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Zhou W, Lv H, Zhang H, Ding Y, Zhou J, Tong H, Cui J. A comparative study on hemostasis effect of different application methods and time of tranexamic acid in total hip arthroplasty. Eur J Trauma Emerg Surg 2024; 50:1015-1021. [PMID: 38062270 DOI: 10.1007/s00068-023-02397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 11/02/2023] [Indexed: 07/16/2024]
Abstract
OBJECTIVES To analyze the hemostatic effect of different application methods and time of tranexamic acid (TXA) on primary unilateral total hip arthroplasty. METHODS A total of 126 patients with primary unilateral total hip replacement admitted between January 2019 and January 2021 were recruited. The patients were divided into three groups (42 people in each group) by random number table method. In group I, 2.0 g TXA was perfused locally into the hip joint cavity through the drainage tube for 2 h. Group II was perfused locally with the same method for 4 h. Group III was given TXA 15 mg/kg intravenously 5-10 min before surgical incision. The hemoglobin concentration, red blood cell (RBC) count, international normalized ratio (INR), activated partial thromboplastin time (APTT), fibrinogen (FIB), D-Dimer (D-D), intraoperative blood loss, postoperative blood loss, implicit blood loss, total blood loss, postoperative blood transfusion and complications were compared. RESULTS The postoperative drainage volume of group I (195.07 ± 34.65) mL and group II (199.62 ± 38.07) mL was significantly lower than that of group III (213.12 ± 25.05) mL (P = 0.037). There was no significant difference in postoperative drainage between group I and group II (P > 0.05). There was no significant difference in intraoperative blood loss, hidden blood loss and total blood loss between the three groups (P > 0.05). There was no difference in the incidence of deep vein thrombosis among the three groups (P > 0.05). CONCLUSIONS TXA is a safe and effective way of hemostasis in total hip arthroplasty. Local intraarticular application of TXA can reduce the postoperative drainage, but the difference is not clinically significant, probably due to the number of samples. There is no difference in the postoperative drainage after local application of 2 or 4 h, and there is no difference in the overall hemostasis effect between intravenous or local application of TXA.
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Affiliation(s)
- Wenjun Zhou
- Department of Anesthesiology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Hui Lv
- ICU Department, Wuhan No. 1 Hospital, Wuhan, China
| | - Huan Zhang
- Department of Anesthesiology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Yong Ding
- Department of Anesthesiology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Jiawei Zhou
- Department of Anesthesiology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Huan Tong
- Operating Room, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Junkai Cui
- Department of Hepatobiliary Surgery, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, 168 Hong Kong Road, Jiang'an District, Wuhan, 430015, Hubei, China.
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Xie J, Huang Q, Huang Z, Wang F, Liu J, Tian H, Huang W, Pei F. High dose of tranexamic acid infusion in primary total knee arthroplasty: A randomized multicenter clinical trail. Chin Med J (Engl) 2024; 137:359-361. [PMID: 38214305 PMCID: PMC10836875 DOI: 10.1097/cm9.0000000000002952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Fei Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Jun Liu
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Hua Tian
- Department of Orthopaedic Surgery, Peking University Third Hospital, Haidian District, Beijing 100191, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing 400016, China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Gibbs VN, Champaneria R, Sandercock J, Welton NJ, Geneen LJ, Brunskill SJ, Dorée C, Kimber C, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD013295. [PMID: 38226724 PMCID: PMC10790339 DOI: 10.1002/14651858.cd013295.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. OBJECTIVES To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology. SEARCH METHODS We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants. DATA COLLECTION AND ANALYSIS We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. MAIN RESULTS We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). AUTHORS' CONCLUSIONS We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Nicky J Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Yu W, Liu C, Bi Z. Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement. Sci Rep 2023; 13:18919. [PMID: 37919317 PMCID: PMC10622435 DOI: 10.1038/s41598-023-41887-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/01/2023] [Indexed: 11/04/2023] Open
Abstract
With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.
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Affiliation(s)
- Wenjiang Yu
- Department of Orthopedics, Linyi People's Hospital, Linyi, Shandong, China
| | - Chengyan Liu
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiguo Bi
- Department of Orthopedics, The First Hospital of Jilin University, Changchun, Jilin, China.
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Gibbs VN, Geneen LJ, Champaneria R, Raval P, Dorée C, Brunskill SJ, Novak A, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures. Cochrane Database Syst Rev 2023; 6:CD013499. [PMID: 37272509 PMCID: PMC10241722 DOI: 10.1002/14651858.cd013499.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications. OBJECTIVES To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones. SEARCH METHODS We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data. MAIN RESULTS We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence). It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence). We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect. Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants). All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here. AUTHORS' CONCLUSIONS We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration). We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Parag Raval
- Trauma and Orthopaedic Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Zheng C, Ma J, Xu J, Wu L, Wu Y, Liu Y, Shen B. The optimal regimen, efficacy and safety of tranexamic acid and aminocaproic acid to reduce bleeding for patients after total hip arthroplasty: A systematic review and Bayesian network meta-analysis. Thromb Res 2023; 221:120-129. [PMID: 36527742 DOI: 10.1016/j.thromres.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/06/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We aimed to evaluate the optimal regimen, efficacy and safety of tranexamic acid (TXA) and aminocaproic acid (EACA) for patients after total hip arthroplasty (THA). METHODS The network meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. The outcomes were total blood loss, transfusion rates, hemoglobin (HB) drop, and risk for pulmonary embolism (PE) or deep vein thrombosis (DVT). Subgroup analyses were performed among most effective regimens to determine the influences of timing and number of doses. RESULTS A total of 56 eligible RCTs with different regimens were assessed. For reducing total blood loss, all high doses of TXA and EACA except high dose of intra-articular (IA) TXA, as well as medium dose of combination of intravenous and intra-articular (combined IV/IA) TXA were most effective. All high doses of TXA, as well as medium dose of combined IV/IA TXA did not show inferiority in reducing transfusion rates and HB drop compared with other regimens. No regimens showed higher risk for PE or DVT compared with placebo, and no statistical differences were seen among most effective regimens in subgroup analyses. CONCLUSIONS As effective as high doses of EACA and TXA, medium dose (20-40 mg/kg or 1.5-3.0 g) of combined IV/IA TXA was enough to control bleeding for patients after THA without increasing risk for PE/DVT. TXA was at least 5 times more potent than EACA. Timing and number of doses had few influences on blood conserving efficacy. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Che Zheng
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jun Ma
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jiawen Xu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Liming Wu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yuangang Wu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yuan Liu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bin Shen
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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7
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Liu J, Chen B, Wu X, Wang H, Zuo X, Lei Y, Huang W. Total Hip Arthroplasty Patients with Distinct Postoperative Fibrinolytic Phenotypes Require Different Antifibrinolytic Strategies. J Clin Med 2022; 11:jcm11236897. [PMID: 36498472 PMCID: PMC9736050 DOI: 10.3390/jcm11236897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Bleeding patients exhibit different fibrinolytic phenotypes after injury, and the universal use of tranexamic acid (TXA) is doubted. We aimed to evaluate the efficacy of postoperative antifibrinolytic treatment in total hip arthroplasty (THA) patients with different fibrinolytic phenotypes. A retrospective analysis was conducted in 238 patients who underwent THA. Patients were divided into two groups by different fibrinolytic phenotypes (non-fibrinolytic shutdown and fibrinolytic shutdown), determined by the LY30 level on postoperative day 1 (POD1). The two groups were further stratified into four sub-groups based on different postoperative TXA regimens (Group A received no TXA postoperatively, while Group B did). Hidden blood loss (HBL), decline of hemoglobin (ΔHb), D-dimer (D-D), fibrinogen/fibrin degradation product (FDP), prothrombin time (PT), activated partial thromboplastin time (APTT), and demographics were collected and compared. The clinical baseline data were comparable between the studied groups. In patients who presented non-fibrinolytic shutdown postoperatively, Group B suffered significantly lower HBL and ΔHb than Group A on POD3 and POD5. In patients who presented postoperative fibrinolytic shutdown, Group B failed to benefit from the postoperative administration of TXA when compared to Group A. No difference was found in postoperative levels of D-D, FDP, PT, and APTT. Postoperative antifibrinolytic therapy is beneficial for THA patients who presented non-fibrinolytic shutdown postoperatively, while the efficacy and necessity should be considered with caution in those with fibrinolytic shutdown. LY30 is a promising parameter to distinguish different fibrinolytic phenotypes and guide TXA administration. However, further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Jiacheng Liu
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Bowen Chen
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiangdong Wu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Han Wang
- Department of Orthopedics, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China
| | - Xiaohai Zuo
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yiting Lei
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Correspondence: (Y.L.); (W.H.)
| | - Wei Huang
- Orthopedic Laboratory of Chongqing Medical University, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Correspondence: (Y.L.); (W.H.)
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Perioperative Management in Shoulder Arthroplasty: A Review of Current Practice. Orthop Clin North Am 2022; 53:483-490. [PMID: 36208890 DOI: 10.1016/j.ocl.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.
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Karayiannis PN, Agus A, Bryce L, Hill JC, Beverland D. Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial. Bone Jt Open 2022; 3:536-542. [PMID: 35816170 PMCID: PMC9350706 DOI: 10.1302/2633-1462.37.bjo-2021-0213.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536–542.
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Affiliation(s)
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Leanne Bryce
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - J. C. Hill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
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Oyama R, Setsu N, Matsumoto Y, Endo M, Fujiwara T, Iida K, Nabeshima A, Nakashima Y. Efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors: a propensity score matching analysis. Jpn J Clin Oncol 2022; 52:1029-1038. [DOI: 10.1093/jjco/hyac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/23/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The aim of this study was to investigate the efficacy and safety of tranexamic acid in patients undergoing surgery for bone and soft tissue tumors.
Methods
Data were retrospectively collected from 454 consecutive patients with bone and soft tissue tumors who underwent open biopsy, marginal resection, curettage or wide resection between January 2017 and December 2018. We performed propensity score matching of patients who received tranexamic acid with those who did not. The primary outcome variables were intra-operative, peri-operative and estimated blood loss (IBL, PBL and EBL, respectively).
Results
Tranexamic acid (+) and tranexamic acid (−) groups were defined according to whether patients received tranexamic acid or not. Among the 454 patients, open biopsy was performed in 102, marginal resection in 175, curettage in 54 and wide resection in 123. Intra-operative blood loss was significantly lower in the tranexamic acid (+) group than in the tranexamic acid (−) group for both marginal and wide resection (marginal resection: 17.3 vs. 70.3 g, respectively, P = 0.045; wide resection: 128.8 vs. 273.1 g, respectively, P = 0.023). Peri-operative blood loss and estimated blood loss were also significantly lower in the tranexamic acid (+) group for wide resection (peri-operative blood loss: 341.5 vs. 686.5 g, respectively, P = 0.0039; estimated blood loss: 320.7 vs. 550.6 ml, respectively, P = 0.030). No venous thromboembolism occurred in either group.
Conclusion
This study suggests that TXA administration safely and effectively reduces blood loss, in particular for wide resection, with no increase in the rate of adverse events.
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Affiliation(s)
- Ryunosuke Oyama
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nokitaka Setsu
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Orthopaedic Surgery, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Endo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshifumi Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiichiro Iida
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Nabeshima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Liu J, Lei Y, Liao J, Liang X, Hu N, Huang W. Pre-Emptive Antifibrinolysis: Its Role and Efficacy in Hip Fracture Patients Undergoing Total Hip Arthroplasty. J Arthroplasty 2022; 37:755-762. [PMID: 34979252 DOI: 10.1016/j.arth.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We aimed to determine the efficacy of pre-emptive antifibrinolysis with tranexamic acid (TXA) in decreasing hidden blood loss (HBL) in the elderly hip fracture patients. METHODS Ninety-six elderly hip fracture patients receiving hip arthroplasty were randomized to receive 100 mL of normal saline (group A) or 1.5 g of TXA (group B) intravenously q12 hours from postadmission day 1 (PAD1) to the day before surgery. Both groups were treated with 1.5 g of TXA q12 hours from postoperative day 1 (POD1) to POD3. HBL was calculated by formulas and recorded as the primary outcome. RESULTS In overall analyses, no difference was found in HBL, while the decline of hemoglobin (ΔHb), allogeneic blood transfusion (ABT) rate, fibrinogen degradation product (FDP-on PAD2, PAD3, POD1, and POD2), and d-dimer (D-D-on PAD2, PAD3, and POD1) were lower in group B. In subgroup analyses for patients receiving intervention within 72 hours of injury, group B had lower postoperative HBL, ΔHb, ABT rate, FDP, and D-D levels (on PAD2, PAD3, POD1, and POD2). For patients receiving intervention over 72 hours after injury, no difference was detected in perioperative HBL, ΔHb, and ABT rate between the 2 groups. The FDP and D-D levels were lower in group B on PAD2 and PAD3. No difference was found in coagulation parameters, wound complications, venous thromboembolism rate, and 90-day mortality in all analyses. CONCLUSION Early administration (within 72 hours of injury) of multidose of TXA is effective in reducing perioperative HBL in elderly hip fracture patients. Delayed use (over 72 hours after injury) of TXA was not beneficial.
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Affiliation(s)
- Jiacheng Liu
- Department of Orthopedics, Orthopedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yiting Lei
- Department of Orthopedics, Orthopedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junyi Liao
- Department of Orthopedics, Orthopedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liang
- Department of Orthopedics, Orthopedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ning Hu
- Department of Orthopedics, Orthopedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopedics, Orthopedic Laboratory of Chongqing Medical University, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Cao G, Xiang S, Yang M, Quan S, Yao J, Cai L, Feng W, Yang X, Xu H, Huang Z, Zhang S, Yue C, Tan H, Pei F. Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty. BMC Musculoskelet Disord 2021; 22:1046. [PMID: 34930202 PMCID: PMC8690997 DOI: 10.1186/s12891-021-04937-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 12/03/2021] [Indexed: 02/08/2023] Open
Abstract
Background Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA. Methods We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared. Results The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05). Conclusion Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.
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Affiliation(s)
- Guorui Cao
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Shiqi Xiang
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, People's Republic of China
| | - Minglu Yang
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Songtao Quan
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Junna Yao
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Litao Cai
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Wei Feng
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Xiuli Yang
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Hong Xu
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Zeyu Huang
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, People's Republic of China
| | - Chen Yue
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Honglue Tan
- Department of Knee Injury, Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, Henan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China.
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Goh GS, D'Amore T, Lonner JH, Fillingham YA. Tranexamic Acid is Associated With Decreasing the Risk of Complications in Patients Undergoing Arthroplasty With Preoperative Coagulopathy. J Arthroplasty 2021; 36:3864-3869.e1. [PMID: 34446329 DOI: 10.1016/j.arth.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/21/2021] [Accepted: 08/04/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative coagulopathy is a risk factor for perioperative blood loss. The antifibrinolytic effects of tranexamic acid (TXA) could negate the association between preoperative coagulopathy and adverse outcomes in patients undergoing total joint arthroplasty (TJA). However, no studies have evaluated this relationship. This study compared the perioperative outcomes of coagulopathic patients undergoing TJA who did and did not receive TXA. METHODS We retrospectively reviewed 2123 primary TJAs (975 knees and 1148 hips) performed in patients with a preoperative coagulopathy. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/μL. TXA was administered in 240 patients and not administered in 1883 patients. Demographics, comorbidities, and surgical details including operative time, blood loss, and thromboprophylaxis agent were recorded. Multivariate regression was used to identify factors associated with 90-day outcomes. RESULTS Patients who received TXA had less intraoperative blood loss and 2.3 times decreased risk of 90-day complications (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20-0.85, P = .021), especially cardiovascular (2.92% vs 12.1%, P <.001) and wound complications (0.0% vs 1.59%, P = .042). TXA was also associated with shorter length of stay (beta 0.74, 95% CI 0.67-0.82, P <.001) and decreased risk of nonhome discharge (OR 0.50, 95% CI 0.29-0.83, P = .009). There was no difference in mortality or 90-day readmissions between the groups. CONCLUSION TXA administration decreased the incidence of perioperative complications and resource utilization in patients undergoing arthroplasty with a preoperative coagulopathy identified on preadmission testing. These findings support the broader adoption of TXA in patients undergoing TJA, particularly when the patient has a preoperative coagulopathy.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Taylor D'Amore
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jess H Lonner
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Fan D, Ma J, Zhang L. Tranexamic acid achieves less blood loss volume of in primary shoulder arthroplasty: a systematic review and meta-analysis of level I randomized controlled trials. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:344-352. [PMID: 37588711 PMCID: PMC10426620 DOI: 10.1016/j.xrrt.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Tranexamic acid (TXA) reduces blood loss in knee and hip arthroplasty, but the effectiveness in shoulder arthroplasty is unknown. This study aimed to evaluate current level I randomized controlled trials examining the efficacy of TXA in primary shoulder arthroplasty. Methods A protocol for the study was designed and registered with PROSPERO (CRD42021230398). The PubMed, Embase, and Cochrane Library databases were searched using the following search strategy: "shoulder replacement" OR "shoulder arthroplasty" OR "reverse shoulder arthroplasty" AND "tranexamic acid." All randomized controlled trials were included in this study. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was followed. Outcomes include blood loss, drain output, hemoglobin, thromboembolic complications, and blood transfusion. Results Five randomized controlled trials of 435 patients (219 patients in the TXA group and 216 patients in the non-TXA group) were included in the systematic review. The results indicated that the group using TXA had less total blood loss (MD, -249.56 mL; 95% confidence interval [CI] -347.60 to -151.52), less drainage output (MD, -113.72 mL; -155.92 to -71.52 95% CI), and less of a change in hemoglobin (MD, -0.68 g/dl; -0.94 to -0.42 g/dl 95% CI). No significant differences in blood transfusion (risk ratio 0.40; -0.11 to 1.45 95% CI) or thromboembolic events (risk ratio 0.13, 0.02 to 1.12 95% CI) were observed. Subgroup analyses showed that there was no significant difference in total blood loss, drainage output, or change in hemoglobin between single dose and multiple doses. Conclusions TXA in primary shoulder arthroplasty can reduce blood loss, drain output, and hemoglobin changes. Subgroup analysis showed that multiple TXA doses have similar results compared with single dose in primary shoulder arthroplasty. More randomized controlled trials comparing different administration routes of TXA in primary and revision shoulder arthroplasty are required.
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Affiliation(s)
- DingYuan Fan
- Beijing University of Chinese Medicine, Beijing, China
- Department of Joint Surgery and Sports Medicine, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jia Ma
- Department of Joint Surgery and Sports Medicine, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lei Zhang
- Department of Joint Surgery and Sports Medicine, Wang Jing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Tan TK, Ng KT, Lim HJ, Radic R. Effect of tranexamic acid in arthroscopic anterior cruciate ligament repair: A systematic review and meta-analysis of randomised clinical trials. J Orthop Surg (Hong Kong) 2021; 29:23094990211017352. [PMID: 34027721 DOI: 10.1177/23094990211017352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Perioperative blood loss remains a major challenge to surgeons in anterior cruciate ligament reconstruction (ACLR) surgery, despite of the introduction of minimally invasive approach. Tranexamic acid (TXA) is believed to reduce blood loss, which may minimise the complication of postoperative haemarthrosis with insufficient evidence on its effectiveness in ACLR. The primary aim of this study was to examine the effect of TXA on postoperative blood loss and other secondary outcomes in patients undergoing arthroscopic ACLR surgery. METHOD PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All randomised clinical trials (RCTs) comparing TXA (intravenous or intra-articular) versus placebo in the arthroscopic ACLR surgery were included. Case series, case report and editorials were excluded. RESULTS Five RCTs comprising of a total of 580 patients (291 in TXA group, 289 in control group) were included for qualitative and quantitative meta-analysis. In comparison to placebo, TXA group was significantly associated with lower postoperative blood loss (mean difference (MD): -81.93 ml; 95% CI -141.80 to -22.05) and lower incidence of needing knee aspiration (odd ratio (OR): 0.19; 95% CI 0.08 to 0.44). Patients who randomised to TXA were also reported to have better range of movement (MD: 2.86; 95% CI 0.54 to 5.18), lower VAS Pain Score (MD: -1.39; 95% CI -2.54 to -0.25) and higher Lysholm Score (MD: 7.38; 95% CI 2.75 to 12.01). CONCLUSION In this meta-analysis, TXA reduced postoperative blood loss with lesser incidence of needing knee aspiration along with better range of knee movement and Lysholm score in patients undergoing arthroscopic ACLR surgery.
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Affiliation(s)
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia
| | - Hui Jane Lim
- 155310Altnagelvin Area Hospital, Londonderry, UK
| | - Ross Radic
- Perth Orthopaedics and Sports Medicine Research Institute, West Perth, WA, Australia
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Tranexamic acid is beneficial for blood management of high tibial osteotomy: a randomized controlled study. Arch Orthop Trauma Surg 2021; 141:1463-1472. [PMID: 32715401 DOI: 10.1007/s00402-020-03558-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate whether TXA can effectively reduce blood loss after HTO and related complications and to evaluate its safety. MATERIALS AND METHODS From March 2016 to March 2018, 100 patients who underwent medial opening wedge HTO in the Department of Orthopedics, the second affiliated hospital of xi'an jiaotong university, with an average age of 52.8 ± 3.2 years, were randomly divided into the TXA group (using intravenous TXA) and the control group (using the same amount of normal saline), with 50 patients in each group. The postoperative wound drainage volume, decrease in hemoglobin and hematocrit value, total blood loss, wound healing, blood transfusion, deep venous thrombosis (DVT) and pulmonary embolism (PE) were compared between the two groups. RESULTS The drainage volume on the first postoperative day and the total drainage volume of the TXA group were significantly lower compared with those of the control group (145.7 vs 264.5 ml, 282.3 vs 413.2 ml, P < 0.05). The decreases in the hemoglobin and hematocrit values on the postoperative first, second and fifth days were lower in the TXA group than those in the control group (1.4 VS 3.5, 2.6 vs 3.3, 1.9 vs 2.9 g, P < 0.05; 3.3 vs 5.5, 5.0 vs 9.1, 3.8 vs 7.2%, P < 0.05), and the mean total blood loss was also lower in the TXA group than that in the control group (477.9 vs 834.6 ml, P < 0.05). In the control group, 1 patient had wound hematoma requiring additional paracentesis and pressure dressing, 1 patient had superficial wound infection requiring additional debridement, and 1 patient had postoperative blood transfusion compared to none in the TXA group (P > 0.05). There was no symptomatic DVT or PE in either of the groups. CONCLUSION Intravenous TXA can effectively and safely reduce blood loss and bleeding-related complications after HTO and was beneficial for the blood management of HTO.
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Changjun C, Xin Z, Yue L, Chengcheng Z, Qiuru W, Qianhao L, Pengde K. Tranexamic acid attenuates early post-operative systemic inflammatory response and nutritional loss and avoids reduction of fibrinogen in total hip arthroplasty within an enhanced recovery after surgery pathway. INTERNATIONAL ORTHOPAEDICS 2021; 45:2811-2818. [PMID: 34409492 DOI: 10.1007/s00264-021-05182-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/30/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Total hip arthroplasty (THA) is an intervention with significant inflammatory response. The impact of additional doses of tranexamic acid (TXA) on inflammatory response, trauma and nutrition parameters, and coagulation and fibrinolysis changes has rarely been reported. METHODS A prospective double-blind randomized trial was performed on elective primary THA. Ninety-nine adult patients were recruited consecutively from 2019 to 2020. They were randomized to receive single-dose of TXA before incision, another dose of TXA at three hours post-operatively, or another two doses of TXA at three and six hours post-operatively. The primary outcomes included changes in white blood cell (WBC) counts, creatine kinase (CK), haemoglobin(Hb), and albumin(Alb); the secondary outcomes included coagulation and fibrinolysis parameters. RESULTS Compared with single-dose TXA, patients received three dose TXA had significantly reduced WBC counts and fibrinogen/fibrin degradation product (FDP) levels, increased albumin and fibrinogen levels, and prolonged PT on post-operative day (POD) three. Though patients received three dose TXA had a tendency that increased Hb, decreased CK, reduced D-D, and prolonged APTT on POD3, it is not statistically significant. And the other measured outcomes on POD1 and POD2W shared a similar statistical result, except PT. The PT is significantly prolonged on POD2W in three dose group compared with single dose. CONCLUSION Three-dose TXA contribute to attenuate early post-operative systemic inflammatory response and nutritional loss, increase fibrinogen, reduce FDP levels, and prolong PT in THA patients within an ERAS pathway, which may associate with reduced early post-operative haemorrhagic tendency, thrombosis risks, and hypercoagulability.
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Affiliation(s)
- Chen Changjun
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zhao Xin
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Luo Yue
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zhao Chengcheng
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Wang Qiuru
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Li Qianhao
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Kang Pengde
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China.
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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19
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Ling T, Zhao Z, Xu W, Ge W, Huang L. Effects of Tranexamic Acid on Hemorrhage Control and Deep Venous Thrombosis Rate After Total Knee Arthroplasty: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2021; 12:639694. [PMID: 34366837 PMCID: PMC8335562 DOI: 10.3389/fphar.2021.639694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 07/07/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Total knee arthroplasty (TKA) surgery has a lot of complications, especially hemorrhage, which can be controlled via tranexamic acid (TXA). The guidelines endorse the integration of TXA interventions in the management of TKA-induced complications. However, uncertainty surrounds the effects of different TXA therapies. This frequentist model network meta-analysis (NMA) aims to compare hemorrhage control and deep venous thrombosis (DVT) rate of different TXA therapies in TKA. Methods: Articles were searched with the PubMed, Embase, Cochrane Library, and Web of Science from 1966 to October 2020. Randomized controlled trials (RCTs) comparing different TXA therapies, or with placebo in patients with TKA were included. Two investigators independently conducted article retrievals and data collection. The outcome was total blood loss and DVT rate. Effect size measures were mean differences (MDs), or odds ratios (ORs) with 95% confidence intervals (CIs). We conducted a random-effects NMA using a frequentist approach to estimate relative effects for all comparisons and rank treatments according to the mean rank and surface under the cumulative ranking curve values. All analyses were performed in Stata software or R software. The study protocol was registered with PROSPERO, number CRD42020202404. Results: We identified 1 754 citations and included 81 studies with data for 9 987 patients with TKA. Overall, all TXA therapies were superior to placebo for total blood loss in TKA. Of all TXA therapies, M therapy (IV/IV infusion + oral TXA > 3g) was most effective for total blood loss (MD=−688.48, −1084.04–−328.93), followed by F therapy (IV TXA ≥ 15 mg/kg or 1 g three times). TXA therapies in this study are not associated with the increase of DVT risk. Conclusions: TXA therapies in this study are effective and safe for the treatment of TKA-induced complications. M therapy (IV/IV infusion + oral TXA > 3 g) may be the most effective TXA therapy for hemorrhage control. TXA therapies in this study do not increase DVT risk. Considering hemorrhage control and DVT rate simultaneously, F therapy (IV TXA ≥ 15 mg/kg or 1 g three times) may be suggested to apply for TKA, and this study may provide a crucial clue to future TXA use.
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Affiliation(s)
- Tao Ling
- Department of Pharmacy, Suqian First Hospital, Suqian, China
| | - Zhihu Zhao
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Wenwen Xu
- Department of Neurology, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lingli Huang
- Department of Pharmacy, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
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Magill P, Hill JC, Bryce L, Martin U, Dorman A, Hogg R, Campbell C, Gardner E, McFarland M, Bell J, Benson G, Beverland D. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total hip arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J 2021; 103-B:1197-1205. [PMID: 34192922 DOI: 10.1302/0301-620x.103b7.bjj-2020-2309.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be "high-risk" with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients. METHODS TRAC-24 was a prospective, phase IV, single centre, open label, parallel group, randomized controlled trial (RCT) involving patients undergoing primary unilateral elective THA. The primary outcome measure was the indirect calculated blood loss (IBL) at 48 hours. The patients were randomized into three groups. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional oral regime for 24 hours postoperatively, group 2 only received the intraoperative dose, and group 3 did not receive any TXA. RESULTS A total of 534 patients were randomized, with 233 in group 1, 235 in group 2, and 66 in group 3; 92 patients (17.2%) were considered high-risk. The mean IBL did not differ significantly between the two intervention groups (848.4 ml (SD 463.8) for group 1, and 843.7 ml (SD 478.7) for group 2; mean difference -4.7 ml (95% confidence interval -82.9 to 92.3); p = 0.916). No differences in mortality or incidence of VTE were observed between any group. CONCLUSION The addition of oral TXA for 24 hours postoperatively does not reduce blood loss beyond that achieved with a single 1 g IV perioperative dose alone. There may be a clinically relevant difference in patients with a normal BMI, which warrants further investigation. Critically, there were no safety issues in patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease. Cite this article: Bone Joint J 2021;103-B(7):1197-1205.
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Affiliation(s)
- Paul Magill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - J C Hill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Leeann Bryce
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Una Martin
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Al Dorman
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Rosemary Hogg
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Christina Campbell
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | - Evie Gardner
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | | | - Jennifer Bell
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | - Gary Benson
- Department of Haematology, Belfast City Hospital, Belfast, UK
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21
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Bailey A, Eisen I, Palmer A, Beaulé PE, Fergusson DA, Grammatopoulos G. Preoperative Anemia in Primary Arthroplasty Patients-Prevalence, Influence on Outcome, and the Effect of Treatment. J Arthroplasty 2021; 36:2281-2289. [PMID: 33549420 DOI: 10.1016/j.arth.2021.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/23/2020] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aims to: 1) Determine the prevalence of preoperative anemia in arthroplasty; 2) Assess whether preoperative anemia is associated with inferior outcomes; and 3) Ascertain whether optimization in a dedicated blood management program (BMP) is associated with improved outcomes. METHODS All primary arthroplasties performed at an academic, tertiary-care, arthroplasty center between 2012 and 2017 were reviewed. Hemoglobin level obtained in the preoperative assessment clinic was recorded. Patients with anemia were then considered for further review in BMP. Outcomes included improvement in hemoglobin level post-BMP; length of stay; perioperative transfusion; 90-day readmission, complication, and reoperation rates. The effect of preoperative anemia and the effect of treatment at the BMP on outcomes were evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS 17% of patients (932/5384) were found to have anemia; 115/357 patients who attended the BMP were no longer anemic. Thus, at time of operation, 15% of patients (817/5384) had anemia. Anemic patients were 4.09 times more likely (95% CI: 2.64-6.35) to require a transfusion; 1.42 times more likely (95% CI: 0.99-2.03) to sustain complications and had 19% longer (95% CI: 13%-26%) length of stay. Those who attended the BMP were less likely to receive a transfusion (OR = 0.32, 95% CI: 0.16-0.66), suffer from postoperative complications (OR = 0.30, 95% CI: 0.14-0.63), or require readmission compared with anemic patients not seen in the BMP (OR = 0.25, 95% CI: 0.09-0.71). CONCLUSIONS The prevalence of anemia in this arthroplasty cohort was 15%. Preoperative, timely, optimization of anemia should be strongly considered as it is likely to reduce "anemia-associated burden" after arthroplasty.
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Affiliation(s)
- Adrian Bailey
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Isabel Eisen
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Antony Palmer
- Nuffield Orthopaedic Centre, Oxford, UK; NDORMS, University of Oxford, Oxford, UK
| | | | - Paul E Beaulé
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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22
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Kimura OS, Freitas EH, Duarte ME, Cavalcanti AS, Fernandes MB. Tranexamic acid use in high-risk blood transfusion patients undergoing total hip replacement: a randomised controlled trial. Hip Int 2021; 31:456-464. [PMID: 31814452 DOI: 10.1177/1120700019889947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We hypothesised that a single preoperative intravenous dose of tranexamic acid (TXA) is effective in patients who undergo total hip arthroplasty (THA) and are at high risk of blood transfusion (preoperative haemoglobin level <13.0 g/dL). METHODS A prospective, randomised controlled study of 308 patients who underwent primary THA was conducted. 256 participants remained in the study and were divided into 2 major groups: high-risk group comprising 116 patients with preoperative Hb < 13.0 g/dL (57 of whom were treated with a 15 mg/kg intravenous bolus of TXA, and 59 of whom did not receive the medication) and low-risk group comprising 140 patients with Hb ⩾ 13.0 g/dL (71 of whom received the same dose of TXA, and 69 of whom did not). Participants were followed up at 3 weeks, 3 months, 6 months, and 1 year after surgery. RESULTS The use of TXA in both groups of patients significantly increased the levels of postoperative Hb and Ht. TXA protected high-risk patients from blood loss and from transfusion. In low-risk patients the use of TXA reduced blood loss but did not protect from blood transfusion. The median length of stay was significantly affected for high-risk patients. No thromboembolic event was recorded in either group. CONCLUSIONS TXA reduces intra- and postoperative bleeding, transfusion rates, and the length of hospital stays in patients with low preoperative Hb. The use of TXA in patients with normal preoperative Hb reduces blood loss but does not affect the transfusion rate.ClinicalTrials.gov Identifier: NCT03019198.
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Affiliation(s)
- Osamu S Kimura
- Master Programme in Musculoskeletal Sciences, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil.,Centre for Specialised Hip Care, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Emílio Hca Freitas
- Centre for Specialised Hip Care, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Maria El Duarte
- Research Division National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Amanda S Cavalcanti
- Research Division National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Marco Bc Fernandes
- Centre for Specialised Hip Care, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
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Ma J, Lu H, Chen X, Wang D, Wang Q. The efficacy and safety of tranexamic acid in high tibial osteotomy: a systematic review and meta-analysis. J Orthop Surg Res 2021; 16:373. [PMID: 34116690 PMCID: PMC8194157 DOI: 10.1186/s13018-021-02512-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/31/2021] [Indexed: 12/26/2022] Open
Abstract
Objective The present meta-analysis was conducted to evaluate the efficacy and safety of the application of tranexamic acid (TXA) in patients undergoing high tibial osteotomy (HTO). Methods PubMed (MEDLINE), EMBASE, and Cochrane Library were systematically searched for relevant literature from inception until 1 February 2021. A combined searching strategy of subject words and random words was adopted. After testing for potential publication bias and/or heterogeneity, we aggregated variables by using the random-effect model. The primary comparison outcome measures were total blood loss, hemoglobin decrease, drain output, wound complications, thrombotic events, and blood transfusion rate of the TXA group versus control. The meta-analysis was performed using the RevMan 5.3 software. Results A total of 5 studies were included involving 532 patients. The results showed that there were significant differences in the two groups concerning total blood loss (95% confidence interval [CI] − 332.74 to − 146.46, P < 0.00001), hemoglobin decrease on postoperative day (POD) 1, 2, and 5 (POD 1 95% CI − 1.34 to − 0.63, P < 0.00001; POD 2 95% CI − 1.07 to − 0.68, P < 0.00001; POD 5 95% CI − 1.46 to − 0.84, P < 0.00001), drain output (POD total 95% CI − 195.86 to − 69.41, P < 0.00001) and wound complications (RR = 0.34, 95% CI 0.12 to 0.97, P = 0.04). Nonsignificant differences were found in the incidence of thromboembolic events (RR = 0.46, 95% CI 0.09 to 2.41, P = 0.36) and blood transfusion rate (RR = 0.25, 95% CI 0.03 to 2.27, P = 0.22). Conclusions This meta-analysis of the available evidence demonstrated that TXA could reduce total blood loss, hemoglobin decrease, drain output, and wound complications without increasing the incidence of thromboembolic events in patients undergoing HTO. But there is no obvious evidence that TXA could reduce blood transfusion rates. Further studies, including more large-scale and well-designed randomized controlled trials, are warranted to assess the efficacy and safety issues of routine TXA use in HTO patients.
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Affiliation(s)
- Jimin Ma
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Hanli Lu
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xinxing Chen
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Dasai Wang
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Qiang Wang
- Department of Orthopedics, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China.
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24
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Luo Y, Zhao X, Yang Z, Yeersheng R, Kang P. Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty. Bone Joint Res 2021; 10:354-362. [PMID: 34096338 PMCID: PMC8242685 DOI: 10.1302/2046-3758.106.bjr-2020-0357.r2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Yue Luo
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Zhao
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhouyuan Yang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Releken Yeersheng
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Pengde Kang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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25
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Wang Z, Lu Y, Huang Q, Xue H, Ran C, Wang Q, Ma T, Zhang K, Li Z, Sun L. Efficacy and Safety of Long-Term Intravenous Tranexamic Acid Administration for Blood Management in Revision Surgery for Femoral Shaft Nonunion: A Retrospective Case-Control Study. Clin Appl Thromb Hemost 2021; 27:10760296211002277. [PMID: 33845609 PMCID: PMC8047849 DOI: 10.1177/10760296211002277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Femoral shaft nonunion is a complication that seriously affects physiological functions. We aimed to assess the effectiveness and safety of short- and long-term intravenous tranexamic acid (TXA) administration in the perioperative period of revision surgery for femoral shaft nonunion. In this retrospective study, 53 patients undergoing double-locking plates with channel bone grafting technology for the treatment of femoral shaft nonunion were divided into 3 groups: the patients in group A without use TXA during hospitalization, the patients in group B received intravenous (IV) 1-g TXA at 30 min before the surgery and deep soaked 1-g TXA for 5 min before closing the incision, and then 1-g TXA IV again 6 h after surgery, and the patients in group C received 1-g TXA IV before the operation, 1-g TXA topically during the operation, and subsequent long-term 1-g TXA IV until discharged. The primary outcomes were total blood loss (TBL) and hidden blood loss (HBL). The secondary outcomes included actual hemoglobin (Hb) loss values, transfusion requirement, number of units transfused, postoperative laboratory values (Hb, hematocrit, fibrinogen, and D-dimer), visual analogue scale (VAS) scores, and hospitalization time. The mean TBL was lower in group C than in group A (1168 mL vs. 2714 mL, P < 0.001) and group B (1168 mL vs. 1557 mL, P = 0.008). The differences in HBL volumes were also significant between groups A and C (P < 0.001) and between groups A and B (P < 0.01). The actual Hb loss in the 3 groups showed a consistent trend with TBL, but no significant differences between groups B and C (P = 0.23). On postoperative day (POD) 3, the Hb level was higher in group C than in group A (111.1 g/L vs. 94.6 g/L, P = 0.02). No significant differences were found in VAS, hospital stay, thromboembolic complications, incision-related complications, and TXA adverse reactions among groups. Long-term intravenous TXA during hospitalization can effectively reduce perioperative blood loss, Hb drop, and postoperative hyperfibrinolysis, but is associated with an increased incidence of adverse reactions.
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Affiliation(s)
- Zhimeng Wang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Yao Lu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China.,The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, People's Republic of China.,Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Hanzhong Xue
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Cheng Ran
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Qian Wang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Liang Sun
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, People's Republic of China
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26
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Maezawa K, Nozawa M, Gomi M, Sugimoto M, Maruyama Y. Association of ABO blood group with postoperative total bleeding volume in patients undergoing total hip arthroplasty. Vox Sang 2021; 116:841-845. [PMID: 33710646 DOI: 10.1111/vox.13072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES As individuals with blood types A, B and AB have approximately 25% higher levels of vWF than those with type O, the risk of developing venous thrombotic events has been investigated in a number of clinical studies, but whether individuals with type O blood experience increased bleeding remains to be clarified. The purpose of this study was to evaluate an association of ABO blood group with intraoperative bleeding and postoperative total bleeding in patients undergoing total hip arthroplasty. MATERIALS AND METHODS We prospectively recruited 84 women who were undergoing total hip arthroplasty. The differences between blood groups in mean age, body weight, preoperative and postoperative Hct levels, and postoperative/preoperative Hct ratio, intraoperative bleeding volume (IBV), and total bleeding volume (TBV) were evaluated. RESULTS Twenty-six patients had type A blood, 17 had type B, 9 had type AB, and 30 had type O. There were no significant differences in mean age, body weight or operating time between the different ABO blood groups. While there was no significant difference in these Hct levels or IBV among the different blood groups, there was a significant difference in TBV between type O and type AB, and between type O and non-type O. CONCLUSION Our study in patients undergoing total hip arthroplasty suggests that patients in blood group O tend to have large amounts of bleeding.
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Affiliation(s)
- Katsuhiko Maezawa
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masahiko Nozawa
- Orthopaedic Surgery, Juntendo University Nerima Hospital, Nerima-ku, Japan
| | - Motoshi Gomi
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Munehiko Sugimoto
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Yuichiro Maruyama
- Orthopaedic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
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27
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The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial. Spine J 2021; 21:312-320. [PMID: 33049411 DOI: 10.1016/j.spinee.2020.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Tranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction. PURPOSE The primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects. STUDY DESIGN Prospective, double-blinded, randomized controlled trial. PATIENT SAMPLE A total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study. OUTCOME MEASURES The primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL. METHODS Patients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo. RESULTS The mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1-786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6-763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL. CONCLUSIONS A multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.
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Deng Z, Sheng P, Xu D, Fu M, He A, Liao W, Kang Y. [Comparison of hemostatic effect and safety in primary unilateral total hip arthroplasty receiving different anticoagulants after anti-fibrinolysis with tranexamic acid]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1561-1567. [PMID: 33319536 DOI: 10.7507/1002-1892.202006007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To compare the hemostatic effect and safety in primary unilateral total hip arthroplasty (THA) receiving nadroparin calcium, enoxaparin sodium, rivaroxaban, or apixaban after anti-fibrinolysis with tranexamic acid (TXA) and explore the best anticoagulant. Methods A retrospective analysis was conducted on 184 patients who underwent the primary unilateral THA between January 2014 and December 2018, administrated 15 mg/kg TXA before surgery and received nadroparin calcium, enoxaparin sodium, rivaroxaban, or apixaban. The patients were divided into four groups based on the different anticoagulants: 46 patients received nadroparin calcium; 45 patients received enoxaparin sodium; 47 patients received rivaroxaban; the other 46 patients received apixaban. There was no significant difference in age, gender, body mass, body mass index, the types of hip joint diseases, complications, anesthesia mode, operation time, and preoperative laboratory indexes (hemoglobin, hematocrit, platelet, prothrombin time, activated partial prothrombin time, blood volume) ( P>0.05). Perioperative blood data (total blood loss, hidden blood loss, dominant blood loss, postoperative drainage volume, maximum loss of hemoglobin, and blood transfusion rate) and complications (incision, bleeding, and thrombosis) were recorded and compared between groups. Results There was no significant difference in total blood loss, hidden blood loss, dominant blood loss, postoperative drainage volume, maximum loss of hemoglobin, and blood transfusion rate between groups ( P>0.05). The comparison of postoperative complications showed that 1 case (2.1%) of redness and swelling of incision occurred in the rivaroxaban group, and 1 case (2.2%) of the other 3 groups each had poor incision healing. No incision infection, fat liquefaction, or other incision complications occurred in the 4 groups. There was no significant difference in incision complication between groups ( P>0.05). There were 2 cases (4.3%) bleeding events (1 case of right inguinal hematoma and 1 case of subcutaneous ecchymosis in front of left leg) in the nadroparin calcium group, while no bleeding event occurred in the other 3 groups, which had no significant difference in bleeding complication between groups ( χ 2=5.612, P=0.132). There was 1 case (2.2%) of intermuscular vein thrombosis of the lower extremity in the nadroparin calcium group and no case in the other 3 groups, which had no significant difference between groups ( χ 2=2.789, P=0.425). Neither deep venous thrombosis nor pulmonary embolism occurred in any group. Conclusion No significant difference in the hemostatic effect and incidences of complications for patients underwent primary unilateral THA receiving nadroparin calcium, enoxaparin sodium, rivaroxaban, or apixaban after anti-fibrinolysis with TXA. One of the four anticoagulants can be selected to prevent thrombosis after anti-fibrinolysis with TXA, which has certain safety.
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Affiliation(s)
- Zengfa Deng
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
| | - Puyi Sheng
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
| | - Dongliang Xu
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
| | - Ming Fu
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
| | - Aishan He
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
| | - Weiming Liao
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
| | - Yan Kang
- Department of Joint Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510080, P.R.China
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Two Doses of Tranexamic Acid Reduce Blood Loss in Primary Posterior Lumbar Fusion Surgery: A Randomized-controlled Trial. Clin Spine Surg 2020; 33:E593-E597. [PMID: 32349059 DOI: 10.1097/bsd.0000000000000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to reduce perioperative blood loss and blood transfusion, but the dosage and efficacy of TXA in posterior lumbar spinal surgery are not fully clear. The aim of this study was to investigate the efficacy and safety of TXA and to determine whether 2 doses of TXA could reduce the blood loss in primary single-segment or double-segment posterior lumbar fusion surgery. MATERIALS AND METHODS A total of 150 patients with lumbar degenerative disease undergoing posterior lumbar interbody fusion surgery between October 2017 and February 2019 were randomized to 3 groups. Group A was treated with 0.9% normal saline solution without TXA, group B was treated with a 15 mg/kg loading dose intravenous infusion 30 minutes before surgery, and group C was treated with a 15 mg/kg loading dose intravenous infusion 30 minutes before surgery; then, the same dose was administered again 3 hours later. The assessed outcomes were the operation time, the total blood loss, the hidden blood loss, postoperative drainage, blood transfusions, incidence of venous thromboembolism, and incision infection. RESULTS The total blood loss, the hidden blood loss, and postoperative drainage were the lowest in group C. The amount of intraoperative blood loss was similar among the 3 groups. The hemoglobin and hematocrit values of the third postoperative day were the highest in group C. No significant differences in the incidence of complications and adverse events from TXA use were observed among the 3 groups. The use of TXA, the operation time, and the number of fusion segments were identified as risk factors related to total blood loss. CONCLUSION Two doses of TXA significantly reduced the total blood loss, the hidden blood loss and postoperative drainage, and decreased hemoglobin and hematocrit drop in patients undergoing posterior lumbar fusion without increasing the risk of complications.
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Huerfano E, Huerfano M, Shanaghan K, Barlow M, Memtsoudis S, Gonzalez Della Valle A. Use of Topical Tranexamic Acid Reduces Direct and Indirect Blood Loss and Transfusion Rates in Revision Total Hip Arthroplasty. HSS J 2020; 16:285-292. [PMID: 33380958 PMCID: PMC7749894 DOI: 10.1007/s11420-019-09718-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND In primary total hip arthroplasty (THA), evidence supports the use of tranexamic acid (TXA) as an effective strategy for reducing blood loss, but scant evidence supports its use in revision THA. QUESTIONS/PURPOSES We aimed to evaluate whether the use of topical TXA in revision THA is associated with less blood loss and lower transfusion rates and to assess its safety, specifically as it relates to thromboembolic complications. METHODS In this retrospective comparative study, two groups who underwent revision THA between 2005 and 2017 were defined: 98 patients who received 3 g of topical TXA (study group) and 475 patients who did not receive TXA (control group). Subjects were divided into subgroups according to the type of revision. Hemoglobin and hematocrit levels, blood loss, and transfusions were recorded. The follow-up period was 6 weeks. RESULTS Median estimated blood loss, hidden blood loss, hemoglobin drop, and transfusion rates were significantly lower in the study group. The rates of post-operative thromboembolism were similar in the two groups. According to subgroup analysis, patients with revision of the femoral component, both components, and staged exchange revisions showed significantly lower rates of transfusion. CONCLUSION Topical TXA administration during revision THA effectively reduced direct and indirect blood loss, including hidden losses, without increasing the rates of thromboembolic events. This effect appeared to be enhanced when the femoral component was revised.
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Affiliation(s)
- Elina Huerfano
- Department of Orthopaedic Surgery, Fundación Cardioinfantil - Instituto de Cardiología, Bogotá, Colombia
| | - Manuel Huerfano
- Department of Nephrology, Hospital Universitario Mayor, Bogotá, Colombia
| | - Kate Shanaghan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Maureen Barlow
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Stavros Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY USA
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Deng ZF, Zhang ZJ, Sheng PY, Fu M, Xu DL, He AS, Liao WM, Kang Y. Effect of 3 different anticoagulants on hidden blood loss during total hip arthroplasty after tranexamic acid. Medicine (Baltimore) 2020; 99:e22028. [PMID: 32899057 PMCID: PMC7478743 DOI: 10.1097/md.0000000000022028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Comparison of different anticoagulants in blood management and complications with tranexamic acid (TXA) in total hip arthroplasty (THA) is unclear. Our aim was to compare the efficacy and safety among receiving nadroparin calcium, enoxaparin sodium or rivaroxaban after TXA in THA.150 patients undergoing primary unilateral THA were received 15 mg/kg intravenous TXA (IV-TXA) before skin incision, followed by 1 of nadroparin calcium (Group A), enoxaparin sodium (Group B), or rivaroxaban (Group C) randomly during hospitalization. The primary outcome was hidden blood loss (HBL). Other outcomes such as the maximum hemoglobin (Hb) drop, total blood loss (TBL), the volume of drainage, transfusion rate, length of hospital stay (LOS), and complications were also compared.There were no statistically significant differences in HBL, the maximum hemoglobin (Hb) drop, transfusion rate, and complications among 3 groups. LOS was significantly higher for patients in Group B than Group A (P = .026). Neither deep venous thrombosis (DVT) nor pulmonary embolism (PE) occurred in any group.There were no differences in efficacy and safety in patients undergoing THA receiving nadroparin calcium, enoxaparin sodium, or rivaroxaban after anti-fibrinolysis with TXA.
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Vajapey SP, Morris J, Li D, Greco NG, Li M, Spitzer AI. Outcome Reporting Patterns in Total Hip Arthroplasty. JBJS Rev 2020; 8:e0197. [DOI: 10.2106/jbjs.rvw.19.00197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Wang F, Nan L, Feng X, Wang Y, Yang J, Tao Y, Cheng X, Zhang S, Zhang L. The efficacy and safety of multiple-dose intravenous tranexamic acid in reducing perioperative blood loss in patients with thoracolumbar burst fracture. Clin Neurol Neurosurg 2020; 193:105766. [PMID: 32146231 DOI: 10.1016/j.clineuro.2020.105766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of tranexamic acid (TXA) for single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach. PATIENTS AND METHODS We identified 264 patients with single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach (January 2016-June 2019) at a single center. The cohort was separated into three groups. Group A received 20 mg/kg TXA at 5 min before skin incision and 16 h after first dose; Group B received 20 mg/kg TXA at 5 min before skin incision; Group C received NS at each same time point. The outcomes were evaluated by hidden blood loss (HBL), total blood loss (TBL), intraoperative blood loss (IBL), transfusion rate, maximum hemoglobin (Hb) drop, prethrombotic state molecular markers, liver and renal function, coagulation function, inflammatory factor and adverse events. RESULTS The HBL, TBL and maximum Hb drop were significantly lower in Group A than those of Group B and Group C, while the difference between Group B and Group C was statistically significant. The IBL was significantly lower in Group A and Group B than that of Group C. However, there was no significantly difference among the three groups in live and renal function, coagulation function, prethrombotic state molecular markers, transfusion rate and complications during the perioperative period. There was significantly lower level of interleukin-6 (IL-6) in Group A than Group C at the day after surgery, and lower level of C-reactive protein (CRP) at the third day after surgery. CONCLUSIONS Intravenous TXA used in the treatment of thoracolumbar burst fracture underwent pedicle screw fixation via Wiltse approach is effective and safe in decreasing perioperative blood loss. The two-dose TXA regimen can further reduce blood loss and alleviate post-operative inflammation response, without affecting prethrombotic state molecular marks and without increasing the risk of complications.
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Affiliation(s)
- Feng Wang
- Department of Orthopedics, Dalian Medical University, Dalian, 116000, China; Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Liping Nan
- Department of Orthopedics, Dalian Medical University, Dalian, 116000, China; Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Yongxiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Jiandong Yang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Yuping Tao
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Xiaofei Cheng
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Orthopaedic Implants, Shanghai, 200011, China
| | - Shengfei Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital of Jiangsu Province, Yangzhou, 225001, China.
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Tranexamic Acid Reduces Total Blood Loss and Inflammatory Response in Computer-Assisted Navigation Total Knee Arthroplasty. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5207517. [PMID: 31886224 PMCID: PMC6925782 DOI: 10.1155/2019/5207517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/11/2019] [Indexed: 11/18/2022]
Abstract
Introduction Tranexamic acid (TXA) is an effective blood salvage agent that reduces perioperative blood loss in conventional total knee arthroplasty (TKA). As computer-assisted surgery for TKA (CAS-TKA) results in a lower perioperative blood loss than conventional TKA, the additional effect of blood conservation by TXA might be mitigated. This study aimed to evaluate the efficacy of TXA in CAS-TKA. Methods We retrospectively reviewed 222 consecutive patients who underwent CAS-TKA. Intravenous TXA was administered in 103 patients (TXA group) at a dosage of 20 mg/kg 15 min before deflation of the tourniquet. The other 119 patients did not receive TXA (control group). Patient demographic data including age, gender, BMI, DM, and hypertension were collected. The primary outcomes were the estimated total blood loss (ETBL) and perioperative data, including tourniquet duration, preoperative and postoperative day 1 (POD1) and day 3 (POD3) serum D-dimer, CRP, hemoglobin (Hb), and hematocrit (Hct) levels. Secondary outcomes including transfusion rate and 90-day complications were recorded. Results The ETBL was lower in the TXA group on both POD1 (404.34 ± 234.77 vs. 595.47 ± 279.04, p < 0.001) and POD3 (761.39 ± 260.88 vs. 987.79 ± 326.58, p < 0.001). The TXA group also demonstrated a lower level of CRP on POD1 (p=0.02) and lower levels of CRP and serum D-dimer on POD3 (p=0.008 and p < 0.001). Consumption of fibrinogen was higher in the control group on both POD1 (p=0.013) and POD3 (p < 0.001). Length of hospital stay was lower in the TXA group (5.42 ± 1.21 vs. 6.25 ± 1.49, p < 0.001). The transfusion rate and perioperative complications were not significantly different between the two groups. Conclusion Administration of TXA is not only effective in reducing perioperative blood loss and length of hospital stay but also exerts an anti-inflammatory effect following CAS-TKA without causing major complications.
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Effect of topical tranexamic acid in total hip arthroplasty patients who receive continuous aspirin for prevention of cardiovascular or cerebrovascular events: A prospective randomized study. Orthop Traumatol Surg Res 2019; 105:1327-1332. [PMID: 31570210 DOI: 10.1016/j.otsr.2019.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 05/23/2019] [Accepted: 06/05/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Due to differences in pharmacological mechanism of action, the effect of tranexamic acid (TA) on aspirin-related bleeding remains unknown. We therefore conducted a prospective randomized study to elucidate: (1) the effect of topical TA administration on blood loss and transfusion rate in total hip arthroplasty (THA) patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events; (2) 90-day complications of topical TA administration; (3) possible variables contributing to blood transfusion. HYPOTHESIS Topical TA administration reduces blood loss and transfusion rate in THA patients receiving continuous aspirin. PATIENTS AND METHODS A total of 102 consecutive THA patients taking continuous aspirin were enrolled and randomized into two groups. In the topical TA (TTA) group (n=55), topical TA was administered at three points during THA; in the control group (n=47), the patients received saline solution as placebo. Based on drop in hemoglobin concentration, total estimated blood loss was calculated as the main assessment criterion. Secondary assessment criteria included transfusion rate and 90-day complications. Finally, a multivariate regression model was used to assess possible predictive factors for blood transfusion. RESULTS (1) Significantly lower total blood loss was observed in the TTA group than in the control group (897±177ml vs. 1153±345ml, p<0.001). Furthermore, lower transfusion rate was observed in the TTA group than in the control group (10.9% vs. 34.0%, p=0.005). (2) No significant difference was observed between the two groups regarding 90-day complications. (3) We identified higher preoperative hemoglobin level (OR=0.675, p=0.002) and topical TA administration (OR=0.002, p=0.012) as negative predictive factors for blood transfusion. DISCUSSION Topical application of TA was safe and beneficial in THA patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events, to reduce blood loss and transfusion rate, without increasing the risk of 90-day complications.
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Cui D, Lei Y, Xu H, Huang Q, Pei F. [Efficacy and safety of a loading high-dose tranexamic acid followed by postoperative five doses in total hip arthroplasty: A randomized controlled trial]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:935-939. [PMID: 31407549 PMCID: PMC8337895 DOI: 10.7507/1002-1892.201902075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/18/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of a loading high-dose tranexamic acid (TXA) followed by postoperative 5 doses in total hip arthroplasty (THA) by a randomized controlled trial. METHODS Seventy-two patients who underwent primary unilateral THA between December 2017 and March 2018 were randomly divided into two groups (36 patients in each group). A single dose of 20 mg/kg TXA was administered intravenously before 5-10 minutes of operation in group A; and a single dose of 40 mg/kg TXA was administered intravenously in group B at the same time point. All patients received 5 doses of 1 g TXA at 3, 6, 12, 18, and 24 hours after the first dose. There was no significant difference in gender, age, weight, height, body mass index, disease type, and combined medical diseases between the two groups ( P>0.05). Total blood loss (TBL), lowest postoperative hemoglobin (Hb) level, fibrinolysis parameters [fibrin (ogen) degradation products (FDP), D-dimer], inflammatory factors [C-reaction protein (CRP), interleukin-6 (IL-6)], adverse events (thrombosis, pulmonary embolism) were recorded and compared between groups. RESULTS The TBL was significantly lower in group B than in group A ( P<0.05). Furthermore, the lowest postoperative Hb level was significantly higher in group B than in group A ( P<0.05). There was no significant difference in FDP and D-dimer before operation between the two groups ( P>0.05). The levels of FDP and D-dimer were significantly lower in group B than in group A at 12 and 36 hours postoperatively ( P<0.05). There was no significant difference in CRP and IL-6 before operation between the two groups ( P>0.05). The levels of CRP and IL-6 were significant lower in group B than in group A at 12, 24, and 36 hours postoperatively ( P<0.05). There was no significant difference at 14 days ( P>0.05). There were 2 patients with intramuscular venous thrombosis in group A and 1 in group B after operation, and there was no significant difference in the incidence of embolic events ( P>0.05). No deep venous thrombosis or pulmonary embolism occurred in all groups. CONCLUSION A loading high-dose TXA followed by postoperative 5 doses can further reduce the blood loss, provide additional fibrinolysis and inflammation control in THA, without increasing the risk of embolic events.
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Affiliation(s)
- Danli Cui
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yiting Lei
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Hong Xu
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Qiang Huang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Fuxing Pei
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Xu H, Xie J, Lei Y, Huang Q, Huang Z, Pei F. Closed suction drainage following routine primary total joint arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a retrospective cohort study. J Orthop Surg Res 2019; 14:163. [PMID: 31142376 PMCID: PMC6542095 DOI: 10.1186/s13018-019-1211-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In an enhanced recovery after surgery program, not placing a closed suction drain following routine primary total joint arthroplasty (TJA) is becoming more acceptable. However, the influence of drain use on transfusion rate and postoperative length of stay (PLOS) in TJA remains controversial. Therefore, we aimed to compare drain use with no drain in routine primary TJA to determine the differences in transfusion rate and PLOS. METHODS We analyzed the data from 12,992 patients undergoing primary unilateral TJA: 6325 total knee arthroplasties (TKA) and 6667 total hip arthroplasties (THA). Patients were divided into two groups according to whether they received a drain postoperatively following TKA and THA. We extracted information for transfusion and PLOS from patients' electronic health records and analyzed the data by logistic and linear regression analyses. RESULTS The transfusion rate and PLOS were 15.07% and 7.75 ± 3.61 days, respectively, in the drain group and 6.72% and 6.54 ± 3.32 days, respectively, in the no-drain group following TKA. The transfusion rate and PLOS were 20.53% and 7.00 ± 3.35 days, respectively, in the drain group and 13.57% and 6.07 ± 3.06 days, respectively, in the no-drain group following THA. After adjusting for the following variables: age, gender, body mass index, orthopedic diagnoses, hypertension, type 2 diabetes, coronary heart disease, chronic obstructive pulmonary disease, preoperative hemoglobin, albumin, analgesic use, anesthesia, American Society of Anesthesiologists class, tranexamic acid use, intraoperative bleeding, operative time, and tourniquet use (for TKA), drain use correlated significantly with a higher transfusion rate (risk ratio = 2.812, 95% confidence interval (CI) 2.224-3.554, P < 0.001 for TKA and risk ratio = 1.872, 95% CI 1.588-2.207, P < 0.001 for THA) and a longer PLOS (partial regression coefficient (B) = 1.099, 95% CI 0.879-1.318, P < 0.001, standard regression coefficient (B') = 0.139 for TKA; B = 0.973, 95% CI 0.695-1.051, P < 0.001, and B' = 0.115 for THA). Two groups showed no significant difference in wound complications. CONCLUSIONS Our findings indicated that drain use was associated with a higher transfusion rate and a longer PLOS in patients undergoing routine primary TJA. The routine use of postoperative drainage is not recommended in primary unilateral TJA.
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Affiliation(s)
- Hong Xu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Jinwei Xie
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Yiting Lei
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Qiang Huang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Zeyu Huang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Fuxing Pei
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
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Krebs NM, VanWagner MJ, Marchewka T, Faraj U, Vitale CR. Tranexamic Acid in the Treatment of Hip Fractures: A Clinical Review. Spartan Med Res J 2019; 3:7026. [PMID: 33655149 PMCID: PMC7746023 DOI: 10.51894/001c.7026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Although regularly used as a method to reduce blood loss in elective orthopedic procedures (e.g., total hip and knee arthroplasty), there currently is little evidence concerning the optimal dosage, timing and route for the use of tranexamic acid to reduce postoperative blood loss in hip fracture repair. SUMMARY OF THE EVIDENCE The current literature suggests that tranexamic acid may be used to reduce postoperative blood loss in addition to reducing the risk of requiring blood transfusions following the surgical repair of hip fractures. Furthermore, it may have the potential to improve patient outcomes and decrease the overall costs of caring for this patient population. CONCLUSIONS Further studies are needed to truly gauge the effect of tranexamic acid on long-term patient outcomes and hospital costs.
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Affiliation(s)
- Nathan M Krebs
- McLaren Macomb Orthopedic Surgery Resident, Michigan State University Statewide Campus System
| | - Michael J VanWagner
- McLaren Macomb Orthopedic Surgery Resident, Michigan State University Statewide Campus System
| | - Tiffany Marchewka
- Michigan State University College of Osteopathic Medicine Medical Student
| | - Usama Faraj
- Michigan State University College of Osteopathic Medicine Medical Student
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Magill P, Cunningham EL, Hill JC, Beverland DE. Identifying the period of greatest blood loss after lower limb arthroplasty. Arthroplast Today 2018; 4:499-504. [PMID: 30569010 PMCID: PMC6288045 DOI: 10.1016/j.artd.2018.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 11/11/2022] Open
Abstract
Background The use of tranexamic acid (TXA) in total hip replacement (THR) typically reduces blood loss by approximately 400 mL, and typical total blood loss is still approximately 1 L. A barrier to harnessing the full potential of TXA is disagreement on the optimum timing of administration. To address this, we aimed to identify the period of greatest blood loss. Methods We analyzed the perioperative data of 870 patients who had undergone THR, total knee replacement, or unicompartmental knee replacement just before the introduction of TXA to our unit. Total blood loss was calculated on postoperative day (POD) 1 and POD2 using an equation based on change in hematocrit. Results Average total blood loss at POD2 was 1505, 1322, and 611 mL for THR, total knee replacement, and unicompartmental knee replacement, respectively. Between 86% and 96% of this blood loss occurred in the period between skin closure and POD1. Intraoperative loss did not correlate with total loss at POD2. Blood transfusion was more likely if the patient was female (odds ratio [OR], 6.8) or if they had preoperative anemia (OR, 8.3) than if there was a high-volume blood loss (OR, 1.6). Conclusions Approximately 90% of blood loss occurs between skin closure and the first postoperative 24 hours. “Intraoperative blood loss” and “transfusion rate” are not reliable markers of total blood loss. The full potential of TXA could be harnessed by using it during the period of greatest blood loss, that is, during the first postoperative 24 hours.
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Affiliation(s)
- Paul Magill
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - Emma L Cunningham
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland.,Centre for Public Health, Queen's University Belfast, Northern Ireland
| | - Janet C Hill
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
| | - David E Beverland
- Primary Joint Outcomes Unit, Musgrave Park Hospital, Belfast, Northern Ireland
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Wang Z, Zhang HJ. Comparative effectiveness and safety of tranexamic acid plus diluted epinephrine to control blood loss during total hip arthroplasty: a meta-analysis. J Orthop Surg Res 2018; 13:242. [PMID: 30241543 PMCID: PMC6151011 DOI: 10.1186/s13018-018-0948-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The standard protocol to achieve haemostasis during total hip arthroplasty (THA) is uncertain. Tranexamic acid plus diluted epinephrine (DEP) and tranexamic acid (TXA) alone are the two most common alternatives. The purpose of this study was to compare the efficacy and safety of TXA plus DEP to treat blood loss in THA patients. METHODS Published randomized controlled trials (RCTs) were identified from the following electronic databases: PubMed, Embase, Web of Science, Cochrane Library and Google from inception to July 10, 2018. Studies comparing TXA plus DEP with TXA alone to treat blood loss were included. Either a random-effects model or a fixed-effects model was used for meta-analysis depending on the heterogeneity. We used the need for transfusion as the primary outcome. Stata 12.0 was used for meta-analysis. RESULTS Six studies involving 703 patients were included in the present meta-analysis. The pooled results demonstrated that TXA plus DEP was associated with a lower transfusion rate than TXA alone (RR = 0.57, 95% CI 0.38-0.86, P = 0.006). Furthermore, TXA plus DEP was associated with less total blood loss and hidden blood loss by approximately 209.79 ml and 297.74 ml, respectively, than TXA alone. There was no significant difference in terms of intraoperative blood loss or the occurrence of deep venous thrombosis or haematoma between the TXA plus DEP and TXA alone groups (P > 0.05). CONCLUSIONS Our meta-analysis suggested that TXA plus DEP significantly decreased the need for transfusion, total blood loss and hidden blood loss among THA patients. Furthermore, TXA plus DEP did not increase the occurrence of DVT or haemostasis. Additional long-term follow-up RCTs are needed to identify the optimal doses of TXA and DEP.
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Affiliation(s)
- Zhao Wang
- Department of Orthopedics, Jingjiang People’s Hospital, Jingjiang, China
| | - Hao-jie Zhang
- Department of Orthopaedics, The 82rn Hospital of People’s Liberation Army of China, No. 100, Jiankangdong Road, Huai’an, Jiangsu China
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Guo WJ, Wang JQ, Zhang WJ, Wang WK, Xu D, Luo P. Hidden blood loss and its risk factors after hip hemiarthroplasty for displaced femoral neck fractures: a cross-sectional study. Clin Interv Aging 2018; 13:1639-1645. [PMID: 30237699 PMCID: PMC6136912 DOI: 10.2147/cia.s174196] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Purpose Several authors have reported the degree of total blood loss (TBL) following hemiarthroplasty for displaced femoral neck fracture; however, the research specifically investigating on hidden blood loss (HBL) after hip hemiarthroplasty is still lacking. The purpose of this study is to evaluate the HBL in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures and to analyze its risk factors. Patients and methods From January 2015 to December 2016, 212 patients (57 males and 155 females) with displaced femoral neck fracture undergoing hip hemiarthroplasty were included in this study. The demographic and relevant clinical information of the patients were collected. According to the Gross’s formula, each patient’s height, weight, and preoperative and postoperative hematocrit were recorded and used for calculating the total perioperative blood loss and HBL. Risk factors were further analyzed by multivariate linear regression. Results The HBL was 525±217 mL, with 61.0%±13.6% in the total perioperative blood loss (859±289 mL), and the perioperative hemoglobin (Hb) loss was 23.8±7.4 g/L. Multivariate linear regression analysis revealed that HBL was positively associated with higher American Society of Anesthesiologists (ASA) classification (regression coefficient=62.169, 95% CI=15.616–108.722; P=0.009), perioperative gastrointestinal bleeding/ulcer (regression coefficient=155.589, 95% CI=38.095–273.083; P=0.010), and transfusion (regression coefficient=192.118, 95% CI=135.578–248.659; P<0.001). Compared with females, males had a risk of increased HBL (regression coefficient=87.414, 95% CI=28.547–146.280; P=0.004), and general anesthesia had an increased HBL compared with spinal anesthesia (regression coefficient=68.920, 95% CI=11.707–126.134; P=0.018). Conclusion HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures in the perioperative period, because it is a significant portion of TBL. Female patients, patients with higher ASA classification and perioperative gastrointestinal bleeding/ulcer, patients who were administered general anesthesia, or patients who underwent transfusion had a greater amount of HBL after hip hemiarthroplasty was performed. Having a correct understanding of HBL may help surgeons improve clinical assessment capabilities and ensure patients’ safety.
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Affiliation(s)
- Wei-Jun Guo
- Department of Orthopaedic Surgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Ji-Qi Wang
- Department of Orthopaedic Surgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Wei-Jiang Zhang
- Department of Orthopaedic Surgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Wei-Kang Wang
- Department of Orthopedics Trauma Surgery, RWTH Aachen University, Aachen, Germany
| | - Ding Xu
- Department of Orthopedics Trauma Surgery, RWTH Aachen University, Aachen, Germany
| | - Peng Luo
- Department of Orthopaedic Surgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
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