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

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.

Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review

Background

The Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA).

Methods

We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables.

Results

We included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012).

Conclusions

This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made.

Level of Evidence

Level I; Systematic Review.

The efficacy and safety of tranexamic acid in the treatment of intertrochanteric fracture: an updated meta-analysis of 11 randomized controlled trials

This meta-analysis was performed to investigate the efficacy and safety of tranexamic acid (TXA) in the elderly patients undergoing intertrochanteric fracture surgery from the current literatures. The electronic literature database of PubMed, Embase and Cochrane library were searched in October 2019. The intraoperative blood loss, hidden blood loss, postoperative drainage and total blood loss, postoperative hemoglobin, length of stay, transfusion rate, mortality rate, thromboembolic events and wound complications were extracted. Stata 14.0 software was used for our meta-analysis. A total of 11 RCTs (3 new RCTs in 2019) with 1202 patients met our inclusion criteria. This meta-analysis showed that administration of TXA can reduce intraoperative blood loss (P = 0.009), hidden blood loss (P = 0.000), total blood loss (P = 0.000), length of stay (P = 0.003), transfusion rate (P = 0.000) and the occurrence of wound complications (P = 0.006). Furthermore, administration of TXA was associated with an increase in the postoperative Hb level at day 1, 2 and 3 (P = 0.000, P = 0.000 and P = 0.000, respectively) after surgery. However, no significant difference was found between the TXA group and control group regarding the occurrence of thromboembolic events (P = 0.978, including deep vein thrombosis, P = 0.850; pulmonary embolism, P = 0.788; cerebrovascular accident, P = 0.549; myocardial infarction, P = 0.395) and mortality rate (P = 0. 338). Our meta-analysis suggested that administration of TXA is effective in reducing intraoperative blood loss, hidden blood loss, total blood loss, length of stay, transfusion rate, wound complications and enhancing postoperative Hb without increasing the risk of thromboembolic events and mortality rate in intertrochanteric fracture surgery. More large multi-center and high-quality RCTs are required for further research.

Comparative efficacy and safety of topical hemostatic agents in primary total knee arthroplasty: A network meta-analysis of randomized controlled trials

BACKGROUND

Topical hemostatic agents are commonly used for reducing perioperative blood loss and transfusion requirement in primary total knee arthroplasty (TKA), although the optimal option has yet to be defined. This study aimed to evaluate the efficacy and safety of topical hemostatic agents and rank the best intervention using the network meta-analysis (NMA) method.

METHODS

We searched Web of science, PubMed, and Cochrane Library database up to April 2020, for randomized controlled trials (RCTs) on topical hemostatic agents in primary TKA. The quality of included studies was assessed using the Cochrane "risk of bias" tool. Direct and indirect comparisons were performed for the result of network meta-analysis followed by consistency test.

RESULTS

Thirty seven RCTs with 3792 patients were included in this NMA and the pooled results indicated that tranexamic acid plus diluted epinephrine (TXA+DEP) displayed the highest efficacy in reducing total blood loss, hemoglobin drop and transfusion requirement. None of the included treatments was found to increase risk of thromboembolic events compared to placebo. According to the results of ranking probabilities, TXA+DEP had the highest possibility to be the best topical hemostatic agent with regard to the greatest comparative efficacy and a relatively high safety level.

CONCLUSION

Current evidence supports that administration of TXA+DEP may be the optimal topical hemostatic agent to decrease blood loss and transfusion requirement in primary TKA. More direct studies that focused on the topical application of TXA+DEP versus other treatments are needed in the future.

Intra-articular Tranexamic Acid in Primary Total Knee Arthroplasty Decreases the Rate of Post-operative Blood Transfusions in People with Hemophilia: A Retrospective Case-Control Study

BACKGROUND

Blood transfusion rates after total knee arthroplasty (TKA) in patients without hemophilia have diminished with the use of a standardized multimodal blood loss prevention method (MBLPM) that includes intra-articular tranexamic acid (TXA) (MBLPM-TXA). However, the topic has not been addressed in people with hemophilia.

QUESTIONS/PURPOSES

Our aim was to investigate whether the MBLPM-TXA prevents blood loss in patients with hemophilia A who undergo TKA, thereby decreasing the need for post-operative blood transfusion.

METHODS

This retrospective case-control comparative study involved 30 TKA patients who had a severe degree of hemophilia A without inhibitions: one group treated with the MBLPM-TXA (n = 15) and a second group treated without it (n = 15). In all cases, the pre-operative hemoglobin level was greater than 13 g/dL.

RESULTS

The MBLPM-TXA group had a transfusion rate of zero, whereas 46.6% of the patients (seven of 15) in the non-MBLPM-TXA group needed transfusion.

CONCLUSION

This retrospective case-control study showed that the use of an MBLPM-TXA in patients with hemophilia A who underwent TKA was effective in reducing rates of transfusion. We recommend its use.

Safety and efficacy of tranexamic acid with epinephrine for prevention of blood loss following surgery for trochanteric femoral fractures

OBJECTIVE

This study aimed to determine whether the local administration of tranexamic acid (TXA) combined with diluted epinephrine (DEP) reduces blood loss and the need for transfusions compared with the administration of TXA alone following surgery for trochanteric femoral fractures.

METHODS

Hundred patients were enrolled in this study. In the target group (TXA/DEP group: n=50; 19 men and 31 women, mean age 72.5±11.1 years), the surgical sites were injected with 35 mL normal saline mixed with 3 g of TXA with 0.2 mg of DEP at a 1:200,000 dilution (TXA/DEP) immediately after musculoaponeurotic closure. In the control group (TXA group: n=50; 22 men and 28 women; mean age: 70.5±12.2 years), the surgical site was injected with 35 mL normal saline containing 3 g of TXA alone. The main outcome measures were postoperative hemoglobin (Hb) levels, hematocrit, drainage volume, and total blood loss (TBL); the secondary measures included transfusion requirements and perioperative complications.

RESULTS

The mean Hb levels among patients in theTXA/DEP group were significantly lower than among those in the TXA group, measured on postoperative day 1 at 101.0±14.1 g/L vs. 106.9±10.5 g/L and day 3 as 104.2±8.2 g/L vs. 108.5±9.1 g/L, respectively (p<0.05). Drainage volume from the surgical site and TBL measured on postoperative day 2 were also significantly reduced in the TXA/DEP group vs. the TXA group, measured at 71.4±26.0 mL vs. 82.5±24.6 mL and 343.6±148.0 mL vs. 419.6±165.4 mL, respectively (p<0.05). Furthermore, 11 patients (22%) from the TXA group and 15 (30%) from the TXA/DEP group received blood transfusions; the mean number of transfusion events (1.2±0.4 vs. 1.9±0.7) and the amount of blood transfused (1.7±0.5 Units vs. 2.9±1.0 Units) was also markedly reduced in the TXA/DEP group (p<0.05). Two cases in the TXA/DEP group and three in the TXA group were diagnosed with deep vein thrombosis, a difference that did not reach statistical significance (p>0.05).

CONCLUSION

Local administration of TXA with DEP reduced blood loss and limited the need for blood transfusions after surgery for trochanteric femoral fracture without increasing the risk of perioperative complications. Our study indicates that the local administration of TXA/DEP is safe and more effective than the administration of TXA alone in treating trochanteric femoral fractures.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Tranexamic Acid Plus Low-dose Epinephrine Reduces Blood Loss in Total Knee Arthroplasty: A Systematic Review and Meta-analysis

The present study assessed the effectiveness of the combined administration of tranexamic acid (TXA) plus low-dose epinephrine in primary total knee arthroplasty (TKA). We searched the following Chinese electronic databases: China National Knowledge Infrastructure and WanFang Data. We also searched the following English electronic databases: PubMed, Embase, Web of Science, and Central Register of Controlled Trials. To search for additional eligible studies, we also used Google's search engine. All randomized controlled trials (RCT) comparing TXA plus low-dose epinephrine (Combined group) and TXA alone in TKA were systematically searched. The primary outcomes were total blood loss, hidden blood loss, the requirement for transfusion, maximum hemoglobin (Hb) drop, and deep venous thrombosis (DVT). Drainage volume, operation time, length of stay, hospital for special surgery (HSS) score, and range of motion (ROM) were considered as secondary outcomes. Subgroup analyses were performed to assess the benefits of using a tourniquet and the application routes of topical or intravenous TXA between the two groups. Statistical analysis was assessed using RevMan 5.3 software. Four independent RCT were included involving 426 patients, with 213 patients in the Combined group and 213 patients in the TXA alone group. In the Combined group there was significant reduction in total blood loss (MD, 204.70; 95% CI, -302.76 to -106.63; P < 0.0001), hidden blood loss (MD, 185.63; 95% CI, -227.56 to -143.71; P < 0.00001), drainage volume (MD, 93.49; 95% CI, -117.24 to -69.74; P < 0.00001), and maximum Hb drop (MD, 5.33, 95% CI, -6.75 to -3.91; P < 0.00001). No statistical differences were found postoperatively in terms of the requirement for transfusion (risk ratio, 0.52; 95% CI, 0.26-1.04; P = 0.06), operation time (MD, 0.85; 95% CI, -2.62 to 4.31; P = 0.63), length of stay (MD, -0.02; 95% CI, -0.52 to 0.47; P = 0.93), HSS score (MD, 0.78; 95% CI, -0.36 to 1.92; P = 0.18), and ROM (MD, 1.40; 95% CI, -1.01 to 3.81; P = 0.26), and not increasing the risk of DVT (risk ratio, 1.00; 95% CI, 0.33 to 3.02; P = 1.00) in the two groups. This meta-analysis demonstrated that the administration of tranexamic acid plus low-dose epinephrine is a safe and efficacious treatment to reduce total blood loss, hidden blood loss, drainage volume, and maximum Hb drop in primary TKA, without increasing the risk of DVT in primary THA.

Severe and morbid obesity and transfusional risk in total knee arthroplasty: An observational study

BACKGROUND

Severe and morbid obesity (Class II -III) represents a challenge for successful knee surgery. There isn't consensus on what influence body mass index has on blood loss and on red blood cell (RBC) transfusion during total knee arthroplasty (TKA). The objective was to determine blood loss and transfusion needs in severe and morbid obese patients undertaking TKA.

METHODS

We recorded retrospectively all patients undergoing TKA. Obesity was assessed according to WHO guidelines. Perioperative haemoglobin and treatments for its optimisation were recorded. Blood losses were estimated from specific formulae for lost red-cell mass and percentage of lost blood volume.

RESULTS

922 patients were included: 35.90% were obese Class I and 18.76% obese Class II - III. Estimated blood volume was 4390  ±  470 ml, 4736  ±  423 ml and 5030 ± 464 ml among non-obese, obese Class I and obese Class II-III, respectively (P < 0.001). The global estimated blood volume (EBV) lost was 1502  ±  680 ml without differences between the three groups. However, the percentage of lost blood volume was lower in obese Class II -III (29.65%) than in non-obese (33.55%) and obese Class I (30.97%) (P < 0.005). Transfusion rates were 12.7%, 12.1% and 6.4% for non-obese, obese Class I and Class II -III, respectively (P = 0.062). A negative transfusion risk was predicted for Class II -III patients.

CONCLUSIONS

Severely and morbidly obese patients did not show greater blood loss nor higher RBC transfusion needs after primary TKA than non-obese and obese Class I patients. This could be because obese Class II -III patients had higher EBV but similar RBC losses.

Blood management in total knee arthroplasty: state-of-the-art review

Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.

Efficacy and Safety of Tranexamic Acid for Blood Salvage in Intertrochanteric Fracture Surgery: A Meta-Analysis

The use of tranexamic acid (TXA) for reducing blood loss in intertrochanteric fracture (IF) surgery remains controversial. We therefore performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of TXA in reducing transfusion requirements and blood loss for IF surgery. Databases, including PubMED, Cochrane, and Embase, were searched for RCTs that were published before February 2018 and that addressed the efficacy and safety of TXA in patients who underwent IF surgery. A total of 746 patients from 7 RCTs were subjected to meta-analysis. The results showed that TXA group had reduced surgical blood loss (weighted mean difference [WMD] = −37.24, 95% confidence interval [CI]: −48.70 to −25.77, P <.00001), reduced total blood loss (WMD = −199.08, 95% CI: −305.16 to −93.01, P = .0002), higher postoperative hemoglobin (WMD = 0.46, 95% CI: 0.12 to 0.79, P = .007), and hematocrit levels (WMD = 1.55, 95% CI: 0.64 to 2.47, P = .008) compared to control group, while no significant differences were found in transfusion rates (relative risk [RR] = 0.75, 95% CI: 0.50 to 1.11, P = .15), postoperative drainage (WMD = −38.82, 95% CI: −86.87 to 9.22, P = .11), and thromboembolic events (RR = 0.94, 95% CI: 0.41 to 2.19, P = .89). In patients undergoing IF surgery, the administration of TXA significantly reduced surgical blood loss and total blood loss, while it had no significant effect on transfusion rate, postoperative drainage, and the risk of thromboembolic events. Nevertheless, due to the variations in the included studies, additional RCTs are required to further validate these conclusions.

Low-Dose Epinephrine Plus Tranexamic Acid Reduces Early Postoperative Blood Loss and Inflammatory Response: A Randomized Controlled Trial

BACKGROUND

The reductions of perioperative blood loss and inflammatory response are important in total knee arthroplasty. Tranexamic acid reduced blood loss and the inflammatory response in several studies. However, the effect of epinephrine administration plus tranexamic acid has not been intensively investigated, to our knowledge. In this study, we evaluated whether the combined administration of low-dose epinephrine plus tranexamic acid reduced perioperative blood loss or inflammatory response further compared with tranexamic acid alone.

METHODS

This randomized placebo-controlled trial consisted of 179 consecutive patients who underwent primary total knee arthroplasty. Patients were randomized into 3 interventions: Group IV received intravenous low-dose epinephrine plus tranexamic acid, Group TP received topical diluted epinephrine plus tranexamic acid, and Group CT received tranexamic acid alone. The primary outcome was perioperative blood loss on postoperative day 1. Secondary outcomes included perioperative blood loss on postoperative day 3, coagulation and fibrinolysis parameters (measured by thromboelastography), inflammatory cytokine levels, transfusion values (rate and volume), thromboembolic complications, length of hospital stay, wound score, range of motion, and Hospital for Special Surgery (HSS) score.

RESULTS

The mean calculated total blood loss (and standard deviation) in Group IV was 348.1 ± 158.2 mL on postoperative day 1 and 458.0 ± 183.4 mL on postoperative day 3, which were significantly reduced (p < 0.05) compared with Group TP at 420.5 ± 188.4 mL on postoperative day 1 and 531.1 ± 231.4 mL on postoperative day 3 and Group CT at 520.4 ± 228.4 mL on postoperative day 1 and 633.7 ± 237.3 mL on postoperative day 3. Intravenous low-dose epinephrine exhibited a net anti-inflammatory activity in total knee arthroplasty and did not induce an obvious hypercoagulable status. Transfusion values were significantly reduced (p < 0.05) in Group IV, but no significant differences were observed in the incidence of thromboembolic complications, wound score, range of motion, and HSS score among the 3 groups (p > 0.05).

CONCLUSIONS

The combined administration of low-dose epinephrine and tranexamic acid demonstrated an increased effect in reducing perioperative blood loss and the inflammatory response compared with tranexamic acid alone, with no apparent increased incidence of thromboembolic and other complications.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of low-dose epinephrine on perioperative hemostasis and inflammatory reaction in major surgical operations: a randomized clinical trial

Essentials Blood loss and immune reaction are closely related to morbidity and recovery after surgery. We studied the effect of epinephrine plus tranexamic acid on blood loss and immune reaction. Epinephrine plus tranexamic acid reduced postoperative total blood loss and immune reaction. Epinephrine plus tranexamic acid did not increase the incidence of complications.

SUMMARY

Background Hemostasis, thrombosis and surgical stress-induced immune reactions are important for perioperative morbidity and recovery after major surgical operations. Objectives To evaluate the effects of combined administration of low-dose epinephrine (LDEPI) and tranexamic acid (TXA) on perioperative blood loss, thromboembolic complications and inflammatory responses in patients undergoing total hip arthroplasty (THA). Patients/Methods Patients scheduled for THA (n = 195) were randomized into three interventions: intravenous LDEPI plus TXA (group IV); topical diluted epinephrine plus TXA (group TP); and TXA alone as control (group CT). The primary outcome was perioperative blood loss on postoperative day (POD) 1. Secondary outcomes included perioperative blood loss on POD 3, intraoperative blood loss, volume of drainage, transfusion values, coagulation and fibrinolysis parameters, inflammatory cytokine levels, cases of thrombosis, intravenous fluid on the operation day, and length of hospital stay. Results The mean calculated amounts of total blood loss in groups IV, TP and CT were 631.2 mL, 760.5 mL, and 825.6 mL, respectively, on POD 1; treatment effects (differences) were 194.4 mL (95% confidence interval [CI] 146.7-242.0) and 65.0 mL (95% CI 17.4-112.7). Groups IV and TP had lower levels of proinflammatory cytokines (tumor necrosis factor-α and interleukin [IL]-1β) and higher levels of the anti-inflammatory cytokine IL-10, and showed faster development of coagulation and fibrinolysis (without change in peak levels), than group CT early postoperation. No differences were observed in transfusion, thromboembolic and other outcomes among the groups. Conclusion The combined administration of LDEPI and TXA was more effective in reducing perioperative blood loss and alleviating the inflammatory response than TXA alone, without increasing the incidence of thromboembolic and other complications.

Tranexamic acid plus diluted-epinephrine versus tranexamic acid alone for blood loss in total joint arthroplasty: A meta-analysis

BACKGROUND

We conducted the present meta-analysis to assess the efficacy and safety of tranexamic acid (TXA) plus diluted-epinephrine (DEP) for patients with total joint arthroplasty (TJA, including total knee arthroplasty (TKA) and total hip arthroplasty (THA)).

METHODS

Electronic databases (PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Chinese Wanfang databases, and Google databases) were systematically searched up to December 2016. Only randomized controlled trials (RCTs) were included. The primary outcomes were total blood loss and need for transfusion. The secondary outcomes were hemoglobin drop and the incidence of deep venous thrombosis (DVT) and hematoma. Continuous outcomes and discontinuous outcomes were compiled as the weighted mean difference (WMD) and relative risk (RR) with 95% confidence intervals (CI), respectively.

RESULTS

A total of 5 RCTs with a total of 493 patients were eligible and ultimately included in the meta-analysis. Compared with the TXA group, TXA plus DEP yielded a significant reduction in total blood loss (WMD = -244.78; 95% CI -290.12 to -199.44; P < .001), need for transfusion (RR = 0.27; 95% CI 0.15-0.48; P < .001) and hemoglobin drop (WMD = -0.81; 95% CI -1.22 to -0.40; P < .001). There was no significant difference in incidence of DVT (RR=0.67; 95% CI 0.27-1.64; P = .382) or hematoma (RR=0.89; 95% CI 0.30-2.61; P = .831) between the TXA plus DEP group and the TXA group.

CONCLUSION

TXA plus DEP can decrease perioperative blood loss without increasing the incidence of DVT compared with TXA alone. However, considering the limited number of included RCTs, this conclusion should be interpreted cautiously, and more high-quality RCTs are needed to verify the efficacy and safety of TXA plus DEP for TJA patients.

The efficacy and safety of epinephrine for postoperative bleeding in total joint arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

Total joint arthroplasty (TJA) usually results in postoperative bleeding. Some randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) have been performed to evaluate the effects of epinephrine on postoperative bleeding after TJA. However, this remained controversial about the efficacy and safety of epinephrine for postoperative bleeding in TJA. The objective of our meta-analysis was to compare the overall effect and safety of epinephrine and placebo for postoperative bleeding in TJA.

METHODS

PubMed, Embase, and the Cochrane Library were searched to identify potentially relevant articles. RCTs or non-RCTs involving epinephrine and placebo for blood loss in total knee arthroplasty or total hip arthroplasty were included. Our study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RevMan v5.3 was used to analyze the relevant data.

RESULTS

Four RCTs and 1 non-RCT involving 646 participants met the inclusion criteria. The overall pooled results from meta-analysis demonstrated that compared with control groups, epinephrine groups could significantly reduce the postoperative bleeding volume (mean difference [MD] = -168.42, 95% confidence interval [CI]: -272.37 to -64.47, P = 0.001). There was no significant difference in intraoperative bleeding volume between epinephrine and control groups (MD = -12.89, 95% CI: -53.45 to 27.69, P = 0.53). No significant difference was found between 2 groups in terms of postoperative hemoglobin loss (MD = -0.28, 95% CI: -0.66 to 0.10, P = 0.15). Compared with the control groups, no statistically significant difference was found in terms of postoperative transfusion rate in epinephrine groups (relative risk [RR] 0.86, 95% CI: 0.64-1.15, P = 0.31). In addition, the results of the meta-analysis also indicated no significant difference in terms of the incidence rate of deep venous thrombosis (DVT) between 2 groups (RR 0.28, 95% CI: 0.05-1.64, P = 0.16).

CONCLUSION

The meta-analysis showed that epinephrine could significantly reduce postoperative bleeding volume in TJA without increasing the incidence of DVT. However, there was no significant reduction in intraoperative bleeding volume, postoperative hemoglobin loss, and transfusion rate after the administration of epinephrine.

LIMITATIONS

In this study, a higher heterogeneity and a risk of selection bias may be present in postoperative hemoglobin loss. In addition, the sample size of the included studies was too small, so our findings need to be further validated with more high-quality and larger scale RCTs in the future.

SYSTEMATIC REVIEW REGISTRATION NUMBER

None.

Topical versus intravenous tranexamic acid in total knee arthroplasty

PURPOSE

The aim of this meta-analysis is to examine the efficacy and safety of intra-articular tranexamic acid (TXA) when compared to intravenous (IV) route.

METHODS

The literature search was conducted using PubMed, Cochrane Library, MEDLINE, EMBASE and China National Knowledge Infrastructure (CNKI). All randomized controlled trials evaluating the effectiveness of topical route and IV route of TXA administration were included.

RESULTS

Eight randomized clinical trials comprising of 857 patients were included in this analysis. We found no statistically significant difference in terms of total blood loss, drain output, transfusion requirement, thromboembolic complication, tourniquet time and surgical duration.

CONCLUSION

Topical TXA has a similar efficacy to IV-TXA in reducing total blood loss, drain output, transfusion rate and haemoglobin drop without any increase in thromboembolic complications.