articular infusion of cocktail combined with tranexamic acid (TXA) in the treatment of patients with frozen shoulder. Method A total of 85 middle-aged and older patients with frozen shoulder who underwent arthroscopic capsular release and received intra-articular infusion of TXA alone (n = 28), cocktail alone (n = 26), and cocktail plus TXA (n = 31) after surgery were retrospective analyzed. The drainage volume within 24 h after surgery, postoperative length of hospital stay, postoperative complications, visual analog scale (VAS), Neer shoulder assessment scale, ASES score, and range of motion (ROM) of the shoulder joint at 1 day, 1 week, 1 month, and 3 months after surgery in all three groups were recorded and compared. Results Postoperative length of hospital stay was significantly shorter in the cocktail + TXA and cocktail groups than that in the TXA group. Postoperative drainage volume was significantly higher in the cocktail group compared with TXA + cocktail group (P < 0.05). At 1 day and 1 week after surgery, pain was more pronounced in the TXA group, which was significantly relieved in the cocktail and the cocktail + TXA groups (P < 0.05). Pain was significantly relieved in all the three groups at 1 and 3 months after surgery. Significant functional improvement of the shoulder was achieved in all three groups at 1 week after surgery, the improvement was apparent in the cocktail + TXA groups (P < 0.05), followed by the cocktail group. At 1 month after surgery, patients in the cocktail + TXA groups obtained excellent functional recovery of the shoulder joint. At 3 months after surgery, patients in all the three groups both obtained good recovery of the shoulder joint function, and the recovery was apparent in the cocktail + TXA groups (P < 0.05). Conclusion Arthroscopic capsular release and postoperative intra-articular infusion of cocktail combined with TXA has good safety and efficacy in the treatment of middle-age and older patients with frozen shoulder, which can reduce postoperative pain and intra-articular bleeding, promote early postoperative functional exercises and accelerate early postoperative recovery.
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Affiliation(s)
- Xiaojin Bai
- Department of Joint Surgery, Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, China
- Correspondence: Xiaojin Bai
| | - Fan Bai
- Department of Joint Surgery, Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, China
| | - Zhi Wang
- Department of Joint Surgery, Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, China
| | - Yan Zhang
- Department of Joint Surgery, Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, China
| | - Fuying Liu
- Department of Neurology, Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, China
| | - Qibing Wang
- Authentication Center for Forensic Medicine and Judicature, Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi), Zunyi, China
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Akdoğan M, Öztürk A, Faruk Çatma M, Akdoğan BM, Gülsoy A, Atilla HA. Use of tranexamic acid may reduce the need for routine tourniquet use in total knee arthroplasty. Jt Dis Relat Surg 2022; 33:547-552. [PMID: 36345182 PMCID: PMC9647687 DOI: 10.52312/jdrs.2022.737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/01/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the effects of tranexamic acid (TXA) administration on bleeding control and to compare its utilization with and without simultaneous use of conventional pneumatic tourniquets during total knee arthroplasty (TKA). PATIENTS AND METHODS Between January 2017 and December 2017, a total of 204 patients (23 males, 181 females; mean age: 66±6.9 years; range, 45 to 86 years) who underwent TKA for Stage 4 gonarthrosis were retrospectively analyzed. The patients were divided into two groups as those with (n=110) and without (n=94) pneumatic tourniquet use. Tranexamic acid (1 g) was administered intravenously to all patients in both study groups. Intra- and postoperative blood loss were calculated, and postoperative pain was evaluated by a Visual Analog Scale. Demographic and clinical data were compared between the study groups. RESULTS The amount of total blood loss and postoperative blood loss were significantly higher in the tourniquet group than that in the no-tourniquet group (589.4±69.5 mL vs. 490.8±55.2 mL and 326±56 mL vs. 164±35.5 mL, respectively; p<0.001 for both). Intraoperative blood loss was significantly higher in the no-tourniquet group (326.9±42.9 mL vs. 263.5±53.8 mL, respectively; p<0.001). The pain score at 24 h was significantly higher in the tourniquet group (p<0.001). CONCLUSION Total blood loss and postoperative pain were significantly higher among patients in whom a tourniquet was used during TKA. Therefore, the routine use of tourniquets with TXA should be reconsidered.
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Affiliation(s)
- Mutlu Akdoğan
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
| | - Alper Öztürk
- Department of Orthopedics and Traumatology, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Faruk Çatma
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
| | - Burak Menderes Akdoğan
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
| | - Atakan Gülsoy
- Department of Orthopedics and Traumatology, Anamur Devlet Hastanesi, Mersin, Türkiye
| | - Halis Atıl Atilla
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
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Shen SN, Wu DX, Lv SJ, Tong PJ. Hidden blood loss of total knee arthroplasty in hemophilia arthritis: an analysis of influencing factors. BMC Musculoskelet Disord 2022; 23:587. [PMID: 35715793 PMCID: PMC9206270 DOI: 10.1186/s12891-022-05535-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total knee arthroplasty is the leading way to treat hemophilia arthritis. At present, there is a lack of research on the influencing factors of blood loss in total knee arthroplasty for hemophilia arthritis. This study comprehensively explores the definite factors affecting the hidden blood loss in total knee arthroplasty for hemophilia patients. MATERIALS AND METHODS Ninety-two hemophilia A patients who underwent total knee arthroplasty in our center were included. Demographics, laboratory data, surgical data, and complications were collected. The Gross equation and Sehat equation were used to calculate the estimated value of hidden blood loss. Multivariate linear regression analysis was used to determine the influencing factors of hidden blood loss. RESULT The hidden blood loss of hemophilia A patients undergoing total knee arthroplasty was 1069.51 ± 341.99 mL, and the age was positively correlated with the hidden blood loss (P < 0.001), while tranexamic acid, FVIII prophylaxis, and incremental invivo recovery were negatively correlated with the hidden blood loss (P < 0.001, P = 0.008, P = 0.017). CONCLUSION Elderly patients have a greater risk of blood loss, and additional preventive measures can be appropriately added. Intraoperative intra-articular injection of tranexamic acid is recommended to reduce hidden blood loss, FVIII prophylaxis is recommended for every patient. We recommend that all HA patients measure the incremental invivo recovery and develop a personalized infusion regimen of coagulation factor.
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Affiliation(s)
- Shao Ning Shen
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China
| | - Dong Xiao Wu
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China
| | - Shuai Jie Lv
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China
| | - Pei Jian Tong
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China.
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Kukreja P, Johnson BM, Traylor C, O'Keefe KJ, Naranje S, McKeown J, Paul CA, Bell B. Comparison of the Utilization of Tranexamic Acid and Tourniquet Use in Total Knee Arthroplasty: A Retrospective Case Series. Cureus 2022; 14:e24842. [PMID: 35702459 PMCID: PMC9177231 DOI: 10.7759/cureus.24842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Total knee arthroplasty (TKA) carries a high risk for significant blood loss due to bone cuts and extensive soft tissue involvement in the knee region. The use of tranexamic acid (TXA) or a tourniquet are two methods commonly employed to prevent significant blood loss and avoid the need for blood transfusion. TXA has been shown to reduce both intraoperative and postoperative bleeding as well as the probability that a patient will require a blood transfusion. The purpose of this study is to compare the efficacy of TXA and tourniquet use, both alone and in combination, in reducing blood loss during TKA. Methods: Data for this retrospective cohort study were obtained by searching records of patients who underwent TKA at a tertiary care center from January 2019 to October 2020. Data from 526 subjects were available. A chart review was conducted to determine if the patient received TXA only, tourniquet only, or both TXA and tourniquet during the TKA procedure. Primary outcomes for this study including procedure length in minutes, estimated blood loss in cubic centimeters, and total infusion pressor (phenylephrine) administered intraoperatively in milligrams were recorded for the study. Data were summarized using means and standard errors. Statistical methods used for analysis include one-way ANOVA, probability plots, the Shapiro-Wilk test for normality, the Kruskal-Wallis test, and Tukey’s test. Results: Data were available for 526 subjects. 122 subjects received tourniquet only (Tourniquet group), 104 received intravenous (IV) TXA only, 264 received both tourniquet and IV TXA (Tourniquet + TXA), and 36 received neither tourniquet nor TXA (None). The groups did not significantly differ in procedure length (p = 0.140) or infusion pressor total (p > 0.20). The groups did significantly differ in estimated blood loss (p < 0.001). Subjects who did not receive either TXA or tourniquet had significantly more blood loss than the Tourniquet and Tourniquet + TXA groups. Similarly, the TXA group had significantly more blood loss than both the Tourniquet and Tourniquet + TXA groups. Conclusion: This study supports the conclusion that the use of a tourniquet is superior to the use of TXA in reducing intraoperative blood loss during TKA. All groups that underwent TKA using a tourniquet, either alone or in combination with TXA, exhibited significantly lower levels of blood loss compared to the control (no intervention) group.
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Hanreich C, Cushner F, Krell E, Gausden E, Cororaton A, Gonzalez Della Valle A, Boettner F. Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better? J Arthroplasty 2022; 37:642-651. [PMID: 34920121 DOI: 10.1016/j.arth.2021.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians. METHODS This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb. RESULTS Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P = .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01). CONCLUSION The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.
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Affiliation(s)
- Carola Hanreich
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Fred Cushner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Ethan Krell
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Elizabeth Gausden
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Agnes Cororaton
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY; Biostatistics Core, Hospital for Special Surgery, New York, NY
| | | | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
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Lai YH, Xu H, Su Q, Wan XF, Yuan MC, Zhou ZK. Effect of tourniquet use on blood loss, pain, functional recovery, and complications in robot-assisted total knee arthroplasty: a prospective, double-blinded, randomized controlled trial. J Orthop Surg Res 2022; 17:118. [PMID: 35189911 PMCID: PMC8862211 DOI: 10.1186/s13018-022-02992-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/04/2022] [Indexed: 02/08/2023] Open
Abstract
Background Robot-assisted total knee arthroplasty (TKA) has been largely studied to confirm its advantages in terms of accurate component positioning, microembolus formation, less blood loss, and so on, but is currently usually performed under tourniquet due to its longer operative time than conventional TKA. The aim of this study was to estimate the effects of tourniquet use in robot-assisted TKA on blood loss, pain, functional recovery, and complications. Methods Patients scheduled for robot-assisted TKA were prospectively randomized into a tourniquet or non-tourniquet group (each n = 14). The primary outcome measure was blood loss. The secondary outcome measures were operation time; visual analog scale (VAS) pain scores; time to achieve the first straight-leg raise; swelling of the thigh, knee, and calf; range of motion; Hospital for Special Surgery score; length of stay; and postoperative complications. Results There was no significant difference in total blood loss between the tourniquet and non-tourniquet groups (738.57 ± 276.158 vs. 866.85 ± 243.422 ml, P = 0.061). The tourniquet group showed significantly lower intraoperative blood loss (P < 0.001), but higher hidden blood loss (P = 0.002). The non-tourniquet group showed better knee range of motion on postoperative days (PODs) 1–3 (all P < 0.001), less thigh swelling on PODs 2 and 3 (P < 0.05), earlier straight-leg raising (P = 0.044), and shorter length of stay (P = 0.044). Thigh pain VAS score at 1 month after surgery was significantly greater in the tourniquet group (P < 0.001), as was knee pain during activity and at rest on PODs 2–3 (all P < 0.05). The tourniquet group also showed a significantly higher rate of tension blisters (28.8% vs. 7.1%, P = 0.038). Conclusions Tourniquet use during robot-assisted TKA does not reduce total blood loss, and it appears to increase postoperative pain, aggravate muscle injury, and prolong postoperative recovery. Trial registration ChiCTR, ChiCTR2100041800. Registered 5 January 2021, http://www.chictr.org.cn/index.aspx.
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Affiliation(s)
- Ya-Hao Lai
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, People's Republic of China
| | - Hong Xu
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qiang Su
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xu-Feng Wan
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, People's Republic of China
| | - Ming-Cheng Yuan
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopaedics, West China Hospital of Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, People's Republic of China.
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12
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Nuñez JH, Angles F, Minguell-Monyart J. Letter to the Editor on "In the Era of Tranexamic Acid, Are Type and Screens for Primary Total Joint Arthroplasty Obsolete?". J Arthroplasty 2021; 36:e36-e37. [PMID: 33931151 DOI: 10.1016/j.arth.2021.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/20/2021] [Indexed: 02/02/2023] Open
Affiliation(s)
- Jorge H Nuñez
- Department of Orthopedic Surgery, University Hospital of Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain; Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain; Member of the Commission for the Use of Blood and Blood Products, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Francesc Angles
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain; Departament de Cirurgia Universitat de Barcelona, Barcelona, Spain
| | - Joan Minguell-Monyart
- Department of Orthopedic Surgery, University Hospital of Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
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14
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Migliorini F, Maffulli N, Aretini P, Trivellas A, Tingart M, Eschweiler J, Baroncini A. Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes. Arch Orthop Trauma Surg 2021; 141:1007-1023. [PMID: 33417033 PMCID: PMC8139941 DOI: 10.1007/s00402-020-03725-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data. MATERIAL AND METHODS The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons. RESULTS Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group. CONCLUSION For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Paolo Aretini
- Fondazione Pisana per la Scienza, Via Ferruccio Giovannini, 13, 56017 San Giuliano Terme, Pisa, Italy
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Markus Tingart
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Alice Baroncini
- Department of Orthopaedic Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
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Johns WL, Walley KC, Seedat R, Jackson B, Boukhemis K, Gonzalez T. Tranexamic Acid Use in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420975419. [PMID: 35097417 PMCID: PMC8564923 DOI: 10.1177/2473011420975419] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery. Methods: A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months. Results: Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05). Conclusions: The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised. Level of Evidence: Level IV, case series.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Raees Seedat
- Virginia Commonwealth University, School of Medicine, Richmond, VA, USA
| | - Benjamin Jackson
- University of South Carolina, School of Medicine, Columbia, SC, USA
| | | | - Tyler Gonzalez
- University of South Carolina, School of Medicine, Columbia, SC, USA
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