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Poursalehian M, Tajvidi M, Ghaderpanah R, Soleimani M, Hashemi SM, Kachooei AR. Efficacy and Safety of Oral Tranexamic Acid vs. Other Routes in Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis. JBJS Rev 2024; 12:01874474-202406000-00003. [PMID: 38889241 DOI: 10.2106/jbjs.rvw.23.00248] [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: 06/20/2024]
Abstract
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.
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Affiliation(s)
- Mohammad Poursalehian
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Tajvidi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Rezvan Ghaderpanah
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Soleimani
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Melika Hashemi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Zhou S, Li L, Li S, Si H, Wu L, Shen B. The Negative Impacts of Sarcopenia on Primary Total Knee Arthroplasty under the Enhanced Recovery after Surgery Protocol. Orthop Surg 2024; 16:1160-1167. [PMID: 38556481 PMCID: PMC11062878 DOI: 10.1111/os.14053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE Sarcopenia, as an emerging public health concern, has been associated with postoperative adverse outcomes in various surgical procedures. However, the evidence regarding the impacts of sarcopenia on total knee arthroplasty (TKA) remained limited. This study aimed to assess the impacts of sarcopenia on primary TKA based on the enhanced recovery after surgery (ERAS) protocol. METHODS This retrospective study included 291 patients who received unilateral TKA from October 2017 to May 2018 in our institution. Sarcopenia was diagnosed based on the algorithm of Asian Working Group for Sarcopenia 2019. The handgrip strength was measured using a handheld dynamometer and the muscle mass was estimated by a previously validated anthropometric equation. Patients were classified into sarcopenia group and non-sarcopenia group. The outcomes included complications, postoperative length of stay (LOS), total hospitalization cost, operative time, total estimated blood loss, blood transfusion rate, and the 12-item forgotten joint score (FJS-12) at the follow-up. The propensity score matching (PSM) was used to adjust confounding factors. We compared continuous variables using Student's t-test and the Wilcoxon Mann-Whitney U test for normal and non-normal distributions, respectively, and categorical variables with chi-square tests. RESULTS Of the 291 patients, 58 (19.9%) patients were identified as having sarcopenia. After PSM, each group matched 42 patients. All matched patients were followed-up at least 5 years. Patients with sarcopenia had higher rates of surgical complications compared to the non-sarcopenia group (p = 0.019), and no significant difference was observed in 30-day readmission, and periprosthetic joint infection. The sarcopenia group had significantly longer LOS (p = 0.038), higher total hospitalization (p = 0.015) than the non-sarcopenia group. For the FJS-12 scores at follow-up, patients with sarcopenia had significantly higher scores than the non-sarcopenia group (p = 0.024). CONCLUSION Our findings indicated sarcopenia may be a risk factor for postoperative complications, prolonged LOS, increased hospitalization cost and reduced patient satisfaction.
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Affiliation(s)
- Shengliang Zhou
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Lan Li
- Department of Endocrinology and Metabolism and Key Lab of Transplant Engineering and Immunology, NHFPC, West China HospitalSichuan UniversityChengduChina
| | - Shuai Li
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Haibo Si
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Limin Wu
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Bin Shen
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
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Meghpara MM, Goh GS, Ciesielka KA, Fillingham YA. Does the Use of Tranexamic Acid in Patients Who Have Preoperative Coagulopathy Undergoing Total Joint Arthroplasty Normalize Their Risk of Complications? A Matched Equivalence Analysis. J Arthroplasty 2023; 38:2264-2268. [PMID: 37244426 DOI: 10.1016/j.arth.2023.05.035] [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: 11/08/2022] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND While patients who have a preoperative coagulopathy have an increased risk of perioperative blood loss, tranexamic acid (TXA) has been shown to decrease the risk of complications in this subset. However, a direct comparison of the use of TXA in coagulopathic and noncoagulopathic patients has not been performed. In addition to comparing differences in decreases in hemoglobin, transfusions, and complications, this study examined whether the use of TXA in coagulopathic patients normalized the risk of blood loss relative to matched noncoagulopathic patients. METHODS We performed a retrospective review of 230 patients who had a preoperative coagulopathy and underwent primary total joint arthroplasty (127 hips, 103 knees) from 2012 to 2019 and received TXA. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/mL (mL). A matched comparison group of 689 patients who did not have a coagulopathy and received TXA was identified. A 2 1-sided test (TOST) analysis was performed to test for equivalence. Assuming a clinically relevant difference of 1 g/dL in postoperative decrease in hemoglobin, the equivalence margin was set as ±1 g/dL between the groups. RESULTS When comparing coagulopathic and noncoagulopathic patients, total hip arthroplasty (THA) patients had no differences in hemoglobin, but had an increased reported estimated blood loss (243 versus 207 mL, P = .040) as well as an increased percent of patients requiring blood transfusions (11.8 versus 5.32%, P = .022). Total knee arthroplasty (TKA) patients had no differences in hemoglobin, estimated blood loss, or percent of patients requiring transfusion. There were no differences in medical or surgical complications for both groups for THA and TKA patients. Equivalence testing for both groups revealed statistical significance that THA and TKA coagulopathic patients receiving TXA had an equivalent risk of blood loss compared to noncoagulopathic patients receiving TXA. CONCLUSION Coagulopathic patients receiving TXA and undergoing THA had an increased risk of receiving a transfusion; however, there were no differences in complications for both TKA and THA, as well as a normalized risk of blood loss when compared to noncoagulopathic patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael M Meghpara
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kerri-Anne Ciesielka
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Hess MC, Andrews NA, Crowley B, Singh NP, Howie C, McGwin G, Siegel H. Intravenous tranexamic acid decreases intraoperative transfusion requirements and does not increase incidence of symptomatic venous thromboembolic events in musculoskeletal sarcoma surgery. Surg Oncol 2023; 50:101989. [PMID: 37717375 DOI: 10.1016/j.suronc.2023.101989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/27/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Tranexamic acid (TXA) is poorly studied in patients with bone and musculoskeletal sarcoma due to perceived increased risk of venous thromboembolism (VTE). This study aims to assess the safety and efficacy of intravenous (IV) TXA for patients undergoing surgical resection of primary bone or soft-tissue sarcoma. METHODS A retrospective, single center review of adult patients with pelvic or extremity sarcoma who underwent surgical resections between January 2005 and March 2020 was performed. Patients between 2005 and 2012 were included as a historical comparison prior to the routine use of IV TXA for all sarcoma resections at our institution. RESULTS Thirty-nine non-TXA and 59 TXA resections were identified. Two non-TXA patients experienced symptomatic pulmonary embolism compared to zero VTEs amongst TXA patients. IV TXA administered at any dose significantly reduced the probability of intraoperative transfusion (p = 0.003) and the median units of blood transfused at the time of any perioperative transfusion (p = 0.007). Intraoperative times were significantly shorter for TXA patients (128 vs 190 min; p = 0.004). A subset of patients who underwent wide resection with endoprosthetic reconstruction and received TXA similarly showed decreased requirement for intraoperative transfusion (p = 0.014) and decreased procedure times (p = 0.009). CONCLUSIONS During sarcoma resection, at least 1 g of IV TXA can safely decrease the need for any intraoperative transfusion and the median number of PRBCs transfused by 2 units when any perioperative transfusion is given.
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Affiliation(s)
- Matthew C Hess
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Nicholas A Andrews
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon Crowley
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington D.C, USA
| | - Nikhi P Singh
- Division of Plastic Surgery, Department of Surgery, Indiana University, Indianapolis, IN, USA
| | - Cole Howie
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herrick Siegel
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Hootsmans NAM, Vellanky S, Grady-Benson J, Cremins MS. A Randomized Trial of Three Routes of Tranexamic Acid Administration in Total Knee Arthroplasty. Orthopedics 2023; 46:285-290. [PMID: 36853950 DOI: 10.3928/01477447-20230224-04] [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: 03/01/2023]
Abstract
Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion rates across a variety of routes of administration and doses in the setting of total knee arthroplasty (TKA). Oral TXA is less studied but has decreased cost and increased ease of administration. This prospective, randomized study compared the efficacy and cost of three routes of TXA administration in the setting of primary TKA. Primary outcomes were 24-hour hemoglobin loss, calculated blood loss, and blood transfusion rate. One-way analysis of variance, Pearson's chi-square test, and Fisher's exact test were used for statistical analysis. One hundred eleven patients were enrolled. The mean 24-hour hemoglobin loss for the intravenous (IV), oral, and topical TXA groups was 2.50±0.95 g/dL, 2.64±0.94 g/dL, and 2.52±0.90 g/dL, respectively, with no clinical or statistically significant differences among the groups (P=.79). Calculated blood loss was not significantly different (P=.61) among the IV TXA (1067±371 mL), oral TXA (1127±455 mL), and topical TXA (1027±454 mL) groups. No patients in any treatment group required a blood transfusion. IV, oral, and topical routes of TXA administration offer similar clinical benefits for perioperative bleeding and blood transfusion rate in TKA. Oral TXA provides a cost-benefit relative to the other routes of administration ($14 vs $114 per patient), making it a more cost-effective choice. Oral TXA has additional logistical challenges compared with other routes of administration due to increased absorption time, which may impact its use in clinical practice. [Orthopedics. 2023;46(5):285-290.].
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Artificial neural networks for the prediction of transfusion rates in primary total hip arthroplasty. Arch Orthop Trauma Surg 2023; 143:1643-1650. [PMID: 35195782 DOI: 10.1007/s00402-022-04391-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty. METHODS A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis. RESULTS The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis. CONCLUSION This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning. LEVEL OF EVIDENCE III, case-control retrospective analysis.
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Nicholson TA, Kirsch JM, Churchill R, Lazarus MD, Abboud JA, Namdari S. The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial. J Shoulder Elbow Surg 2022; 31:2211-2216. [PMID: 35970278 DOI: 10.1016/j.jse.2022.06.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/19/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair. METHODS This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance. RESULTS There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery. CONCLUSION The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.
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Affiliation(s)
- Thema A Nicholson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jacob M Kirsch
- Boston Sports and Shoulder Center at New England Baptist Hospital, Boston, MA, USA
| | | | - Mark D Lazarus
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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Costantini J, Esteves TA, Nicolino TI, Carbó L, Costa Paz M. ¿Es seguro el ácido tranexámico en la cirugía de reemplazo total de rodilla de pacientes con enfermedad coronaria? REVISTA DE LA ASOCIACIÓN ARGENTINA DE ORTOPEDIA Y TRAUMATOLOGÍA 2022. [DOI: 10.15417/issn.1852-7434.2022.87.5.1602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introducción: El ácido tranexámico reduce la pérdida sanguínea y los requerimientos de transfusiones luego de un reemplazo total de rodilla. Una de sus contraindicaciones relativas son los antecedentes de colocación de prótesis intravasculares coronarias, por un supuesto aumento de eventos tromboembólicos.
Materiales y Métodos: Análisis retrospectivo de pacientes sometidos a un reemplazo total de rodilla primario y de revisión que recibieron ácido tranexámico y tenían antecedente de colocación de prótesis intravascular coronaria. Se los comparó con un grupo sin estas prótesis. Se analizó la presencia de cualquier cambio clínico o electrocardiográfico de oclusión coronaria aguda, eventos tromboembólicos, el requerimiento de transfusión sanguínea y el nivel de hemoglobina pre y posoperatorio.
Resultados: 57 pacientes (59 cirugías, 56 reemplazos primarios y 3 revisiones) con colocación de prótesis intravascular coronaria, al menos, un año antes de la artroplastia. Un paciente tuvo síntomas de síndromecoronario agudo y cambios en el electrocardiograma. No hubo diferencias en la cantidad de eventos tromboembólicos. Solo un paciente del grupo de control recibió una transfusión de glóbulos rojos. El sangrado relativo fue menor en el grupo coronario independientemente del uso crónico de aspirina y clopidogrel antes de la cirugía (2,09 vs. 3,06 grupo de control; p = 0,01). En pacientes del alto riesgo, el ácido tranexámico no se asoció con más eventos tromboembólicos.
Conclusiones: El ácido tranexámico impresionó ser seguro y efectivo en nuestro grupo de pacientes con prótesis intravasculares coronarias; sin embargo, se necesita un estudio prospectivo con más casos para confirmar estos resultados
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Tarazi JM, Zois TP, Bohm A, Mont MA, Scuderi GR. Elevated Pre-operative D-Dimer Levels Do Not Impact the Effect of Tranexamic Acid on Revision Total Knee Arthroplasty. Orthop Clin North Am 2022; 53:139-143. [PMID: 35365258 DOI: 10.1016/j.ocl.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to determine if elevated pre-operative D-dimer levels in patients undergoing revision total knee arthroplasty (rTKA) pose an increased risk of: (1) post-operative venous thromboemboli (VTE); (2) intra-operative blood loss; and (3) need for transfusion of blood products. Eighty-nine patients who underwent rTKA by a single surgeon between January 1, 2017, and December 31, 2019, met the inclusion criteria. Elevated pre-operative D-dimer levels did not pose an increased risk of VTE, blood loss, or transfusion of blood products, demonstrating that elevated pre-operative D-dimer is not a contraindication to the use of tranexamic acid for rTKA.
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Affiliation(s)
- John M Tarazi
- Department of Orthopaedics, Northwell Health-Huntington Hospital, 270 Park Avenue, Huntington, NY, 11743, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA
| | - Theofanis P Zois
- Department of Orthopaedics, Northwell Health-Lenox Hill Hospital, 130 East 77th Street, 11th Floor, Black Hall, New York, NY, 10075, USA
| | - Andrew Bohm
- Department of Orthopaedics, Northwell Health-Lenox Hill Hospital, 130 East 77th Street, 11th Floor, Black Hall, New York, NY, 10075, USA
| | - Michael A Mont
- Department of Orthopaedics, Northwell Health-Lenox Hill Hospital, 130 East 77th Street, 11th Floor, Black Hall, New York, NY, 10075, USA; Rubin Institute of Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA.
| | - Giles R Scuderi
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Boulevard, Hempstead, NY, 11549, USA; Department of Orthopaedics, Northwell Health-Lenox Hill Hospital, 130 East 77th Street, 11th Floor, Black Hall, New York, NY, 10075, USA
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Outcomes of Tourniquet-Less Revision Total Knee Arthroplasty: A Matched Cohort Analysis. J Am Acad Orthop Surg 2021; 29:e1343-e1352. [PMID: 34037577 DOI: 10.5435/jaaos-d-20-00796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/03/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION A tourniquet is routinely used in total knee arthroplasty (TKA) to limit perioperative blood loss and increase the visibility of the surgeon's field of view. This study aims to evaluate the postoperative clinical outcomes and complications associated with tourniquet use in revision TKA. METHODS We conducted a retrospective review of 1,904 consecutive patients who underwent revision TKA. Propensity score-based matching was done to adjust for baseline differences in patient demographics and procedure details. RESULTS Propensity score matching resulted in a cohort of 548 revision total joint arthroplasty patients, 274 (50.0%) of whom were tourniquet patients matched to 274 (50.0%) tourniquet-less patients. Multivariate regression analyses demonstrated that, compared with the tourniquet-less cohort, the tourniquet cohort had significantly less intraoperative (413.7 to 353.2 mL, P < 0.01) and total perioperative (1,548.7 to 1,417.8 mL, P < 0.01) blood loss. However, no significant differences were present in total perioperative (8.4%, 6.6%, P = 0.43) transfusion rates. The tourniquet cohort had increased length of stay (3.2 to 3.7 days, P < 0.001) and 30-day readmissions (P = 0.04). DISCUSSION This study demonstrated that although omitting the tourniquet in revision TKA leads to markedly increased perioperative blood loss, notable differences in perioperative transfusion rates were not observed. Furthermore, revision TKA without tourniquet use was associated with reduced postoperative length of stay, 30-day readmissions, and increased range of flexion.
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Magill P, Hill JC, Bryce L, Martin U, Dorman A, Hogg R, Campbell C, Gardner E, McFarland M, Bell J, Benson G, Beverland D. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J 2021; 103-B:1595-1603. [PMID: 34587808 DOI: 10.1302/0301-620x.103b10.bjj-2020-2308.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In total knee arthroplasty (TKA), blood loss continues internally after surgery is complete. Typically, the total loss over 48 postoperative hours can be around 1,300 ml, with most occurring within the first 24 hours. We hypothesize that the full potential of tranexamic acid (TXA) to decrease TKA blood loss has not yet been harnessed because it is rarely used beyond the intraoperative period, and is usually withheld from 'high-risk' patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease, a patient group who would benefit greatly from a reduced blood loss. METHODS TRAC-24 was a prospective, phase IV, single-centre, open label, parallel group, randomized controlled trial on patients undergoing TKA, including those labelled as high-risk. The primary outcome was indirect calculated blood loss (IBL) at 48 hours. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional 24-hour postoperative oral regime of four 1 g doses, while Group 2 only received the intraoperative dose and Group 3 did not receive any TXA. RESULTS Between July 2016 and July 2018, 552 patients were randomized to either Group 1 (n = 241), Group 2 (n = 243), or Group 3 (n = 68), and 551 were included in the final analysis. The blood loss did differ significantly between the two intervention groups (733.5 ml (SD 384.0) for Group 1 and 859.2 ml (SD 363.6 ml) for Group 2; mean difference -125.8 ml (95% confidence interval -194.0 to -57.5; p < 0.001). No differences in mortality or thromboembolic events were observed in any group. CONCLUSION These data support the hypothesis that in TKA, a TXA regime consisting of IV 1 g perioperatively and four oral 1 g doses over 24 hours postoperatively significantly reduces blood loss beyond that achieved with a single IV 1 g perioperative dose alone. TXA appears safe in patients with history of thromboembolic, cardiovascular, and cerebrovascular disease. Cite this article: Bone Joint J 2021;103-B(10):1595-1603.
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Affiliation(s)
- Paul Magill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Janet C Hill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Leeann Bryce
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Una Martin
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Al Dorman
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Rosemary Hogg
- Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Christina Campbell
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | - Evie Gardner
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | | | - Jennifer Bell
- Northern Ireland Clinical Trials Unit, Royal Victoria Hospital, Belfast, UK
| | - Gary Benson
- Department of Haematology, Belfast City Hospital, Belfast, UK
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Kim JK, Park JY, Lee DY, Ro DH, Han HS, Lee MC. Optimal dose of topical tranexamic acid considering efficacy and safety in total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2021; 29:3409-3417. [PMID: 32869124 DOI: 10.1007/s00167-020-06241-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This study aimed to evaluate the optimal dosage of topical tranexamic acid (TXA) considering the efficacy and safety for controlling bleeding after total knee arthroplasty (TKA). METHODS This prospective randomized double-blinded placebo-controlled comparative study included 325 patients scheduled to undergo TKA, who were randomly assigned to five groups based on the topical TXA injection (n = 65 per group): control; group 1, 0.5 g TXA; group 2, 1.0 g TXA; group 3, 2.0 g TXA; and group 4, 3.0 g TXA. The primary outcome was decrease in postoperative hemoglobin levels. The secondary outcomes were blood loss calculated using Good's method, drainage volume, frequency of transfusion, and range of motion (ROM). Plasma TXA levels and complications were also evaluated. RESULTS Significant differences were noted in the decrease in hemoglobin levels between the control group and groups 2 (p = 0.0027), 3 (p = 0.005), and 4 (p = 0.001). No significant differences were shown among the experimental groups. Significant differences in total blood loss and frequency of transfusion were noted between the control group and groups 2 (p = 0.004, 0.002, respectively), 3 (p = 0.007, 0.001, respectively), and 4 (p = 0.001, 0.009, respectively) without showing significant differences among the experimental groups. With respect to drainage volume, no significant differences were observed among the groups. The serum TXA levels increased proportionally with the applied dose of topical TXA immediately and at 3 and 6 h postoperatively. Symptomatic deep vein thrombosis or pulmonary embolism was not observed in any group. Other complications related to TXA administration were not detected. CONCLUSION Topical application of 1.0 g or more of TXA shows significant bleeding control without a dose-response relationship. Blood TXA levels increase with the TXA dose following topical TXA application. Therefore, to prevent overdosing and reduce potential complications with ensuring the effectiveness, 1.0 g of TXA is recommended as a topical application. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Jong-Keun Kim
- Department of Orthopaedic Surgery, Hanil General Hospital, Seoul, South Korea
| | - Jae-Young Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Do Yoon Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea.
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Khan H, Dhillon K, Mahapatra P, Popat R, Zakieh O, Kim WJ, Nathwani D. Blood loss and transfusion risk in robotic-assisted knee arthroplasty: A retrospective analysis. Int J Med Robot 2021; 17:e2308. [PMID: 34288356 DOI: 10.1002/rcs.2308] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/03/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The purpose of this study was to compare total blood loss and the risk of receiving a blood transfusion in robotic-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) against conventional jig-based techniques. METHODS Robotic TKA (n = 50) and UKA (n = 50) patients were matched to contemporary controls for TKA (n = 50) and UKA (n = 50) and retrospectively analysed. RESULTS Robotic TKA patients experienced 23.7% less blood loss compared to conventional TKA patients (911.0 ml vs 1193.7 ml, p < 0.01), and were associated with an 83% relative risk reduction of receiving a transfusion (2% of patients vs 12%, p = 0.02). Robotic UKA patients did not demonstrate less blood loss compared to corresponding controls (821.7 ml vs 854.7 ml, p = 0.69). Both UKA groups received no transfusions. CONCLUSIONS Robotic surgical systems in TKA reduces blood loss and lowers the risk of requiring a blood transfusion. In UKA, robotic-assisted arthroplasty did not reduce blood loss compared to conventional arthroplasty.
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Affiliation(s)
- Hasaan Khan
- Department of Medicine, Imperial College London, South Kensington Campus, London, UK
| | - Kieran Dhillon
- Department of Medicine, Imperial College London, South Kensington Campus, London, UK
| | - Piyush Mahapatra
- Department of Orthopaedics, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Ravi Popat
- Department of Orthopaedics, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Omar Zakieh
- Department of Medicine, Imperial College London, South Kensington Campus, London, UK
| | - Woo Jae Kim
- Department of Orthopaedics, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Dinesh Nathwani
- Department of Orthopaedics, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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14
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Haddad FS. Celebrating three years of Hip Society and Knee Society supplements. Bone Joint J 2021; 103-B:1174-1175. [PMID: 34192929 DOI: 10.1302/0301-620x.103b7.bjj-2021-0765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal, London, UK
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15
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Affiliation(s)
- Ahmed A Magan
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK.,The Bone & Joint Journal, London, UK
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16
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Grzelecki D, Dudek P, Okoń T, Marczak D, Kordasiewicz B, Sibiński M, Kowalczewski J. Efficacy of intravenous tranexamic acid administration in revision hip arthroplasty. DER ORTHOPADE 2021; 50:464-470. [PMID: 32761422 DOI: 10.1007/s00132-020-03959-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to evaluate the efficiency of constant dose intravenous administration of tranexamic acid (TXA) in reducing postoperative blood loss, hemoglobin (Hb) concentration, and the number of transfusions in revision hip arthroplasty (RHA). METHODS The study included 145 consecutive patients who had undergone RHA: a TXA group (75 patients) who received two doses of TXA (1.0 g 15 min before skin incision and 1.0 g during wound closure) and a no-TXA group (70 patients). Percentage blood loss and quantitative blood loss were calculated. RESULTS The percentage blood loss (23.82 ± 10.6% vs. 39.17 ± 15.1%; P < 0.001), Hb drop (2.9 ± 1.14 g/dL vs. 4.22 ± 1.4 g/dL; P < 0.001), and total blood loss (1030 ± 477 mL vs. 1736 ± 761 mL; P < 0.001) were significantly lower in the TXA group than in the no-TXA group on postoperative day 1. Percentage blood loss (37.5 ± 10.4% vs. 43.1 ± 12.5%; P < 0.01), Hb drop (4.64 ± 1.5 g/dL vs. 5.22 ± 1.6 g/dL; P < 0.01) and total blood loss (1639 ± 543 mL vs. 1908 ± 681 mL; P = 0.02) were significantly lower in the TXA group than in the no-TXA group on the 5th postoperative day. The blood transfusion requirements were lower in the TXA group than those in the no-TXA group (30.7% vs. 71.4% of patients; P < 0.001), with a lower transfusion per patient ratio of 0.55 in the TXA group and 1.4 in the no-TXA group. No postoperative complications were associated with TXA administration, including deep-vein thrombosis and pulmonary embolism. CONCLUSION Administration of TXA is an effective method to reduce perioperative blood loss, Hb drop and the number of transfusions in RHA.
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Affiliation(s)
- Dariusz Grzelecki
- Department of Orthopedics and Rheumoorthopedics, Professor Adam Gruca Teaching Hospital, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400, Otwock, Poland.
| | - Piotr Dudek
- Department of Orthopedics and Rheumoorthopedics, Professor Adam Gruca Teaching Hospital, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400, Otwock, Poland
| | - Tomasz Okoń
- Department of Orthopedics and Rheumoorthopedics, Professor Adam Gruca Teaching Hospital, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400, Otwock, Poland
| | - Dariusz Marczak
- Department of Orthopedics and Rheumoorthopedics, Professor Adam Gruca Teaching Hospital, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400, Otwock, Poland
| | - Bartłomiej Kordasiewicz
- Department of Traumatology and Orthopedic Surgery, Professor Adam Gruca Teaching Hospital, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400, Otwock, Poland
| | - Marcin Sibiński
- Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Łódź, Pomorska 251, 92-213, Łódź, Poland
| | - Jacek Kowalczewski
- Department of Orthopedics and Rheumoorthopedics, Professor Adam Gruca Teaching Hospital, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400, Otwock, Poland
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17
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Zak SG, Tang A, Sharan M, Waren D, Rozell JC, Schwarzkopf R. Tranexamic Acid Is Safe in Patients with a History of Coronary Artery Disease Undergoing Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:900-904. [PMID: 33983147 DOI: 10.2106/jbjs.20.01226] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is increasingly used to minimize blood loss during total joint arthroplasty (TJA). Although TXA has been shown to be highly effective in reducing operative blood loss, many surgeons believe that it places patients with coronary artery disease (CAD) or a history of coronary stents at an increased risk for myocardial infarction. The purpose of this study was to determine if TXA is safe to use in patients with a history of CAD or coronary stents. METHODS We performed a retrospective analysis at a single, tertiary academic medical center identifying consecutive total hip and knee arthroplasty cases over an 8-year period. From this cohort who received TXA intraoperatively, we identified patients with a history of CAD or coronary stents and determined the total myocardial infarction and venous thromboembolism (VTE) rates within a 90-day postoperative period. Chi-square analyses were used to identify differences in VTE rates between cohorts. A post hoc power analysis was also performed to determine whether our results were powered to detect a difference in VTE rates. RESULTS In the 26,808 identified at-risk patients, there were no postoperative myocardial infarctions. No significant differences were observed for VTE rates compared with the control cohort using either topical or intravenous TXA, with regard to CAD (0.29% compared with 0.76%; p = 0.09) or coronary stents (0% compared with 0.76%; p = 0.14). Moreover, there was no significant difference observed in VTE rates when administration was subcategorized into intravenous and topical methods with regard to CAD (0.13% compared with 0.72%; p = 0.12) or coronary stents (0% compared with 0%; p = 1.0). CONCLUSIONS In our series, topical and intravenous TXA were equally safe when used in patients with a history of CAD and coronary stents in comparison with the control cohort. With equal efficacy and risk of adverse events, we recommend intravenous TXA, which may enable easier institutional implementation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stephen G Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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18
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Saad BN, Menken LG, Elkattaway S, Liporace FA, Yoon RS. Tranexamic acid lowers transfusion requirements and hospital length of stay following revision total hip or knee arthroplasty. Patient Saf Surg 2021; 15:21. [PMID: 33975621 PMCID: PMC8111901 DOI: 10.1186/s13037-021-00295-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/26/2021] [Indexed: 11/18/2022] Open
Abstract
Backgroud Intravenous tranexamic acid (TXA) has been shown to reduce blood loss in patients undergoing total joint arthroplasty without systemic complications. There is limited evidence of its effectiveness in revision procedures. This study evaluated intravenous TXA effect on blood loss, transfusion rates, and length of hospital stay in revision joint replacement. Methods One-hundred revision total joint arthroplasty patients were retrospectively reviewed [44 revision total hip arthroplasty (THA) and 54 revision total knee arthroplasty (TKA)] who underwent surgery from 2013 to 2016. Fifty-four revision joint patients (23 THA and 31 TKA) received intravenous TXA intra-operatively, while 46 revision joint patients (23 THA/TKA) did not. Primary outcome measures were blood loss, transfusion rates, and length of hospital stay. Results The mean blood loss difference between revision THA patients who received TXA vs. not receiving TXA was 180ml in revision THA patients (p < .005). Mean length of hospital stay was 6 days in non-TXA vs. 3 days in TXA patients (p < .001). Eighteen patients received transfusions in the non-TXA revision TKA group compared to nine patients in the TXA revision TKA group (p < .001). Average length of hospital stay was 5 days in the non-TXA revision TKA group compared to 3 days in the TXA revision TKA group (p < .003). There was no increased risk of thromboembolic complications in TXA groups for either procedure. Conclusions Intravenous TXA reduced length of hospital stay in both revision cohorts, decreased blood loss in revision THA and decreased the rate of transfusion in revision TKA without an increase in thromboembolic complications. Level of Evidence Level III (Case-control study)
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Affiliation(s)
- Bishoy N Saad
- Divison of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, City Medical Center-RWJBarnabas Health, 377 Jersey Ave, Suite 280A, NJ, 07302, Jersey City, USA
| | - Luke G Menken
- Divison of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, City Medical Center-RWJBarnabas Health, 377 Jersey Ave, Suite 280A, NJ, 07302, Jersey City, USA
| | - Sherif Elkattaway
- Divison of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, City Medical Center-RWJBarnabas Health, 377 Jersey Ave, Suite 280A, NJ, 07302, Jersey City, USA
| | - Frank A Liporace
- Divison of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, City Medical Center-RWJBarnabas Health, 377 Jersey Ave, Suite 280A, NJ, 07302, Jersey City, USA
| | - Richard S Yoon
- Divison of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, City Medical Center-RWJBarnabas Health, 377 Jersey Ave, Suite 280A, NJ, 07302, Jersey City, USA.
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19
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Chalmers BP, Mishu M, Cushner FD, Sculco PK, Nguyen J, Westrich GH. Is There a Synergistic Effect of Topical Plus Intravenous Tranexamic Acid Versus Intravenous Administration Alone on Blood Loss and Transfusions in Primary Total Hip and Knee Arthroplasties? Arthroplast Today 2021; 7:194-199. [PMID: 33553549 PMCID: PMC7856320 DOI: 10.1016/j.artd.2020.12.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/24/2020] [Accepted: 12/20/2020] [Indexed: 01/25/2023] Open
Abstract
Background The optimal route and dosing regimen of tranexamic acid (TXA) in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unclear. As such, we sought to analyze if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and transfusions. Methods We retrospectively analyzed 6720 primary TKAs and 6559 THAs performed from February 1, 2016 to December 31, 2019 at a single institution in patients who received a double IV dose (6159 TKAs and 6276 THAs) compared with a combined single IV and topical dose (561 TKAs and 283 THAs) of TXA. Multivariate logistic regression models, adjusting for age, body mass index, American Society of Anesthesiologists class, preoperative hemoglobin, and TXA administration, were performed for significant variables from a univariate analysis. Results In the TKA cohort, the mean total blood loss was statistically similar for double IV (305 mL, 95% confidence interval [CI] = 301-310 mL) TXA compared with combined TXA (310 mL, 95% CI = 299-321 mL) (P = .43). Furthermore, there was no difference in the rate of transfusion (odds ratio = 1.23, 95% CI = 0.57-2.67, P = .598). In the THA cohort, there was statistically higher blood loss with double IV (328 mL, 95% CI = 323-333 mL) TXA than in the combined group (295 mL, 95% CI = 280-310 mL) (P < .001). The rate of transfusion was statistically similar at ~2% (P = .970). Conclusions A double IV TXA dose and a combined single IV and topical TXA dose were equally effective in minimizing blood transfusions (~2%) at primary TKA and THA. We did not find a synergistic effect when combining a systemic IV TXA with a topical TXA. Level of Evidence Level III.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Mithun Mishu
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Fred D Cushner
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Peter K Sculco
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Nguyen
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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20
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Tandogan RN, Polat M, Beyzadeoglu T, Karabulut E, Yildirim K, Kayaalp A. Topical co-delivery of platelet rich fibrin and tranexamic acid does not decrease blood loss in primary total knee arthroplasty compared to the standard of care: a prospective, randomized, controlled trial. Knee Surg Sports Traumatol Arthrosc 2021; 29:519-528. [PMID: 32170355 DOI: 10.1007/s00167-020-05938-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/03/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the efficacy of intra-operative co-administration of tranexamic acid (TA) and platelet rich fibrin (PRF) using a proprietary co-delivery system on the amount of blood loss, early functional outcomes and wound complications after primary total knee arthroplasty (TKA). The intervention was compared to the standard of care (combined intravenous & topical TA) in a prospective, randomized, blinded setting. METHODS 80 patients undergoing primary cemented TKA without tourniquet were prospectively randomized into control (combined intravenous and topical TA) and PRF (intra-venous TA and co-delivery of topical PRF and TA) groups after informed consent. Total blood loss, drainage blood loss, knee range of motion, VAS pain scores, length of stay and wound complications were analysed. Data collection was performed in a double blind manner on days 1, 3 and 21. RESULTS There was no statistically significant difference in drainage blood loss (550 ml vs. 525 ml, p = 0.643), calculated total blood loss on day 1 (401 ml vs. 407 ml, p = 0.722), day 3 (467 ml vs 471 ml, p = 0.471) and day 21 (265 ml vs. 219 ml, p = 0.082) between the PRF and control groups respectively. The PRF group had a small but statistically significant increase in median knee extension in the early post-operative period, however this difference evened out at 3 weeks. No significant difference could be demonstrated between the PRF and control groups in length of stay, VAS pain scores, narcotic usage, wound complications and knee flexion at all time points. CONCLUSIONS The topical co-delivery of PRF and TA does not significantly decrease blood loss in primary TKA compared to the standard of care. Slightly better active knee extension in the first 3 postoperative days can be achieved, however this benefit is not clinically relevant. LEVEL OF EVIDENCE I, Therapeutic study.
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Affiliation(s)
- Reha N Tandogan
- Ortoklinik and Cankaya Orthopedics, Cinnah caddesi 51/4, Cankaya, 06680, Ankara, Turkey.
| | - Metin Polat
- Ortoklinik and Cankaya Orthopedics, Cinnah caddesi 51/4, Cankaya, 06680, Ankara, Turkey
| | - Tahsin Beyzadeoglu
- Orthopaedics and Traumatology, Halic University and Beyzadeoglu Clinic, Bagdat Cad. No: 333 Erenkoy, 34738, Istanbul, Turkey
| | - Erdem Karabulut
- Department of Biostatistics, Hacettepe University, Sihhiye Campus, Ankara, Turkey
| | - Kerem Yildirim
- Orthopaedics and Traumatology, Istanbul Gelisim University and Beyzadeoglu Clinic, Bagdat Cad. No: 333 Erenkoy, 34738, Istanbul, Turkey
| | - Asim Kayaalp
- Ortoklinik and Cankaya Orthopedics, Cinnah caddesi 51/4, Cankaya, 06680, Ankara, Turkey
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21
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Sershon RA, Fillingham YA, Abdel MP, Malkani AL, Schwarzkopf R, Padgett DE, Vail TP, Nam D, Nahhas C, Culvern C, Della Valle CJ. The Optimal Dosing Regimen for Tranexamic Acid in Revision Total Hip Arthroplasty: A Multicenter Randomized Clinical Trial. J Bone Joint Surg Am 2020; 102:1883-1890. [PMID: 33148955 DOI: 10.2106/jbjs.20.00010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this multicenter, randomized trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss in revision total hip arthroplasty. METHODS Six centers prospectively randomized 175 patients to 1 of 4 regimens: (1) 1-g intravenous (IV) TXA prior to incision (the single-dose IV group), (2) 1-g IV TXA prior to incision followed by 1-g IV TXA after arthrotomy wound closure (the double-dose IV group), (3) a combination of 1-g IV TXA prior to incision and 1-g intraoperative topical TXA (the combined IV and topical group), or (4) 3 doses totaling 1,950-mg oral TXA (the multidose oral group). Randomization was based on revision subgroups to ensure equivalent group distribution. An a priori power analysis (α = 0.05; β = 0.80) determined that 40 patients per group were required to identify a >1-g/dL difference in postoperative hemoglobin reduction between groups. Per-protocol analysis involved an analysis of variance, Fisher exact tests, and two 1-sided t tests for equivalence. Demographic and surgical variables were equivalent between groups. RESULTS No significant differences were found between TXA regimens when evaluating reduction in hemoglobin (3.4 g/dL for the single-dose IV group, 3.6 g/dL for the double-dose IV group, 3.5 g/dL for the combined IV and topical group, and 3.4 g/dL for the multidose oral group; p = 0.95), calculated blood loss (p = 0.90), or transfusion rates (14% for the single-dose IV group, 18% for the double-dose IV group, 17% for the combined group, and 17% for the multidose oral group; p = 0.96). Equivalence testing revealed that all possible pairings were statistically equivalent, assuming a >1-g/dL difference in hemoglobin reduction as clinically relevant. There was 1 venous thromboembolism, with no differences found between groups (p = 1.00). CONCLUSIONS All 4 TXA groups tested had equivalent blood-sparing properties in the setting of revision total hip arthroplasty, with a single venous thromboembolism reported in this high-risk population. Based on the equivalence between groups, surgeons should utilize whichever of the 4 investigated regimens is best suited for their practice and hospital setting. Given the transfusion rate in revision total hip arthroplasty despite TXA utilization, further work is required in this area. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Robert A Sershon
- Department of Orthopedic Surgery, Anderson Orthopaedic Research Institute, Alexandria, Virginia
| | - Yale A Fillingham
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arthur L Malkani
- Department of Orthopedic Surgery, University of Louisville, Louisville, Kentucky
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, New York University, New York, NY
| | - Douglas E Padgett
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Thomas P Vail
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California
| | - Denis Nam
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Cindy Nahhas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Chris Culvern
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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22
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Levack AE, McLawhorn AS, Dodwell E, DelPizzo K, Nguyen J, Sink E. Intravenous tranexamic acid reduces blood loss and transfusion requirements after periacetabular osteotomy. Bone Joint J 2020; 102-B:1151-1157. [PMID: 32862676 DOI: 10.1302/0301-620x.102b9.bjj-2019-1777.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing orthopaedic surgery. There remains a lack of prospective evidence for the use of TXA in patients undergoing periacetabular osteotomy (PAO). The purpose of this study was to determine if intravenous (IV) TXA is effective in reducing calculated blood loss and transfusions after PAO. METHODS This was a single-centre prospective double-blind placebo-controlled randomized trial of 81 patients aged 12 to 45 years undergoing elective PAO by a single surgeon. The intervention group (n = 40) received two doses of IV TXA of a maximum 1 g in each dose; the control group (n = 41) received two doses of 50 ml 0.9% saline IV. The primary outcome was perioperative calculated blood loss. Secondary outcomes included allogenic transfusions and six-week postoperative complications. RESULTS There were no differences in demographics or intraoperative variables between study groups. The TXA group demonstrated lower mean calculated blood loss (1,265 ml, (SD 321) vs 1,515 ml, (SD 394); p = 0.002) and lower frequency of allogenic transfusion (10%/n = 4 vs 37%/n = 15; p = 0.008). Regression analyses associated TXA use with significant reductions in calculated blood loss (p < 0.001) and transfusion (p = 0.007) after adjusting for age, sex, body mass index, preoperative haemoglobin, cell-saver volume, intraoperative mean arterial blood pressure, and operating time. No patients suffered venous thromboembolic complications. CONCLUSION In this trial, IV TXA decreased postoperative calculated blood loss by 293 ml and reduced the frequency of allogenic transfusions by 73% (37% vs 10%) following PAO. TXA may be safe and effective for reducing blood loss in patients undergoing PAO. Cite this article: Bone Joint J 2020;102-B(9):1151-1157.
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Affiliation(s)
| | | | - Emily Dodwell
- Hospital for Special Surgery, New York, New York, USA
| | | | - Joseph Nguyen
- Hospital for Special Surgery, New York, New York, USA
| | - Ernest Sink
- Hospital for Special Surgery, New York, New York, USA
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23
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Affiliation(s)
- Daniel C. Perry
- University of Oxford, Oxford, UK; Alder Hey Hospital, Liverpool, UK
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Cuff DJ, Simon P, Gorman RA. Randomized prospective evaluation of the use of tranexamic acid and effects on blood loss for proximal humeral fracture surgery. J Shoulder Elbow Surg 2020; 29:1627-1632. [PMID: 32713466 DOI: 10.1016/j.jse.2020.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce blood loss in orthopedic surgery. It has been shown to decrease blood loss in upper- and lower-extremity arthroplasty, as well as lower-extremity fracture surgery. The use of TXA for proximal humeral fracture surgery has yet to be evaluated. The purpose of this study was to examine the effects of TXA on blood loss in patients undergoing open reduction-internal fixation (ORIF) or arthroplasty for the treatment of proximal humeral fractures. MATERIALS AND METHODS A total of 101 patients were randomized to receive either a single preoperative dose of intravenous TXA (53 patients) or a control dose of saline solution (48 patients) at the time of proximal humeral fracture surgery. On the basis of patient age and fracture pattern, ORIF was performed in 57 patients (30 TXA and 27 control patients) and reverse shoulder arthroplasty (RSA) was performed in the other 44 patients (23 TXA and 21 control patients). Intraoperative blood loss plus 24-hour drain output was used to calculate total blood loss for each procedure. The preoperative-to-postoperative change in hemoglobin level was also evaluated for each patient. Further stratification of blood loss and change in hemoglobin level based on procedure (ORIF or RSA) was performed as well. RESULTS Compared with the control group, the TXA group had less average intraoperative blood loss (178 mL vs. 129 mL, P < .0001), less postoperative drain output (103 mL vs. 62 mL, P < .0001), and less total blood loss (280 mL vs. 188 mL, P < .0001). Compared with the control group, the TXA group had a smaller average preoperative-to-postoperative change in hemoglobin level (-2.6 g/dL vs. -1.5 g/dL, P < .0001). Further stratification based on procedure showed that among patients undergoing ORIF and patients undergoing RSA, those receiving TXA had less average total blood loss and a smaller decrease in hemoglobin level than the control group. No identifiable intraoperative or postoperative complications associated with the use of TXA occurred in any patient. CONCLUSION TXA was effective in reducing total blood loss and led to a smaller preoperative-to-postoperative decrease in hemoglobin level compared with control in patients undergoing surgery for proximal humeral fractures. This effect was consistent in patients treated with either ORIF or arthroplasty as the surgical procedure. TXA can be used to decrease blood loss in the surgical treatment of proximal humeral fractures.
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Affiliation(s)
- Derek J Cuff
- Suncoast Orthopaedic Surgery and Sports Medicine, Venice, FL, USA.
| | - Peter Simon
- Foundation for Orthopaedic Research and Education, Tampa, FL, USA; Department of Medical Engineering, University of South Florida, Tampa, FL, USA
| | - R Allen Gorman
- Foundation for Orthopaedic Research and Education, Tampa, FL, USA
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Zhao HY, Yeersheng R, Kang XW, Xia YY, Kang PD, Wang WJ. The effect of tourniquet uses on total blood loss, early function, and pain after primary total knee arthroplasty: a prospective, randomized controlled trial. Bone Joint Res 2020; 9:322-332. [PMID: 32670565 PMCID: PMC7342055 DOI: 10.1302/2046-3758.96.bjr-2019-0180.r3] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aims The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. Methods This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay. Conclusion Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA. Cite this article: Bone Joint Res 2020;9(6):322–332.
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Affiliation(s)
- Hai-Yan Zhao
- Department of Orthopedics, The First Hospital of Lanzhou University, Lanzhou, China
| | - Releken Yeersheng
- Department of Orthopedics, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xue-Wen Kang
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Ya-Yi Xia
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, China
| | - Peng-De Kang
- Department of Orthopedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Wen-Ji Wang
- Department of Orthopedics, The First Hospital of Lanzhou University, Lanzhou, China
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Response to Letter to the Editor on "Topical Tranexamic Acid in Revision Total Knee Arthroplasty Reduces Transfusion Rates and May Be Associated With Earlier Recovery". J Arthroplasty 2020; 35:1447-1448. [PMID: 32061476 DOI: 10.1016/j.arth.2020.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 02/01/2023] Open
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Reply to the Letter to the Editor: Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial. Clin Orthop Relat Res 2020; 478:917-918. [PMID: 32039956 PMCID: PMC7282592 DOI: 10.1097/corr.0000000000001164] [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: 01/31/2023]
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Springer BD, Haddad FS. The Knee Society Closed Meeting Supplement 2019. Bone Joint J 2019; 101-B:1-2. [PMID: 31256652 DOI: 10.1302/0301-620x.101b7.bjj-2019-0604] [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: 11/05/2022]
Affiliation(s)
- B D Springer
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina, USA
| | - Fares S Haddad
- The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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