Oral tranexamic acid is equivalent to topical tranexamic acid without drainage in primary total hip arthroplasty: A double-blind randomized clinical trial

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

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

Efficacy and Safety of Oral Tranexamic Acid vs. Other Routes in Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis

BACKGROUND

Total joint arthroplasty (TJA) is often associated with significant blood loss, leading to complications such as acute anemia and increased risk of infection and mortality. Tranexamic acid (TXA), an antifibrinolytic agent, has been recognized for effectively reducing blood loss during TJA. This systematic review and network meta-analysis aims to evaluate the efficacy and safety of oral TXA compared with other administration routes in TJA.

METHODS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, Embase, and Web of Science, focusing on randomized clinical trials involving oral TXA in TJA. The studies were assessed for quality using the Cochrane risk assessment scale. Data synthesis involved network meta-analyses, comparing outcomes including hemoglobin drop, estimated blood loss (EBL), transfusion rate, and deep vein thrombosis (DVT) rate.

RESULTS

Our comprehensive literature search incorporated 39 studies with 7,538 participants, focusing on 8 TXA administration methods in TJA. The combination of oral and intra-articular (oral + IA) TXA markedly reduced hemoglobin drop more effectively than oral, intravenous (IV), and IA alone, but the difference was not significant. Oral + IA TXA significantly reduced EBL more effectively than oral + IV, IA + IV, and oral, IV, and IA alone. Perioperative transfusion rates with oral + IA TXA was significantly lower than that of oral, IA, and IV alone. The DVT rate with oral + IA was significantly lower than that with all other routes, including oral + IV, IA + IV, and oral, IA, and IV alone.

CONCLUSION

Oral TXA, particularly in combination with IA administration, demonstrates significantly higher efficacy in reducing blood loss and transfusion rates in TJA, with a safety profile comparable with that of other administration routes. The oral route, offering lower costs and simpler administration, emerges as a viable and preferable option in TJA procedures.

LEVEL OF EVIDENCE

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

Drainage in primary and revision hip and knee arthroplasty

Drainage after total hip or knee arthroplasty (THA, TKA) used to be systematic to prevent complications and notably hematoma and infection. However, improvement in practices, the introduction of blood-sparing protocols and above all the conclusions reported in many studies have cast doubt on this dogma. There is abundant literature on the pros and cons of drainage after primary THA and TKA. The main endpoints were transfusion rates and volumes, total blood loss and variations in hemoglobin levels. Clinical endpoints comprised pain, edema, postoperative hematoma and, more rarely, short-to-medium-term function. Except for a few studies reporting greater pain and edema without drainage, there is agreement that drainage not only provides no benefit but actually aggravates postoperative bleeding. There are fewer studies of drainage in revision procedures for the hip and very few for the knee. The interest of drainage has not been demonstrated and again postoperative bleeding is aggravated. Whether in primary or revision arthroplasty, tranexamic acid is recommended when not contraindicated, whatever the administration protocol. However, it should not be seen as the sole and determining reason for abandoning drainage. LEVEL OF EVIDENCE: V, expert opinion.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis

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.

Perioperative safety and efficacy of robot-assisted total hip arthroplasty in ERAS-managed patients: a pilot study

AIMS

Robot-assisted total hip arthroplasty (rTHA) boasts superior accuracy in implant placement, but there is a lack of effective assessment in perioperative management in the context of enhanced recovery after surgery (ERAS). This study aimed to compare the effectiveness and safety of rTHA versus conventional total hip arthroplasty (cTHA) in ERAS-managed patients.

METHODS

In this prospective trial, a total of 60 eligible patients aged between 18 and 80 years were randomly divided into two groups to undergo either rTHA or cTHA. The primary outcomes included blood loss parameters. Secondary outcomes were the duration of the operation, surgical time, WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, Harris score, and postoperative complications.

RESULTS

The study cohort analyzed 59 eligible participants, 30 of whom underwent rTHA and 29 of whom underwent cTHA. Analysis could not be conducted for one patient due to severe anemia. Notably, the cTHA group had a significantly shorter surgical time than the rTHA group (69.49 ± 18.97 vs. 104.20 ± 19.63 min, P < 0.001). No significant differences were observed between the rTHA and cTHA groups for blood loss parameters, including total blood loss (1280.30 ± 404.01 vs. 1094.86 ± 494.39 ml, P = 0.137) and drainage volume (154.35 ± 121.50 vs. 159.13 ± 135.04 ml, P = 0.900), as well as intraoperative blood loss (126.67 ± 38.80 vs. 118.52 ± 60.68 ml, P = 0.544) and hidden blood loss (982.43 ± 438.83 vs. 784.00 ± 580.96 ml, P = 0.206). Only one patient in the cTHA group required allogeneic blood transfusion. At 3 months postoperatively, both groups showed improvements in WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, and Harris score, with no significant differences found between the two groups. Few complications were reported in both groups without significant differences.

CONCLUSIONS

Despite the longer surgical time, rTHA did not negatively affect blood loss, pain, or functional recovery or lead to an increased risk of complications in ERAS-managed patients, suggesting that rTHA can be safely and effectively incorporated into an ERAS program for primary THA.

The effect of perioperative tranexamic acid (TXA) in patients with calcaneal fractures: a meta-analysis and systematic review of randomized controlled trials

BACKGROUND

Calcaneal fractures are a common orthopedic disease, account for approximately 2% of all bone fractures, and represent 60% of fractures of tarsal bones. Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that competitively blocks the lysine-binding sites of plasminogen, plasmin, and tissue plasminogen activator, delaying fibrinolysis and blood clot degradation. However, the effect of TXA on patients with calcaneal surgery remains controversial. Our objective was to evaluate the effectiveness of TXA in calcaneal fractures surgeries.

METHODS

The electronic literature databases of Pubmed, Embase, and Cochrane library were searched in December 2022. The data on blood loss, the stay in the hospital, the duration of surgery, hemoglobin, hematocrit, platelet count, prothrombin time, activated partial thromboplastin time, and wound complication were extracted. The Stata 22.0 software was used for the meta-analysis.

RESULTS

Four randomized controlled studies met our inclusion criteria. This meta-analysis showed that TXA significantly reduced postoperative blood loss during the first 24 h (p < 0.001), improved the level of hemoglobin (p < 0.001) and hematocrit (p = 0.03), and reduced the risk of wound complications (p = 0.04). There was no significant difference between the two groups regarding total and intraoperative blood loss, hospital stay, duration of surgery, platelet count, activated partial thromboplastin time, and prothrombin time.

CONCLUSION

TXA significantly reduced blood loss during the first 24 h postoperatively, improved the level of hemoglobin and hematocrit, and reduced the risk of wound complications. Given the evidence, TXA can be used in patients with calcaneal fractures and had the potential benefit of blood reduction.

PROTOCOL REGISTRATION

The protocol was registered in PROSPERO (registration No. CRD42023391211).

The Efficacy of Topical Tranexamic Acid in Femoral Neck Fractured Patients Undergoing Cemented Bipolar Hemiarthroplasty: A Randomized Double Blinded Controlled Trial

Objective  Tranexamic acid (TXA) is an antifibrinolytic that is widely used for decreasing blood loss and blood transfusion rates in total hip arthroplasty. However, there is limited evidence of topical TXA usage in hip hemiarthroplasty for femoral neck fractures. The present study aimed to evaluate the effects of topical TXA on blood loss and on blood transfusions in femoral neck fracture patients who underwent cemented bipolar hemiarthroplasty. Methods  Twenty-six patients with femoral neck fractures who were scheduled for bipolar cemented arthroplasty were randomized into two groups. The first group of 12 patients received topical TXA during their operation, whereas 14 patients in the second group received a placebo. Hematocrit was measured at 6 and 24 hours postoperatively. Blood transfusions and postoperative complications were also recorded. Results  Total blood loss was not different between the TXA group and the control group (TXA group: 459.48 ± 456.32 ml, and control group: 732.98 ± 474.02 ml; p  = 0.14). However, there were no patients within the TXA group who required a blood transfusion, while there were 4 patients in the control group who received allogenic blood transfusions ( p  = 0.044). There were no postoperative complications, such as wound complication, venous thromboembolism, or cardiovascular complications within either group. Conclusion  Topical TXA could not decrease total blood loss but was able to reduce transfusion rates in patients who underwent cemented bipolar hip hemiarthroplasty in femoral neck fractures. Further studies in doses of topical TXA in a larger sample size would be beneficial. Level of Evidence  II.

Addition of infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to local infiltration analgesia for total knee arthroplasty: a prospective randomized controlled trial

BACKGROUND

Local infiltration analgesia (LIA) is a popular analgesic technique commonly administered during total knee arthroplasty (TKA). Recent studies have demonstrated that the infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) can be complementary to analgesic modalities. However, the combined and relative efficacy of LIA and IPACK is unclear. We aimed to evaluate the analgesic and functional outcomes among LIA, IPACK, and LIA+IPACK.

MATERIALS AND METHODS

A total of 120 patients undergoing primary TKA were randomly allocated to 1 of 3 groups: LIA (50 mL of 0.25% ropivacaine and 2.0 μg/mL epinephrine); IPACK (20 mL of 0.25% ropivacaine and 2.0 μg/mL epinephrine); and LIA+IPACK. The primary outcome was the visual analog scale (VAS) pain score. Secondary outcomes were opioid use, knee range of motion (ROM), quadriceps muscle strength, mobilization distance, timed up and go (TUG) test, and postoperative complications.

RESULTS

The mean VAS pain scores were significantly higher after using IPACK alone than after using LIA+IPACK and LIA within 24 hours (all p＜0.05). LIA+IPACK had lower mean VAS pain scores than LIA when the knees were at rest (within 12 hours, p < 0.05) and flexion (within 8 hours, p＜0.05). Patients receiving LIA+IPACK and LIA had significantly lower morphine equivalents (ME) than those receiving IPACK alone within 24 hours (26.3, 28.9 versus 47.8, both p＜0.05) and during hospitalization (98, 101.6, versus 128.4 both p＜0.05). Both LIA+IPACK and LIA had higher ROM (within two days), higher level of muscle strength (within 12 hours), longer mobilization distances (within one day), and shorter TUG time (till discharge) compared with IPACK alone (all p＜0.05), while LIA+IPACK only had a higher knee ROM than LIA on the first postoperative day (p＜0.05). There was no significant difference in any other outcomes.

CONCLUSIONS

This randomized controlled trial demonstrated that there were significantly lower pain scores, less opioid consumption, and better functional results with LIA+IPACK and LIA when compared with IPACK alone, suggesting that IPACK alone was inferior for pain control.

The optimal regimen, efficacy and safety of tranexamic acid and aminocaproic acid to reduce bleeding for patients after total hip arthroplasty: A systematic review and Bayesian network meta-analysis

OBJECTIVES

We aimed to evaluate the optimal regimen, efficacy and safety of tranexamic acid (TXA) and aminocaproic acid (EACA) for patients after total hip arthroplasty (THA).

METHODS

The network meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. The outcomes were total blood loss, transfusion rates, hemoglobin (HB) drop, and risk for pulmonary embolism (PE) or deep vein thrombosis (DVT). Subgroup analyses were performed among most effective regimens to determine the influences of timing and number of doses.

RESULTS

A total of 56 eligible RCTs with different regimens were assessed. For reducing total blood loss, all high doses of TXA and EACA except high dose of intra-articular (IA) TXA, as well as medium dose of combination of intravenous and intra-articular (combined IV/IA) TXA were most effective. All high doses of TXA, as well as medium dose of combined IV/IA TXA did not show inferiority in reducing transfusion rates and HB drop compared with other regimens. No regimens showed higher risk for PE or DVT compared with placebo, and no statistical differences were seen among most effective regimens in subgroup analyses.

CONCLUSIONS

As effective as high doses of EACA and TXA, medium dose (20-40 mg/kg or 1.5-3.0 g) of combined IV/IA TXA was enough to control bleeding for patients after THA without increasing risk for PE/DVT. TXA was at least 5 times more potent than EACA. Timing and number of doses had few influences on blood conserving efficacy.

LEVEL OF EVIDENCE

Level I.

Effects of Preoperative Oral Electrolyte-Carbohydrate Nutrition Supplement on Postoperative Outcomes in Elderly Patients Receiving Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Objective

Patients undergoing total knee arthroplasty (TKA) were primarily geriatric, with high risk of postoperative electrolyte disorders and malnutrition. Randomized controlled trials regarding oral nutrition supplement (ONS) strategies in TKA was sparse. This study aimed to evaluate the efficacy of preoperative oral electrolyte‐carbohydrate nutrition supplement (OECNS) on patients (aged >65 years) undergoing TKA.

Methods

From April 2019 to January 2020, 94 patients undergoing primary elective unilateral TKA in our hospital were considered in this prospective randomized controlled study. This study included patients aged over 65 years with ASA I‐III, and excluded patients with electrolyte disorders, malnutrition, and comorbidities. The control group (control group) received meal nutrition supplements (preoperative 6 h [Pre 6h]) and water (Pre 2h), while OECNS group (intervention group) received meal nutrition supplements (Pre 6h) and OECNS (Pre 2). The Student's t test and χ² test was used. The primary outcomes were the patient‐reported comfort indicators (PRCIs) including hunger, thirst, nausea, vomiting, weakness, pain, anxiety, and general comfort. The secondary outcomes included indicators of electrolyte, nutrition, functional scores, clinical results, and complications.

Results

The scores of preoperative hunger (0.43 ± 0.10), pain (2.30 ± 0.34), and anxiety (9.04 ± 2.71) were significantly lower in OECNS group compared with control group (hunger, 1.19 ± 0.21; pain, 3.79 ± 0.26; anxiety, 11.21 ± 3.02) (Pre 1h) (all p < 0.05) as well as the weakness score on the first postoperative day (POD1) (OECNS group 3.57 ± 0.24; control group 5.15 ± 0.29; p < 0.001). A higher level of Na + (OECNS group 140.54 ± 3.39; control group 138.07 ± 5.21; p = 0.008) and a reduced rate of hyponatremia (OECNS group 6.4%; control group 21.3%; p = 0.036) on POD1 were found. Moreover, the higher level of blood glucose (Post 2h) and reduced rates of abnormal blood glucose (Pre 2h, Post 6h) were verified in control group (all p < 0.05). There was no significant difference regarding the other outcomes.

Conclusion

The administration of OECNS significantly improved subjective comfort, electrolytes, and blood glucose without increasing the rates of complications in patients (aged over 65 years) undergoing TKA.

Tranexamic acid versus aminocapróic acid in multiple doses via the oral route for the reduction of postoperative bleeding in total primary hip arthroplasty: a prospective, randomized, double-blind, controlled study

To compare the effects of oral ε-aminocaproic acid (EACA) as a hemostatic agent versus the use of oral tranexamic acid (TXA) administered in multiple doses pre and postsurgery in patients undergoing elective primary total hip arthroplasty (THA). We enrolled 102 patients that were randomly divided into two groups: received three oral doses of EACA (2000 mg per dose) or three oral doses of TXA (1300 mg per dose). The medication was given according to the following schedule: 2 h before surgery and 6 and 12 h after surgery. The variables 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 analog scale, and surgical complications. There were no significant differences between any of the study variables for the group receiving oral TXA and the group receiving oral EACA (P > 0.05). Our study showed that the use of oral EACA was similar to its counterpart TXA regarding the evaluated parameters. TXA did not have superior blood conservation effects, safety profile, or differences in functional scales compared with EACA in THA. We consider the use of multiple oral doses of aminocaproic acid at the selected dose to be effective as a standard protocol to achieve less blood loss and a lower rate of transfusion and adverse events related to the medication in patients undergoing a THA.

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

Effect of the application of the "Patient blood management" programme on the approach to elective hip and knee arthroplasties

BACKGROUND AND OBJECTIVES

The "Patient Blood Management" (PBM) programmes have demonstrated their value in the continuous improvement of care practice, due to continuous systematic reviewing of results and their dynamic and multidisciplinary updating in accordance with new clinical evidence. Our goal is to demonstrate the effectiveness of simple protocols, applicable in second level hospitals.

PATIENTS AND METHODS

702 patients undergoing scheduled arthroplasty from 2011 to 2018 were retrospectively analysed. During this period, the evolution of transfusion rates and anaemia and bleeding management were recorded in the patients' computerised clinical histories.

RESULTS

Stages and transfusion rates were: Year 2011-2012, "Universal self-donation programme": 62.4%; year 2013, "Optimization of preoperative haemoglobin and universal self-donation withdrawal", 22.5%; year 2015, "Stopping the use of cell-savers and drains", 13.2%; and year 2017, "Introduction of routine tranexamic acid", 3.6%. A significant reduction in the transfusion rate and volume (P<.001) and the average hospital stay (8 to 6 days) (P<.001) was achieved. In multivariate models, transfused patients have a .5-day stay and there is a trend towards a reduction in complications, being fewer in patients receiving tranexamic acid (OR .44).

CONCLUSION

A simple progressive and multidisciplinary PBM programme, with continued re-evaluation, has allowed a reduction in transfusion rates and average hospital stay.

Results after the application of tranexamic acid intravenous or intra-articular in the control of postsurgical bleeding after total hip arthroplasty: a randomized controlled trial

INTRODUCTION

A frequent complication after total hip arthroplasty is bleeding; to reduce it, intravenous or intra-articular tranexamic acid (TXA) is used. There is no evidence yet on which route of administration is better.

MATERIALS AND METHOD

This was a prospective, controlled, randomized study in 2 arms between February 2017 and February 2019. In group A, 15 mg/kg intravenous TXA was administered and in group B 2 g intra-articular TXA. Haemoglobin and haematocrit values were evaluated at 24-72 h, also volume of drained blood, volume of blood lost, transfusions and complications.

RESULTS

A total of 195 patients were included: 110 in group A and 85 group B. Haemoglobin dropped 3.10 ± 1.32 g/dl in 24 h and 3.63 ± 1.41 g/dl at 72 h in group A; the haematocrit dropped 8.38 ± 4.67% in 24 h and 15.40 ± 4.39% in 72 h. In group B, haemoglobin dropped 3.09 ± 1.40 g/dl in 24 h and 3.34 ± 1.23 g/dl in 72 h and haematocrit 9.75 ± 3.95% and 10.40 ± 3.72% in 24 and 72 h. No significant differences were found for haemoglobin values at 24 and 72 h and haematocrit at 24 h (p > 0.05); we did not obtain statistically significant differences in drainage, blood loss between groups or in the proportion of transfused. When stratifying the results by age, we obtained significant differences in the decrease in haemoglobin (p = 0.021) and haematocrit (p = 0.025) in patients > 65 years.

CONCLUSIONS

The different routes of administration of TXA in PTC have a similar effect in reducing post-operative bleeding without evidencing an increase in complications.

LEVEL OF EVIDENCE

I.

Comparison of hemocoagulase atrox versus tranexamic acid used in primary total knee arthroplasty: A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) has been considered as an effective choice for end-stage osteoarthritis or rheumatic arthritis. Tranexamic acid (TXA) has been widely used to prevent excessive blood loss perioperatively. Similarly, hemocoagulase atrox can significantly diminish blood loss and transfusion requirements in surgeries, however, it was rarely used in TKA. The purpose of this study is to identify whether hemocoagulase atrox is equal to TXA in reducing blood loss and transfusion rates following TKA, and compare clinical outcomes and complications between the two groups.

METHODS

74 patients were randomized to receive TXA (1.5 g intra-articular combined with 1.5 g intravenous), or hemocoagulase atrox (1 U intra-articular combined with 1 U intravenous). The primary outcome was total blood loss. The secondary outcomes included reduction of hemoglobin concentration, clinical outcomes, blood coagulation values, thromboembolic complications, and transfusion rates.

RESULTS

The mean total blood loss was 431.7 mL in the TXA group compared with 644.6 mL in the hemocoagulase atrox group, with statistical significance (P < 0.05). There were significant differences in reduction of hemoglobin level (P < 0.05). The rate of deep vein thrombosis (DVT) in patients given TXA was higher than those given hemocoagulase atrox, however, there were no significant differences. No transfusions were required in either group, and no significant differences were found in the length of hospital stay and clinical outcomes.

CONCLUSIONS

Although the blood loss was significantly greater in the hemocoagulase atrox group, no transfusions were required and no significant differences were observed for any other outcomes measured. Meanwhile, the rate of DVT in the hemocoagulase atrox group tends to be lower than those in TXA group. We concluded that hemocoagulase atrox was not superior to TXA in reducing perioperative blood loss. Further studies are warranted to evaluate if hemocoagulase atrox use could improve perioperative blood loss in patients with high thrombotic risk undergoing TKA.

Use of topical tranexamic acid in primary total hip arthroplasty. Efficiency and safety. Our experience

BACKGROUND AND AIM

Intravenous tranexamic acid has been shown to reduce bleeding and the need for transfusions in total hip arthroplasty, although it has a theoretical risk of producing thromboembolic phenomena. Recently some papers have been published using the topical application of tranexamic acid, but the ideal administration protocol has not yet been clearly defined. The aim of this paper was to demonstrate that our protocol of topical tranexamic acid is effective and safe.

MATERIALS AND METHODS

Prospective data collection from a case series of 80 primary hip arthroplasties, in which the following topical tranexamic acid protocol is used: 1.5 grams diluted to a total volume of 60ml were administered, applying 20ml in the acetabular bed, 20ml in the femoral canal and 20ml through the Redon drain, keeping it closed for 20minutes.

RESULTS

Eighty patients were operated. Preoperative haemoglobin 14.26g / dL; preoperative haematocrit 42.39%. An average loss of 2.74g / dL of haemoglobin and 8% of haematocrit was obtained. Eleven percent of the patients required transfusion, of whom 67% had known previous anaemia; only 3 patients without prior anaemia required transfusion (4%). There were no thromboembolic complications in our series.

CONCLUSIONS

The use of topical tranexamic acid was safe and effective in primary total hip arthroplasty, reducing the need for blood transfusion compared to that described in the literature in untreated patients.

The efficiency and safety of oral tranexamic acid in total hip arthroplasty: A meta-analysis

BACKGROUND

Intravenous (IV), topical and combination of both application of tranexamic acid (TXA) can reduce blood loss, hemoglobin drop, and transfusion rate in patients following total hip arthroplasty (THA). Lately, published articles reported that oral TXA had as similar blood-saving as IV and topical TXA in THA. The purpose of this meta-analysis is to investigate the efficiency and safety of oral TXA in THA.

METHODS

We systematically searched articles about oral administration of TXA in THA from PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Chinese Wanfang database.

STUDY ELIGIBILITY CRITERIA

The outcomes were collected and analyzed by the Review Manager 5.3.

RESULTS

Nine RCTs and 1 CCT, containing 1305 patients, were ultimately included according to the inclusion criteria and exclusion criteria in the meta-analysis. The effectiveness of oral TXA was as similar as the IV or topical TXA in regard to hemoglobin drop (SMD = -0.14; 95% CI, [-0.28, 0.01]; P = .06), total blood loss (SMD = 0.01; 95% CI, [-0.13, 0.16]; P = .84), transfusion rate (OR = 0.76; 95% CI, [0.38, 1.55]; P = .37). Compared with single oral TXA or blank group, multiple oral TXA effectively reduced hemoglobin drop (SMD = -1.06; 95% CI, [-1.36, -0.77]; P < .05), total blood loss (SMD = -1.30; 95% CI, [-1.66, -0.94]; P < .05), transfusion rate (OR = 0.53; 95% CI, [0.29, 0.95]; P = .03). There were no significant difference in terms of length of stay and complication among all of enrolled studies.

CONCLUSION

Oral TXA has favorable effect of blood-saving and do not increase risk of complication in patients following THA. Oral TXA may have no effect in the length of stay. More high quality RCTs are necessary.

Effect of topical tranexamic acid in total hip arthroplasty patients who receive continuous aspirin for prevention of cardiovascular or cerebrovascular events: A prospective randomized study

BACKGROUND

Due to differences in pharmacological mechanism of action, the effect of tranexamic acid (TA) on aspirin-related bleeding remains unknown. We therefore conducted a prospective randomized study to elucidate: (1) the effect of topical TA administration on blood loss and transfusion rate in total hip arthroplasty (THA) patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events; (2) 90-day complications of topical TA administration; (3) possible variables contributing to blood transfusion.

HYPOTHESIS

Topical TA administration reduces blood loss and transfusion rate in THA patients receiving continuous aspirin.

PATIENTS AND METHODS

A total of 102 consecutive THA patients taking continuous aspirin were enrolled and randomized into two groups. In the topical TA (TTA) group (n=55), topical TA was administered at three points during THA; in the control group (n=47), the patients received saline solution as placebo. Based on drop in hemoglobin concentration, total estimated blood loss was calculated as the main assessment criterion. Secondary assessment criteria included transfusion rate and 90-day complications. Finally, a multivariate regression model was used to assess possible predictive factors for blood transfusion.

RESULTS

(1) Significantly lower total blood loss was observed in the TTA group than in the control group (897±177ml vs. 1153±345ml, p<0.001). Furthermore, lower transfusion rate was observed in the TTA group than in the control group (10.9% vs. 34.0%, p=0.005). (2) No significant difference was observed between the two groups regarding 90-day complications. (3) We identified higher preoperative hemoglobin level (OR=0.675, p=0.002) and topical TA administration (OR=0.002, p=0.012) as negative predictive factors for blood transfusion.

DISCUSSION

Topical application of TA was safe and beneficial in THA patients receiving continuous aspirin for prevention of cardiovascular or cerebrovascular events, to reduce blood loss and transfusion rate, without increasing the risk of 90-day complications.

Intravenous and subsequent long-term oral tranexamic acid in enhanced-recovery primary total knee arthroplasty without the application of a tourniquet: a randomized placebo-controlled trial

BACKGROUND

To assess the efficacy and safety of intravenous and subsequent long-term oral tranexamic acid (TXA) following total knee arthroplasty (TKA) without a tourniquet.

METHODS

In this double-blinded trial, 118 patients undergoing primary TKA were randomized into two groups: the patients in group A received intravenous TXA at 20-mg/kg 10 min before the surgery and 3 h postoperatively, and then oral 1 g TXA from postoperative day (POD) 1 to POD 14, and the patients in group B received intravenous TXA at 20-mg/kg 10 min before surgery and 3 h postoperatively, and then oral 1 g placebo from postoperative day (POD) 1 to POD 14. The primary outcome was total blood loss. Secondary outcomes included ecchymosis area and morbidity, postoperative transfusion, postoperative laboratory values, postoperative knee function and length of hospital stay. Complications, and patient satisfaction were also recorded.

RESULTS

The mean total blood loss was lower in Group A than in Group B (671.7 ml vs 915.8 ml, P = 0.001). There was no significant difference in the transfusion rate between the two groups. Group A had a higher hemoglobin than Group B on POD 3 (106.0 g/L vs 99.7 g/L, P = 0.001). However, no significant difference was found for Hb or hematocrit on POD 1 or POD 14 between the two groups. Patients in Group A had less ecchymosis morbidity (7 vs 38, P = 0.001), smaller ecchymosis area (1.6 vs 3.0, P = 0.001) than Group B. The blood coagulation level as measured by fibrinolysis (D-Dimer) was lower in Group A than in Group B on POD 1 and POD 3 (4.6 mg/L vs. 8.4 mg/L, respectively, P = 0.001; 1.5 mg/L vs. 3.3 mg/L, respectively, P = 0.001). However, there was no significant difference on POD 14, and the fibrin degradation products showed the same trend. Patients in Group A had less swelling than those in Group B on POD 3 and POD 14. The circumference of the knee was 43.1 cm vs. 46.1 cm (POD 3, P = 0.001) and 41.4 cm vs. 44.9 cm (POD 14, P = 0.001) in Group A vs Group B, respectively. Nevertheless, the circumference of the knee in the two groups was similar on POD 1 and POD 3 M. No significant differences were identified in knee function, pain score, or hospital stay. No significant differences were identified in thromboembolic complications, infection, hematoma, wound healing and patients satisfaction between the two groups.

CONCLUSION

Intravenous and subsequent long-term oral TXA produced less blood loss and less swelling and ecchymosis compared with short-term TXA without increasing the risk of complications.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17012264 ).

Comparative effectiveness and safety of tranexamic acid plus diluted epinephrine to control blood loss during total hip arthroplasty: a meta-analysis

BACKGROUND

The standard protocol to achieve haemostasis during total hip arthroplasty (THA) is uncertain. Tranexamic acid plus diluted epinephrine (DEP) and tranexamic acid (TXA) alone are the two most common alternatives. The purpose of this study was to compare the efficacy and safety of TXA plus DEP to treat blood loss in THA patients.

METHODS

Published randomized controlled trials (RCTs) were identified from the following electronic databases: PubMed, Embase, Web of Science, Cochrane Library and Google from inception to July 10, 2018. Studies comparing TXA plus DEP with TXA alone to treat blood loss were included. Either a random-effects model or a fixed-effects model was used for meta-analysis depending on the heterogeneity. We used the need for transfusion as the primary outcome. Stata 12.0 was used for meta-analysis.

RESULTS

Six studies involving 703 patients were included in the present meta-analysis. The pooled results demonstrated that TXA plus DEP was associated with a lower transfusion rate than TXA alone (RR = 0.57, 95% CI 0.38-0.86, P = 0.006). Furthermore, TXA plus DEP was associated with less total blood loss and hidden blood loss by approximately 209.79 ml and 297.74 ml, respectively, than TXA alone. There was no significant difference in terms of intraoperative blood loss or the occurrence of deep venous thrombosis or haematoma between the TXA plus DEP and TXA alone groups (P > 0.05).

CONCLUSIONS

Our meta-analysis suggested that TXA plus DEP significantly decreased the need for transfusion, total blood loss and hidden blood loss among THA patients. Furthermore, TXA plus DEP did not increase the occurrence of DVT or haemostasis. Additional long-term follow-up RCTs are needed to identify the optimal doses of TXA and DEP.