Risk of deep venous thrombosis in drain clamping with tranexamic acid and carbazochrome sodium sulfonate hydrate in total knee arthroplasty

The efficacy and safety of the internal medication therapy of the triple drugs for chronic subdural hematoma: Retrospective analysis

The recurrence of chronic subdural hematoma (CSDH) after surgical treatment is a severe problem with no effective prevention method. This retrospective study aimed to investigate factors associated with CSDH recurrence after burr hole surgery and hematoma changes on computed tomography before surgery to examine prevention methods for recurrence. A total of 166 hematomas were enrolled in this study, with 139 patients undergoing burr hole surgery for CSDH. Among these patients, 17 (12 %) had recurrence. Propensity score matching was performed based on postoperative drug therapy, including goreisan, carbazochrome sodium sulfonate hydrate, and tranexamic aid, resulting in 39 matched cases in 0-2 and 3 drug therapy groups. The recurrence rates were 18 % for the 0-2-drug therapy group and 3 % for the 3-drug therapy group. Univariate analysis revealed that the use of 0-2 drugs was associated with a higher risk of CSDH recurrence (odds ratio [OR], 8.31; 95 % confidence interval [CI], 0.97-71.17; p = 0.05) compared to the use of 3 drugs. Multivariate regression analysis further confirmed that 0-2 drug therapy after surgery was associated with an increased risk of CSDH recurrence (OR, 11.06; 95 % CI, 1.16-105.4; p = 0.037). Additionally, 36 hematomas were evaluated before surgery, with hematoma changes such as lower density and new trabecular formation detected in 14 CSDHs (39 %). Multivariate regression analysis showed that 3-drug therapy was associated with more cases of hematoma change than 0-2-drug therapy (OR, 13.9; 95 % CI, 1.09-177.65; p = 0.043). The 3-drug therapy was effective in reducing the recurrence of hematoma after burr hole surgery and promoted hematoma thrombosis.

Global trends in research of venous thromboembolism associated with lower limb joint arthroplasty: A bibliometric analysis

This study aims to visualize publications related to venous thromboembolism (VTE) and lower limb joint arthroplasty to identify research frontiers and hotspots, providing references and guidance for further research. We retrieved original articles published from 1985 to 2022 and their recorded information from the Web of Science Core Collection. The search strategy used terms related to knee or hip arthroplasty and thromboembolic events. Microsoft Excel was used to analyze the annual publications and citations of the included literature. The rest of the data were analyzed using the VOSviewer, citespace and R and produced visualizations of these collaborative networks. We retrieved 3543 original articles and the results showed an overall upward trend in annual publications. The United States of America had the most significant number of publications (Np) and collaborative links with other countries. McMaster University had the greatest Np. Papers published by Geerts WH in 2008 had the highest total link strength. Journal of Arthroplasty published the most articles on the research of VTE associated with lower limb joint arthroplasty. The latest research trend mainly involved "general anesthesia" "revision" and "tranexamic acid." This bibliometric study revealed that the research on VTE after lower limb joint arthroplasty is developing rapidly. The United States of America leads in terms of both quantity and quality of publications, while European and Canadian institutions and authors also make significant contributions. Recent research focused on the use of tranexamic acid, anesthesia selection, and the VTE risk in revision surgeries.

Periarticular infiltration used in total joint replacements: an update and review article

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

Comparative study of carbazochrome sodium sulfonate and tranexamic acid in reducing blood loss and inflammatory response following direct anterior total hip arthroplasty: a prospective randomized controlled trial

PURPOSE

Carbazochrome sodium sulfonate (CSS) is a haemostatic agent. However, its hemostatic and anti-inflammatory effects in patients undergoing total hip arthroplasty (THA) via a direct anterior approach (DAA) are unknown. We investigated the efficacy and safety of CSS combined with tranexamic acid (TXA) in THA using DAA.

METHODS

This study enrolled 100 patients who underwent primary, unilateral THA through a direct anterior approach. Patients were randomly divided into two groups: Group A used a combination of TXA and CSS, while Group B used TXA only. The primary outcome was total perioperative blood loss. The secondary outcomes were hidden blood loss, postoperative blood transfusion rate, inflammatory reactant levels, hip function, pain score, venous thromboembolism (VTE), and incidence of associated adverse reactions.

RESULTS

The total blood loss (TBL) in group A was significantly lower than in group B. The levels of inflammatory reactants and the rate of blood transfusion were also significantly lower. However, the two groups had no significant differences in intraoperative blood loss, postoperative pain score, or joint function. There were no significant differences in VTE or postoperative complications between the groups.

CONCLUSION

As a haemostatic agent, CSS combined with TXA can reduce postoperative blood loss in patients undergoing THA via DAA and seems to have an anti-inflammatory effect. Moreover, it did not increase the incidence of VTE or its related complications.

Topical Tranexamic Acid Can Be Used Safely Even in High Risk Patients: Deep Vein Thrombosis Examination Using Routine Ultrasonography of 510 Patients

Background and Objectives: Previous studies regarding tranexamic acid (TXA) in total knee arthroplasty (TKA) investigated only symptomatic deep vein thrombosis (DVT), or did not include high risk patients. The incidence of DVT including both symptomatic and asymptomatic complications after applying topical TXA has not been evaluated using ultrasonography. Materials and Methods: The medical records of 510 patients who underwent primary unilateral TKA between July 2014 and December 2017 were retrospectively reviewed. Because TXA was routinely applied through the topical route, those who had a history of venous thromboembolism, myocardial infarction, or cerebral vascular occlusive disease, were not excluded. Regardless of symptom manifestation, DVT was examined at 1 week postoperatively for all patients using ultrasonography, and the postoperative transfusion rate was investigated. The study population was divided according to the use of topical TXA. After the two groups were matched based on the propensity scores, the incidence of DVT and the transfusion rate were compared between the groups. Results: Of the 510 patients, comprising 298 patients in the TXA group and 212 patients in the control group, DVT was noted in 22 (4.3%) patients. Two patients had DVT proximal to the popliteal vein. After propensity score matching (PSM), 168 patients were allocated to each group. In all, 11 patients in the TXA group and seven patients in the control group were diagnosed with DVT, which did not show a significant difference (p = 0.721). However, the two groups differ significantly in the transfusion rate (p < 0.001, 50.0% in the TXA group, 91.7% in the control group). Conclusions: The incidence of DVT, whether symptomatic or asymptomatic, was not affected by the use of topical TXA. The postoperative transfusion rate was reduced in the TXA group. Topical TXA could be applied safely even in patients who had been known to be at high risk.

The application of tranexamic acid in joint arthroplasty: A 20-year bibliometric analysis

Background

With the arrival of the era of the aging population, the amount of joint arthroplasty surgery keeps rising, and the articles related to the application of tranexamic acid (TXA) in joint arthroplasty (we called the application of tranexamic acid in joint arthroplasty as TIA in this study) also show a blowout growth. Therefore, we conducted a bibliometric analysis of TIA-related publications to identify the main research trends and hot spots in this field in the last 20 years.

Methods

In this study, publications in the field of TIA from January 1, 2002 to December 31, 2021 were searched in the Web of Science Core Collection (WoSCC). A total of 1,013 publications were evaluated for specific characteristics with Microsoft Excel software, CiteSpace, VOSviewer, and Online Analysis Platform of Literature Metrology (http://bibliometric.com/).

Results

A total of 1,013 TIA-related articles were included in this study, and the number of articles in this field has increased yearly over the past 20 years. The USA and China dominated in the field of TIA. The Sichuan University published the most TIA-related articles among all the institutions. Of all the authors, Professor Pei was the most productive author with 64 articles. The lack of international cooperation was a significant problem in this field during the past 20 years. Furthermore, the results of the co-citation analysis and citation bursts analysis revealed that the safety and effectiveness of TIA and the optimal use strategy were the main trends and hotspots for the current and future.

Conclusion

This bibliometric study reviewed the evolution trend of TIA research, and identified the countries, institutions, authors and journals that have made significant contributions to this field in the past 20 years, as well as the limitations and deficiencies in this field. In addition, this study revealed that the effectiveness and safety of TIA and the optimal use strategy was the current or future research trend and hotspot in this field.

Efficacy and safety of tranexamic acid in unicompartmental knee arthroplasty: A systematic review and meta-analysis

This meta-analysis aimed to assess whether administration tranexamic acid (TXA) could reduce blood loss and vascular events in patients undergoing unicompartmental knee arthroplasty (UKA). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and case control trials (CCT) that compared outcomes of patients who did and did not receive TXA during UKA. We searched Cochrane Central Register of including PubMed, EMBASE, Web of Science, the Cochrane Library, Wan Fang data, CBM and CNKI for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was operation time, intraoperative blood loss, postoperative HCT, postoperative HB, transfusion rate, dominant blood loss, postoperative drainage volume, hidden blood loss, total blood loss, postoperative ROM,postoperative VAS score, postoperative complications. Data were using fixed-effects or random-effects models with standard mean differences and risk ratios for continuous and dichotomous variables, respectively. Finally, 9 clinical studies with 744 patients were included in this meta-analysis. Compared with the control group, TXA group could reduced transfusion rate, dominant blood loss, postoperative drainage volume, hidden blood loss, and total blood loss, and increased postoperative HB with statistically significance. The main findings of this meta-analysis are that the transfusion rate, dominant blood loss, postoperative drainage volume, hidden blood loss, total blood loss and postoperative HB in the tranexamic acid group were superior to those in the routine group. Additional high-quality RCTs should be conducted in the future.

Optimal Release Timing of Drain Clamping to Reduce Postoperative Bleeding after Total Knee Arthroplasty with Intraarticular Injection of Tranexamic Acid

Background and Objectives: Intraarticular injection of tranexamic acid (IA-TXA) plus drain-clamping is a preferred method of reducing bleeding after total knee arthroplasty (TKA). However, no consensus has been reached regarding the timing of the clamping. The purpose of this study was to determine the optimum duration of drain-clamping after TKA with IA-TXA. Materials and Methods: We retrospectively reviewed 151 patients that underwent unilateral TKA with IA-TXA plus drain-clamping for 30 min, 2 h, or 3 h. The total drained volume was reviewed as the primary outcome, and hematocrit (Hct) reductions, estimated blood loss (EBL), transfusion rates, and wound complications were reviewed as secondary outcomes. Results: The mean total drained volume, Hct reduction, and EBL were significantly less in the 3 h group than in the 30 min group. Between the 2 h and 3 h groups, there was no statistical difference in the mean total drained volume, Hct reduction, or EBL. The proportion of patients who drained lesser than 300 mL was high in the 3 h group. No significant intergroup difference was observed for transfusion volume, transfusion rate, and wound related complications. Conclusions: In comparison of the IA-TXA plus drain-clamping after TKA, there was no difference in EBL between the 2 h group and the 3 h group, but the amount of drainage volume was small in the 3 h group.

Carbazochrome sodium sulfonate is not effective for prevention of post-gastric endoscopic submucosal dissection bleeding: A retrospective study

Background

Carbazochrome sodium sulfonate (CSS) is conventionally administered to prevent post-endoscopic submucosal dissection (ESD) bleeding in many institutions, but research on its preventive efficacy is lacking. Therefore, we investigated the risk of post-ESD bleeding and the preventive efficacy of CSS administration.

Methods

We retrospectively reviewed 304 lesions in 259 patients with gastric neoplasms who underwent ESD at Asahikawa Medical University Hospital from 2014 to 2021. In the CSS group, CSS 100 mg/day was intravenously infused with maintenance fluid replacement on postoperative days 0–2. The risk factors of post-ESD bleeding, including CSS administration, were investigated.

Results

The overall rate of post-ESD bleeding was 4.6% (14/304). The univariate analysis showed that atrial fibrillation (Af), warfarin intake, heparin replacement, and tumor location in the lower third were significant risk factors for increasing the likelihood of postoperative bleeding. In the multivariate analysis, Af (odds ratio [OR] 3.83, 95% CI 1.02–14.30; p < 0.05), heparin replacement (OR 4.60, 95% CI 1.02–20.70; p < 0.05), and tumor location in the lower third of the stomach (OR 6.67, 95% CI 1.43–31.00; p < 0.05) were independent factors for post-ESD bleeding. Post-ESD bleeding was observed in 5.2% (9/174) of the CSS group and 3.8% (5/130) of the non-CSS group, with no significant difference between the two groups (p = 0.783). Additionally, CSS was not shown to have preventive effects in groups with higher-risk factors, such as Af diagnosis, warfarin use, heparin replacement, and tumor location in the lower third of the stomach.

Conclusion

CSS administration was not effective for the prevention of the post-ESD bleeding in the overall patient population as well as in higher-risk patients. This suggests that the administration of CSS for post-ESD bleeding prevention may need to be reconsidered.

The effect of local injection of tranexamic acid into peri-articular tissue versus drain clamping in total knee arthroplasty: a randomized controlled trial

Background

Tranexamic acid (TXA) is used as a synthetic anti-fibrinolytic agent for total knee arthroplasty (TKA) to reduce postoperative bleeding. Though the effects on bleeding reduction of several methods of administering TXA have been demonstrated, the optimal method remains controversial. Recently, the hemostatic effect of periarticular local injection of TXA during TKA was reported. Although this method can be expected to suppress postoperative bleeding without placing a drain, its hemostatic effect has not yet been assessed in comparison with local injection and other methods of administering TXA. The aim of this randomized, prospective study was to assess the efficacy of local injection of TXA during TKA.

Methods

To confirm the effect of the local injection of TXA, drain clamping was set as the control. The subjects included a prospective series of 109 patients randomly divided into 2 groups: the local injection (group L) and the drain clamping (group D). The main outcome measure was postoperative bleeding. Secondary outcomes included pain, physical measurements, and laboratory findings.

Results

The calculated total blood loss (CTBL) in groups L and D was nearly equal and did not show the non-inferiority of group L to group D (883 ± 248 vs. 841 ± 257 ml, P = .564). Drained blood loss was significantly higher in group L than in group D (395 ± 130 vs 276 ± 78.8 ml, P < .0001). There was no significant difference in hidden blood loss between the groups (488 ± 269 vs 565 ± 261 ml, P = .131). The other laboratory findings and physical measurements were identical between the groups.

Conclusions

Although CTBL in group L did not show non-inferiority to group D, the local injection of TXA was considered to be superior for suppressing bleeding considering the risk of the adverse effects of using a drain.

Trial registration

This was a randomized, prospective study registered with UMIN Clinical Trials Registry (Registration number: UMIN000036146, date of disclosure: 10/3/2019).

Effects of carbazochrome sodium sulfonate combined with tranexamic acid on hemostasis and inflammation during perioperative period of total hip arthroplasty: A randomized controlled trial

BACKGROUND

The hemostatic effect of tranexamic acid (TXA) combined with carbazochrome sodium sulfonate (CSS) in total hip arthroplasty (THA) has not been determined. Therefore we performed a randomized study aiming to evaluate the effects of CSS combined with TXA on perioperative blood loss and inflammatory response of THA.

HYPOTHESIS

CSS combined with TXA can effectively reduce perioperative blood loss and immune response compared to TXA.

MATERIAL AND METHODS

This randomized placebo-controlled trial assigned 150 patients undergoing unilateral primary total hip arthroplasty who underwent direct anterior approach surgery to 3 groups: group A received TXA plus topical CSS; group B received TXA only; and group C received placebo. The main outcome was total blood loss. Secondary outcomes included reduction in hemoglobin concentration, coagulation parameters, inflammatory marker levels, perioperative visual analog scale (VAS) pain score, transfusion rates, postoperative hospital stay, and incidence of thromboembolic events.

RESULTS

Total blood loss in group A (668.84±230.95ml) was lower than in group B (940.96±359.22ml) and C (1166.52±342.85ml, p<0.05). We also found that compared with group B, postoperative hip pain, biomarker level of inflammation, visual analogue score (VAS) pain score in group A were significantly improved. The transfusion rate and unit of group A were significantly lower than group C (8 patients; 17.5 units), but there was no statistical difference between group A (no transfusion) and group B (2 patients; 4 units). No differences were observed in thromboembolic and other outcomes among the groups.

DISCUSSION

The combined application of topic CSS and TXA is more effective than TXA alone following THA in regard of reducing total blood loss. In addition, CSS combined with TXA is better than TXA alone in terms of improving postoperative hip pain and reducing the level of inflammatory factors.

LEVEL OF EVIDENCE

I; randomized controlled study.

Significantly reducing blood loss via a peri-articular injection of tranexamic acid during total knee arthroplasty: a retrospective study

Background

The administration of an intra-articular injection (IAI) of tranexamic acid (TXA) has been demonstrated to be effective in reducing both blood loss and transfusion rate during total knee arthroplasty (TKA); however, few studies have reported the efficiency of a peri-articular injection (PAI) of TXA. We studied the efficiency of a PAI of TXA in reducing blood loss during TKA.

Methods

Fifty patients undergoing primary simultaneous bilateral TKA were enrolled in this retrospective study. The right knee received a PAI of 1 g of TXA (Group I), and the left knee received an IAI of 1 g of TXA (Group II). The clinical outcome measures were a change in blood loss from Hemovac drains and surgical time.

Results

The decrease in blood loss from the Hemovac was significantly lower in Group I (460.1 ± 36.79 vs. 576.0 ± 34.01, P < 0.001) than in Group II, and no significant difference in surgical times was observed. The blood transfusion rate in the present study was 16 %.

Conclusions

A PAI of TXA may reduce blood loss more efficiently than an IAI of TXA during TKA without increased complications such as surgical site infection, poor wound healing, skin necrosis, pulmonary embolism, and deep vein thrombosis.

Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty

AIMS

The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA.

METHODS

This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo).

RESULTS

Mean total blood loss (TBL) in groups A (605.0 ml (SD 235.9)), B (790.9 ml (SD 280.7)), and C (844.8 ml (SD 248.1)) were lower than in group D (1,064.9 ml (SD 318.3), p < 0.001). We also found that compared with group D, biomarker level of inflammation, transfusion rate, pain score, and hip range of motion at discharge in groups A, B, and C were significantly improved. There were no differences among the four groups in terms of intraoperative blood loss (IBL), intramuscular venous thrombosis (IMVT), and length of hospital stay (LOS).

CONCLUSION

The combined application of CSS and TXA is more effective than TXA alone in reducing perioperative blood loss and transfusion rates, inflammatory response, and postoperative hip pain, results in better early hip flexion following THA, and did not increase the associated venous thromboembolism (VTE) events. Intravenous combined with topical injection of CSS was superior to intravenous or topical injection of CSS alone in reducing perioperative blood loss. Cite this article: Bone Joint Res 2021;10(6):354-362.

Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials

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.

Hemostatic and Anti-Inflammatory Effects of Carbazochrome Sodium Sulfonate in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Postoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.

METHODS

This study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.

RESULTS

Total blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).

CONCLUSION

CSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications.

A nested case-control study on the risk factors of deep vein thrombosis for Chinese after total joint arthroplasty

Background

Deep vein thrombosis (DVT) is one of the life-threatening complications of total joint arthroplasty (TJA) postoperatively, and its risk factors are still controversial. The aim of this study was to identify the risk factors of DVT after TJA.

Study design and methods

A nested case-control study based on a large dataset of 15,326 patients undergoing TJA was performed. Potential risk factors of DVT and demographic information were extracted from the electronic health record. Patients with DVT (73 patients) were treated as study group while non-DVT patients who were matched 1:4 according to the anticoagulant type, were considered as control group (292 patients). These variables of potential risk factors for DVT including age, sex, body mass index (BMI), American Society of Anesthesiologists class, comorbidity, preoperative hemoglobin (HB) level and analgesic use, surgical site (knee or hip) and type, the start time of drug anticoagulation, ambulation time, transfusion, and whether to use tranexamic acid (TXA), drain, human serum albumin, and measures of physical thromboprophylaxis after operation were collected and evaluated by survival analysis and presented as P value and odds ratio with 95% confidence interval.

Results

There were 15,326 patients underwent TJA and 73 (0.48%) patients had DVT among them, and the occurrence rates were 0.71% for the patients underwent total knee arthroplasty (TKA) while 0.24% for total hip arthroplasty. The risk factors associated with DVT included TKA (compared with THA), advanced age (> 70 years), drain use, and delayed ambulation (≥ 72 h) postoperatively.

Conclusion

The present results suggest that the occurrence rate of DVT on the patients underwent TJA was low (0.48%) relatively. And the risk factors associated with increased risk of DVT included TKA (compared with THA), advanced age, drain use, and delayed ambulation postoperatively. Individualized and more efficient risk stratification protocols of anticoagulation after TJA for Chinese may need to be developed in the future.

Is the combined application of both drain-clamping and tranexamic acid superior to the single use of either application in patients with total-knee arthroplasty?: A meta-analysis of randomized controlled trials

BACKGROUND

To compare the efficacy and safety of the combined application of both drain-clamping and tranexamic acid (TXA) versus the single use of either application in patients with total-knee arthroplasty (TKA).

METHODS

Databases (EMBASE, PubMed, Cochrane Library, Web of Sciences, the Google database, and the Ovid database) were searched from their inception through April 2018 for randomized controlled trials (RCTs) comparing the combined application of both drain-clamping and TXA versus single use of either application in patients with TKA. The Cochrane risk of bias (ROB) tool was used to assess the methodologic quality. The primary outcomes were blood loss in drainage, total blood loss, transfusion rate, and hemoglobin decline. The secondary outcomes were postoperative complications, the Knee Society Score (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The statistical analysis was performed with RevMan 5.3.5 software.

RESULTS

A total of five RCTs (479 participants) were included in our meta-analysis. The present meta-analysis indicated that significant differences existed in the total blood loss (mean difference [MD] = -145.86, 95% confidence interval [CI]: -228.64 to -63.08, P = .0006), blood loss in drainage (MD = -169.06, 95% CI: -248.56 to -89.57, P < .0001), hemoglobin decline (MD = -0.66, 95% CI: -1.00 to -0.33, P = .0001), and transfusion rate (MD = 0.44, 95% CI: 0.26-0.75, P = .002) between the groups. However, regarding postoperative complications, no significant differences were found between the 2 groups in the KSS and the WOMAC score (P > .05).

CONCLUSION

Combined application of both drain-clamping and TXA was associated with significant reductions in blood loss in drainage, total blood loss, hemoglobin decline, and the need for transfusion. However, high-quality, well-designed RCTs with long-term follow-up are still required.

An Unusual Case of Deep Vein Thrombosis After Orthognathic Surgery: A Case Report and Review of the Literature

Deep vein thrombosis (DVT) is caused primarily by obstruction of blood flow in the deep veins in the lower limbs. It is a form of thrombophlebitis and can be a major cause of morbidity and mortality in hospitalized patients. This report describes an unusual case of DVT in a 21-year-old woman with Class III malocclusion who underwent bimaxillary orthognathic surgery (bilateral sagittal split osteotomy and Le Fort I osteotomy) under general anesthesia. She developed DVT unexpectedly 1 week after surgery, with episodes of sweating and chills in addition to lower limb edema, tenderness, and rigidity. D-dimer laboratory testing and venous Doppler sonography were performed and the DVT diagnosis was confirmed; therefore, the patient was admitted to the intensive care unit for anticoagulant and supportive therapy. Although the incidence rate of thromboembolism in hospitalized patients undergoing oral and maxillofacial surgery is low, it is not an operation without risk of DVT. This complication can cause fatal acute pulmonary thromboembolism and death. This case study illustrates that pharmacologic treatment of menorrhagia with mefenamic acid combined with intraoperative use of tranexamic acid for control of blood loss might put the patient at increased risk of DVT. Hence, maxillofacial surgeons should assess all their patients preoperatively for thromboembolism risk; if they suspect any risk factors in the patient, prompt diagnostic tests and management should be ordered.

The optimal protocol to reduce blood loss and blood transfusion after unilateral total knee replacement: Low-dose IA-TXA plus 30-min drain clamping versus drainage clamping for the first 3 h without IA-TXA

INTRODUCTION

Although intraarticular tranexamic acid (IA-TXA) administration or drainage clamping are popular methods used to reduce blood loss after total knee replacement (TKR), the protocol remains controversial. We aimed (1) to establish new protocols through investigating whether two methods, that is, low-dose (500 mg) IA-TXA plus 30-min drain clamping and drainage clamping for the first 3 h without IA-TXA, can reduce blood loss and blood transfusion after unilateral TKR and (2) to make recommendations related to clinical application.

MATERIALS AND METHODS

This study, conducted from September 2014 to June 2016 related to enrolled 95 patients with primary osteoarthritis who were to have a unilateral cemented TKR, was nonrandomized and retrospective. In group A, the drain was released following tourniquet deflation. In group B, 500-mg TXA was injected into the knee joint via a drain tube after fascia closure and the drain was clamped for the first 30 min to prevent leakage. In group C, the drain was clamped for the first 3-h postoperation. Demographic characteristics and clinical data were collected, including the levels of hematocrit (Hct), the total blood loss (TBL), drained blood volume (BV), the amount of blood transfused, and any complications that developed.

RESULTS

We found a significantly lower postoperative TBL, drained BV, decreasing Hct level, and less transfused BV in the IA-TXA injection group (group B) and the 3-h drainage clamping group (group C) compared to the conventional negative drainage group (group A; p < 0.001). There was no significant difference between groups B and C ( p = 0.99).

CONCLUSIONS

The drainage clamping method can be safer than IA-TXA administration in patients with risk factor of venous thromboembolic complication. Furthermore, the IA-TXA administration can be more optimal than drainage clamping in patients with high bleeding tendency or lateral retinacular release during TKR, who would be concerned about postoperative wound complication.

Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

The efficacy of tranexamic acid (TXA) plus drain-clamping in reducing blood loss after total knee arthroplasty (TKA) is controversial. This meta-analysis aimed to identify whether combined tranexamic acid and drain-clamping was superior to TXA alone, drain clamping alone and control treatments.

METHODS

We searched the PubMed, EMBASE, Web of Science and Google databases and the Cochrane Database of Systematic Reviews. Patients prepared for primary TKA and who underwent TXA plus drain-clamping for blood loss were included in this meta-analysis. Outcomes included the need for transfusion, total blood loss, blood loss in drainage, a decrease in hemoglobin and the occurrence of deep venous thrombosis (DVT). Stata 12.0 was used for meta-analysis.

RESULTS

Finally, 7 clinical studies with 839 patients were included in this meta-analysis. Compared with the control group, TXA group and drain clamping group treatments, TXA plus drain-clamping could reduce the need for transfusion, total blood loss, blood loss in drainage and the decrease in hemoglobin with statistically significance.

CONCLUSIONS

TXA plus drain-clamping is an efficient method for controlling blood loss after TKA, and more studies should focus on the optimal clamping duration.

Efficacy of tranexamic acid plus drain-clamping to reduce blood loss in total knee arthroplasty: A meta-analysis

BACKGROUND

Perioperative blood loss is still an unsolved problem in total knee arthroplasty (TKA). The efficacy of the preoperative use of tranexamic acid (TXA) plus drain-clamping to reduce blood loss in TKA has been debated. This meta-analysis aimed to illustrate the efficacy of TXA plus drain-clamping to reduce blood loss in patients who underwent a TKA.

METHODS

In February 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews, and Google Scholar. Data from patients prepared for TKA in studies that compared TXA plus drain-clamping versus TXA alone, drain-clamping alone, or controls were retrieved. The primary endpoint was the need for transfusion. The secondary outcomes were total blood loss, blood loss in drainage, the decrease in hemoglobin, and the occurrence of deep venous thrombosis. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.

RESULTS

Ultimately, 5 clinical studies with 618 patients (TXA plus drain-clamping group = 249, control group = 130, TXA-alone group = 60, and drain-clamping group = 179) were included. TXA plus drain-clamping could decrease the need for transfusion, total blood loss, blood loss in drainage, and the decrease in hemoglobin than could the control group, the TXA-alone group, and the drain-clamping group (P < .05). There was no significant difference between the occurrence of deep venous thrombosis between the included groups (P > .05).

CONCLUSIONS

TXA plus drain-clamping can achieve the maximum effects of hemostasis in patients prepared for primary TKA. Because the number and the quality of the included studies were limited, more high-quality randomized controlled trials are needed to identify the optimal dose of TXA and the clamping hours in patients prepared for TKA.

Efficiency and Safety of Intravenous Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-analysis

The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of i.v. tranexamic acid (TXA) in simultaneous bilateral total knee arthroplasty (TKA). Potentially relevant published reports were identified from the following electronic databases: Medline, PubMed, Embase, ScienceDirect and Cochrane Library. RevMan v5.3was used to pool data. Two randomized controlled trials and four case-control studies met the inclusion criteria. The current meta-analysis identified significant differences between TXA group and control groups in terms of postoperative hemoglobin concentration (P < 0.01), drainage volume (P < 0.01), transfusion rate (P < 0.01) and units transfused (P = 0.006). There were no significant differences in length of stay (P = 0.66), operation time (P = 0.81) or and incidence of adverse effects such as infection (P = 0.42), deep venous thrombosis (DVT) (P = 0.88) and pulmonary embolism (PE) (P = 0.11). Our results show that i.v. administration of TXA in simultaneous bilateral TKA reduces postoperative drops in hemoglobin concentration, drainage volume, and transfusion requirements and does not prolong length of stay or operation time. Moreover, no adverse effects, such as infection, DVT or PE, were associated with TXA.

Use of tranexamic acid in total knee arthroplasty

PURPOSE

different strategies have been developed to reduce blood loss in total knee arthroplasty (TKA). The efficacy of both systemic and local tranexamic acid (TXA) administration is demonstrated in the literature. The aim of the present study was to compare the efficacy of systemic, local and combined (systemic + local) administration of TXA in reducing blood loss after TKA.

METHODS

we enrolled all patients submitted to a primary TKA in our department between November 2014 and August 2015. They were divided into three groups corresponding to the method of TXA administration used: intravenous (IV), intra-articular (IA), and a combination of the two. Demographic data, as well as preoperative hemoglobin and platelet levels, were collected. The primary outcome was the maximum hemoglobin loss, while the secondary outcomes were the amount of blood in the drain (cc/hour) and the rate of transfusions; postoperative pain was also assessed. Student's t-test or a χ² test was used to evaluate between-group differences, using p<0.05 as the cut-off for statistically significant differences.

RESULTS

the sample comprised 34 patients: IV, 10 cases; IA, 15 cases, and combined (IV + IA), 9 cases. The average age of the patients was 71.1±6.4 years. No significant differences in the outcome measures were found between the groups, with the exception of a significantly lower maximum hemoglobin loss in the combined versus the IV group (p=0.02). There were no differences between the groups in the amount of blood in the drain or the rate of transfusions.

CONCLUSIONS

the data from this preliminary study, as well as data from the literature, confirm that TXA administration is safe and effective in reducing total blood loss in TKA, and no administration protocol seems to be superior to the others.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Topical Tranexamic Acid May Improve Early Functional Outcomes of Primary Total Knee Arthroplasty

INTRODUCTION

The use of tranexamic acid (TXA) reduces postoperative anemia and blood transfusion requirements. We investigated if these beneficial effects improve the early outcomes of primary total knee arthroplasty (TKA).

METHODS

We retrospectively studied 166 consecutive patients (179 TKAs) who received topical TXA (3 g before tourniquet deflation). This "study group" was compared with a "control group" of 197 consecutive patients (209 TKAs) in whom no TXA was used. We captured outcomes during the first 4 postoperative months. Knee Society score (KSS) was determined preoperatively, 6 weeks, and 4 months postoperatively. The outcomes were compared using univariate analysis. Multiple logistic regressions were calculated to assess differences between groups in KSS at 6 weeks and 4 months, controlling for age, sex, body mass index, and preoperative KSS.

RESULTS

Postoperative hemoglobin was significantly higher in the study than that in the control group on day 1, day 2, and at discharge (P < .0001). Blood transfusions were required in 5% and 22% of patients (P < .001), respectively. Six weeks postoperatively, the functional KSS and its 5 categories (ability to walk, negotiate stairs up and down, stand up from a chair, and the use of support) were significantly higher in the study than those in the control group (P ≤ .001). Four months postoperatively, there was no difference in the KSS between the groups.

DISCUSSION

Our study suggests that the clinical benefit of topical TXA administration extends beyond the hospitalization period. Its use may improve knee function during the first 6 postoperative weeks. This beneficial clinical effect seems to be negligible afterward.

Tranexamic Acid Reduces Hidden Blood Loss in Patients Undergoing Total Knee Arthroplasty: A Comparative Study and Meta-Analysis

BACKGROUND

To explore the efficacy of tranexamic acid (TXA) on reducing hidden blood loss (HBL) in total knee arthroplasty (TKA) by conducting a comparative study and meta-analysis.

MATERIAL/METHODS

A total of 108 patients underwent TKA was equally distributed to experimental and control groups. The only difference between two groups was the administrations of 15 mg of TXA mixed in 100 mL normal saline for experimental group and 100 mL of normal saline for control group. The volumes of blood loss, red blood loss (RBL) were recorded, calculated and analyzed. Stata 12.0 software was applied for data analysis.

RESULTS

The intraoperative and postoperative blood loss volume in experimental group were remarkably reduced compared with those in control group (intraoperative: 105.1±12.1 mL vs. 185.5±20.3 mL, P<0.001; postoperative: 220.7±16.8 mL vs. 290.5±22.4 mL, P<0.001). Accordingly, the control group had significantly higher transfusion rate than experimental group (3.7% vs.25.9%, P=0.001). Our results also found that both the measured and hidden RBL were obviously reduced in experimental group compared with control group (measured RBL: 96.9±11.8 mL vs. 135.2±13.5 mL, P<0.001; hidden RBL: 170.8±37.2 mL vs. 364.2±41.5 mL, P<0.001). Furthermore, meta-analysis confirmed that TXA can notably decrease HBL (SMD=2.68, 95%CI=1.55~3.80, P<0.001).

CONCLUSIONS

TXA can significantly reduce the intraoperative and postoperative blood loss and HBL, therefore decreasing the transfusion need in TKA.

Low Dose Perioperative Intravenous Tranexamic Acid in Patients Undergoing Total Knee Arthroplasty: A Double-Blind Randomized Placebo Controlled Clinical Trial

Background and Objectives. The null hypothesis of this study was that TA has no effect on postsurgical bleeding in patients undergoing TKA. Methods. This study was a double-blind randomized trial. In the first group (T) patients received 500 mg of intravenous Tranexamic acid (TA) twice (once preoperatively and once 3 hours postoperatively) and in the second group (P) they received slow infusion of normal saline as placebo. The primary outcome of the study was the level of Hb 48 hours after surgery. Results. Hb levels 48 hours after surgery as the primary outcome were 10.92 ± 0.97 and 10.23 ± 0.98 (g/dL) in groups T and P, respectively, and the difference was statistically significant (P = 0.001). Statistically significant differences were also observed in Hb levels 6 and 24 hours after surgery, the drain output 48 hours after surgery, and the number of units of packed cells transfused between study groups (P < 0.05). There was no significant difference in duration of hospitalization between the study groups (P = n.s.). Conclusions. The low dose perioperative intravenous TA significantly reduces blood loss, requirement for blood transfusion, and drain output in patients undergoing TKA. However, duration of hospitalization did not change significantly.

An In Vivo Study of Low-Dose Intra-Articular Tranexamic Acid Application with Prolonged Clamping Drain Method in Total Knee Replacement: Clinical Efficacy and Safety

Background. Recently, combined intra-articular tranexamic acid (IA-TXA) injection with clamping drain method showed efficacy for blood loss and transfusion reduction in total knee replacement (TKR). However, until now, none of previous studies revealed the effect of this technique on pharmacokinetics, coagulation, and fibrinolysis. Materials and Methods. An experimental study was conducted, during 2011-2012, in 30 patients undergoing unilateral TKR. Patients received IA-TXA application and then were allocated into six groups regarding clamping drain duration (2-, 4-, 6-, 8-, 10-, and 12-hours). Blood and drainage fluid were collected to measure tranexamic acid (TXA) level and related coagulation and fibrinolytic markers. Postoperative complication was followed for one year. Results. There was no significant difference of serum TXA level at 2 hour and 24 hour among groups (p < 0.05). Serum TXA level at time of clamp release was significantly different among groups with the highest level at 2 hour (p < 0.0001). There was no significant difference of TXA level in drainage fluid, postoperative blood loss, blood transfusion, and postoperative complications (p < 0.05).  Conclusions. Low-dose IA-TXA application in TKR with prolonged clamping drain method is a safe and effective blood conservative technique with only minimal systemic absorption and without significant increase in systemic absorption over time.

Topical Administration of Tranexamic Acid Plus Diluted-Epinephrine in Primary Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Trial

The aim of this trial was to evaluate the efficacy and safety of intra-articular administration of tranexamic acid (TXA) plus diluted-epinephrine (DEP) on perioperative blood loss and transfusion in primary unilateral total knee arthroplasty (TKA) without drainage. One hundred patients scheduled to undergo TKA were randomized into two groups: 50 patients received intra-articular 3g TXA plus 0.25mg DEP (1:200,000), and 50 patients received 3g topical TXA alone. The results showed that topical combined administration significantly reduced total blood loss (P=0.006), hidden blood loss (P=0.000) and transfusion rate (0% vs. 4%), without increasing the risk of thromboembolic and hemodynamic complications (P>0.05). Therefore, topical TXA plus DEP was effective and safe in reducing blood loss and transfusion following TKA, without substantial complications.

Effect of Topical Tranexamic Acid in Reducing Bleeding and Transfusions in TKA

Intravenous tranexamic acid (TXA) has been identified to be effective in total knee arthroplasty (TKA), but the effect of topical application is still unclear. Therefore, the authors conducted a meta-analysis to assess the effect of topical TXA in TKA. Twelve trials with a total of 1179 knees were included. The results revealed that the application of topical TXA in TKA significantly reduced total blood loss by a mean of 280.65 mL and reduced transfusions without increasing the risks of deep venous thrombosis and pulmonary embolism. Topical TXA also reduced postoperative drain output by a mean of 194.59 mL and lowered postoperative hemoglobin drop by a mean of 0.66 g/dL. In addition, subgroup analysis showed that high-concentration TXA may be better at reducing bleeding and transfusions than low-concentration TXA. Therefore, the authors concluded that topical TXA can effectively reduce bleeding and transfusion rate in TKA without increasing the risk of deep venous thrombosis and pulmonary embolism, and high-concentration (20 mg/mL or more) topical TXA is recommended.

A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

Safety and efficacy of intra-articular injection of tranexamic acid in total knee arthroplasty

Tranexamic acid was intra-articularly injected in total knee arthroplasty (TKA) to reduce blood loss and transfusion. However, no single study has been large enough to definitively determine whether it is safe and effective. To determine the safety and efficacy of intra-articular tranexamic acid in TKA, the authors searched various databases for relevant randomized controlled trials. Mean difference (MD) in total blood loss, risk ratio (RR) for transfusion, and complication rate in the tranexamic acid-treated group vs the placebo group were calculated. Seven randomized controlled trials, including 622 patients (174 men and 448 women), were identified. All 7 placebo-controlled randomized trials had a low risk of bias. The pooled results showed a positive effect of tranexamic acid in all treatment groups, with significant reduction in total blood loss (MD, -396.42 mL [95% confidence interval (CI), -629.64 to -163.20]; P=.0009). However, there was significant heterogeneity in the finding (chi-square=27.16, df=3, I(2)=89%; P<.00001) among studies. The pooled results indicated that 5.8% (18 of 309) of tranexamic acid-treated patients required transfusion compared with 27.2% (85 of 313) of placebo-treated patients. This difference was significant (RR, 0.22; 95% CI, 0.14-0.35; P<.00001). There was no significant difference between the groups in the incidence of deep venous thrombosis (RR, 0.83; 95% CI, 0.35-1.98; P=.68) or pulmonary embolism (RR, 0.54; 95% CI, 0.10-2.85; P=.46). In all, intra-articular tranexamic acid significantly reduced total blood loss, drainage, reduction of hemoglobin, and the need for transfusion without increasing the incidence of deep venous thrombosis and pulmonary embolism. Intra-articular tranexamic acid is safe and efficacious in TKA.

Practical issues for the use of tranexamic acid in total knee arthroplasty: a systematic review

PURPOSE

This systematic review was undertaken to answer three specific questions relating to the clinical values of tranexamic acid (TNA) in total knee arthroplasty (TKA): (1) Whether there are differences in blood-saving effects between the systemic and topical administrations; (2) Whether blood-saving effects of TNA differ by doses and timings of administration; and (3) Whether the use of TNA is safe at all reported doses, timings, and routes of administration with respect to the incidences of symptomatic deep-vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A systematic review was carried out with 28 randomised controlled trials to evaluate the efficacy and safety of TNA use in TKA identified from the literature.

RESULTS

Both systemic and topical administrations reduced blood loss after TKA, but transfusion reducing effects varied in studies whether systemic or topical administrations. The effects of TNA were influenced by doses and timings of administration. No increased incidences of symptomatic DVT and PE were found for all reported doses, timings, and routes of TNA administration.

CONCLUSION

Surgeons can consider incorporating the use of TNA to their blood-saving protocols in TKA without serious concern of adverse events but need to adopt optimal doses, timings, and routes of TNA administrations.

Clinical value of tranexamic acid in unilateral and simultaneous bilateral TKAs under a contemporary blood-saving protocol: a randomized controlled trial

PURPOSE

Despite the documented blood-saving effects of tranexamic acid (TNA) in total knee arthroplasty (TKA), the question whether clinical values of TNA are identical in unilateral and bilateral TKAs remains unclear. This study was undertaken to determine the clinical values of TNA in unilateral and simultaneous bilateral TKAs under a contemporary blood-saving protocol in terms of efficacy (total blood loss and transfusion rate) and safety (the incidences of symptomatic deep vein thrombosis and pulmonary embolism).

METHODS

One hundred and eighty unilateral and 146 bilateral TKA patients were randomized into TNA group or control group. In unilateral TKA patients, TNA (10 mg/kg) was administered intravenously 20 min before tourniquet deflation and repeated 3 h after surgery. In bilateral TKA patients, one more dose (10 mg/kg) was given before tourniquet deflation in the second TKA. A contemporary blood-saving protocol was applied to all patients. The TNA and control groups were compared separately in unilateral and bilateral TKA patients for the efficacy and safety variables.

RESULTS

In unilateral TKA patients, the TNA group had less total blood loss (905 vs. 1,018 mL, p = 0.018) than the control group, but there was no difference in the allogenic transfusion rate (1 vs. 7 %, n.s.). In bilateral TKA patients, the TNA group showed no differences in total blood loss (1,282 vs. 1,379 mL, n.s.), but a significant reduction in the allogenic transfusion rate (7 vs. 27 %, p = 0.002). No symptomatic deep vein thrombosis or pulmonary embolism was found in all patients.

CONCLUSION

This study demonstrates that the use of TNA reduces total blood loss, but the effects on the transfusion rate can differ depending on the type of TKAs (unilateral vs. bilateral) and the blood-saving protocols.

Can tranexamic acid and hydrogen peroxide reduce blood loss in cemented total knee arthroplasty?

INTRODUCTION

The use of tourniquet in total knee arthroplasty (TKA) has resulted in negligible intra-operative blood loss but notable post-operative blood loss, creating the ideal scenario for using topical haemostatic agents intra-operatively. Recently, medical adjuvants including tranexamic acid (TXA) and hydrogen peroxide (H2O2) have been introduced. The aim of this study was to evaluate the effectiveness of intra-articular TXA and H2O2 in reducing blood loss during TKA.

MATERIALS AND METHODS

Fifty patients, who underwent a primary TKA with 1,500 mg of intra-articular TXA between May 2011 and December 2011, were compared with two matching cohorts of 50 patients each who underwent TKA with 100 ml of 3 % H2O2 wash and TKA without any TXA or H2O2. All surgeries were performed by two senior surgeons. The total blood loss was calculated by the hemoglobin balance method.

RESULTS

The pre-operative serum hemoglobin levels were 13.1 ± 1.3, 13.1 ± 1.3 and 13.0 ± 1.2 g/dl (p > 0.05); while the drop in serum hemoglobin levels post-operatively was 2.0 ± 0.7, 2.4 ± 0.9 and 2.7 ± 0.8 g/dl for the TXA, H2O2 and Control groups, respectively (p < 0.001). The total amount of blood loss was 596 ± 449, 710 ± 279 and 760 ± 228 ml, respectively (p = 0.046). There was no difference in the duration of surgery between the three groups (p > 0.05).

CONCLUSIONS

This study showed that intra-articular TXA reduced blood loss during TKA without significantly increasing the duration of surgery. We cannot justify H2O2 wash as an alternative to intra-articular TXA to reduce blood loss during TKA.

Topical administration of tranexamic acid in primary total hip and total knee arthroplasty

Major blood loss is a known potential complication in total hip and total knee arthroplasty. We conducted a prospective, stratified, randomized, double-blind, placebo-controlled trial that evaluated 100 patients undergoing total knee or total hip arthroplasty to evaluate the effect on blood loss using the topical application of tranexamic acid. Participants received either 2 g of topical tranexamic acid or the equivalent volume of placebo into the joint prior to surgical closure. Tranexamic acid resulted in a lower mean maximum decline in postoperative hemoglobin levels when compared to placebo (P = 0.013). Patients in the tranexamic acid group demonstrated an improved but non-significant reduction in the units of blood transfused compared to placebo (P = 0.423). There was no clinically significant increase in complications in the tranexamic acid group, including no incidence of venous thromboembolism.

Efficacy of low-dose intra-articular tranexamic acid in total knee replacement; a prospective triple-blinded randomized controlled trial

BACKGROUND

Recently, a number of studies using intra-articular application of tranexamic acid (IA-TXA), with different dosage and techniques, successfully reduced postoperative blood loss in total knee replacement (TKR). However, best of our knowledge, the very low dose of IA-TXA with drain clamping technique in conventional TKR has not been yet studied. This study aimed to evaluate the effectiveness and dose-response effect of two low-dose IA-TXA regimens in conventional TKR on blood loss and blood transfusion reduction.

METHODS

Between 2010 and 2011, a triple-blinded randomized controlled study was conducted in 135 patients undergoing conventional TKR. The patients were allocated into three groups according to intra-articular solution received: Control group (physiologic saline), TXA-250 group (TXA 250 mg), and TXA-500 group (TXA 500 mg). The solution was injected after wound closure followed by drain clamping for 2 hours. Blood loss and transfusion were recorded. Duplex ultrasound was performed. Functional outcome and complication were followed for one year.

RESULTS

There were forty-five patients per groups. The mean total hemoglobin loss was 2.9 g/dL in control group compared with 2.2 g/dL in both TXA groups (p > 0.001). Ten patients (22%, control), six patients (13%, TXA-250) and none (TXA-500) required transfusion (p = 0.005). Thromboembolic events were detected in 7 patients (4 controls, 1 TXA-250, and 2 TXA-500). Functional outcome was non-significant difference between groups.

CONCLUSIONS

Combined low-dose IA-TXA, as 500 mg, with 2-hour clamp drain is effective for reducing postoperative blood loss and transfusion in conventional TKR without significant difference in postoperative knee function or complication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01850394.

Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty: a prospective randomized controlled trial

PURPOSE

The objective of this prospective randomized controlled trial was to assess the efficacy and safety of simultaneous application of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty (TKA).

METHODS

Seventy-two primary osteoarthritis patients undergoing unilateral TKA using fondaparinux as a basic thromboprophylaxis were randomized to receive either placebo (36 patients) or tranexamic acid (36 patients). Prophylaxis against venous thromboembolism in all patients was administered with subcutaneous doses of 2.5 mg fondaparinux for 5 days post-operatively. Post-operative retransfusion volume, allogenic transfusion volumes and drain amount were recorded for each patient. Level of haemoglobin, prothrombin time, activated partial thromboplastin time and D-dimer were also assessed. Doppler ultrasonography was performed preoperatively and 7 days after surgery.

RESULTS

The rate of transfusion was lower in the tranexamic acid group than in the placebo group (p = 0.007). The drained blood volume during the initial 24 h and until drain removal was smaller in the tranexamic acid group than in the placebo group (p < 0.001). However, the haematologic laboratory results did not show any significant differences between the two groups. The prevalence of deep-vein thrombosis (DVT) was 4 (11.1 %) in the placebo group and 3 (8.3 %) in the tranexamic acid group (p = n.s.). There was no proximal DVT and no symptomatic pulmonary embolism in either group.

CONCLUSION

The use of tranexamic acid could reduce acute blood loss significantly without any adverse effect resulted from drug interaction with concomitant use of indirect factor Xa inhibitor following TKA. Therefore, simple combination of these drugs can be recommended to reduce post-operative blood loss as well as to reduce DVT following TKA.

Topical tranexamic acid in total knee replacement: a systematic review and meta-analysis

BACKGROUND

To examine the safety and efficacy of topical use of tranexamic acid (TA) in total knee arthroplasty (TKA).

METHODS

An electronic literature search of PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, identifying studies published in any language from 1966 to February 2013. The studies enrolled adults undergoing a primary TKA, where topical TA was used. Inverse variance statistical method and either a fixed or random effect model, depending on the absence or presence of statistical heterogeneity were used; subgroup analysis was performed when possible.

RESULTS

We identified a total of seven eligible reports for analysis. Our meta-analysis indicated that when compared with the control group, topical application of TA limited significantly postoperative drain output (mean difference: -268.36ml), total blood loss (mean difference=-220.08ml), Hb drop (mean difference=-0.94g/dL) and lowered the risk of transfusion requirements (risk ratio=0.47, 95CI=0.26-0.84), without increased risk of thromboembolic events. Sub-group analysis indicated that a higher dose of topical TA (>2g) significantly reduced transfusion requirements.

CONCLUSIONS

Although the present meta-analysis proved a statistically significant reduction of postoperative blood loss and transfusion requirements with topical use of TA in TKA, the clinical importance of the respective estimates of effect size should be interpreted with caution.

LEVEL OF EVIDENCE

I, II.

Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty

The objective of this study was to determine if tranexamic acid (TXA) applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). Two hundred and ninety consecutive patients from a single surgeon were enrolled. In TKA, TXA solution was injected into the knee after closure of the arthrotomy. In THA, the joint was bathed in TXA solution at three points during the procedure. In both THA and TKA the TXA solution was at a concentration of 3 g TXA per 100 mL saline. The mean blood loss was significantly higher in the non-TXA patients in both TKA and THA groups. Postoperative transfusions decreased dramatically with TXA, dropping from 10% to 0%, and from 15% to 1%, in the TKA and THA groups, respectively. Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in TKA and THA.

The comparative efficacies of intra-articular and IV tranexamic acid for reducing blood loss during total knee arthroplasty

PURPOSE

Reduction in blood loss during surgery stabilizes hemodynamic status and aids in recovery after total knee arthroplasty (TKA). In this study, the authors examined whether different administration routes of tranexamic acid (TNA) might affect the amount of blood loss after TKA.

METHODS

A total of 150 patients were prospectively allocated to each of the three groups (intravenous, intra-articular, and placebo group) and underwent unilateral TKA. During closing the operative wound, TNA (1.5 g mixed in 100 cc of saline) was administered intravenously or intra-articularly according to the enrolled group, and an equivalent volume of normal saline was administered into the knee joint cavity and intravenously in the placebo group, respectively. The amount of blood loss and transfusion, and changes in haemoglobin levels were documented accordingly.

RESULTS

The mean blood loss in the intravenous, intra-articular, and placebo groups were 528 ± 227, 426 ± 197, and 833 ± 412 ml, respectively. About 66 % (intravenous), 80 % (intra-articular), and 6 % (placebo) of each group did not require transfusion for any reason, and the mean amount of transfusion was 273.6, 129.6, and 920.8 ml, respectively. Preoperative haemoglobin values decreased by 1.6 ± 0.8, 1.8 ± 0.8, and 2.0 ± 0.9 mg/dl, respectively.

CONCLUSION

Compared to intravenous administration, intra-articular administration of TNA seems to be more effective in terms of reducing blood loss and transfusion frequency. TNA may improve the general conditions of patients given TKA by maintaining a hemodynamically stable state, aiding in recovery, and reducing the chance of transfusion-associated side effects and complications.

LEVEL OF EVIDENCE

II.

The effect of tranexamic acid on blood loss and transfusion rate in primary total knee arthroplasty

Allogeneic blood transfusions remain common in primary total knee arthroplasty. We reviewed our experience with 2269 consecutive primary total knee arthroplasties in 2069 patients over a 3.5 year period. In our cohort, 1838 received no TXA, 330 received TXA via IV infusion, and 130 had TXA applied topically. The need for blood transfusion, as well as hematocrit levels immediately after surgery in the recovery room and the day of discharge were recorded. Tranexamic acid infusion demonstrated a statistically significant decrease in blood transfusion (P=0.001), as did topical application of TXA (P=0.019). The transfusion rate without TXA was 6.5% (120/1839) but only 0.3% (1/330) with TXA infusion. There were no transfusions (0/130) with topical TXA. Statistical differences were also noted in both immediate post operative and day of discharge hematocrit levels in patients having TXA infusion while those values for patients with TXA irrigation failed to obtain statistical significance. No significant change in the rate of symptomatic deep venous thrombosis or pulmonary embolism was noted.

Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis

Tranexamic acid, a synthetic derivative of the amino acid lysine, is an antifibrinolytic agent that acts by binding to plasminogen and blocking the interaction of plasmin(ogen) with fibrin, thereby preventing dissolution of the fibrin clot. Tranexamic acid (Transamin®) is indicated in Japan for use in certain conditions with abnormal bleeding or bleeding tendencies in which local or systemic hyperfibrinolysis is considered to be involved. This article reviews the efficacy and tolerability of tranexamic acid in conditions amenable to antifibrinolytic therapy and briefly overviews the pharmacological properties of the drug. In large, randomized controlled trials, tranexamic acid generally significantly reduced perioperative blood loss compared with placebo in a variety of surgical procedures, including cardiac surgery with or without cardiopulmonary bypass, total hip and knee replacement and prostatectomy. In many instances, tranexamic acid also reduced transfusion requirements associated with surgery. It also reduced blood loss in gynaecological bleeding disorders, such as heavy menstrual bleeding, postpartum haemorrhage and bleeding irregularities caused by contraceptive implants. Tranexamic acid significantly reduced all-cause mortality and death due to bleeding in trauma patients with significant bleeding, particularly when administered early after injury. It was also effective in traumatic hyphaema, gastrointestinal bleeding and hereditary angioneurotic oedema. While it reduces rebleeding in subarachnoid haemorrhage, it may increase ischaemic complications. Pharmacoeconomic analyses predicted that tranexamic acid use in surgery and trauma would be very cost effective and potentially life saving. In direct comparisons with other marketed agents, tranexamic acid was at least as effective as ε-aminocaproic acid and more effective than desmopressin in surgical procedures. It was more effective than desmopressin, etamsylate, flurbiprofen, mefenamic acid and norethisterone, but less effective than the levonorgestrel-releasing intra-uterine device in heavy menstrual bleeding and was as effective as prednisolone in traumatic hyphaema. Tranexamic acid was generally well tolerated. Most adverse events in clinical trials were of mild or moderate severity; severe or serious events were rare. Therefore, while high-quality published evidence is limited for some approved indications, tranexamic acid is an effective and well tolerated antifibrinolytic agent.

Use of Topical Tranexamic Acid or Aminocaproic Acid to Prevent Bleeding After Major Surgical Procedures

OBJECTIVE:

To evaluate the literature describing topical use of tranexamic acid or aminocaproic acid for prevention of postoperative bleeding after major surgical procedures.

DATA SOURCES:

Literature was retrieved through MEDLINE (1946-September 2011) and International Pharmaceutical Abstracts(1970-September 2011) using the terms tranexamic acid, aminocaproic acid, antifibrinolytic, topical, and surgical. In addition, reference citations from publications identified were reviewed.

STUDY SELECTION AND DATA EXTRACTION:

All identified articles in English were evaluated. Clinical trials, case reports, and meta-analyses describing topical use of tranexamic acid or aminocaproic acid to prevent postoperative bleeding were included.

DATA SYNTHESIS:

A total of 16 publications in the setting of major surgical procedures were included; the majority of data were for tranexamic acid. For cardiac surgery, 4 trials used solutions containing tranexamic acid (1-2.5 g in 100-250 mL of 0.9% NaCl), and 1 trial assessed a solution containing aminocaproic acid (24 g in 250 mL of 0.9% NaCl). These solutions were poured into the chest cavity before sternotomy closure. For orthopedic procedures, all of the data were for topical irrigation solutions containing tranexamic acid (500 mg-3 g in 50-100 mL of 0.9% NaCl) or for intraarticular injections of tranexamic acid (250 mg to 2 g in 20-50 mL of 0.9% sodium chloride, with or without carbazochrome sodium sulfate). Overall, use of topical tranexamic acid or aminocaproic acid reduced postoperative blood loss; however, few studies reported a significant reduction in the number of packed red blood cell transfusions or units given, intensive care unit stay, or length of hospitalization.

CONCLUSIONS:

Topical application of tranexamic acid and aminocaproic acid to decrease postsurgical bleeding after major surgical procedures is a promising strategy. Further data are needed regarding the safety of this hemostatic approach.