Tranexamic Acid Decreases Incidence of Blood Transfusion in Simultaneous Bilateral Total Knee Arthroplasty

Is sequential bilateral robotic total knee arthroplasty a safe procedure? A matched comparative pilot study

INTRODUCTION

To our knowledge, no papers have reported the results of robotic-assisted surgery for sequential bilateral Total Knee Arthroplasty (TKA). Indeed, sequential bilateral TKA present several benefits, as one single anesthesia, surgical episode, hospitalization, and rehabilitation. The purpose of our study was to evaluate peri-operative outcomes and compare the complication rates, clinical outcomes, and implant positioning of sequential bilateral TKA performed with a robotic-assisted system versus a conventional technique.

MATERIALS AND METHODS

All patients who underwent a sequential bilateral robotic-assisted primary TKA (raTKA) in our institution between November 2019 and February 2021 were included. Twenty patients met the inclusion criteria and were matched with 20 sequential bilateral TKA performed with a conventional technique. The two groups were comparable for the demographic data and the preoperative parameters, including preoperative anticoagulation and ASA score. The minimum follow-up was 6 months.

RESULTS

The operative time was significantly longer in the robotic group (< 0.0001), with a mean additional time of 29 min. There was no significant difference between both groups for postoperative blood loss, rate of blood transfusion, or postoperative pain. The average length of stay was 5 days. There was one early complication in the robotic group due to the tibial trackers. The functional outcomes were similar between both groups, except for the functional KSS score, which was better at 6 months in the robotic group (p < 0.0001). The restoration of the knee alignment and the distal femoral anatomy were significantly better in the robotic group than in the conventional group.

CONCLUSIONS

Despite a longer operative time, the peri-operative parameters of sequential bilateral TKA were similar between robotic and conventional techniques. Further, sequential bilateral raTKA was at least as safe as a conventional technique, without additional risk of medical 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.

No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA

BACKGROUND

Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained.

QUESTIONS/PURPOSES

We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery.

METHODS

Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism.

RESULTS

With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction.

CONCLUSION

The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Should we use similar perioperative protocols in patients undergoing unilateral and bilateral one-stage total knee arthroplasty?

BACKGROUND

Bilateral one-stage total knee arthroplasty (BTKA) is now in greater use as an alternative option for patients with bilateral end-stage knee arthropathy. However, postoperative pain and disablement during convalescence from BTKA, and procedure-related complications have been concerning issues for patients and surgeons. Although some studies reported that BTKA in selected patients is as safe as the staged procedure, well-defined guidelines for patient screening, and perioperative care and monitoring to avoid procedure-related complications are still controversial.

AIM

To compare the perioperative outcomes including perioperative blood loss (PBL), cardiac biomarkers, pain intensity, functional recovery, and complications between unilateral total knee arthroplasty (UTKA) and BTKA performed with a similar perioperative protocol.

METHODS

We conducted a retrospective study on consecutive patients undergoing UTKA and BTKA that had been performed by a single surgeon with identical perioperative protocols. The exclusion criteria of this study included patients with an American Society of Anesthesiologists score > 3, and known cardiopulmonary comorbidity or high-sensitivity Troponin-T (hs-TnT) > 14 ng/L. Outcome measures included visual analogue scale (VAS) score of postoperative pain, morphine consumption, range of knee motion, straight leg raise (SLR), length of stay (LOS), and serum hemoglobin (Hb) and hs-TnT monitored during hospitalization.

RESULTS

Of 210 UTKA and 137 BTKA patients, those in the BTKA group were younger and more predominately female. The PBL of the UTKA vs BTKA group was 646.45 ± 272.26 mL vs 1012.40 ± 391.95 mL (P < 0.01), and blood transfusion rates were 10.48% and 40.88% (P < 0.01), respectively. Preoperative Hb and body mass index were predictive factors for blood transfusion in BTKA, whereas preoperative Hb was only a determinant in UTKA patients. The BTKA group had significantly higher VAS scores than the UTKA group at 48, 72, and 96 h after surgery, and also had a significantly lower degree of SLR at 72 h. The BTKA group also had a significantly longer LOS than the UTKA group. Of the patients who had undergone the procedure, 5.71% of the UTKA patients and 12.41% of the BTKA patients (P = 0.04) had hs-TnT > 14 ng/L during the first 72 h postoperatively. However, there was no difference in other outcome measures and complications.

CONCLUSION

Following similar perioperative management, the blood transfusion rate in BTKA is 4-fold that required in UTKA. Also, BTKA is associated with higher pain intensity at 48 h postoperatively and prolonged LOS when compared to the UTKA. Hence, BTKA patients may require more extensive perioperative management for blood loss and pain, even if having no higher risk of complications than UTKA.

Incidence and risk factors for blood transfusion in simultaneous bilateral total hip arthroplasty

OBJECTIVES

This study aims to investigate the incidence and risk factors for blood transfusion in patients undergoing simultaneous bilateral total hip arthroplasty (SimBTHA).

PATIENTS AND METHODS

Between January 2011 and June 2021, a total of 341 patients (289 males, 52 females; median age: 53 years; range, 43 to 66 years) who underwent SimBTHA were retrospectively analyzed. The patients were divided into two groups as those who did and did not require allogeneic blood transfusion. Univariate and multivariate logistic regression models were used to identify independent risk factors for transfusion.

RESULTS

The incidence of transfusion in SimBTHA was 12.9%. We found that a higher preoperative hemoglobin level (odds ratio [OR]: 0.91; 95% confidence interval [CI]: 0.86-0.96), tranexamic acid (TXA) use (OR: 0.25; 95% CI: 0.09-0.58), and intraoperative autologous blood transfusion from a closed suction drainage system (OR: 0.30; 95% CI: 0.09-0.80) were protective against the need for transfusion in patients after SimBTHA. In addition, drainage use (OR: 3.52; 95% CI: 1.49-8.32) and intraoperative blood loss (OR: 1.17; 95% CI: 1.04-1.33) were the independent risk factors for blood transfusion.

CONCLUSION

The risk factors for transfusion after SimBTHA should be evaluated to establish specific, personalized transfusion risk assessments for each individual patient. For SimBTHA, the main risk factors include intraoperative bleeding and the use of drainage tube, while higher preoperative hemoglobin levels, TXA use, and autologous blood transfusion from a closed suction drainage system may reduce transfusion risk.

Dose tranexamic acid reduce blood loss associated with simultaneous bilateral distal tibial tubercle-high tibial osteotomy?

Background

Simultaneous bilateral distal tibial tubercle high tibial osteotomy (SBDTT-HTO) can result in increased blood loss. The aim of this study is to evaluate the actual hemostatic effect of different tranexamic acid (TXA) treatment regimen in SBDTT-HTO.

Methods

We conducted a retrospective case–control study including 54 patients who underwent SBDTT-HTO. The single-dose group (n = 18) received 1 g of intravenous TXA 15–30 min before surgery, the two-dose group (n = 18) received an additional 1 g of intravenous TXA 6 h after surgery, and the multiple-dose group (n = 18) received an additional 1 g intravenous TXA per-day until discharge. Blood loss, hemoglobin levels, occurrence of any adverse events,functional analysis, quality of life, and pain assessmentswere compared among the three groups.

Results

The total blood loss, hidden blood loss, drainage volumes, and haemoglobin level in the multiple-dose group all occupy a significant advantage.(p < 0.05). In addition, better quality of life were observed in patients belonging to the multiple-dose group then single-dose group.(p < 0.05).

Conclusions

Based on our results, for patients undergoing SBDTT-HTO, sequential intravenous TXA administration can effectively and safely reduce blood loss,maintain postoperative Hb levels,and with the advantage of accelerating recovery.

Comparison of the Effect and Complications of Sequential Bilateral Arthroplasty at Different Time Intervals and Simultaneous Bilateral Total Knee Arthroplasty: A Single-Centre Retrospective Cohort Study

INTRODUCTION

To the authors' knowledge, there is no current consensus regarding the optimal interprocedural interval for patients who have undergone bilateral total knee arthroplasty (BTKA). The purpose of this study is to evaluate complication rates and functional outcome in patients who have undergone BTKA (simultaneous or sequential at different time intervals), and to determine an optimal time frame for the second knee.

METHODS

Data from 315 patients who were able to tolerate simultaneous BTKA according to the anaesthesiologist's preoperative assessment between 2016 and 2020 were analysed retrospectively. According to the operative time interval, they were divided into simultaneous, ≤ 1-month sequential, 1- to 3-month sequential, and ≥ 3-month sequential BTKA groups. The primary outcomes were revision and readmission rates during the follow-up period, and the secondary outcomes were hospital length of stay (LOS), transfusion and postoperative complications.

RESULTS

There was no difference in the implant survival or readmission rate between the groups (p > 0.05). Multivariable linear regression showed that interprocedural interval and body mass index (BMI) affected LOS; the LOS of simultaneous BTKA was the shortest (p < 0.05). BMI was associated with an increased LOS of 0.25 days (95% CI 0.02-0.48, p = 0.03). A modified Poisson regression model showed that the odds of blood transfusion were reduced in sequential BTKAs of any interval (p < 0.05), and preoperative haemoglobin (Hb) was also a risk factor (RR 0.96, 95% CI 0.95-0.98, p < 0.001). The interprocedural interval was not a risk factor for postoperative cardiovascular and cerebrovascular complications.

CONCLUSION

For appropriate patients, simultaneous BTKA is beneficial. However, higher preoperative haemoglobin was required to mitigate the high blood transfusion rate associated with simultaneous surgeries. If suitable patients refuse simultaneous BTKA for other non-medical reasons, sequential BTKA with an interval greater than 1 month is recommended.

Simultaneous Bilateral Total Knee Arthroplasty Becomes Safer after Institution of Optimal Perioperative Management: A Longitudinal Cohort Study

Simultaneous bilateral total knee arthroplasty (SBTKA) increases the rates of procedure-related complications and mortality compared with unilateral TKA. There are no well-defined guidelines for selecting patients to avoid mortality and proposing an upgrade treatment to decrease complication rates. This study aimed to evaluate whether optimal perioperative management could improve the safety of SBTKA. From 2005 to 2017, 1,166 cases of SBTKA were identified from 14,209 TKA procedures. We retrospectively examined the SBTKA patients' demographics, comorbidity profiles, procedure-related complications, and perioperative management during two time periods. Optimal perioperative workup for managing SBTKA significantly decreased the incidences of major complication from 6.2 to 2.4% (p = 0.001) and minor complications from 28.9 to 21.5% (p = 0.004) during period I and period II, respectively. The efficiency of less tourniquet use along with intraarticular tranexamic acid injection was demonstrated by the decreases of hemoglobin (Hb) change in the first 2 days after surgery (p = 0.005) and blood transfusion requirement (p = 0.035) during the SBTKA. Furthermore, the less tourniquet use group had less thigh pain (visual analog scale decreased from 6.0 to 4.2, p = 0.003), shorter duration of hospital stay (decreased from 7.8 to 7.1, p < 0.001), and lower coagulation time (decrease from 3.5 to 2.9, p < 0.001) than the routine tourniquet use group. Patient's screening must be performed carefully for cardiopulmonary compromise in patients aged >80 years and with an American Society of Anesthesiologists score of 3. Additionally, hospitalists should consider developing methods for the eligibility, testing, and perioperative monitoring of patients who undergo SBTKA with the aim of avoiding complications and improving outcomes.

Effects of disusing closed suction drainage in simultaneous bilateral total hip arthroplasty: A retrospective cohort study

Purpose

Increased blood loss remains a major drawback of simultaneous bilateral total hip arthroplasty (SBTHA). We examined the effects of disusing closed suction drainage (CSD) on postoperative blood loss and transfusion requirement in cementless SBTHA.

Methods

A retrospective cohort study was conducted with a consecutive series of cementless SBTHAs performed by a single surgeon between January 2014 and March 2017. The surgeon routinely used CSD until May 2015 and refrained from CSD in all primary THAs thereafter. This study included SBTHAs with intravenous administration of tranexamic acid (TXA). Postoperative hemoglobin drop, blood loss, transfusion rate, pain scores, complication rates, and implant survivorships were compared between the groups of SBTHA with and without CSD. The minimum follow-up duration was 1 year.

Results

Among the 110 patients (220 hips), 46 (92 hips) and 64 (128 hips) underwent SBTHA with and without CSD, respectively. Maximum hemoglobin drop (mean, 4.8 vs. 3.9 g/dL; P = 0.001), calculated blood loss (mean, 1530 vs. 1190 mL; P<0.001), transfusion rate (45.7% vs. 21.9%; P = 0.008), and length of hospital stay (mean, 6.6 vs. 5.8 days; P = 0.004) were significantly lower in patients without CSD. There were no significant differences in postoperative pain scales and wound complication rates. The mean Harris Hip scores at final follow-up (92.5 vs. 92.1; P = 0.775) and implant survivorships with an end-point of any revision at 4 years (98.9% vs. 98.4%; log-rank, P = 0.766) were similar between groups.

Conclusions

Disusing CSD significantly reduced postoperative blood loss and transfusion requirement without increasing postoperative pain and surgical wound complications in cementless SBTHA with concurrent administration of intravenous TXA.

The Utility of Obtaining a Complete Blood Count After Total Knee Arthroplasty in the Era of Tranexamic Acid

Questioning the routine use of postoperative laboratory tests is a strategy to combat rising health care costs. The goal of this study was to determine the utility and cost of routine postoperative complete blood count (CBC) testing after primary total knee arthroplasty (TKA) in the era of tranexamic acid (TXA). This retrospective chart review identified patients who underwent primary TKA performed by a single surgeon at a single private institution during a 2-year period. All patients received TXA intraoperatively. Exact tests were used to determine whether there was a significant difference in transfusion rates between patients with and without preoperative anemia. Of 628 primary TKA procedures, 390 patients (62.10%) had anemia postoperatively. However, only 1 patient (0.16%) required transfusion. A total of 956 CBC tests were performed without intervention, at a total cost of $116,804.08. In addition, 1 of 26 patients with preoperative anemia vs 0 of 602 patients without preoperative anemia required transfusion (P=.04). Healthy patients undergoing primary TKA who receive TXA do not require postoperative CBC. This change has the potential to reduce this laboratory cost by more than 97% compared with the current practice of obtaining postoperative CBC testing for every patient undergoing TKA. Only patients with preoperative anemia should undergo postoperative CBC testing to help to identify those who require transfusion. The potential health care savings associated with eliminating routine postoperative CBC testing are substantial and should be considered by arthroplasty surgeons. [Orthopedics. 2021;44(1):e26-e30.].

Is there an optimal timing of administration of single-dose intravenous tranexamic acid in bilateral total knee arthroplasty? A comparison between preoperative and intraoperative dose

PURPOSE

There is no consensus on the optimum timing of administration of tranexamic acid (TA) in bilateral total knee arthroplasty (TKA). We aimed to determine whether the timing of administration of single-dose intravenous TA (either given preoperatively or intraoperatively) has a significant effect on blood loss reduction.

METHODS

We compared two cohorts of patients with end-stage arthritis of knees who underwent bilateral TKA and were given single-dose intravenous TA (1 g or 15 mg/kg) at different times during surgery. The retrospective cohort group consisting of 40 patients (preoperative (PO) group) received TA before the skin incision. The prospective cohort consisting of 40 patients (intraoperative (IO) group) received TA 10 min before deflating the tourniquet on the first knee. Primary outcome measures were mean hemoglobin difference, A (between PO and day 1 postoperative hemoglobin), mean hemoglobin difference, B (between PO and lowest postoperative hemoglobin), and rate of allogeneic blood transfusion. Secondary measure was drain blood loss.

RESULTS

Both cohorts were well matched with respect to age, gender, duration of surgery, and length of hospital stay. The hemoglobin drop in the IO group was significantly lesser than the PO group on the first postoperative day (2 vs. 2.9 g/dL, p < 0.001). Although statistically insignificant, the patients in the IO group received less allogenic transfusion of packed cell units than in the PO group (11/40, 27.5% vs. 14/40, 35% ). Mean hemoglobin difference, B, and secondary drain loss were comparable in both groups.

CONCLUSION

Single-dose intravenous TA given before the start of surgery is as effective as a dose given during arthroplasty of the first knee in reducing blood loss in bilateral TKA.

The Effect of Prosthesis Design on Blood Loss in Simultaneous Bilateral Total Knee Arthroplasty: Closed-Box versus Open-Box Prosthesis

Background

Various pre- and perioperative risk factors have been reported in association with blood loss in knee arthroplasty. However, the effect of the uncovered cancellous surface on blood loss in simultaneous bilateral total knee arthroplasty (SBTKA) by different prosthetic designs is not well elucidated. Therefore, this study aimed to compare the blood loss and transfusion rate between different knee prostheses in SBTKA and to identify risk factors that influence blood loss and transfusion after SBTKA.

Methods

Demographic and perioperative data of patients who underwent SBTKA using either a closed-box or an open-box femoral component of posterior-stabilized fixed-bearing (PS FB) knee system were retrospectively reviewed. The calculated blood loss (CBL) and blood transfusion rate were compared by using Student t-test and confirmed with multivariate regression analysis.

Results

There was no significant difference in preoperative parameters between 54 closed-box and 56 open-box PS FB TKAs. The CBL of the closed-box TKA group was 135.23 mL less (95% confidence interval [CI], −215.30 to −55.16; p = 0.001) than that of the open-box TKA group. However, the blood transfusion rates of the closed- and open-box TKA groups were not significantly different (24.1% and 38.5%, p = 0.11). For each additional minute of total operative time, 3.75 mL (95% CI, 1.75 to 5.76; p < 0.001) of blood loss was anticipated. For each additional mg/dL of preoperative hemoglobin, 71% (p < 0.001) reduction of blood transfusion probability was predicted.

Conclusions

The use of closed- and open-box knee prostheses resulted in a significant difference in blood loss in SBTKA. Prolonged operative time also significantly increased CBL. Therefore, strategies to control the bleeding surface and shorten operative duration may be considered if blood loss is of special concern. The preoperative hemoglobin was the only factor that affects the probability of blood transfusion in SBTKA.

The efficacy and safety of tranexamic acid for reducing blood loss following simultaneous bilateral total knee arthroplasty: a multicenter retrospective study

Background

The purpose of the study was to evaluate whether tranexamic acid (TXA) administration could reduce blood loss and transfusion risk after simultaneous bilateral total knee arthroplasty (SBTKA).

Methods

As a multicenter retrospective study, a total of 575 patients were assigned into three groups on the basis of TXA usage, including intravenous (IV) group (1 g IV TXA 5–10 min prior to the incision), combined group (1 g IV TXA combined with intra-articular injection of 1 g TXA prior to the closure every knee) and control group (no TXA use). The primary outcomes were total blood loss (TBL). The secondary outcomes were maximum hemoglobin (Hb) and hematocrit (Hct) drop, transfusion rate, drain volume, length of stay, hospitalization expenses and the incidence of complications.

Results

The mean TBL in control group (1685.0 ± 571.4 mL) were higher than that in IV group (1061.1 ± 689.6 mL, p = 0.006 and combined group (988.3 ± 559.3 mL, p = 0.003). The maximum Hb and Hct drop in combined group (28.5 ± 13.4 g/L, p = 0.016; 0.074 ± 0.053, p < 0.001) and IV group (28.8 ± 14.5 g/L, p = 0.025; 0.082 ± 0.056, p = 0.001) were lower than those in control group (33.4 ± 14.0; 0.131 ± 0.049). But the difference between IV and combined groups was not significant. The similar trend was detected on drain volume, length of stay and hospitalization expenses. The incidence of complications did not differ significantly among the three groups (p > 0.05).

Conclusions

The study indicates that TXA could reduce blood loss with no apparent increase in the incidence of complications during SBTKA.

Efficacy and safety of limb position on blood loss and range of motion after total knee arthroplasty without tourniquet: A randomized clinical trial

BACKGROUND

The purpose of this study was to investigate the effect of postoperative limb position on blood loss and knee function after primary total knee arthroplasty without tourniquet.

MATERIAL AND METHODS

One hundred patients were randomly assigned into 2 groups: Group A was given a knee flexion position at 60° for 24 h after surgery but without the tourniquet use. Patients in group B was received the tourniquet use the same flexion position as the Group A. All patients received intravenous (IV) tranexamic acid (TXA) 15 mg/kg before skin incision and another 1 g of IV-TXA after 3 h.

RESULTS

The total blood loss was similar in the 2 groups. Group A had significantly less hidden blood loss and drainage volume (P = 0.023, P < 0.001), and higher intraoperative blood loss than the Group B (P < 0.001). The visual analog scale and knee circumference in Group A were lower than the Group B on postoperative days 1, 3 and 5. The range of motion was also lowering in Group A than the Group B on postoperative days 1, 3, 5 and at the 1 month. No significant differences (P > 0.05) were observed between the 2 groups regarding maximum hemoglobin drop, transfusion rate, postoperative hospital stay, DVT and/or PE, and wound-related complications.

CONCLUSION

Based on the current evidence, patients treated with postoperative limb positions without a tourniquet can effectively reduce hidden blood loss and drainage volume, as well as better early clinical benefits than those treated with a tourniquet.

LEVEL OF EVIDENCE

Therapeutic Level I.

Optimizing Intraoperative Blood Management for One-Stage Bilateral Total Knee Arthroplasty

BACKGROUND

Effective blood management strategies are a major determinant of successful outcomes after one-stage bilateral total knee arthroplasty (BTKA). Proper patient selection with preoperative optimization and intra- and postoperative interventions can reduce transfusion risk and associated morbidity in these patients.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate intraoperative blood management modalities based on three keystone questions: (1) What is the role of the anesthesiologist?, (2) Which are the surgeon-dependent strategies?, and (3) Is there any place for pharmacologic interventions?

METHODS

We searched the established electronic literature database MEDLINE. After critical appraisal, 94 studies were deemed eligible from which to draw documented evidence.

RESULTS

A number of blood-conserving methods are currently implemented in patients undergoing one-stage BTKA. Among them, regional anesthesia, tourniquet use, and tourniquet deflation after wound closure, femoral canal sparing or femoral canal plugging, avoidance of drains, and tranexamic acid use were the intraoperative strategies with documented efficacy in blood conservation.

CONCLUSION

Combined proper intraoperative anesthesiologic, surgical, and pharmacologic interventions reduce blood loss and need for transfusion in BTKA patients. However, contemporary relevant literature is lacking evidence-based guidelines.

Incidence and Risk Factors for Blood Transfusion in Simultaneous Bilateral Total Joint Arthroplasty: A Multicenter Retrospective Study

BACKGROUND

The aim of this study was to identify the incidence and risk factors for blood transfusion in patients undergoing simultaneous bilateral total hip arthroplasty (SBTHA) and simultaneous bilateral total knee arthroplasty (SBTKA).

METHODS

We identified 414 SBTHA and 1147 SBTKA procedures, and separated the patients into those who did and did not require allogeneic blood transfusion. A multivariate logistic regression model was used to identify independent risk factors for transfusion.

RESULTS

The transfusion rate after SBTHA was 50.0%, and significant risk factors for transfusion were female gender (odds ratio [OR] = 2.612), lower body mass index (OR = 1.093), inflammatory arthritis (OR = 1.970), American Society of Anesthesiologists (ASA) class ≥3 (OR = 3.477), drain use (OR = 4.607), and increased intraoperative bleeding. We also found that higher preoperative hemoglobin (Hb) and tranexamic acid use decreased the risk of transfusion. The transfusion rate after SBTKA was 29.1%, and significant risk factors for transfusion were ASA class ≥3 (OR = 8.959), tourniquet use (OR = 2.129), drain use (OR = 4.970), and increased intraoperative bleeding. A higher preoperative Hb was the only protective factor for transfusion.

CONCLUSION

For SBTHA, the risk factors included female gender, lower body mass index, inflammatory arthritis, ASA class ≥3, drain use, and increased intraoperative bleeding, while for SBTKA, risk factors were ASA class ≥3, tourniquet use, drain use, and increased intraoperative bleeding. Increasing the preoperative Hb level may decrease transfusion risk. In addition, tranexamic acid was encouraged to use to decrease transfusion need in SBTHA.

Tranexamic acid reduces blood loss and transfusion requirements in primary simultaneous bilateral total knee arthroplasty: a meta-analysis of randomized controlled trials

: The aim of this meta-analysis is to assess the effectiveness and safety of intravenous application tranexamic acid (TXA) in primary simultaneous bilateral total knee arthroplasty (TKA). We searched electronic databases including PubMed, Embase, the Web of Science, the Cochrane Library and the Google Scholar, for published studies involving the intravenous application TXA in primary simultaneous bilateral TKA. All randomized controlled trials were included. The focus of the meta-analysis was on the outcomes of total blood loss, drainage volume, transfusion requirements and deep venous thrombosis (DVT) and/or pulmonary embolism. The relevant data were analyzed using RevMan 5.2. Six high randomized controlled trials were included, with a total sample size of 394 patients. The intravenous application of TXA significantly reduced total blood loss [95% confidence interval (CI), -519.52 to -126.40; P = 0.001], drainage volume (95% CI, -551.76 to -138.57; P = 0.001) and transfusion requirements (risk ratio, 0.38; 95% CI, 0.21-0.68; P = 0.001) compared with the control group. In addition, there were no significant differences in the rate of DVT (P = 1.00) and/or pulmonary embolism between the two groups. Based on the current evidence, this meta-analysis showed that intravenous application of TXA is effective and a well tolerated treatment to reduce total blood loss, drainage volume and transfusion requirements without increasing the risk of DVT and/or pulmonary embolism in primary simultaneous bilateral TKA.

Combined Intravenous and Intra-Articular Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty without Tourniquet Use

Background:

A combined intravenous and intra-articular regimen is one of the most effective administration routes of tranexamic acid (TXA) to reduce perioperative blood loss in unilateral total knee arthroplasty. However, there have been few reports regarding use of the combined regimen for patients undergoing simultaneous bilateral total knee arthroplasty, in which blood-management strategy is more challenging.

Methods:

We compared perioperative blood loss in 30 consecutive patients undergoing simultaneous bilateral total knee arthroplasty who received both 1,000 mg of TXA intravenously and 1,000 mg of intra-articular TXA in each knee (combined TXA group) with that in a consecutive series of 51 patients who only received 1,000 mg of TXA intravenously (intravenous TXA group). Additional intravenous TXA was administered 6 hours after the initial administration in both groups. Except for the intraoperative TXA administration regimen, an identical perioperative blood-management strategy was applied to both groups; this consisted of transfusion of 800 or 400 mL of predeposited autologous blood except for patients with a preoperative hemoglobin level of <11.0 g/dL, who received 4 units of allogenic blood. All surgical procedures were performed with spinal anesthesia and without use of a pneumatic tourniquet. Perioperative blood loss was calculated using the blood volume and change in hemoglobin level from the preoperative measurement to postoperative day 3.

Results:

There was significantly less perioperative blood loss in the combined TXA group compared with the intravenous TXA group (mean and standard deviation, 1,201 ± 347 versus 1,638 ± 400 mL, respectively; mean difference, 437 mL; 95% confidence interval, 263 to 613 mL; p < 0.0001). No patient in the combined TXA group and 1 patient (2%) in the intravenous TXA group required additional allogenic blood transfusion. No thrombotic events occurred in either group.

Conclusions:

In a nonrandomized comparison, combined intra-articular and intravenous TXA significantly reduced the calculated perioperative blood loss in simultaneous bilateral total knee arthroplasty compared with that found in patients treated only with intravenous TXA.

Level of Evidence:

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

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.

The effectiveness and safety of tranexamic acid in bilateral total knee arthroplasty: A meta-analysis

OBJECTIVE

A meta-analysis was performed to investigate the effectiveness and safety of tranexamic acid (TXA) for the treatment of blood loss after a bilateral total knee arthroplasty (TKA).

METHODS

Patients prepared for bilateral TKA and intervention including TXA versus placebo were comprehensively retrieved from MEDLINE (PubMed), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science from the time of the establishment of these databases to January 2016. The outcomes were all calculated by Stata 12.0 software. The continuous endpoints (total blood loss and blood loss in drainage) were calculated as mean difference (MD) and 95% confidence intervals (CIs). Binary variables (the need for transfusion, and the occurrence of deep venous thrombosis [DVT]) were calculated as relative risk (RR) with 95% CIs.

RESULTS

Pooled results revealed that treatment with TXA associated with less need for transfusion (P = 0.000) and the value of Hb drop postoperatively (P = 0.290) after bilateral TKA. The results also indicated that TXA can decrease the total blood loss and blood loss in drainage after bilateral TKA (P < 0.05). Meanwhile, TXA can decrease the blood units transfused per patient by 1.23 U (P = 0.001). There is no statistically significant difference in terms of the occurrence of DVT between the 2 groups (P = 0.461).

CONCLUSION

Based on the current evidence, TXA can decrease the need for transfusion and the total blood loss without increasing the occurrence of DVT, and its administration is recommended routinely in bilateral TKA.