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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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Sivasubramanian H, Tan CMP, Wang L. Effects of local infiltration of analgesia and tranexamic acid in total knee replacements: safety and efficacy in reducing blood loss and comparability to intra-articular tranexamic acid. Singapore Med J 2024; 65:16-22. [PMID: 34617694 PMCID: PMC10863735 DOI: 10.11622/smedj.2021130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The use of periarticular (PA) tranexamic acid (TXA) and its efficacy in comparison with intra-articular (IA) TXA have not been well explored in the literature. This retrospective cohort study aimed to compare the effects of IA and PA TXA with analgesic components in reducing blood loss and improving immediate postoperative pain relief and functional outcomes in patients after unilateral primary total knee arthroplasty (TKA). METHODS A total of 63 patients underwent TKA, and they were divided into the IA TXA delivery group ( n = 42) and PA TXA delivery group ( n = 21). All patients were administered 1 g of TXA. They also received pericapsular infiltration consisting of 0.5 mL of adrenaline, 0.4 mL of morphine, 1 g of vancomycin, 1 mL of ketorolac and 15 mL of ropivacaine. Outcomes for blood loss and surrogate markers for immediate functional recovery were measured. RESULTS Of the 63 patients, 54% were female and 46% male. The mean drop in postoperative haemoglobin levels in the PA and IA groups was 2.0 g/dL and 1.6 g/dL, respectively, and this was not statistically significant ( P = 0.10). The mean haematocrit drop in the PA and IA groups was 6.1% and 5.3%, respectively, and this was also not statistically significant ( P = 0.58). The postoperative day (POD) 1 and discharge day flexion angles, POD 1 and POD 2 visual analogue scale (VAS) scores, gait distance on discharge and length of hospitalisation stay were largely similar in the two groups. CONCLUSION Our study showed that both IA and PA TXA with analgesic components were equally efficient in reducing blood loss and improving immediate postoperative pain relief and functional outcomes.
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Affiliation(s)
- Harish Sivasubramanian
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
| | - Cheryl Marise Peilin Tan
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
| | - Lushun Wang
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
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Fakharian M, Fakharian A, Keshmiri Z, Khorrami AM. Comparison of the effect of combined administration of intravenous and intra-articular tranexamic acid versus their administration alone in the management of blood loss in total knee arthroplasty: a prospective, multicenter study in Iran. BMC Musculoskelet Disord 2023; 24:974. [PMID: 38104059 PMCID: PMC10724898 DOI: 10.1186/s12891-023-07089-z] [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] [Received: 08/06/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with significant blood loss. Antifibrinolytic agents such as tranexamic acid (TXA) are widely used to manage blood loss during TKA. This study aimed to compare the efficacy of three different administration approaches of TXA in TKA. METHODS In a prospective, multicenter study, 285 patients with end-stage osteoarthritis who underwent TKA between 2020 and 2022 in three orthopedic surgery centers were included in the study. To manage bleeding during TKA, one of the three methods of intravenous administration (IV), intra-articular injection (IA), and combination administration of TXA was performed for the patients. Postoperative blood loss was calculated using blood volume and change in hemoglobin level from preoperative measurement to postoperative day 3. RESULTS The mean baseline Hemoglobin (Hb) was not significantly different between the three study groups (p > 0.05). The mean postoperative Hb of 12 h, 24 h, and 48 h after the surgery was not significantly different between the three stud groups (p > 0.05). The mean intraoperative blood loss in the combined TXA group was significantly lower compared to the IV and IA groups (0.025). The number of blood transfusions in the three study groups was not statistically significant (p > 0.05). No side effect was recorded in any group, as well. CONCLUSION Blood loss in the combination TXA group was significantly less than in the other two groups. Combination TXA can help reduce blood loss after TKA surgery.
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Affiliation(s)
- Mohammadali Fakharian
- Orthopedic Surgeon Department, Mostafa Khomeni Hospital, Shahed University of Medical Sciences, Tehran, Iran
| | - Arman Fakharian
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | | | - Amir Mohsen Khorrami
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Baharestan Square, Tehran, 1157637131, Iran.
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Yang YZ, Cheng QH, Zhang AR, Yang X, Zhang ZZ, Guo HZ. Efficacy and safety of single- and double-dose intravenous tranexamic acid in hip and knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:593. [PMID: 37563702 PMCID: PMC10413625 DOI: 10.1186/s13018-023-03929-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/13/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVE With the increasing prevalence of osteoarthritis of the hip and knee, total joint replacement, the end-stage treatment, provides pain relief and restoration of function, but is often associated with massive blood loss. Tranexamic acid (TXA) has been reported to reduce perioperative blood loss in hip or knee arthroplasty. However, the optimal dose of TXA administration remains controversial. Therefore, we performed a meta-analysis combining data from 5 trials comparing the efficacy and safety of one fixed dose of 1 g intravenously administered TXA with two doses of 1 g each administered intravenously for hip or knee arthroplasty. METHODS PubMed, Medline, Embase, Web of Science, and The Cochrane Library were searched from January 2000 to February 2023. Our meta-analysis included randomized controlled trials and cohort studies comparing the efficacy and safety of different doses of intravenous TXA (IV-TXA) for THA or TKA. The observation endpoints included total blood loss, postoperative hemoglobin drop, blood transfusion rate, length of hospital stay, incidence of deep venous thrombosis (DVT), and incidence of pulmonary embolism (PE). Meta-analysis was performed according to Cochrane's guidelines and PRISMA statement. The Danish RevMan5.3 software was used for data merging. RESULTS Five cohort studies involving 5542 patients met the inclusion criteria. Our meta-analysis showed that the two groups were significantly higher in total blood loss (mean difference (MD) = - 65.60, 95% confidence interval (CI) [- 131.46, 0.26], P = 0.05); blood transfusion rate (risk difference (RD) = 0.00, 95% CI [- 0.01, 0.02], P = 0.55); postoperative hemoglobin (MD = 0.02, 95% CI [- 0.09, 0.13], P = 0.31); postoperative hospital stay days (MD = - 0.13), 95% CI [- 0.35, 0.09], P = 0.25); DVT (RD = 0.00, 95% CI [- 0.00, 0.01], P = 0.67); PE (RD = 0.00, 95% CI [- 0.01, 0.00], P = 0.79). There was some inherent heterogeneity due to variance in sample size across each major study. CONCLUSION 1 dose of 1 g and 2 doses of 1 g IV-TXA each time have similar effects on reducing blood loss, blood transfusion rate, postoperative hemoglobin level, and postoperative hospital stay after TKA or THA, without increasing the risk of postoperative complications risk. For patients at high risk of thromboembolic events, one dose of 1 g TXA throughout surgery may be preferred. However, higher-quality RCT is needed to explore the optimal protocol dose to recommend the widespread use of TXA in total joint arthroplasty. Trial registration We conducted literature selection, eligibility criteria evaluation, data extraction and analysis on the research program registered in Prospero (CRD42023405387) on March 16, 2023.
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Affiliation(s)
- Yong-Ze Yang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, 204 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Qing-Hao Cheng
- People's Hospital of Gansu Province, 204 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - An-Ren Zhang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, 204 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Xin Yang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, 204 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Zhuang-Zhuang Zhang
- First Clinical Medical College of Gansu, University of Traditional Chinese Medicine, Lanzhou, China
- People's Hospital of Gansu Province, 204 Donggang West Road, Chengguan District, Lanzhou, 730000, China
| | - Hong-Zhang Guo
- People's Hospital of Gansu Province, 204 Donggang West Road, Chengguan District, Lanzhou, 730000, China.
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Liu H, Li J, Hu Y, Guo J, Lou T, Luo G, Chen S, Wang W, Ruan H, Sun Z, Fan C. Association Between Tranexamic Acid Use and Heterotopic Ossification Prevalence After Elbow Trauma Surgery: A Propensity-Score-Matched Cohort Study. J Bone Joint Surg Am 2023; 105:1093-1100. [PMID: 37339180 DOI: 10.2106/jbjs.22.01212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication of elbow trauma that can affect limb mobility. Inflammation is an initiating factor for HO formation. Tranexamic acid (TXA) can reduce the inflammatory response after orthopaedic surgery. However, evidence regarding the effectiveness of TXA use for HO prevention after elbow trauma surgery is lacking. METHODS This retrospective observational propensity-score-matched (PSM) cohort study was conducted from July 1, 2019, to June 30, 2021, at the National Orthopedics Clinical Medical Center, Shanghai, People's Republic of China. A total of 640 patients who underwent surgery following elbow trauma were evaluated. The present study excluded patients with an age of <18 years; those with a history of elbow fracture; those with a central nervous system injury, spinal cord injury, burn injury, or destructive injury; and those who had been lost to follow-up. After 1:1 matching on the basis of sex, age, dominant arm, injury type, open injury, comminuted fracture, ipsilateral trauma, time from injury to surgery, and nonsteroidal anti-inflammatory drug use, the TXA group and the no-TXA group comprised 241 patients each. RESULTS In the PSM population, the prevalence of HO was 8.71% in the TXA group and 16.18% in the no-TXA group (with rates of 2.07% and 5.80% for clinically important HO, respectively). Logistic regression analyses showed that TXA use was associated with a lower rate of HO (odds ratio [OR], 0.49; 95% CI, 0.28 to 0.86; p = 0.014) than no TXA use, as well as with a lower rate of clinically important HO (OR, 0.34; 95% CI, 0.11 to 0.91; p = 0.044). None of the baseline covariates significantly affected the relationship between TXA use and HO rate (p > 0.05 for all). Sensitivity analyses supported these findings. CONCLUSIONS TXA prophylaxis may be an appropriate method for the prevention of HO following elbow trauma. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hang Liu
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Juehong Li
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Yuehao Hu
- Department of Orthopaedic Surgery, Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jingyi Guo
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Tengfei Lou
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Gang Luo
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Shuai Chen
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Wei Wang
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Hongjiang Ruan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Ziyang Sun
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, People's Republic of China
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Toolyodpun S, Laoruengthana A, Kositanurit I, Podjanasupawun S, Saenghirunvattana C, Pongpirul K. Effect of multiple analgesic pathways including local infiltration analgesia, peripheral nerve blocks, and intrathecal morphine for controlling pain after total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03405-w. [PMID: 36260155 DOI: 10.1007/s00590-022-03405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND We questioned whether the triple analgesic pathways procedure via local infiltration analgesia (LIA), peripheral nerve blocks, and intrathecal morphine (ITM) is superior to LIA only for controlling pain after Total Knee Arthroplasty (TKA). METHODS This retrospective study included 192 primary TKA patients. Group A (76 patients) received LIA only, Group B (61 patients) had ITM, adductor canal block and LIA, while Group C (55 patients) received ITM, femoral nerve block and LIA. A propensity score-matched analysis was used to compare visual analog scales (VAS) for pain intensity, total amount of morphine consumption (TMC), angle of knee flexion, and length of hospital stay (LHS). RESULTS Group A showed significantly higher VAS than Group B at 12 h (4.27 ± 2.70 vs 2.42 ± 2.35) and 18 h (4.24 ± 2.35 vs 2.18 ± 2.02), and significantly higher than Group C at 6 h (3.46 ± 3.07 vs 0.60 ± 1.50), 12 h (4.27 ± 2.70 vs 0.89 ± 1.48), and 18 h postoperative (4.24 ± 2.35 vs 1.82 ± 2.18). However, the VAS of Group C and B converged to equalize with Group A after 12 and 18 h, respectively. The TMC at 48 h postoperative of Group A was higher than that of Group B (p < 0.01). Nevertheless, there was no difference between groups in terms of knee flexion and LHS, except the LHS of Group B was longer than Group A (p = 0.04). CONCLUSION Triple analgesic pathways could provide a better initial analgesic profile. However, the pain seems to be rebound after resolution of nerve block and ITM, with potentially longer LHS.
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Affiliation(s)
- Siriluk Toolyodpun
- Department of Anesthesiology, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Inthiporn Kositanurit
- Department of Anesthesiology, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand.
| | | | | | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Liu Y, Shan D, Tian P, Li ZJ, Xu GJ, Fu X. Peri-Articular Injection of Tranexamic Acid Reduce Blood Loss and Transfusion Requirement During Total Knee Arthroplasty: A Meta-analysis. Geriatr Orthop Surg Rehabil 2022; 13:21514593221101264. [PMID: 35573906 PMCID: PMC9096185 DOI: 10.1177/21514593221101264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this meta-analysis was to evaluate the efficacy and safety of peri-articular injection of tranexamic acid (TXA) during total knee arthroplasty (TKA) from clinical controlled trials. Method Eligible scientific articles published prior to October 2021 were retrieved from the PubMed, Springer, ScienceDirect and Cochrane Library databases. The statistical analysis was performed with RevMan 5.1. Result 2 RCTs and 3 non-RCTs met the inclusion criteria. Meta-analysis showed significant differences in terms of hemoglobin reduction (MD = -1.04, 95% CI: -1.33 to -.76, P < .00001), total blood loss (MD = -342.80.70, 95% CI: -437.52 to -248.08, P < .00001), drainage volume (MD = -297.24, 95% CI: -497.26 to -97.23, P = .004) and blood transfusion rate (OR = .30, 95% CI: .14 to .62, P = .001) were found in the control group. No postoperative infection and deep venous thrombosis were found between 2 groups. Conclusion Peri-articular injection of TXA can effectively decrease perioperative blood loss and blood transfusion rate without increasing the incidence of postoperative complications during TKA.
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Affiliation(s)
- Yue Liu
- Department of Minimally Invasive Spine Surgery, Tianjin Hospital Tianjin University, Tianjin, China
| | - Duo Shan
- Department of Orthopedics, Tianjin Hospital Tianjin University, Tianjin, China
| | - Peng Tian
- Department of Traumatic Orthopedics, Tianjin Hospital Tianjin University, Tianjin, China
| | - Zhi-Jun Li
- Department of Orthopedics, Tianjin Hospital Tianjin University, Tianjin, China
| | - Gui-Jun Xu
- Department of Orthopedics, Tianjin Hospital Tianjin University, Tianjin, China
| | - Xin Fu
- Department of Orthopedics, Tianjin Hospital Tianjin University, Tianjin, China
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Tan TK, Lee JY, Tay A, Kuster M. Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:709-738. [PMID: 35377071 DOI: 10.1007/s00590-022-03241-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
AIM The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | | | - Aaron Tay
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Markus Kuster
- Department of Orthopaedic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
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BASILGAN S, POLAT A, BUYUKKUSCU MO, DİNÇEL YM, YAĞMURLU F. Tranexamic acid in knee arthroplasty: the effect of preoperative intravenous administration of together with postoperative intravenous maintenance and periarticular administration on bleeding, transfusion, and hospitalization time – a retrospective cohort study. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1024881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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10
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Guler O, Çarkcı E, Çerci MH, Gümüşsuyu G, Öztürk Ç. Comparison of weight-based versus standard dosing of tranexamic acid for blood loss and transfusion amount in knee arthroplasty without tourniquet. Acta Orthop Belg 2022; 88:53-60. [PMID: 35512155 DOI: 10.52628/88.1.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of the study is to compare weight-based versus standard dosing of intravenous (IV) tranexamic acid (TXA) for blood loss and transfusion amount in total knee arthroplasty (TKA) without a tourniquet. A total of 99 patients were divided into two groups: Group 1 (standard): 1 g of IV TXA 30 min before skin incision, and 1 g at postoperative 30 min and 3 h. Group 2 (weight-based): 10 mg/kg IV TXA 30 min before the skin incision, and 10 mg/kg at postoperative 30 min, and 3 h. Hemoglobin levels, before, and 1, and 2 days after the operation, postoperative amount of decrease in hemoglobin levels, and amount of erythrocyte transfusion were recorded. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Society Score (KSS) were applied in the evaluation of TKA results preoperatively, and at 1., 3., 6., and 12. months, postoperatively. In both study groups, hemoglobin levels in male patients dropped significantly more deeply than female patients. Also, in both study groups, hemo- globin levels were significantly lower in patients with comorbid illnesses. A statistically significant difference was not detected between both groups in terms of pre- and postoperative WOMAC scores, KSS knee scores, and KSS function scores. Our study showed that standard and weight-based dosing of IV TXA treatments were similar in efficacy and safety. Both treatments reduce blood loss and the need for transfusion. Also, there was no significant difference in terms of reliability between two groups.
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Yuenyongviwat V, Dissaneewate K, Iamthanaporn K, Tuntarattanapong P, Hongnaparak T. EFFICACY OF EXTENDED ORAL TRANEXAMIC ACID ON BLOOD LOSS IN PRIMARY TOTAL KNEE ARTHROPLASTY. ACTA ORTOPÉDICA BRASILEIRA 2022; 30:e247197. [PMID: 35864836 PMCID: PMC9270054 DOI: 10.1590/1413-785220223001e247197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/12/2021] [Indexed: 11/29/2022]
Abstract
Introduction: Tranexamic acid is widely used for patients undergoing total knee arthroplasty (TKA). However, the duration of systemic tranexamic acid (TXA) administration varies in many reports. Hence, this study aims to compare blood loss between a single intravenous (IV) TXA dose, and one dose of IV TXA combined with oral TXA, during 48-hour postoperative care in primary TKA. Methods: Ninety-four patients with primary osteoarthritis, who underwent primary TKA, were randomized into two groups. The first group consisted of 47 patients and received a dose of 750 mg IV TXA and 750 mg oral TXA postoperatively at 8-hour intervals for 48 hours. In the second group, 47 patients received a single dose of IV TXA and a placebo at the same intervals for the same time duration. Hemoglobin (Hb) was measured at 4, 24 and 72 hours after operation. Results: The mean total blood loss were not different between the two groups (p=0.37). There was no difference in total Hb reduction or closed suction drainage outputs (p=0.9 and 0.07, respectively). Conclusion: The extended use of oral TXA for 48-hour postoperative care did not decrease the total blood loss following TKA compared with a single dose of IV TXA. Level Of Evidence I; High quality randomized trial .
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Abdallah AA, Sallam AA, Arafa MS, Henawy AT. Topical Tranexamic Acid in Total Knee Arthroplasty: Does It Augment the Effect of the Intravenous Administration in Patients with Moderate-to-High Risk of Bleeding? A Randomized Clinical Trial. J Knee Surg 2021; 34:1570-1578. [PMID: 32434234 DOI: 10.1055/s-0040-1710549] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study aimed to compare the superimposed clinical value of topical tranexamic acid (TXA) application when it is simultaneously combined with intravenous (IV) administration versus the use of either IV TXA alone or IA TXA alone during primary total knee arthroplasty (TKA) in patients with moderate-to-high risk of bleeding. We hypothesized that the combined administration approach will result in a more adequate reduction in the perioperative blood loss and blood transfusion rate. Ninety-four patients undergoing primary TKA were randomly allocated into intra-articular (IA) alone, IV alone, and combined group. We used 2 g of IV TXA in the IV TXA alone and combined groups 10 minutes before tourniquet deflation. However, we applied 1.5 g TXA in 100 mL isotonic saline half topically before arthrotomy closure and half retrogradely after wound closure through the drain. Follow-up period was 6 weeks. The primary outcome measures included the drainage blood volume, total blood loss, hidden blood loss, intraoperative blood loss, and the allogenic transfusion rate. Secondary outcomes included postoperative hemoglobin drop, amount of transfused blood units, thromboembolism, and wound complications. Combined administration of TXA provided significantly better results in terms of blood volume collected by the drain, total blood loss, and hidden blood loss (p < 0.01). Contrarily, the intraoperative blood loss, the allogeneic transfusion rate, and the number of transfused units were similar in all groups (p > 0.05). The subgroup analysis revealed that a combined IA and IV TXA administration significantly reduced the total blood loss in patients with either moderate or high risk of bleeding. Moreover, the degree of hemoglobin drop was significantly lesser with the combined approach. No thromboembolic complications or wound infection occurred. In conclusion, the combined use of topical and IV tranexamic acid resulted in a significant reduction in postoperative blood loss and hemoglobin level following TKA but did not influence the rate of allogeneic blood transfusion. This is a Level I, therapeutic study.
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Affiliation(s)
- Ahmed A Abdallah
- Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Ismailia, Egypt
| | - Asser A Sallam
- Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Ismailia, Egypt
| | - Mohamed S Arafa
- Department of Orthopaedic Surgery, Fayoum University Hospital, Fayoum, Egypt
| | - Ayman T Henawy
- Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Ismailia, Egypt
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13
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Xu JW, Qiang H, Li TL, Wang Y, Wei XX, Li F. Efficacy of topical vs intravenous tranexamic acid in reducing blood loss and promoting wound healing in bone surgery: A systematic review and meta-analysis. World J Clin Cases 2021; 9:4210-4220. [PMID: 34141783 PMCID: PMC8173404 DOI: 10.12998/wjcc.v9.i17.4210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/24/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been used as an anti-fibrinolytic drug for over half a century and has received much attention in recent decades.
AIM To evaluate the efficacy of topical vs intravenous TXA in reducing blood loss and promoting wound healing in bone surgery.
METHODS From the electronic resources, PubMed, Cochrane Library, Embase, ISI, and Scopus were used to perform a literature search over the last 10 years between 2010 and 2020. EndNote™ X8 was used for managing the electronic resource. Searches were performed with mesh terms. The data were retracted blindly by two independent reviewers. Random effects were used to deal with potential heterogeneity and I2 showed heterogeneity. Chi-square (I2) tests were used to quantify the extent of heterogeneity (P < 0.01 was considered statistically significant). The efficacy of topical TXA in reducing blood loss and promoting wound healing in bone surgery was compared with intravenous TXA and placebo.
RESULTS According to the research design, 1360 potentially important research abstracts and titles were discovered in our electronic searches, and 18 papers remained in agreement with our inclusion criteria. It was found that TXA reduced 277.51 mL of blood loss compared to placebo, and there was no significant difference between topical TXA and IV TXA in reducing blood loss in bone surgery. Our analyses also showed that TXA significantly reduced blood transfusion compared to placebo and there was no significant difference between topical TXA and IV TXA.
CONCLUSION The use of both topical and intravenous TXA are equally effective in reducing blood loss in bone surgery, which might be beneficial for wound healing after surgery.
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Affiliation(s)
- Jian-Wen Xu
- Nursing Department, Yangpu District Shidong Hospital, Shanghai 200438, China
| | - Hong Qiang
- Nursing Department, Yangpu District Shidong Hospital, Shanghai 200438, China
| | - Ting-Li Li
- Nursing Department, Yangpu District Shidong Hospital, Shanghai 200438, China
| | - Yi Wang
- Emergency Services Department, Yangpu District Shidong Hospital, Shanghai 200438, China
| | - Xiao-Xiao Wei
- Nursing Department, Yangpu District Shidong Hospital, Shanghai 200438, China
| | - Fei Li
- The Second Neurological Department, Yangpu District Shidong Hospital, Shanghai 200438, China
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Morales-Avalos R, Ramos-Morales T, Espinoza-Galindo AM, Garay-Mendoza D, Peña-Martínez VM, Marfil-Rivera LJ, Garza-Ocañas L, Acosta-Olivo C, Cerda-Barbosa JK, Valdés-González NL, Vílchez-Cavazos F. First Comparative Study of the Effectiveness of the Use of Tranexamic Acid against ε-Aminocapróic Acid via the Oral Route for the Reduction of Postoperative Bleeding in TKA: A Clinical Trial. J Knee Surg 2021; 34:383-405. [PMID: 31491796 DOI: 10.1055/s-0039-1696722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total primary knee replacement results in significant postoperative bleeding. There are reports that 20 to 50% of the patients require a blood transfusion, which has been related to many complications, resulting in the search for strategies to reduce bleeding. The use of oral antifibrinolytics is becoming a low cost and safe way of achieving this goal. The hypothesis of this study was that the use of oral aminocaproic acid could provide similar results to the use of oral tranexamic acid (TXA). The purpose was to compare the effects of oral aminocaproic acid as a hemostatic agent versus the use of oral TXA administered in multiple doses pre and postsurgery in patients undergoing total primary knee replacement. We enrolled 92 patients that were randomly divided into two groups: received three doses of aminocaproic acid (2,000 mg per dose) or three doses of oral TXA (1,300 mg per dose). The drugs were administered according to the following schedule: 2 hours before surgery and 6 and 12 hours after surgery. The variables that were analyzed to compare the effectiveness of the hemostatic agents were total blood loss; hidden blood loss; external blood loss; transfusion rate; intraoperative blood loss; decreases in hemoglobin and hematocrit values; surgical drainage output; visual analogue scale; and surgical complications. There were no significant differences between any of the study variables for the group receiving oral aminocaproic acid and the group receiving oral TXA (p > 0.05), with the exception of patients who received TXA, who presented with more adverse events (p = 0.04). Our study showed that the use of oral aminocaproic acid was similar to its counterpart TXA regarding the evaluated parameters. Although patients who received TXA presented an average of 140 mL less blood loss than patients in the ε-ACA group, the difference did not appear to be clinically important, the transfusion rate was very low, and there were no between-group differences in postoperative complications.
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Affiliation(s)
- Rodolfo Morales-Avalos
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Tomas Ramos-Morales
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Ana María Espinoza-Galindo
- Department of Anesthesiology, University Hospital "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Domingo Garay-Mendoza
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Víctor M Peña-Martínez
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Luis Javier Marfil-Rivera
- Department of Hemaotology, University Hospital "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Lourdes Garza-Ocañas
- Department of Pharmacology and Toxicology, Faculty of Medicine, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Carlos Acosta-Olivo
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Jessica K Cerda-Barbosa
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Nancy L Valdés-González
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
| | - Félix Vílchez-Cavazos
- Knee Unit, Department of Orthopaedics and Traumatology, University Hospital "Dr. José Eleuterio González," Universidad Autonoma de Nuevo Leon (UANL), Monterrey, Nuevo León, México
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Laoruengthana A, Rattanaprichavej P, Tantimethanon T, Eiamjumras W, Teekaweerakit P, Pongpirul K. Usefulness of an accelerometer-based navigation system in bilateral one-stage total knee arthroplasty. BMC Musculoskelet Disord 2021; 22:164. [PMID: 33568132 PMCID: PMC7877091 DOI: 10.1186/s12891-021-04027-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Bilateral one-stage total knee arthroplasty (BTKA) have increased because it provides a number of advantages. Recently, Accelerometer-based navigation (ABN) system which guide the cutting plane without intramedullary disturbance might result in less endothelial and microvascular damage. Therefore, we hypothesized that the ABN may reduce blood loss, reduce postoperative pain, and better restore BTKA alignment compared to conventional instruments. Methods We retrospectively compared 44 consecutive patients receiving ABN assisted BTKA (iBTKA) to 57 patients with conventional instruments (cBTKA). Identical pre- and post-operative care was utilized to all patients. The outcome measures assessed were hemoglobin (Hb), calculated blood loss (CBL), blood transfusion, VAS score for pain, morphine consumption, knee flexion angle, and length of stay (LOS). Radiographic assessment included mechanical axis (MA) and component positioning at 3–6 months of follow up. Results Both iBTKA and cTKA groups had equivalent demographic data. Postoperative Hb of the cBTKA group was significantly lower than those in the iBTKA group at 24 h (p = 0.02), but there was no significant difference in drain volume, CBL, and blood transfusion rate. For radiographic measures, the iBTKA group had more accurate MA and component orientation, and had a lower number of outliers than those in the cBTKA group (p ≤ 0.01), except for the sagittal femoral component angle. Conclusion The ABN assisted BTKA could not reduce blood loss or postoperative pain more than cBTKA, nor improve functional recovery. However, the ABN significantly improved the accuracy of MA and prostheses positioning. Trial registration The protocol of this study was registered in the Thai Clinical Trials Registry database No. TCTR20180731001# on 25 July 2018.
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Affiliation(s)
- Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9 Thapho, Phitsanulok, 65000, Thailand
| | - Piti Rattanaprichavej
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9 Thapho, Phitsanulok, 65000, Thailand.
| | - Thanawat Tantimethanon
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9 Thapho, Phitsanulok, 65000, Thailand
| | - Watcharapong Eiamjumras
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9 Thapho, Phitsanulok, 65000, Thailand
| | - Passakorn Teekaweerakit
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9 Thapho, Phitsanulok, 65000, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Laoruengthana A, Chaibhuddanugul N, Rattanaprichavej P, Malisorn S, Tangsripong P, Pongpirul K. Perioperative Outcomes of Patients Who Were Not Candidates for Additional Nonsteroidal Anti-inflammatory Drugs in a Multimodal Pain Control Regimen for Total Knee Arthroplasty. Clin Orthop Surg 2020; 13:160-167. [PMID: 34094006 PMCID: PMC8173236 DOI: 10.4055/cios20154] [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: 06/17/2020] [Revised: 07/26/2020] [Accepted: 07/26/2020] [Indexed: 12/03/2022] Open
Abstract
Backgroud Postoperative pain following total knee arthroplasty (TKA) may hamper patients from a rapid recovery and increase perioperative blood loss and stress on the cardiovascular system. Therefore, our objective was to assess perioperative outcomes after TKA in patients who were not candidates for the additional nonsteroidal anti-inflammatory drugs (NSAIDs) in a multimodal pain control regimen. Methods Propensity score matching for age, sex, body mass index, American Society of Anesthesiologists class, and preoperative hemoglobin level was conducted on patients undergoing unilateral TKA, and thereby 52 patients remained in each group. The control group comprised patients who received parenteral parecoxib every 12 hours during the first 48 hours after TKA. The No-NSAIDs group did not receive NSAIDs because of known contraindications. Identical postoperative pain control including intravenous patient-controlled analgesia was applied for all patients. Visual analog scale (VAS) score for pain, knee flexion, blood loss, serum cardiac troponin-T (cTnT), and length of stay (LOS) were determined. Results The No-NSAIDs group had significantly higher VAS scores in 6–96 hours and consumed more morphine at 24 hours and 48 hours after the surgery than the control group. The No-NSAIDs group had significantly less knee flexion at 48 hours (p = 0.045) and tended to have more emesis and longer LOS than the control group. The blood loss of the No-NSAIDs and control group was 552.52 mL and 397.65 mL (p = 0.02), respectively, and blood transfusion rate was 23.1% and 17.3% (p = 0.63), respectively. The cTnT of the No-NSAIDs group rose over the first 48 hours and was significantly higher than that of the control group at 48 hours. Conclusions Patients who were not candidates for NSAIDs had significantly higher pain scores and consumed more morphine after TKA. They also tended to have greater blood loss and the rising of cardiac biomarkers during the first 48 hours after TKA. Hence, these patients may benefit from supplementary analgesia and appropriate perioperative monitoring.
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Affiliation(s)
- Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | | | - Piti Rattanaprichavej
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Saran Malisorn
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Piroon Tangsripong
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Li J, Liu R, Rai S, Ze R, Tang X, Hong P. Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty. J Orthop Surg Res 2020; 15:581. [PMID: 33267906 PMCID: PMC7709322 DOI: 10.1186/s13018-020-02119-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal dosage and administration approach of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains controversial. In light of recently published 14 randomized controlled trials (RCTs), the study aims to incorporate the newly found evidence and compare the efficacy and safety of intra-articular (IA) vs. intravenous (IV) application of TXA in primary TKA. METHODS PubMed, Embase, Web of Science, and Cochrane Library were searched for RCTs comparing IA with IV TXA for primary TKA. Primary outcomes included total blood loss (TBL) and drain output. Secondary outcomes included hidden blood loss (HBL), hemoglobin (Hb) fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time. RESULT In all, 34 RCTs involving 3867 patients were included in our meta-analysis. Significant advantages of IA were shown on TBL (MD = 33.38, 95% CI = 19.24 to 47.51, P < 0.001), drain output (MD = 28.44, 95% CI = 2.61 to 54.27, P = 0.03), and postoperative day (POD) 3+ Hb fall (MD = 0.24, 95% CI = 0.09 to 0.39, P = 0.001) compared with IV. There existed no significant difference on HBL, POD1 and POD2 Hb fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time between IA and IV. CONCLUSION Intra-articular administration of TXA is superior to intravenous in primary TKA patients regarding the performance on TBL, drain output, and POD3+ Hb fall, without increased risk of perioperative complications. Therefore, intra-articular administration is the recommended approach in clinical practice for primary TKA.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Renhao Ze
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Laoruengthana A, Rattanaprichavej P, Reosanguanwong K, Chinwatanawongwan B, Chompoonutprapa P, Pongpirul K. A randomized controlled trial comparing the efficacies of ketorolac and parecoxib for early pain management after total knee arthroplasty. Knee 2020; 27:1708-1714. [PMID: 33197808 DOI: 10.1016/j.knee.2020.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/30/2020] [Accepted: 10/08/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to reduce pain after orthopedic surgery. Currently, selective COX-2 inhibitors can provide effective pain reduction with less platelet inhibition compared with conventional NSAIDs. We aimed to compare the analgesic effect and perioperative blood loss (PBL) after total knee arthroplasty (TKA) between ketorolac and parecoxib administration. METHODS We conducted a prospective randomized controlled study of 100 unilateral TKAs. The ketorolac group of 50 patients received an intraoperative periarticular injection (PAI) with 100 mg of bupivacaine and 30 mg of ketorolac. Afterwards, 30 mg of ketorolac was intravenously injected every 12 h until 48 h. In the parecoxib group of 50 patients, 20 mg of parecoxib was added to PAI, and the first intravenous dose was 20 mg followed by 40 mg every 12 h. The primary outcomes were visual analog scales (VASs) of postoperative pain, amount of morphine consumption, PBL, and blood transfusion rate. RESULTS The ketorolac group had a significantly lower VAS pain score than the parecoxib group at 6 h after TKA (2.38 ± 2.52 vs. 4.12 ± 2.86, P < 0.01). Thereafter, the VAS of both groups and total morphine consumption at 24 and 48 h were comparable. The PBLs of the ketorolac and parecoxib groups were 529.72 ± 263.02 and 402.40 ± 191.47 ml, respectively (P = 0.01). However, the blood transfusion rates between groups were not different. CONCLUSION Parecoxib provides comparable analgesic effects to ketorolac. Additionally, perioperative use of parecoxib is safe and is associated with significantly less blood loss after TKA.
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Affiliation(s)
- Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Piti Rattanaprichavej
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand.
| | - Kongpob Reosanguanwong
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | | | | | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Ye W, Liu Y, Liu WF, Li XL, Shao J. The optimal regimen of oral tranexamic acid administration for primary total knee/hip replacement: a meta-analysis and narrative review of a randomized controlled trial. J Orthop Surg Res 2020; 15:457. [PMID: 33023637 PMCID: PMC7539468 DOI: 10.1186/s13018-020-01983-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022] Open
Abstract
Background Oral tranexamic acid (TXA) has been demonstrated to reduce the blood loss in primary total knee and hip arthroplasty, but the optimal regimen of oral TXA administration is still unknown. This study aimed to find the best number of administrations of oral TXA for primary total knee and hip arthroplasty. Methods The PubMed, Embase, and Cochrane Library databases were searched for relevant studies published before March 20, 2020. Studies clearly reporting a comparison of multiple administrations of oral TXA for total hip/knee replacement were included, and the total blood loss (TBL), intraoperative blood loss (IBL), decline in hemoglobin (DHB), deep vein thrombosis (DVT), intramuscular venous thrombosis (IVT), length of hospital stay (LOS), and transfusion rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed effects or random effects model. Results Nine studies involving 1678 patients were included in this meta-analysis (TXA 1363 (one administration, 201; two administrations, 496; three administrations, 215; four administrations, 336; five administrations, 115); placebo 315); the results show that compared with placebo groups, oral TXA could significantly reduce the TBL, IBL, DHB, LOS, and transfusion rate. In addition, the incidences of IVT and DVT were similar between the TXA and placebo groups. Moreover, two administrations of oral TXA significantly reduced the TBL and DHB compared with one administration, three administrations of oral TXA were better than two administrations, and four administrations of oral TXA were better than three administrations. Conclusion Our results suggested that oral TXA could significantly reduce the blood loss and the length of hospital stay but could not increase the incidence of DVT and IVT for total joint replacement patients; additionally, the effectiveness of oral TXA administration increased as the number of administrations increased.
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Affiliation(s)
- Wei Ye
- Department of Orthopedics Medicine, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213000, China.
| | - Yafang Liu
- Department of Respiratory Medicine, The Wujin Clinical college of Xuzhou Medical University, Changzhou, 213000, China
| | - Wei Feng Liu
- Department of Orthopedics Medicine, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213000, China
| | - Xiao Long Li
- Department of Orthopedics Medicine, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213000, China
| | - Jianshu Shao
- Department of Orthopedics Medicine, Wujin Hospital Affiliated with Jiangsu University, Changzhou, 213000, China
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Amin MS, Habib MK, Rehman AU. Comparison of blood loss between intra-articular and intra-venous administration of tranexamic acid in primary total knee arthroplasty. SICOT J 2020; 6:20. [PMID: 32553103 PMCID: PMC7301632 DOI: 10.1051/sicotj/2020017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/27/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To compare the blood loss between intra-articular and intra-venous administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty. DESIGN OF STUDY It was a randomized controlled trial. Study duration and settings: This study was carried out at the Orthopedic Departments of Combined Military Hospital Lahore and Rawalpindi from Jan 2016 to March 2018. METHODOLOGY Patients of both the genders were involved this study who had age in the rage of 40-80 years undergoing primary unilateral total knee arthroplasty for degenerative conditions like osteoarthritis and rheumatoid arthritis. These patients were randomly divided into two treatment groups. Patients in IA group received intra-articular tranexamic acid while those in IV group received intravenous tranexamic acid. From all the patients, a written signed consent was taken. FINDINGS Females were predominant with male-to-female ratio of 1:3.7. The mean age of the patients was 67.3 ± 8.2 years while the mean BMI was 30.9 ± 2.9 Kg/m2. Majority (n = 191, 95.5%) of the patients had osteoarthritis while remaining 9 (4.5%) patients had rheumatoid arthritis. There was no statistically significant difference between intra-articular and intra-venous administration of tranexamic acid in terms of mean post-operative hemoglobin (9.93 ± 1.14 vs. 9.87 ± 1.26 g/dL; p-value = 0.724), mean post-operative hematocrit (34.8 ± 1.66 vs. 34.73 ± 1.27%; p-value = 0.594), and mean fall in hemoglobin (2.27 ± 0.34 vs. 2.25 ± 0.30 g/dL; p-value = 0.587) and hematocrit (2.34 ± 0.94 vs. 2.46 ± 0.28%; p-value = 0.216). CONCLUSION Intra-articular administration of tranexamic acid was found to be as effective and safe as intra-venous administration in reducing blood loss in primary total knee arthroplasty. Due to convenience, the use of intra-articular administration of tranexamic acid after primary TKA may be considered in future practice.
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Affiliation(s)
- Muhammad Suhail Amin
- Professor Orthopedic, CMH Hospital Rawalpindi and CMH Lahore Orthopedic ward, CMH Hospital Rawalpindi, Pakistan
| | - Muhammad Khurram Habib
- Assistant Professor Orthopedics, DHQ Hospital Faisalabad, Clinical Fellow, CMH Lahore, DHQ Hospital Faisalabad Orthopedics ward, Pakistan
| | - Aziz Ur Rehman
- Clinical fellow CMH Hospital Rawalpindi and CMH Lahore, Pakistan
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Pernik MN, Dosselman LJ, Aoun SG, Walker AD, Hall K, Peinado Reyes V, McDonagh DL, Bagley CA. The effectiveness of tranexamic acid on operative and perioperative blood loss in long-segment spinal fusions: a consecutive series of 119 primary procedures. J Neurosurg Spine 2020; 32:768-774. [PMID: 31978874 DOI: 10.3171/2019.11.spine191174] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine if the use of tranexamic acid (TXA) in long-segment spinal fusion surgery can help reduce perioperative blood loss, transfusion requirements, and morbidity. METHODS In this retrospective single-center study, the authors included 119 consecutive patients who underwent thoracolumbar fusion spanning at least 4 spinal levels from October 2016 to February 2019. Blood loss, transfusion requirements, perioperative morbidity, and adverse thrombotic events were compared between a cohort receiving intravenous TXA and a control group that did not. RESULTS There was no significant difference in any measure of intraoperative blood loss (1514.3 vs 1209.1 mL, p = 0.29) or transfusion requirement volume between the TXA and control groups despite a higher number of pelvic fusion procedures in the TXA group (85.9% vs 62.5%, p = 0.003). Postoperative transfusion volume was significantly lower in TXA patients (954 vs 572 mL, p = 0.01). There was no difference in the incidence of thrombotic complications between the groups. CONCLUSIONS TXA appears to provide a protective effect against blood loss in long-segment spine fusion surgery specifically when pelvic dissection and fixation is performed. TXA also seems to decrease postoperative transfusion requirements without increasing the risk of adverse thrombotic events.
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Affiliation(s)
| | | | | | | | | | | | - David L McDonagh
- 2Anesthesiology and Pain Management, UT Southwestern Medical Center Dallas, Texas
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Gianakos AL, Hurley ET, Haring RS, Yoon RS, Liporace FA. Reduction of Blood Loss by Tranexamic Acid Following Total Hip and Knee Arthroplasty: A Meta-Analysis. JBJS Rev 2019; 6:e1. [PMID: 29738409 DOI: 10.2106/jbjs.rvw.17.00103] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND This study involved a meta-analysis of 36 published studies to examine the efficacy of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss, drain output, thromboembolic complications, and hospital stay following total hip and total knee arthroplasty. This study also evaluated whether treatment with a combination of both IA and IV TXA has an effect on these outcomes. Lastly, this study attempted to analyze the method and technique of TXA administration in order to establish a best practice for its use in reducing overall blood loss in arthroplasty procedures. METHODS MEDLINE, Embase, and the Cochrane Library database were screened. Studies comparing IV TXA with IA TXA or with combined IV and IA TXA were included. Data including total blood loss, drain output, thromboembolic complications, and hospital stay, where available, were analyzed using meta-analysis with fixed effects. Results are presented as the standardized mean difference (SMD), and meta-regression was employed to explore plausible demographic contributions to heterogeneity. RESULTS Twenty-eight randomized controlled trials, 3 prospective cohort studies, and 5 retrospective cohort studies with 5,499 patients were included in this review. IA administration during total knee arthroplasty showed a significant advantage in terms of total blood loss (SMD = -0.14, 95% confidence interval [CI] = -0.027 to -0.02, I = 78.2%) and drain output (SMD = -0.30, 95% CI = -0.43 to -0.18). There was no significant difference between IV and IA administration in total hip arthroplasty. Combined IA plus IV TXA was associated with a significant reduction in blood loss versus IV TXA alone in both total knee arthroplasty and total hip arthroplasty. IV TXA dosing varied, as 14 (39%) of the studies used a weight-based approach while 22 (61%) used a standard dose. Twenty-seven (96%) of 28 studies of IA administration used standard dosing while 1 study followed a weight-based protocol. There was no difference in symptomatic thromboembolic complications, with overall rates in total knee arthroplasty and total hip arthroplasty of 1.0% and 1.0% for IV administration and 1.1% and 0.3% for IA administration, respectively. There was no difference in length of hospital stay for IV versus IA TXA administration. CONCLUSIONS IA TXA, either alone or in conjunction with IV TXA, reduces total blood loss and/or drain output in total knee arthroplasty and total hip arthroplasty. Optimal methodology remains to be clarified; however, there are substantial economic benefits of utilizing either IV or IA TXA, with greater cost benefits when using IA TXA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arianna L Gianakos
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
| | | | - R Sterling Haring
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Complex Adult Reconstruction, Department of Orthopaedic Surgery, RWJBarnabas Health - Jersey City Medical Center, Jersey City, New Jersey
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Rattanaprichavej P, Laoruengthana A, Rasamimogkol S, Varakornpipat P, Reosanguanwong K, Pongpirul K. The Effect of Prosthesis Design on Blood Loss in Simultaneous Bilateral Total Knee Arthroplasty: Closed-Box versus Open-Box Prosthesis. Clin Orthop Surg 2019; 11:409-415. [PMID: 31788163 PMCID: PMC6867911 DOI: 10.4055/cios.2019.11.4.409] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 03/25/2019] [Indexed: 01/13/2023] Open
Abstract
Background Various pre- and perioperative risk factors have been reported in association with blood loss in knee arthroplasty. However, the effect of the uncovered cancellous surface on blood loss in simultaneous bilateral total knee arthroplasty (SBTKA) by different prosthetic designs is not well elucidated. Therefore, this study aimed to compare the blood loss and transfusion rate between different knee prostheses in SBTKA and to identify risk factors that influence blood loss and transfusion after SBTKA. Methods Demographic and perioperative data of patients who underwent SBTKA using either a closed-box or an open-box femoral component of posterior-stabilized fixed-bearing (PS FB) knee system were retrospectively reviewed. The calculated blood loss (CBL) and blood transfusion rate were compared by using Student t-test and confirmed with multivariate regression analysis. Results There was no significant difference in preoperative parameters between 54 closed-box and 56 open-box PS FB TKAs. The CBL of the closed-box TKA group was 135.23 mL less (95% confidence interval [CI], −215.30 to −55.16; p = 0.001) than that of the open-box TKA group. However, the blood transfusion rates of the closed- and open-box TKA groups were not significantly different (24.1% and 38.5%, p = 0.11). For each additional minute of total operative time, 3.75 mL (95% CI, 1.75 to 5.76; p < 0.001) of blood loss was anticipated. For each additional mg/dL of preoperative hemoglobin, 71% (p < 0.001) reduction of blood transfusion probability was predicted. Conclusions The use of closed- and open-box knee prostheses resulted in a significant difference in blood loss in SBTKA. Prolonged operative time also significantly increased CBL. Therefore, strategies to control the bleeding surface and shorten operative duration may be considered if blood loss is of special concern. The preoperative hemoglobin was the only factor that affects the probability of blood transfusion in SBTKA.
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Affiliation(s)
- Piti Rattanaprichavej
- Department of Orthopedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Artit Laoruengthana
- Department of Orthopedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Supachok Rasamimogkol
- Department of Orthopedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Panapol Varakornpipat
- Department of Orthopedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Kongpob Reosanguanwong
- Department of Orthopedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Reducing red blood cell transfusion in orthopedic and cardiac surgeries with Antifibrinolytics: A laboratory medicine best practice systematic review and meta-analysis. Clin Biochem 2019; 71:1-13. [DOI: 10.1016/j.clinbiochem.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/02/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
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Blood loss reduction: effect of different knee prosthesis designs and use of tranexamic acid-a randomized controlled trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1519-1524. [PMID: 31119383 DOI: 10.1007/s00590-019-02450-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 05/17/2019] [Indexed: 01/16/2023]
Abstract
PURPOSE In regard to blood loss in total knee arthroplasty (TKA), the effect of either knee prosthesis designs or bone preparation is still unclear. While the benefit of using tranexamic acid (TXA) is well demonstrated, our study aims to determine the effect of different knee prosthesis designs uses and efficacy of blood loss reduction by different routes of TXA administration. METHODS The 228 patients undergone primary TKA were randomized to determine between open-box and closed-box prosthesis. Among each group, a second randomization was applied to categorize the patients into (1) no use of TXA (No-TXA), (2) intra-articular TXA use (IA-TXA) and (3) intravenous TXA use (IV-TXA). The calculated blood loss (CBL), drain volume (DV) and an average number of units of blood transfused (ANUBT) were blindly evaluated. RESULTS The open-box TKA had 85.60 and 63.29 ml (p = 0.02 and p < 0.01) more CBL and DV compared to closed-box TKA. The IA-TXA and IV-TXA significantly reduced CBL by 190.75 and 162.01 ml (p < 0.01 and p < 0.01) and reduced DV by 129.07 and 61.04 ml (p < 0.01 and p = 0.01), respectively, when compared to No-TXA. Patients who received IA and IV-TXA had ANUBT of 0.21 and 0.23 unit, which was significantly lower than 0.42 unit of No-TXA group (p = 0.03). CONCLUSIONS Use of the different prosthesis designs could significantly affect CBL and DV following TKA. However, the use of either design resulted in a comparable ANUBT. Regardless of prosthetic type, either IA- or IV-TXA could significantly reduce the CBL and ANUBT when compared to No-TXA.
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Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, Galassi M, Weerakul S, Pongpirul K. Intra-Articular Tranexamic Acid Mitigates Blood Loss and Morphine Use After Total Knee Arthroplasty. A Randomized Controlled Trial. J Arthroplasty 2019; 34:877-881. [PMID: 30755381 DOI: 10.1016/j.arth.2019.01.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/09/2019] [Accepted: 01/12/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used in total knee arthroplasty (TKA) for blood loss reduction. Given limited evidence on potential relationship between the TXA and improvement of pain control and functional outcome after TKA, this study aimed at comparing the blood loss, pain scores, morphine consumption, and knee flexion across the TXA administration routes. METHODS The 228 primary TKA were randomized into no TXA use (No-TXA), intra-articular TXA (15 mg/kg) use (IA-TXA), and intravenous TXA (10 mg/kg) use (IV-TXA). A multivariate regression analysis was used for comparing perioperative blood loss (PBL), drain output, average number of units of blood transfused (ANUBT), visual analogue scales (VAS) for pain, amount of morphine consumption, and knee flexion angle. RESULTS The IA-TXA and IV-TXA group had 193.26 (P < .01) and 160.30 mL (P < .01) less PBL than No-TXA, respectively. No-TXA significantly required higher ANUBT than IA-TXA and IV-TXA (P = .03). The IA-TXA group had lower VAS at 6 (P = .04), 12 (P = .03), and 24 hours (P = .02) postoperative when compared to No-TXA, while IV-TXA had no effect. The IA-TXA required 18.26 mg less total morphine at 48 hours than No-TXA (P = .02), whereas IV-TXA used insignificantly (5.31 mg; P = .31) less total morphine at 48 hours than No-TXA. Both TXA routes tended to improve knee flexion, but not statistically significant. CONCLUSION Both IA-TXA and IV-TXA could significantly reduce PBL and ANUBT. The IA-TXA could significantly mitigate VAS and morphine use after TKA. Hence, IA-TXA could minimize blood loss and may be considered as an adjunct to pain control following TKA.
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Affiliation(s)
- Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Piti Rattanaprichavej
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Supachok Rasamimongkol
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Monton Galassi
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Santi Weerakul
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Sun Q, Li J, Chen J, Zheng C, Liu C, Jia Y. Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials. BMJ Open 2019; 9:e024350. [PMID: 30696680 PMCID: PMC6352808 DOI: 10.1136/bmjopen-2018-024350] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE This study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). DESIGN This was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE). SETTING We searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration. PARTICIPANTS Patients undergoing TKA or THA. INTERVENTIONS Intravenous, topical or combined intravenous and topical TXA. RESULTS Twenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=-34.53, p=0.50), postoperative Hb levels (WMD=-0.01, p=0.96), Hb decline (WMD=-0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles. CONCLUSIONS The combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.
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Affiliation(s)
- Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jinyu Li
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jiang Chen
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chenying Zheng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chuyin Liu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yusong Jia
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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Yaghmour KM, Atkinson S, Chisari E, McDonnell SM, Khan W. Effectiveness and safety of tranexamic acid in total joint arthroplasty. J Perioper Pract 2019; 29:356-360. [PMID: 30650055 DOI: 10.1177/1750458919825812] [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: 11/17/2022]
Abstract
Total joint arthroplasty is associated with significant blood loss, that could result in the need of blood transfusions. Several techniques are being utilised to limit the volume of blood loss, in order to avoid transfusion. In this review, we look at blood loss in total joint arthroplasty and the perioperative strategies to limit the loss of blood. With the use of tranexamic acid gaining popularity, we analyse the published literature on its use in patients undergoing total joint arthroplasty. We have found that published studies favour using tranexamic acid in total joint arthroplasty as a safe and effective method of reducing blood loss.
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Affiliation(s)
- Khaled M Yaghmour
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Sam Atkinson
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Emanuele Chisari
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico, University of Catania, Catania, Italy
| | - Stephen M McDonnell
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Wasim Khan
- Division of Trauma & Orthopaedics Surgery Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Han X, Gong G, Han N, Liu M. Efficacy and safety of oral compared with intravenous tranexamic acid in reducing blood loss after primary total knee and hip arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2018; 19:430. [PMID: 30509227 PMCID: PMC6278110 DOI: 10.1186/s12891-018-2358-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/22/2018] [Indexed: 01/02/2023] Open
Abstract
Background Tranexamic acid (TXA) is an anti-fibrinolytic agent successfully preventing blood loss when using intravenously (IV) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). An oral administration, which is available on blood sparing, has been reported exhibit profound cost-saving benefits. The aim of this meta-analysis is to investigate whether the administration of oral and intravenous tranexamic acid postoperatively has equivalent blood-sparing properties in these patients. Methods The online electronic databases were searched for eligible literatures updated on September 2018. Studies assessing the effect between oral TXA and intravenous TXA (IV-TXA) in those undergoing TKA or THA were included. All the data were pooled with the corresponding 95% confidence interval (CI) using RevMan software. Based on the heterogeneity, we performed a systematic analysis to explore the overall results across the included studies. Results Nine studies met our inclusion criteria. No significant differences were identified with regard to the Hb drop (SMD = − 0.03,95%CI = − 0.18–0.12, P = 0.67), total Hb loss (SMD = 0.10,95%CI = − 0.06–0.26, P = 0.24), total blood loss (SMD = − 0.00,95%CI = − 0.20–0.20, P = 1.00), transfusion rate (OR = 0.77,95%CI = 0.54–1.10, P = 0.14), DVT rate (OR = 0.58,95%CI = 0.19–1.75, P = 0.33), and length of hospital stay (SMD = − 0.05,95%CI = − 0.28–0.17, P = 0.63) between the oral groups and intravenous group. Conclusion The blood-sparing efficacy of oral TXA is similar to that of the intravenous forms in the setting of THA and TKA. Considering the cost-benefit superiority and ease of administration of oral TXA, further studies and clinical trials are required to further identify the optimal administration for THA and TKA.
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Affiliation(s)
- Xiaozhen Han
- Department of Orthopedics, Jinan Zhangqiu District Hospital of Traditional Chinese Medicine, No. 1463 Xiushui Street,Mingshui subdistrict office, Zhangqiu district, Jinan, 250200, Shandong, China
| | - Guiqing Gong
- Department of Orthopedics, Jinan Zhangqiu District Hospital of Traditional Chinese Medicine, No. 1463 Xiushui Street,Mingshui subdistrict office, Zhangqiu district, Jinan, 250200, Shandong, China
| | - Naili Han
- Clinical Laboratory, Jinan Zhangqiu District Hospital of Traditional Chinese Medicine, No. 1463 Xiushui Street,Mingshui subdistrict office, Zhangqiu district, Jinan, 250200, Shandong, China
| | - Mei Liu
- Department of Intensive Care Unit, Wuhan No.1 Hospital, No.215 Zhongshan Ave, Wuhan, 430022, Hubei, China.
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The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis. J Arthroplasty 2018; 33:3090-3098.e1. [PMID: 29805106 DOI: 10.1016/j.arth.2018.04.043] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty. METHODS We searched Ovid MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases for publications before July 2017 on TXA in primary total joint arthroplasty. All included studies underwent qualitative and quantitative homogeneity testing. Direct and indirect comparisons were performed as a network meta-analysis, and results were tested for consistency. RESULTS After critical appraisal of the available 2113 publications, 67 articles were identified as representing the best available evidence. Topical, intravenous (IV), and oral TXA formulations were all superior to placebo in terms of decreasing blood loss and risk of transfusion, while no formulation was clearly superior. Use of repeat IV and oral TXA dosing and higher doses of IV and topical TXA did not significantly reduce blood loss or risk of transfusion. Preincision administration of IV TXA had inconsistent findings with a reduced risk of transfusion but no effect on volume of blood loss. CONCLUSIONS Strong evidence supports the efficacy of TXA to decrease blood loss and the risk of transfusion after primary TKA. No TXA formulation, dosage, or number of doses provided clearly improved blood-sparing properties for TKA. Moderate evidence supports preincision administration of IV TXA to improve efficacy.
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Xiong H, Liu Y, Zeng Y, Wu Y, Shen B. The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2018; 19:321. [PMID: 30193586 PMCID: PMC6129000 DOI: 10.1186/s12891-018-2181-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/10/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The combined administration of intravenous (IV) and topical tranexamic acid (TXA) in primary total knee (TKA) knee remains controversial. The purpose of this meta-analysis was to assess the efficacy and safety of combined administration of IV and topical TXA in primary TKA. METHODS PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Google Search Engine and China National Knowledge Infrastructure databases were searched for randomized controlled trials (RCTs) were comparing the combined administration of IV and topical TXA following primary TKA. The primary outcomes were total blood loss, maximum hemoglobin drop, and deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The second outcomes were drainage volume and transfusion requirements. Data were analyzed using RevMan 5.3. RESULTS A total of 6 RCTs involving 701 patients were included in the meta-analysis. The combined group provided lower total blood loss (MD - 156.34 mL, 95% CI, - 241.51 to - 71.18; P = 0.0003), drainage volume (MD - 43.54 mL, 95% CI, - 67.59 to - 19.48; P = 0.0004), maximum hemoglobin drop (MD - 0.56 g/dl, 95% CI, - 0.93 to - 0.19; P = 0.003) than IV TXA alone. No significant difference were found in terms of transfusion requirements (RR 0.48, 95% CI, 0.16 to 1.44; P = 0.19), DVT (RR 1.01, 95% CI, 0.14 to 7.12; P = 0.99) and PE (RR 0.33, 95% CI, 0.01 to 7.91; P = 0.49) between the two group. Subgroup analyses shows that the combined group was less total blood loss in non-tourniquet (P = 0.0008), topical TXA dose > 1.5 g (P < 0.00001) and number of IV TXA ≥ 2 doses (P = 0.005) of TXA compared with the IV group alone. CONCLUSIONS The available evidence indicates combined group were associated with lower total blood loss, drainage volume, and maximum hemoglobin drop. A similar transfusion requirement was found in both groups. Subgroup analyses demonstrates that total blood loss was less in patients with non-tourniquet, topical TXA dose > 1.5 g and number of IV TXA ≥ 2 doses of TXA. There was no increase the rates of DVT and PE.
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Affiliation(s)
- Huazhang Xiong
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China.,Department of Orthopedic Surgery, The First Affiliated Hospital of Zunyi Medical College, Zunyi, 563003, Guizhou Province, China
| | - Yi Liu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zunyi Medical College, Zunyi, 563003, Guizhou Province, China
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, People's Republic of China.
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Stoicea N, Moran K, Mahmoud AR, Glassman A, Ellis T, Ryan J, Granger J, Joseph N, Salon N, Ackermann W, Rogers B, Niermeyer W, Bergese SD. Tranexamic acid use during total hip arthroplasty: A single center retrospective analysis. Medicine (Baltimore) 2018; 97:e10720. [PMID: 29794747 PMCID: PMC6392984 DOI: 10.1097/md.0000000000010720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent that has shown promise in reducing blood loss during total hip arthroplasty (THA). Several studies have reported side effects of high-dose TXA administration, including myocardial infarction (MI), thromboembolic events, and seizures. These possible side effects have prevented the widespread adoption of TXA in the surgical community. METHODS We conducted a retrospective chart review of 564 primary and revision THAs performed at a single academic center. Surgical patients received either no TXA or 1 g IV TXA at the beginning of surgery followed by a second bolus just before the surgical wound closure, at the surgeon's discretion. We analyzed differences in hemoglobin (Hb), hematocrit (Hct), estimated blood loss (EBL), and adverse events in patients receiving TXA versus patients not receiving TXA up to 2 days following surgery. RESULTS Significantly higher Hb and Hct values were found across all time points among patients undergoing primary posterior or revision THA who had received TXA. In addition, transfusion rates were significantly decreased in both primary posterior THAs and revision THAs when TXA was administered. Patients who received TXA experienced significantly fewer adverse events than those who did not for all surgery types. CONCLUSION Administration of low-dose intravenous (IV) and intra-articular (IA) TXA does not appear to increase rates of adverse events and may be effective in minimizing blood loss, as reflected by Hb and Hct values following THA.
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Affiliation(s)
| | | | - Abdel-Rasoul Mahmoud
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Andrew Glassman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | | | - John Ryan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | - Jeffrey Granger
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | | | - Nathan Salon
- Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL
| | | | | | | | - Sergio D. Bergese
- Department of Anesthesiology
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Comparing the efficacy of intravenous or intra-articular tranexamic acid in reducing blood loss in simultaneous bilateral knee replacement surgery without the use of tourniquet. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1417-1420. [PMID: 29594528 DOI: 10.1007/s00590-018-2194-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 03/21/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To compare the effect of intravenous or intra-articular route of administration of tranexamic acid in reducing the blood loss in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquets. METHODS Prospective cohort study of 30 consecutive patients grouped into two groups; Group 1: intravenous group and group 2: intra-articular group. Two outcome measures were studied; mean drop in post-operative haemoglobin and need for blood transfusion in both groups. RESULTS No significant difference in mean drop of haemoglobin and need for blood transfusion in both groups. CONCLUSION Route of administration of tranexamic acid does not influence on the mean drop of haemoglobin and need for blood transfusion in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquet.
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Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, Tinmouth A, Lavallée LT, Fergusson DA, Breau RH. The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis. Transfus Med Rev 2018; 32:S0887-7963(17)30151-7. [PMID: 29567052 DOI: 10.1016/j.tmrv.2018.02.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 12/21/2022]
Abstract
Tranexamic acid (TXA) is an effective hemostatic agent used for the reduction of blood loss and transfusion. However, the safety profile of TXA remains in question due to a potential increased risk of venous thromboembolism. By applying TXA topically as opposed to intravenously, systemic absorption may be reduced and unwanted side-effects mitigated. The objective of our review is to investigate the efficacy and safety of topically applied tranexamic acid compared to both placebo, and the intravenous administration. Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ISI Web of Science, PubMed, and Clinicaltrials.gov were searched from inception to November, 2016. We included randomized controlled trials that compared topical tranexamic acid to either placebo (or standard care) or intravenous administration, in adult patients. Surgical and non-surgical trials were included. Abstract, full-text selection, data extraction and risk of bias assessment were all performed in duplicate. In total, 67 studies involving 6,034 patients met inclusion criteria. The majority of trials evaluated orthopedic procedures. Compared to placebo, the administration of topical TXA significantly reduced the odds of receiving a blood transfusion (pooled OR 0.28, 95% CI 0.20 to 0.38; P < 0.001) and significantly reduced mean blood loss (WMD -276.6, 95% CI -327.8 to -225.4; P < 0.0001). When compared to the intravenous administration, there was no difference between the two groups in terms of transfusion requirements (pooled OR 1.03, 95% CI 0.72 to 1.46; P=0.88) or blood loss (WMD -21.95, 95% CI -66.61 to 27.71; P=0.34). There was no difference in the odds of developing a venous thromboembolic complication between the topical TXA and control groups (pooled OR=0.78, 95% CI 0.47 to 1.29; P=0.33) or the topical and intravenous groups (pooled OR=0.75, 95% CI 0.39 to 1.46; P=0.40). The topical application of TXA effectively reduces both transfusion risk and blood loss compared to placebo, without increasing thromboembolic risks. There were no major differences between topical and intravenous tranexamic acid with respect to safety and efficacy, and both were superior to placebo with regards to blood loss and transfusion requirements. Further study of the topical application is required outside of the field of orthopedics.
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Affiliation(s)
- Joshua Montroy
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada
| | - Preveshen Moodley
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nicholas A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Luke T Lavallée
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; University of Ottawa, School of Epidemiology, Community Medicine and Preventive Medicine, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
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Subramanyam KN, Khanchandani P, Tulajaprasad PV, Jaipuria J, Mundargi AV. Efficacy and safety of intra-articular versus intravenous tranexamic acid in reducing perioperative blood loss in total knee arthroplasty: a prospective randomized double-blind equivalence trial. Bone Joint J 2018; 100-B:152-160. [PMID: 29437056 DOI: 10.1302/0301-620x.100b2.bjj-2017-0907.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIMS The aims of this study were to compare the efficacy and safety of intra-articular and intravenous (IV) tranexamic acid (TXA) in controlling perioperative blood loss in total knee arthroplasty (TKA) using a randomized, double-blinded equivalence trial. PATIENTS AND METHODS A total of 182 patients aged between 45 and 75 years undergoing unilateral TKA at a tertiary centre were randomized to receive TXA, either 1.5 g intra-articularly after closure of the wound (n = 91) or two doses of 10 mg/kg IV (n = 91). The primary outcome measure was the reduction in the level of haemoglobin (Hb) in the blood on the fifth postoperative day. Secondary outcome measures were the total, visible, and hidden blood losses (TBL, VBL, HBL). We assumed equivalence of the primary outcome in both routes with a margin of ± 0.35gm/dl. Block randomization using computer-generated random numbers was used. The patients and the assessor of outcome were blinded. RESULTS All patients completed the study. The mean difference in the reduction of the level of Hb between the two groups was -0.0055 gm/dl, with two-sided 95% confidence interval (CI) being -0.29 to 0.27, well within the predefined equivalence margin of ± 0.35gm/dl. The groups were comparable with regard to TBL, VBL, HBL, and complications. No patient needed a blood transfusion. CONCLUSION A single intra-articular dose and two IV doses of TXA give equivalent efficacy and safety in the management of blood loss at TKA. Cite this article: Bone Joint J 2018;100-B:152-60.
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Affiliation(s)
- K N Subramanyam
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - P Khanchandani
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - P V Tulajaprasad
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - J Jaipuria
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
| | - A V Mundargi
- Sri Sathya Sai Institute of Higher Medical Sciences-Prasanthigram, Puttaparthi, Andhra Pradesh 515134, India
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Prakash J, Seon JK, Song EK, Lee DH, Yang HY, Jin C. Is Combined Administration of Tranexamic Acid Better than Both Intravenous and Topical Regimes for Total Loss, Hidden Loss and Post-operative Swelling? A Randomized Control Trial. Indian J Orthop 2018; 52:117-123. [PMID: 29576638 PMCID: PMC5858204 DOI: 10.4103/ortho.ijortho_179_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bleeding is one of the unavoidable complications of total knee arthroplasty (TKA). Tranexamic acid (TXA) in last decade has emerged as an effective and safe way to decrease postoperative bleeding and transfusion rates. Although there is little doubt on the efficacy of the drug, the debate on ideal mode is more recent. We undertook this study to find out the most effective and yet safest way of TXA administration. MATERIALS AND METHODS A single institution - two hospital-based, double-blinded, prospective, randomized control trial was conducted from January 2015 to December 2015. One hundred and fifty patients were randomly divided in one of the three groups using computer-generated tables - intravenous (IV), intraarticular and combined. Evident loss through drain, total loss based on gross method and hemoglobin balance method, hidden blood losses, hemoglobin, and hematocrit drop, all possible complications related to TXA were evaluated and compared among groups. The analysis of variance and Tukey's post hoc were used for continuous outcome variables and Chi-square test for binary outcome variables. RESULTS Evident loss in combined group was 574.25 ± 209.8 ml, significantly less than IV (685.4 ± 289.9 ml) and intraarticular group (724.3 ± 246.8 ml). Total loss was similarly least for combined group (930.1 ± 262.2 ml) compared to IV (1208.3 ± 368.8 ml) and intraarticular group (1198.1 ± 356.8 ml). There were no transfusions in combined group compared to five in IV and four in intraarticular group. Combined group also had least hidden losses after surgery. No patients in any group developed symptomatic deep venous thrombosis. CONCLUSION Combined administration of drug is most effective way to decrease postoperative bleeding and requirement of transfusion in unilateral TKA without increasing any risk of complications.
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Affiliation(s)
- Jatin Prakash
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Korea
| | - Jong-Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Korea
| | - Eun-Kyoo Song
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Korea,Address for correspondence: Prof. Eun-Kyoo Song, Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, 80, Deongnam-gil, Nam-gu, Gwangju, 503-340, Korea. E-mail:
| | - Dong-Hyun Lee
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Korea
| | - Hong-Yeol Yang
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Korea
| | - Cheng Jin
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Korea
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Topical Tranexamic Acid Reduces Blood Loss in Minimally Invasive Total Knee Arthroplasty Receiving Rivaroxaban. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9105645. [PMID: 29410968 PMCID: PMC5749315 DOI: 10.1155/2017/9105645] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/19/2017] [Accepted: 10/04/2017] [Indexed: 02/07/2023]
Abstract
Background It is unclear whether topical (intra-articular) or intravenous TXA reduces blood loss in minimally invasive TKA patients receiving a direct oral anticoagulant for thromboprophylaxis. This study is to investigate whether TXA given intravenously or intra-articularly is effective in reducing blood loss in minimally invasive TKA patients using rivaroxaban for thromboprophylaxis. Methods Ninety-three patients who underwent primary minimally invasive TKA were divided into placebo group (30 patients) that received saline both intravenously and intra-articularly, intravenous (IV) group (31 patients) that received 1 g TXA intravenously, and topical group (32 patients) that received 3 g TXA in 100 ml saline intra-articularly. All patients received oral rivaroxaban of 10 mg daily for 14 days postoperatively. Results p < 0.001 and p = 0.041. The mean total blood loss was 1131 mL (567–1845) in placebo, which was higher than that in the IV group (921 mL; range, 465–1495; p = 0.014) and the topical group (795 mL; range, 336–1350; p < 0.001). The total blood loss did not differ between the IV and the topical group (p = 0.179). Conclusion This prospective, randomized, controlled trial demonstrated an equal efficacy of TXA in blood conservation when administered intravenously or topically in minimally invasive TKA patients receiving rivaroxaban for thromboprophylaxis.
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Boutsiadis A, Reynolds RJ, Saffarini M, Panisset JC. Factors that influence blood loss and need for transfusion following total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:418. [PMID: 29201870 DOI: 10.21037/atm.2017.08.11] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Blood loss during total knee arthroplasty (TKA) remains a concern, as many patients require blood transfusions, which increase risks of allergic reactions, disease transmission, and thromboembolisms. The purpose was to determine factors associated with blood loss and need for transfusion in patients receiving routine TKA. Methods The authors prospectively analyzed 150 consecutive uncemented TKAs for age, gender, body mass index (BMI), anticoagulant medication, type of anesthesia, tranexamic acid (TXA) administration, tourniquet inflation, drain placement, pre- and post-operative Haemoglobin (Hb) level (g/dL), and whether transfusion was necessary. Univariable and multivariable regression analyses were performed to identify factors associated with Hb loss and need for transfusion with significance level set at P value<0.05. Results The cohort comprised 92 women and 58 men, aged 69.5±8.9 years. The mean Hb loss was 3.7±1.3 g/dL. The 20 patients (13%) who had transfusions also had lower preoperative Hb (12.6±1.2 g/dL) compared to the remaining patients (14.3±1.2 g/dL). Hb loss was significantly associated with preoperative Hb, TXA, and gender, but multivariable regression identified gender as a confounder and indicated that TXA reduced Hb loss by 0.92 g/dL. Multivariable regression revealed the need for transfusion was only significantly associated with preoperative Hb and indicated that a decrease of preoperative Hb by 1 g/dL nearly quadrupled the chances of needing transfusion. Conclusions Hb loss was significantly associated with preoperative Hb levels and use of TXA, while the need for transfusion was only associated with preoperative Hb levels. These findings could help identify patients at risk for blood transfusions. Level of evidence: level III, prospective case series.
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Affiliation(s)
- Achilleas Boutsiadis
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | | | - Mo Saffarini
- Medical Technology, ReSurg SA, Nyon, Switzerland
| | - Jean-Claude Panisset
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
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Yuan X, Li B, Wang Q, Zhang X. Comparison of 3 Routes of Administration of Tranexamic Acid on Primary Unilateral Total Knee Arthroplasty: A Prospective, Randomized, Controlled Study. J Arthroplasty 2017; 32:2738-2743. [PMID: 28455182 DOI: 10.1016/j.arth.2017.03.059] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/13/2017] [Accepted: 03/25/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The mode of administration for tranexamic acid (TXA) to significantly reduce the decrease in hemoglobin (Hb), number of transfusions, relevant costs, and side effects in patients undergoing primary unilateral total knee arthroplasty (TKA) has not been resolved. METHODS A total of 560 patients undergoing primary unilateral TKA were randomized into 4 groups: intravenous group (140 patients receiving 2 doses of 20 mg/kg intravenous TXA), topical group (140 patients administered 3.0 g topical TXA), oral group (140 patients given 2 doses of 20 mg/kg oral TXA), and a control group (140 patients not given TXA). The primary outcomes included postoperative 48-hour Hb loss and drainage volume, number of transfusions, transfusion and TXA costs, and thromboembolic complications. Secondary outcomes were postoperative inpatient time and wound healing 3 weeks after TKA. RESULTS Baseline data among the 4 groups were similar. The 48-hour Hb loss and drainage volume in the intravenous, topical, and oral groups were significantly less (P < .05) than those in the control group, and the latter had significantly more transfusions and transfusion costs than the other 3 groups (P < .05). The TXA cost was lowest in the oral group compared with that in the topical and intravenous groups (P < .05). No differences in thromboembolic complications, postoperative inpatient time, or wound healing were observed among the groups. However, wound dehiscence and continuous wound discharge occurred in the topical group. CONCLUSION All the 3 modes of TXA administration significantly reduced postoperative Hb loss, the number of transfusions, and transfusion costs compared with those in the control group. No pulmonary embolism or infection was observed. Oral TXA is recommended because it provided a similar clinical benefit and resulted in the lowest TXA cost compared with the other 2 modes of TXA administration.
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Affiliation(s)
- Xiangwei Yuan
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Li
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiaojie Wang
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xianlong Zhang
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Sridharan K, Sivaramakrishnan G. Tranexamic Acid in Total Knee Arthroplasty: Mixed Treatment Comparisons and Recursive Cumulative Meta-Analysis of Randomized, Controlled Trials and Cohort Studies. Basic Clin Pharmacol Toxicol 2017; 122:111-119. [DOI: 10.1111/bcpt.12847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/04/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Kannan Sridharan
- Pharmacology; School of Health Sciences; College of Medicine, Nursing and Health Sciences; Fiji National University; Suva Fiji Islands
| | - Gowri Sivaramakrishnan
- Prosthodontics; School of Oral Health; College of Medicine, Nursing and Health Sciences; Fiji National University; Suva Fiji Islands
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Lee SY, Chong S, Balasubramanian D, Na YG, Kim TK. What is the Ideal Route of Administration of Tranexamic Acid in TKA? A Randomized Controlled Trial. Clin Orthop Relat Res 2017; 475:1987-1996. [PMID: 28283902 PMCID: PMC5498377 DOI: 10.1007/s11999-017-5311-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/01/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND TKA commonly involves substantial blood loss and tranexamic acid has been used to reduce blood loss after TKA. Numerous clinical trials have documented the efficacy and safety of intravenous (IV) or intraarticular (IA) use of tranexamic acid. Combined administration of tranexamic acid also has been suggested; however, there is no consensus regarding the ideal route of tranexamic acid administration. QUESTIONS/PURPOSES (1) To compare the efficacy of tranexamic acid in terms of total blood loss and the allogeneic transfusion rate among three routes of administration: IV alone, IA alone, and combined IV and IA. (2) To compare these regimens in terms of venous thromboembolism (VTE) and the frequency of wound complications. METHODS In total, 376 patients undergoing TKA between March 2014 and March 2015 were randomized to four groups by the route of tranexamic acid administration: IV only, IA only, low-dose combined (IV + IA injection of 1 g), and high-dose combined (IV + IA injection of 2 g). The calculated total blood loss, allogeneic transfusion rate, decrease in hemoglobin, the frequency of symptomatic deep vein thrombosis and pulmonary embolism, wound complications, and periprosthetic joint infection were compared among the groups. Total blood loss was calculated using estimated total body blood volume and hemoglobin loss. The decision regarding when to transfuse was determined based on preset criteria. RESULTS The high- and low-dose combined groups and the IA-only group had lower total blood loss (564 ± 242 mL, 642 ± 242 mL, and 633 ± 205 mL, respectively) than the IV-only group (764 ± 217 mL; mean differences = 199 mL [95% CI, 116-283 mL], p < 0.001; 121 mL [95% CI, 38-205 mL], p = 0.001; 131 mL [95% CI, 47-214 mL], p < 0.001); no differences were found among the other three groups. No patients in any study group received an allogeneic transfusion. One patient in the IV-only group had a symptomatic pulmonary embolism develop, but no other symptomatic VTE events occurred in any group. In addition, no differences were observed in wound complications, such as superficial wound necrosis (one patient in the IV-only and the high-dose combined group, respectively) and oozing (IV-only, IA-only, low-dose combined, high-dose combined = 3%, 4%, 4%, and 7%; p = 0.572) between the groups. No patients had a periprosthetic joint infection. CONCLUSION IA tranexamic acid administration further reduces blood loss after TKA in comparison to IV use alone; no additional effect in further reducing blood loss was found in combination with IV tranexamic acid. Appropriately powered studies are needed to confirm the safety of this route of administration as the preferred route of administration in TKA. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Sung Yup Lee
- Joint Reconstruction Center, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Suri Chong
- Joint Reconstruction Center, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Dhanasekaraprabu Balasubramanian
- Joint Reconstruction Center, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Young Gon Na
- Department of Orthopaedic Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Tae Kyun Kim
- Joint Reconstruction Center, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
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Mayer M, Naylor J, Harris I, Badge H, Adie S, Mills K, Descallar J. Evidence base and practice variation in acute care processes for knee and hip arthroplasty surgeries. PLoS One 2017; 12:e0180090. [PMID: 28723917 PMCID: PMC5516983 DOI: 10.1371/journal.pone.0180090] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 06/10/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Lack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence. METHODS Part 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients. RESULTS Continuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely. CONCLUSION Recommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.
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Affiliation(s)
- Marcel Mayer
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, UNSW, Randwick, Australia
- Technical University Munich, Munich, Bavaria, Germany
| | - Justine Naylor
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, UNSW, Randwick, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Ian Harris
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, UNSW, Randwick, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Helen Badge
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, UNSW, Randwick, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Sam Adie
- South Western Sydney Clinical School, UNSW, Randwick, Australia
| | | | - Joseph Descallar
- South Western Sydney Clinical School, UNSW, Randwick, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
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Mi B, Liu G, Zhou W, Lv H, Liu Y, Zha K, Wu Q, Liu J. Intra-articular versus intravenous tranexamic acid application in total knee arthroplasty: a meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2017; 137:997-1009. [PMID: 28378211 DOI: 10.1007/s00402-017-2683-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND The purpose of this meta-analysis was to compare the blood loss and complications of intra-articular (IA) with intravenous (IV) tranexamic acid (TXA) for total knee arthroplasty (TKA). METHODS A comprehensive search of studies was conducted to identify related articles in Pubmed, Embase, Cochrane central Register of Controlled Trials, springerLink, OVID and the Research published from January 1980 to September 2016. All studies that compared IA TXA with IV TXA application on TKA were included. Main outcomes of the two methods were collected and analyzed by using Review Manager 5.3. RESULTS There were 16 randomized controlled trials with 1308 cases met the criteria. Compared with IV TXA, IA TXA had similar blood volume of drainage, hidden blood loss, transfusion rate and complications (P > 0.05). IA TXA had lower total blood loss than IV TXA, and there was significant difference (P < 0.05). Subgroup analysis of total blood loss based on times of IV TXA administration showed that repeat dose of IV TXA had a higher total blood loss and postoperative hemoglobin drop (P < 0.05) than IA TXA. However, single dose of IV TXA had a similar efficacy on total blood loss and postoperative hemoglobin drop (P > 0.05) when compared with IA TXA. CONCLUSIONS Both IA TXA and single dose of IV TXA are effective in reducing total blood loss and postoperative hemoglobin drop without increasing complications of DVT or PE. The current meta-analysis suggests that 1.5 g TXA by IA administration or 1 g TXA by IV administration 10 min before tourniquet deflation is effective and safe in patients undergoing TKA.
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Affiliation(s)
- Bobin Mi
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China.
| | - Wu Zhou
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Huijuan Lv
- Deparetment of Rheumatology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yi Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Kun Zha
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Qipeng Wu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
| | - Jing Liu
- Department of Orthopedics, Union Hospital, Huazhong University of Science and Technology, 1277, Jie fang Avenue, Wuhan, China
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Chen JY, Chin PL, Moo IH, Pang HN, Tay DKJ, Chia SL, Lo NN, Yeo SJ. Reply to letter to the editor on "Intravenous versus intra-articular tranexamic acid in total knee arthroplasty: A double-blinded randomised controlled noninferiority trial". Knee 2017; 24:700-701. [PMID: 28215979 DOI: 10.1016/j.knee.2016.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
| | - Pak Lin Chin
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Ing How Moo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Hee Nee Pang
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Shi-Lu Chia
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Ngai Nung Lo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Seng Jin Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Moo IH, Chen JYQ, Pagkaliwaga EH, Tan SW, Poon KB. Bone Wax Is Effective in Reducing Blood Loss After Total Knee Arthroplasty. J Arthroplasty 2017; 32:1483-1487. [PMID: 28089184 DOI: 10.1016/j.arth.2016.12.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 12/11/2016] [Accepted: 12/15/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with major blood loss and blood transfusion is often required. This study aimed to evaluate the efficacy of bone wax in reducing blood loss and transfusion rates after TKA. METHODS A prospective randomized controlled study that included 100 patients undergoing primary unilateral TKA with cement was conducted in a tertiary center between March 2014 and June 2014. The bone wax group received 2.5 g of bone wax, applied onto the uncovered bone around the prostheses and the nail holes before the tourniquet was released, whereas the control group had hemostasis achieved using electrocautery only. Total blood loss was calculated using the hemoglobin balance method. RESULTS There were no demographic differences between the 2 groups. The preoperative serum hemoglobin levels were comparable between the 2 groups. The drop in serum hemoglobin levels at 24 h post-TKA was 1.6 ± 0.9 and 2.1 ± 1.1 g/dL in the bone wax and control groups respectively (P = .021), while the drop in serum hemoglobin levels at 72 h post-TKA was 2.7 ± 1.1 and 3.6 ± 1.2 g/dL respectively (P = .013). Total blood loss at 72 h post-TKA was 987.9 and 1183.5 mL for the bone wax and control groups respectively (P = .017). There was no adverse event associated with the use of bone wax at the 3-month follow-up. CONCLUSION The application of bone wax in TKA was safe and effective for reducing total blood loss and maintaining higher hemoglobin levels.
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Affiliation(s)
- Ing H Moo
- Department of Orthopaedics Surgery, Changi General Hospital, Singapore
| | - Jerry Y Q Chen
- Department of Orthopaedics Surgery, Changi General Hospital, Singapore
| | | | - See W Tan
- Department of Orthopaedics Surgery, Changi General Hospital, Singapore
| | - Kein B Poon
- Department of Orthopaedics Surgery, Changi General Hospital, Singapore
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Xie J, Hu Q, Huang Q, Ma J, Lei Y, Pei F. Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis. Thromb Res 2017; 153:28-36. [PMID: 28319822 DOI: 10.1016/j.thromres.2017.03.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/26/2017] [Accepted: 03/09/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The appropriate route for administering tranexamic acid in primary total hip (THA) and knee arthroplasty (TKA) remains controversial. The purpose of this meta-analysis was to compare the efficacy and safety of topical or intravenous tranexamic acid. METHODS PubMed, EMBASE, and the Cochrane Library databases were systematically searched for randomized controlled trials (RCTs) comparing topical and intravenous tranexamic acid following primary THA or TKA. Primary outcomes were transfusion frequency and maximum drop in hemoglobin. Other parameters included total blood loss (TBL), hidden blood loss, drainage volume, hemoglobin level on postoperative day 1 (POD 1), deep vein thrombosis (DVT), pulmonary embolism (PE), wound complications and other adverse events. Data were analyzed using Rev Man 5.2. RESULTS A total of 18 RCTs involving TKA and 4 RCTs involving THA, corresponding to approximately 2260 patients, were included in the meta-analysis. No significant difference between topical and intravenous tranexamic acid was found in transfusion requirement (RR 1.14, 95%CI 0.87 to 1.50, p=0.35). The maximum drop in hemoglobin was significantly smaller in the intravenous group than in the topical group (MD 0.33g/dL, 95%CI 0.07 to 0.58, p=0.01); similar results were observed for the subset of studies involving THA (MD 0.49g/dL, 95%CI 0.28 to 0.70, p<0.001) and the subset involving TKA (MD 0.30g/dL, 95%CI 0.02 to 0.59, p=0.04). The topical and intravenous groups did not differ significantly in TBL, drainage volume, hemoglobin level on POD 1, DVT, PE, wound complications or other adverse events. CONCLUSION The available evidence indicates similar transfusion requirements and safety for topical and intravenous tranexamic acid in THA and TKA. However, intravenous injection seems to be associated with a smaller maximum drop in hemoglobin.
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Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Qinsheng Hu
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Qiang Huang
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Jun Ma
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Yiting Lei
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Fuxing Pei
- Department of Orthopaedic Surgery and Dermatology, West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
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Song EK, Seon JK, Prakash J, Seol YJ, Park YJ, Jin C. Combined Administration of IV and Topical Tranexamic Acid is Not Superior to Either Individually in Primary Navigated TKA. J Arthroplasty 2017; 32:37-42. [PMID: 27633946 DOI: 10.1016/j.arth.2016.06.052] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/18/2016] [Accepted: 06/23/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In this study, we tried to assess if combined method (intravenous [IV] and topical) of tranexamic acid (TXA) administration, which has been shown to be superior in conventional arthroplasty, has similar effect in navigational arthroplasty compared to administration of drug either individually. METHODS In present randomized control trial, 200 patients were randomly divided in one of the 4 groups using computer-generated tables-control, IV, intraarticular, and combined. We studied evident loss through drain, total loss based on Gross method and hemoglobin balance method, hidden losses, hemoglobin and hematocrit drop, functional scores, and all possible complications related to TXA. RESULTS Evident loss in combined group was 535.55 mL, not significantly less than IV (585 mL, P = .15) and intraarticular group (514 mL, P = .74). However, these were significantly less than control group (696 mL, P = .000). Functional scores and recovery rates were, however, comparable in all 4 groups. No patients in any group developed symptomatic deep vein thrombosis. CONCLUSION Tranexamic use decreases blood loss in navigation-assisted arthroplasty, however, less than that observed for conventional arthroplasty in literature. Further, combined group has no added advantage over other methods of drug administration. We believe that additional amount of TXA administered in combined regimen may not be clinically useful. Further TXA group did not have any advantage in terms of functional recovery over control group.
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Affiliation(s)
- Eun-Kyoo Song
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
| | - Jong-Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
| | - Jatin Prakash
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
| | - Young-Jun Seol
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Yong Jin Park
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
| | - Cheng Jin
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
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Fu Y, Shi Z, Han B, Ye Y, You T, Jing J, Li J. Comparing efficacy and safety of 2 methods of tranexamic acid administration in reducing blood loss following total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2016; 95:e5583. [PMID: 27977593 PMCID: PMC5268039 DOI: 10.1097/md.0000000000005583] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) were to gather data to evaluate the efficacy and safety of topical tranexamic acid (TXA) versus intravenous (IV) TXA for blood loss after a total knee arthroplasty (TKA). METHODS Electronic databases: Pubmed, Web of Science, Cochrane library, and Embase from inception to June 2016 were searched. RCTs that comparing topical with IV TXA for blood loss control in patients prepared for TKA were included in this meta-analysis. The Cochrane risk of bias tool was used to appraise risk of bias. The primary outcomes were needed for transfusion, total blood loss, and blood loss in drainage. Secondary outcomes are hemoglobin (Hb) value at 24-hour post TKA and complication (deep venous thrombosis [DVT] and infection). The efficacy of blood loss was tested by total blood loss, drainage volume, Hb drop, and the Hb value at 24 hours after TKA. The safety was measured by the occurrence of DVT and infection. Continuous outcomes were expressed as the mean difference with the respective 95% confidence intervals (CIs). Discontinuous outcomes were expressed as the relative risk with 95% CIs. Stata 12.0 software (Stata Corp., College Station, TX) was used for the meta-analysis. RESULTS A total of 14 articles involving 1390 patients were finally included for this meta-analysis. The pooled results revealed that there were no significant difference between the need for transfusion, total blood loss, blood loss in drainage, Hb value at 24-hour post TKA, the occurrence of complications (infection and DVT) between topical administration of TXA and IV TXA. CONCLUSION Topical TXA has similar efficacy for blood loss control to IV TXA without sacrificing safety in TKA. However, the dose of topical TXA and IV TXA is different, thus, optimal timing and dose of TXA are still needed to explore the maximum effect of TXA.
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Affiliation(s)
- Yu Fu
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Zhigang Shi
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Bing Han
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Yong Ye
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Tao You
- Department of Orthopaedics, The First Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Juehua Jing
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Jun Li
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
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Yuan QM, Zhao ZH, Xu BS. Efficacy and safety of tranexamic acid in reducing blood loss in scoliosis surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:131-139. [DOI: 10.1007/s00586-016-4899-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 10/11/2016] [Accepted: 11/25/2016] [Indexed: 01/25/2023]
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Wang S, Gao X, An Y. Topical versus intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials. INTERNATIONAL ORTHOPAEDICS 2016; 41:739-748. [PMID: 27837327 DOI: 10.1007/s00264-016-3296-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/15/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug used widely to prevent bleeding in total knee arthroplasty (TKA). However, there is no consensus regarding the administration routes of TXA. This meta-analysis aimed to investigate the efficacy of topical (intra-articular) versus intravenous TXA in reducing blood loss and transfusion rate in patients who underwent TKA. METHOD We conducted a Pubmed, EMBASE, Cochrane Library, and Web of Science search for randomized controlled trials (RCTs) comparing topical versus intravenous TXA in TKA. Two authors conducted selection of studies, data extraction, and assessment of risk of bias independently. A pooled meta-analysis was performed using RevMan 5.3 software. RESULT Sixteen RCTs with a total of 1330 patients were included. Current meta-analysis indicated that there were no significant differences in total blood loss (MD = -41.64 ml; 95 % CI: -163.43 ml to 80.18 ml; P = 0.50), drain output (MD = 22.44, 95 % CI: -11.18 to 56.06, P = 0.19), transfusion rate (RR = 0.89, 95 % CI: 0.62 to 1.27, P = 0.52), the drop of Hb level at post-operative day 1 (MD = 0.26, 95 % CI -0.03 to 0.55, P = 0.03), day 2 (MD = -0.08, 95 % CI -0.76 to 0.59, P = 0.81), day 3 (MD = -0.20, 95 % CI -0.77 to 0.37, P = 0.49), and length of stay (MD = -0.10; 95 % CI: -0.17 to -0.02; P = 0.02) between the topical group and intravenous group. In addition, no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis (RR = 1.08, 95 % CI: 0.48 to 2.40, P = 0.86), pulmonary embolism (RR = 0.56, 95 % CI: 0.05 to 5.99, P = 0.63), wound complications (RR = 0.56, 95 % CI: 0.05 to 5.99, P = 0.63), and infection (RR = 0.74, 95 % CI: 0.30 to 1.85, P = 0.52) between the two groups. CONCLUSION Our meta-analysis of 16 RCTs revealed that both topical TXA and intravenous TXA are effective in reducing blood loss and transfusion rates in patients who underwent TKA.
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Affiliation(s)
- Shangquan Wang
- Department of Comprehensive Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No. 6 Zhonghuan South Road, Beijing, 100102, China
| | - Xinxia Gao
- Department of Comprehensive Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No. 6 Zhonghuan South Road, Beijing, 100102, China
| | - Yan An
- Department of Comprehensive Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No. 6 Zhonghuan South Road, Beijing, 100102, China.
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