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Hoffman RA, Green A, Paxton ES. Optimizing Visualization in Shoulder Arthroscopy: An Evidence-Based Guide. J Am Acad Orthop Surg 2024:00124635-990000000-01033. [PMID: 38996206 DOI: 10.5435/jaaos-d-23-01025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Indexed: 07/14/2024] Open
Abstract
Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.
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Affiliation(s)
- Ryan A Hoffman
- From the Division of Shoulder and Elbow Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Eckhof ML, von Hertzberg-Bölch S, Eidmann A, Lüdemann M, Rudert M, Jakuscheit A. Total blood loss and early clinical outcomes under different tranexamic acid regimes in total knee arthroplasty. Arch Orthop Trauma Surg 2024; 144:2795-2802. [PMID: 38819459 DOI: 10.1007/s00402-024-05229-1] [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: 10/06/2023] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Many different regimes of intravenous and local tranexamic acid (TXA) reduce total blood loss (TBL) in patients undergoing total knee arthroplasty (TKA). However, the most effective TXA regime in reducing blood loss might not be most beneficial for the patient. The aim of the present study was to investigate the effect of commonly used TXA regimes on blood loss and on early clinical outcomes. METHODS We performed this monocentric retrospective study in patients undergoing primary TKA. Primary outcome was the estimated TBL. Secondary outcomes were the rates of adverse events (AE) as well as the range of motion (ROM), mobility and pain intensity during the first three physiotherapy sessions (PTS). RESULTS We analysed the data of 1250 TKAs. 5 different TXA regimes were applied. TBL (mean ± SE) was 953 ± 64 ml (2xiv), 999 ± 19 ml (2xiv + 1xlocal), 1075 ± 19 ml (1xiv + 1xlocal), 1191 ± 39 ml (1xlocal) and 1241 ± 48 ml (1xiv) (p < 0.01). In the linear regression model for TBL a lower number of TXA applications was a predictor for increased blood loss (p < 0.01). AE rates were lowest under 2xiv (0%) and 2xiv + 1xlocal (4.8%). Highest mobility and lowest pain intensity were observed under 1x iv and 2x iv. The largest portions of fully mobile patients on day three were observed under 1xiv (100%), 2xiv (100%) and 2xiv + 1local TXA (86.9%). CONCLUSION Our results suggest that multiple applications of TXA are more effective in decreasing blood loss than excessive dosing of TXA. Interestingly, local use of TXA might be associated with higher pain intensity and decreased mobility on the first days after surgery.
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Affiliation(s)
- Mona-Lisa Eckhof
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany.
| | | | - Annette Eidmann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Martin Lüdemann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
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余 鸿, 董 珍, 施 政, 李 黎, 董 开, 刘 昊, 李 彦. [Early effectiveness of local injection of multimodal drug cocktail during anterior cruciate ligament reconstruction and its influence on cartilage]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:562-569. [PMID: 38752242 PMCID: PMC11096880 DOI: 10.7507/1002-1892.202402054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024]
Abstract
Objective To explore the early effectiveness and influence on cartilage of local injection of multimodal drug cocktail (MDC) during anterior cruciate ligament reconstruction (ACLR). Methods Between February 2022 and August 2023, patients undergone arthroscopic ACLR using autologous hamstring tendons were selected as the study subjects. Among them, 90 patients met the selection criteria and were randomly divided into 3 groups ( n=30) according to the different injection drugs after ligament reconstruction. There was no significant difference in baseline data such as gender, age, body mass index, surgical side, disease duration, preoperative thigh circumference, and preoperative levels of tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), IL-1, matrix metalloproteinase 3 (MMP-3), MMP-13, and aggrecan (ACAN) in synovial fluid between groups ( P>0.05). After the ligament reconstruction during operation, corresponding MDC (consisting of ropivacaine, tranexamic acid, and betamethasone in group A, and ropivacaine, betamethasone, and saline in group B) or saline (group C) were injected into the joint and tendon site, respectively. The length of hospital stay, postoperative tramadol injection volume, incidence of complications, degree of knee joint swelling and range of motion, visual analogue scale (VAS) score, International Knee Documentation Committee (IKDC) score, Lyshlom score, and Hospital for Special Surgery (HSS) score were recorded and compared between groups. The T2 * values in different cartilage regions were detected by MRI examination and the levels of TNF-α, IL-6, IL-1, MMP-3, MMP-13, and ACAN in synovial fluid were detected by ELISA method. Results The patients in group A, B, and C were followed up (12.53±3.24), (13.14±2.87), and (12.82±3.32) months, respectively. All incisions healed by first intention. Compared with group C, group A and group B had shorter length of hospital stay, less tramadol injection volume, and lower incidence of complications, showing significant differences ( P<0.05); there was no significant difference between group A and group B ( P>0.05). The degree of knee swelling in group A was significantly less than that in group B and group C ( P<0.05), but there was no significant difference between group B and group C ( P>0.05). At 3, 6, 12, 24, and 48 hours after operation, VAS scores of group A and group B were significantly lower than those of group C ( P<0.05); at 72 hours after operation, there was no significant difference among the three groups ( P>0.05). At 3 days, 14 days, and 1 month after operation, the range of motion of knee joint in group A were significantly better than those in group C ( P<0.05), and there was no significant difference between the other groups ( P>0.05). At 1 month after operation, the IKDC score of group A and group B was significantly higher than that of group C ( P<0.05); there was no significant difference among the three groups at other time points ( P>0.05). There was no significant difference in Lyshlom score and HSS score among the three groups at each time point ( P>0.05). At 14 days after operation, the levels of IL-1 and IL-6 in the synovial fluid in groups A and B were significantly lower than those in group C ( P<0.05). There was no significant difference in the levels of TNF-α, MMP-3, MMP-13, and ACAN between groups A and B ( P>0.05). At 1 month after operation, there was no significant difference in the above indicators among the three groups ( P>0.05). At 3, 6, and 12 months after operation, there was no significant difference in the T2 * values of different cartilage regions among the three groups ( P>0.05). Conclusion Injecting MDC (ropivacaine, tranexamic acid, betamethasone) into the joint and tendon site during ACLR can achieve good early effectiveness without significant impact on cartilage.
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Affiliation(s)
- 鸿 余
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 珍林 董
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 政良 施
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 黎 李
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 开颜 董
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 昊龙 刘
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 彦林 李
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
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Yu H, Shi Z, Xiong B, Li Y, Qin Y, Dong K, Li Y, Li L. [Research progress on early postoperative pain management strategies after arthroscopic anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:218-225. [PMID: 38385236 PMCID: PMC10882226 DOI: 10.7507/1002-1892.202311105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Objective To summarize the early postoperative pain management strategies for anterior cruciate ligament reconstruction (ACLR), and to select a reasonable and effective pain management plan to promote functional rehabilitation after ACLR. Methods The literature about the early postoperative pain management strategies of ACLR both domestically and internationally in recent years was extensiverly reviewed, and the effects of improving postoperative pain were reviewed. Results Currently, physical therapy and oral medication have advantages such as economy and simplicity, but the effect of improving postoperative pain is not satisfactory, often requires a combination of intravenous injection or intravenous pump, which is also a common way to relieve pain. However, in order to meet the analgesic needs of patients, the amount of analgesic drugs used is often large, which increases the incidence of various adverse reactions. Local infiltration analgesia (LIA), including periarticular or intra-articular injection of drugs, can significantly improve the early postoperative pain of ACLR, and achieve similar postoperative effectiveness as nerve block. LIA can be used as an analgesic technique instead of nerve block, and avoid the corresponding weakness of innervated muscles caused by nerve block, which increases the risk of postoperative falls. Many studies have confirmed that LIA can alleviate postoperative early pain in ACLR, especially the analgesic effects of periarticular injection are more satisfactory. It can also avoid the risk of cartilage damage caused by intra-articular injection. However, the postoperative analgesic effect and timeliness still need to be improved. It is possible to consider combining multimodal mixed drug LIA (combined with intra-articular and periarticular) with other pain intervention methods to exert a synergistic effect, in order to avoid the side effects and risks brought by single drugs or single administration route. LIA is expected to become one of the most common methods for relieving postoperative early pain in ACLR. Conclusion Early pain after arthroscopic ACLR still affects the further functional activities of patients, and all kinds of analgesic methods can achieve certain effectiveness, but there is no unified standard at present, and the advantages and disadvantages of various analgesic methods need further research.
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Affiliation(s)
- Hong Yu
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Zhengliang Shi
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Bohan Xiong
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Yajuan Li
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Yihua Qin
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Kaiyan Dong
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Yanlin Li
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - Li Li
- Department of Sports Medicine, First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
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Wang M, Li Y, Lin S, Ong MTY, Yung PSH, Li G. In Vivo Effect of Single Intra-Articular Injection of Tranexamic Acid on Articular Cartilage and Meniscus: Study in a Rat Model. J Bone Joint Surg Am 2024; 106:232-240. [PMID: 38015926 DOI: 10.2106/jbjs.23.00294] [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: 11/30/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) has been increasingly used in arthroscopic surgery to prevent hemarthrosis. Despite its effectiveness, safety concerns have been raised regarding its potential cytotoxicity to articular cartilage and meniscus following intra-articular injection. METHODS To evaluate the impact of TXA on cartilage and meniscus, a rat model of knee instability was utilized wherein anterior cruciate ligament (ACL) transection surgery was followed by a single intra-articular injection of TXA at varying concentrations (0, 20, 50, 100, and 150 mg/mL) in saline solution. Cell viability assessment of the cartilage and meniscus (n = 6 per group) was conducted at 24 hours, and gross observation and histological analysis of the medial tibial plateau and medial meniscus were conducted at 2, 4, and 8 weeks (n = 6 per group and time point). RESULTS The chondrocyte viability was significantly decreased in the 50, 100, and 150 mg/mL TXA groups compared with the specimens injected with saline solution only (saline group) (p = 0.001, p < 0.001, p < 0.001, respectively), as was meniscal cell viability (p = 0.042, p < 0.001, p < 0.001, respectively). At week 8, the saline and 20 and 50 mg/mL groups showed relatively normal appearances, whereas the 100 and 150 mg/mL groups exhibited increased and varying severity of cartilage and meniscal degeneration. In the 150 mg/mL group, the mean Osteoarthritis Research Society International score was significantly higher than that in the saline and 20 mg/mL groups (p = 0.010 and p = 0.007). Additionally, the mean meniscus score in the 150 mg/mL group was significantly higher than that in the saline, 20 mg/mL, and 50 mg/mL groups (p = 0.020, p = 0.021, p = 0.031, respectively). CONCLUSIONS Our findings indicate that concentrations of TXA at or above 100 mg/mL can lead to decreased cell viability in both cartilage and meniscus, resulting in significant cartilage degeneration in rats with ACL transection. Furthermore, the use of 150 mg/mL of TXA led to significant meniscal degeneration. CLINICAL RELEVANCE It is prudent to avoid using concentrations of TXA at or above 100 mg/mL for intra-articular injection, as such concentrations may result in adverse effects on the cartilage and meniscus.
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Affiliation(s)
- Ming Wang
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Yucong Li
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Sien Lin
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Michael T Y Ong
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Patrick S H Yung
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Gang Li
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
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Akcaalan S, Akcan G, Tufan AC, Caglar C, Akcaalan Y, Akkaya M, Dogan M. Is tranexamic acid safe for the hip joint? NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:1197-1207. [PMID: 37644283 DOI: 10.1007/s00210-023-02693-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023]
Abstract
To show the effects of tranexamic acid, which is a drug frequently used to control bleeding, on the hip joint and sciatic nerve in animal experiments. There were 15 rats in each of the 3 groups, with a total of 45 rats. Topical saline injections were applied to the first group, topical TXA injections to the second group, and intravenous (IV) TXA injections to the third group. In the samples taken from the hip joint 3 weeks later, femoral head cartilage, sciatic nerve, and joint capsule thicknesses were analyzed histologically. Statistically significantly more cartilage degradation was detected in the femoral head cartilage in both the IV and intraarticular TXA group when compared to the control group. The groups were also compared in terms of acetabular cartilage; however, no histological difference was found between the groups. It was seen that when the femoral head cartilage thickness (the average of the measurements made from 3 different points were used) was examined, the cartilage thickness in the topical TXA group was less when compared to the other 2 groups. However, this difference was determined to not be statistically significant. The data of the hip joint capsule thickness measurement, it was found that the capsule thickness in the topical TXA applied group was less when compared to the other 2 groups. However, this difference was not statistically significant. When the sciatic nerves in all 3 groups were compared, no different staining characteristics were found in the immunofluorescence examination. TXA, which is frequently used in orthopedic practice, shows negative effects on hip joint cartilage in both topical and intravenous application.
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Affiliation(s)
- Serhat Akcaalan
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey.
| | - Gulben Akcan
- Department of Histology and Embryology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Ahmet Cevik Tufan
- Department of Histology and Embryology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Ceyhun Caglar
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06800, Ankara, Turkey
| | | | - Mustafa Akkaya
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Metin Dogan
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
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Çağlar C, Akçaalan S, Akçaalan Y, Akcan G, Tufan AC, Akkaya M, Doğan M. Tranexamic acid administered intraarticularly to the knee is safer for the articular cartilage and anterior cruciate ligament compared to intravenous administration: Histological analysis of an experimental rat model. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:1045-1051. [PMID: 37566306 DOI: 10.1007/s00210-023-02666-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/08/2023] [Indexed: 08/12/2023]
Abstract
In this study, the effects of tranexamic acid (TXA) on the knee's articular cartilage, anterior cruciate ligament (ACL), and joint capsule were assessed histologically. There were 15 rats in each of the 3 groups, totaling 45 rats. Intraarticular (IA) saline injections were applied for the first group, IA TXA injections for the second group, and intravenous (IV) TXA injections for the third group. Using samples taken from the knee joint 3 weeks later, the medial/lateral femoral condyle and medial/lateral tibial plateau articular cartilages were evaluated with Osteoarthritis Research Society International (OARSI) scoring, while ACL diameter and joint capsule thickness were analyzed histologically. In comparisons of OARSI scores for the medial/lateral femoral condyle and medial/lateral tibial plateau cartilage regions, the scores obtained for the IV TXA group were significantly higher than those of the IA saline group (P < 0.001, P = 0.001, P = 0.003, P = 0.011). In comparisons of medial/lateral femoral condyle and medial/lateral tibial plateau OARSI scores, the scores obtained for the IV TXA group were again significantly higher than those of the IA TXA group (P < 0.001, P < 0.001, P < 0.001, P = 0.002). When ACL diameters were compared, a significant decrease was observed in the ACL diameters of the IV TXA group compared to the IA saline and IA TXA groups (P < 0.001, P = 0.039). Histologically, IV TXA damages the articular cartilage and ACL more than IA TXA. IA administration of TXA is more protective when the articular cartilage and ACL are preserved.
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Affiliation(s)
- Ceyhun Çağlar
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06800, Ankara, Turkey.
| | - Serhat Akçaalan
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06800, Ankara, Turkey
| | - Yasemin Akçaalan
- Department of Anesthesiology and Reanimation, Ankara City Hospital, 06800, Ankara, Turkey
| | - Gülben Akcan
- Department of Histology and Embryology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Ahmet Cevik Tufan
- Department of Histology and Embryology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Mustafa Akkaya
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Metin Doğan
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
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Borsinger TM, Chandi SK, Puri S, Debbi EM, Gausden EB, Chalmers BP. The Efficacy and Safety of Tranexamic Acid in Total Hip and Knee Arthroplasty: A Literature Review. HSS J 2024; 20:10-17. [PMID: 38356752 PMCID: PMC10863588 DOI: 10.1177/15563316231208716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/03/2023] [Indexed: 02/16/2024]
Abstract
Historically, total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been associated with significant perioperative blood loss and a relatively high rate of allogeneic blood transfusions. However, in recent years, tranexamic acid (TXA), a competitive inhibitor of tissue plasminogen activator, inhibiting fibrinolysis of existing thrombi, has substantially decreased the need for blood transfusion in THA and TKA. Various administration strategies have been studied, but there remains a lack of consensus on an optimal route and dosing regimen, with intravenous and topical regimens being widely used. A growing body of literature has demonstrated the safety and efficacy of TXA in primary and revision THA and TKA to reduce blood loss, allogeneic transfusions, and complications; it is associated with lowered lengths of stay, costs, and readmission rates.
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Affiliation(s)
- Tracy M Borsinger
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Sonia K Chandi
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Simarjeet Puri
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Eytan M Debbi
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Elizabeth B Gausden
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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Ghaffari S, Fateh S, Faramarzi F, Rafiei A, Razavipour M, Zafari P. The effect of tranexamic acid on synovium of patients undergoing arthroplasty and anterior cruciate ligament reconstruction surgery. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3733-3742. [PMID: 37318523 DOI: 10.1007/s00210-023-02555-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
Abstract
Preoperative hemorrhage can be reduced using anti-fibrinolytic medicine tranexamic acid (TXA). During surgical procedures, local administration is being used more and more frequently, either as an intra-articular infusion or as a perioperative rinse. Serious harm to adult soft tissues can be detrimental to the individual since they possess a weak ability for regeneration. Synovial tissues and primary fibroblast-like synoviocytes (FLS) isolated from patients were examined using TXA treatment in this investigation. FLS is obtained from rheumatoid arthritis (RA), osteoarthritis (OA), and anterior cruciate ligament (ACL)-ruptured patients. The in vitro effect of TXA on primary FLS was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays for cell death, annexin V/propidium iodide (PI) staining for apoptotic rate, real-time PCR for p65 and MMP-3 expression, and enzyme-linked immunosorbent assay (ELISA) for IL-6 measurement. MTT assays revealed a significant decrease in cell viability in FLS of all groups of patients following treatment with 0.8-60 mg/ml of TXA within 24 h. There was a significant increase in cell apoptosis after 24 h of exposure to TXA (15 mg/ml) in all groups, especially in RA-FLS. TXA increases the expression of MMP-3 and p65 expression. There was no significant change in IL-6 production after TXA treatment. An increase in receptor activator of nuclear factor kappa-Β ligand (RANK-L) production was seen only in RA-FLS. This study demonstrates that TXA caused significant synovial tissue toxicity via the increase in cell death and elevation of inflammatory and invasive gene expression in FLS cells.
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Affiliation(s)
- Salman Ghaffari
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Soroosh Fateh
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Faramarzi
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Rafiei
- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehran Razavipour
- Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Parisa Zafari
- Ramsar Campus, Mazandaran University of Medical Sciences, Ramsar, Iran.
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Wang J, Liang S, Ma T, Chen S, Hu Y, Wang L. Tranexamic Acid Causes Chondral Injury Through Chondrocytes Apoptosis Induced by Activating Endoplasmic Reticulum Stress. Arthroscopy 2023; 39:2529-2546.e1. [PMID: 37683831 DOI: 10.1016/j.arthro.2023.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE To investigate whether tranexamic acid (TXA) is cytotoxic in chondrocyte and cartilage tissues, as well as explore the mechanisms behind the possible toxicity in detail. METHODS We detected the cell viability of chondrocytes in vitro and the change of morphology and specific in vivo contents of cartilage after TXA treatment. Furthermore, we detected apoptosis in cartilage. We used apoptosis-specific staining, reactive oxygen species detection, mitochondrial membrane potential detection, flow cytometry, and western blot for apoptosis detection. Finally, we detected the activation of endoplasmic reticulum stress (ERS) in TXA-treated chondrocytes to clarify the mechanism behind chondrocyte apoptosis. RESULTS TXA presented an increasing toxic effect with increasing concentrations, especially in the 100 mg/mL group. In addition, we found that 50 mg/mL and 100 mg/mL TXA significantly increased apoptosis in cartilage and subchondral bone. TXA could induce chondrocyte apoptosis in cell and protein levels with reactive oxygen species generation and mitochondrial membrane depolarization. An apoptosis inhibitor could inhibit the induced apoptosis. Next, TXA induced calcium overload in chondrocytes and increased ERS-specific protein expression, whereas ERS inhibitor blocked ERS activation and further inhibited chondrocyte apoptosis. CONCLUSIONS We concluded that TXA had a toxic effect on chondrocytes by inducing apoptosis through ERS activation, especially in 50 mg/mL and 100 mg/mL groups. We recommend TXA concentrations of less than 50 mg/mL in joint surgeries. CLINICAL RELEVANCE It is still unclear whether TXA has a toxic effect on cartilage when topically used in joint surgeries. The concentration also varies. This study provides additional evidence that TXA at high concentrations will cause cartilage damage, which will help to provide a new understanding of the clinical administration of TXA.
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Affiliation(s)
- Jiahao Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China
| | - Shuailong Liang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China
| | - Tianliang Ma
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China
| | - Sijie Chen
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yihe Hu
- Department of Orthopedics, First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China.
| | - Long Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratary of Aging Biology, Xiangya Hospital, Central South University, Changsha, China.
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Han C, Liu M, Lian X, Sun T, Yan S, Bai X, Gan D, Leng B, Qiu Y, Ren Y. Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis. J Shoulder Elbow Surg 2023; 32:2389-2399. [PMID: 37468032 DOI: 10.1016/j.jse.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE Although tranexamic acid (TXA) is being increasingly used in orthopedic arthroplasty and lower-extremity arthroscopic procedures, its use in arthroscopic rotator cuff repair (ARCR) is less widely reported. The aim of this study was to evaluate the clinical effectiveness and safety of TXA administration in ARCR. METHODS A systematic review and meta-analysis of randomized controlled trials was performed to compare clinical outcomes in patients who underwent ARCR with or without TXA. Literature was retrieved using the Cochrane Library, MEDLINE, PubMed, and Embase electronic databases. The primary outcome of this study was visual clarity. Secondary outcomes contained total operative time, postoperative pain score, amount of blood loss, shoulder swelling (change in shoulder circumference), volume of irrigation fluid, number of adjustments of the pump pressure for irrigation, and adverse cardiovascular events. RESULTS Seven studies (3 and 4 with level I and II evidence, respectively), which included 272 and 265 patients who underwent arthroscopy with and without TXA, respectively, met the eligibility criteria. Pooled analysis showed significant improvements in visual clarity (mean difference, 9.10%; 95% CI, 4.05-14.15; P = .0004) and total operative time (mean difference, -11.24 minute; 95% CI, -19.90 to -2.57) associated with perioperative TXA application. None of the trials reported adverse events and complications associated with TXA. CONCLUSION The best available evidence indicates that TXA administration could significantly improve arthroscopic visual clarity and effectively save operative time in ARCR without increasing the incidence of adverse events. Furthermore, the optimal dose, route, and timing of TXA application in ARCR surgery remains to be validated by future high-level evidence studies.
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Affiliation(s)
- Changxu Han
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Ming Liu
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xin Lian
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Tao Sun
- Emergency Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Shengjuan Yan
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xianming Bai
- Spine Surgery Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Dige Gan
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Bing Leng
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Yi Qiu
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
| | - Yizhong Ren
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
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Pimenta FS, de Oliveira Campos TV, de Abreu E Silva GM, Buzelin MA, Nunes CB, de Andrade MAP. Chondrotoxic effects of tranexamic acid and povidone-iodine on the articular cartilage of rabbits. INTERNATIONAL ORTHOPAEDICS 2023; 47:2429-2437. [PMID: 37099167 DOI: 10.1007/s00264-023-05820-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/18/2023] [Indexed: 04/27/2023]
Abstract
PURPOSE To evaluate the chondrotoxic effects of intra-articular use of TXA 20 mg/kg and/or 0.35% PVPI on knee joint cartilage in an experimental model of rabbits. METHODS Forty-four male New Zealand adult rabbits were randomly assigned to four groups (control, tranexamic acid (TXA), povidone-iodine (PVPI), and PVPI + TXA). The knee joint cartilage was accessed through an arthrotomy and exposed to physiological saline SF 0.9% (control group), TXA, PVPI, and PVPI followed by TXA. Sixty days after surgical procedure, the animals were sacrificed and osteochondral specimens of the distal femur were obtained. Histological sections of cartilage from this area were stained with hematoxylin/eosin and toluidine blue. The following cartilage parameters were evaluated by the Mankin histological/histochemical grading system: structure, cellularity, glycosaminoglycan content in the extracellular matrix, and integrity of the tidemark. RESULTS The isolated use of PVPI causes statistically significant changes in cartilage cellularity (p-value = 0.005) and decrease glycosaminoglycan content (p = 0.001), whereas the isolated use of TXA decreased significantly the glycosaminoglycan content (p = 0.031). The sequential use of PVPI + TXA causes more pronounced alterations in the structure (p = 0.039) and cellularity (p = 0.002) and decreased content of glycosaminoglycans (p < 0.001) all with statistical significance. CONCLUSION Data suggest that intra-articular use of tranexamic acid 20 mg/kg and intraoperative lavage with 0.35% povidone-iodine solution for three min are toxic to the articular cartilage of the knee in an experimental in vivo study in rabbits.
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Affiliation(s)
- Frederico Silva Pimenta
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil.
| | - Túlio Vinícius de Oliveira Campos
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Guilherme Moreira de Abreu E Silva
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Marcelo Araújo Buzelin
- Institute of Education and Research Santa Casa, Ave dos Andradas 2688, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Cristiana Buzelin Nunes
- Pathologic Anatomy Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
| | - Marco Antônio Percope de Andrade
- Orthopaedic Department, Universidade Federal de Minas Gerais, Ave Prof. Alfredo Balena 190, Belo Horizonte, Minas Gerais, 30130100, Brazil
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Li X, Jiao G, Li J, Ji W, Hao Z, Gong F, Chen Y. Combined Use of Tranexamic Acid and Rivaroxaban in Posterior/Transforaminal Lumbar Interbody Fusion Surgeries Safely Reduces Blood Loss and Incidence of Thrombosis: Evidence From a Prospective, Randomized, Double-Blind, Placebo-Controlled Study. Global Spine J 2023; 13:1229-1237. [PMID: 34569334 PMCID: PMC10416579 DOI: 10.1177/21925682211024556] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A prospective, randomized, double-blind, placebo-controlled study. OBJECTIVES There are few studies examining the balance between preventing venous thrombus embolism (VTE) and reducing blood loss in posterior/transforaminal lumbar interbody fusion (PLIF/TLIF) surgeries. This study aimed to evaluate the efficacy and safety of the combine application of TXA and rivaroxaban in patients undergoing PLIF/TLIF and explore relevant factors related to blood loss and VTE. METHODS Patients in group A which was the control group received 0.9% NaCl solution intravenously. Group B was treated by an intravenous injection of 2 g tranexamic acid (TXA) and the local use of 1 g intraoperatively. Group C was treated the same as group B intraoperatively, and they received 10 mg rivaroxaban qd treatment postoperatively. Eligible patients with an Autar score ≤ 10 were randomly assigned to group A or group B. Patients with an Autar score >10 were allocated into group C. RESULTS The intraoperative blood loss and postoperative drainage were lower in groups B and C than in group A (P < .001). The blood transfusion rate in group B was lower than that in group A (P < .001), while the incidence of VTE in group C was lower (P < .001). Four factors were found to be positively correlated with obvious total blood loss (P < .05). The data showed that 5 factors were correlated with the development of a thrombus (P < .1). CONCLUSIONS The combination of TXA and rivaroxaban in PLIF/TLIF patients is safe and effective in reducing D-dimer levels associated with VTE and reducing blood loss.
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Affiliation(s)
- Xiang Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Lixia District, Ji’nan, Shandong, China
| | - Guangjun Jiao
- Department of Orthopedics, Qilu Hospital of Shandong University, Lixia District, Ji’nan, Shandong, China
| | - Jingyi Li
- Department of Endocrinology, Shandong Provincial Hospital, Huaiyin District, Jinan, Shandong, China
| | - Weibin Ji
- Department of Orthopedics, Weihaiwei People’s Hospital, Huancui District, Weihai, Shandong, China
| | - Zhiwei Hao
- Department of Orthopedics, Liao Cheng People’s Hospital, Liaocheng, Shandong, China
| | - Fangli Gong
- Shengli Oilfield Central Hospital, Dongying, Shandong, China
| | - Yunzhen Chen
- Department of Orthopedics, Qilu Hospital of Shandong University, Lixia District, Ji’nan, Shandong, China
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Li J, You M, Yao L, Fu W, Li Q, Chen G, Tang X, Li J, Xiong Y. Topical administration of tranexamic acid reduces postoperative blood loss and inflammatory response in knee arthroscopic arthrolysis: a retrospective comparative study. BMC Musculoskelet Disord 2023; 24:269. [PMID: 37020204 PMCID: PMC10074680 DOI: 10.1186/s12891-023-06349-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Knee arthroscopic arthrolysis serves as an effective treatment for knee arthrofibrosis. However, hemarthrosis is the most common complication in arthroscopic surgery, which has potential adverse effects on postoperative rehabilitation. The purpose of this study was to evaluate the effects of topical tranexamic acid (TXA) in knee arthroscopic arthrolysis. METHODS A total of 87 patients with knee arthrofibrosis who underwent arthroscopic arthrolysis from September 2019 to June 2021 were eligible for this retrospective review. Patients in the TXA group (n = 47) received topical administration of TXA (50 mL, 10 mg/mL) at the end of the surgery, and patients in the control group (n = 40) received no TXA. The postoperative drainage volumes, hematologic levels, inflammatory marker levels, knee range of motion (ROM), visual analog scale (VAS) pain scores, Lysholm knee scores and complications were compared between the two groups. The curative effect of each group was calculated according to Judet's criteria. RESULTS The mean drainage volumes on postoperative day (POD) 1 and POD 2, and total drainage volume were significantly lower in the TXA group than in the control group (P < 0.001 for all). The TXA group had significantly lower postoperative CRP and IL-6 levels on POD 1 and POD 2, and at postoperative week (POW) 1 and POW 2 than the control group. The VAS pain scores in the TXA group were significantly lower on POD 1 and POD 2, and at POW 1 and POW 2 than those in the control group (P < 0.001 for all). Patients in the TXA group showed better postoperative ROM and Lysholm knee scores at POW 1 and POW 2. No patient had any complications such as deep venous thrombosis (DVT) or infection. The excellent and good rates of knee arthroscopic arthrolysis were comparable between the two groups at the sixth postoperative month (P = 0.536). CONCLUSIONS Topical administration of TXA in knee arthroscopic arthrolysis can reduce postoperative blood loss and inflammatory response, alleviate early postoperative pain, increase early postoperative knee ROM, and improve early postoperative knee function without increased risks.
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Affiliation(s)
- Junqiao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Mingke You
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lei Yao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qi Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Gang Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yan Xiong
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China.
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15
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Bildik C, Pehlivanoglu T. Arthroscopic rotator cuff repair performed with intra-articular tranexamic acid: could it provide improved visual clarity and less postoperative pain? A prospective, double-blind, randomized study of 63 patients. J Shoulder Elbow Surg 2023; 32:223-231. [PMID: 36403924 DOI: 10.1016/j.jse.2022.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) has been widely used in orthopedic surgery with the aim of reducing intraoperative and postoperative bleeding, as well as bleeding-related complications. The purpose of this study was to assess whether intra-articular use of TXA during arthroscopic rotator cuff tear (RCT) repair could improve visual clarity, shorten the duration of the operation, and provide superior pain management as compared with placebo. METHODS We conducted a prospective, randomized, double-blind, placebo-controlled study. Patients aged ≥18 years with a magnetic resonance imaging-confirmed RCT and a history of failed conservative treatment for ≥6 months were included. Patients with a history of coagulopathy; a history of cardiac, renal, or hepatic disease; a history of conservative treatment for <6 months; and/or acute RCTs were excluded. Visual clarity as the primary outcome was assessed using an arthroscopic visual scale comprising 5 grades-ranging from grade 1, best visual clarity, to grade 5, worst visual clarity (requiring conversion to open surgery)-after the procedure by the operating surgeon every 10 minutes throughout the video of the operation. Secondary outcomes were operative duration and postoperative pain scores. RESULTS A total of 63 patients with similar demographic data (age and sex) and intraoperative mean arterial pressure were enrolled and randomized into 2 groups: The TXA group comprised 32 patients with a mean age of 56.46 years, and the placebo group comprised 31 patients with a mean age of 57.83 years. The TXA group was reported to have significantly superior visual clarity (mean arthroscopic visual scale score, 1.5 ± 0.5 vs. 2.86 ± 1.7; P < .001), with a significantly higher percentage of grade 1 visual clarity (78.1% vs. 32.2%, P < .001) and a significantly lower percentage of grade 4 visual clarity (0% vs. 3.2%, P = .003). Grade 5 visual clarity was not recorded in any patient in either group. The TXA group showed a significantly shorter operative duration (55.73 minutes vs. 67.26 minutes, P = .001) and superior pain scores at 8 hours (2.3 vs. 3.6, P = .002) and 24 hours (1.6 vs. 2.4, P < .001) postoperatively. No complications were recorded in either group. CONCLUSIONS This study showed that during arthroscopic rotator cuff repair procedures, intra-articular use of TXA was able to provide superior arthroscopic visual clarity while shortening the total operative duration significantly and providing significantly superior pain management in the first 8 and 24 hours postoperatively as compared with placebo. This study underlines the safety and efficacy of intra-articular TXA use in arthroscopic rotator cuff repair.
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Affiliation(s)
- Celaleddin Bildik
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey
| | - Tuna Pehlivanoglu
- Orthopedic Surgery and Traumatology, Faculty of Health Sciences, Yeni Yüzyıl University, Istanbul, Turkey; Department of Orthopaedic Surgery, Liv Hospital Ulus, Istanbul, Turkey.
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Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA.,Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D'Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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Xu S, Yang L, Wu X, Yang Y, Zhou Y, Ye C. Rapid in situ hepatic hemostasis using a P34HB/tranexamic acid fibrous membrane delivered by a handheld electrospinning apparatus. JOURNAL OF POLYMER RESEARCH 2022. [DOI: 10.1007/s10965-022-03174-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Benjumea A, Díaz-Navarro M, Hafian R, Cercenado E, Sánchez-Somolinos M, Vaquero J, Chana F, Muñoz P, Guembe M. Tranexamic Acid in Combination With Vancomycin or Gentamicin Has a Synergistic Effect Against Staphylococci. Front Microbiol 2022; 13:935646. [PMID: 35847081 PMCID: PMC9280180 DOI: 10.3389/fmicb.2022.935646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent applied in orthopedic surgery and has been proven to reduce post-surgery infection rates. We previously showed that TXA also had an additional direct antimicrobial effect against planktonic bacteria. Therefore, we aimed to evaluate whether it has a synergistic effect if in combination with antibiotics. Materials and Methods Three ATCC and seven clinical strains of staphylococci were tested against serial dilutions of vancomycin and gentamicin alone and in combination with TXA at 10 and 50 mg/ml. The standardized microtiter plate method was used. Minimal inhibitory concentrations (MICs) were calculated by standard visualization of well turbidity (the lowest concentration at which complete absence of well bacterial growth was observed by the researcher) and using the automated method (the lowest concentration at which ≥80% reduction in well bacterial growth was measured using a spectrophotometer). Results Tranexamic acid-10 mg/ml reduced the MIC of vancomycin and gentamicin with both the standard method (V: 1-fold dilution, G: 4-fold dilutions) and the automated turbidity method (vancomycin: 8-fold dilutions, gentamicin: 8-fold dilutions). TXA-50 mg/ml reduced the MIC of gentamicin with both the standard turbidity method (6-fold dilutions) and the automated turbidity method (1-fold dilutions). In contrast, for vancomycin, the MIC remained the same using the standard method, and only a 1-fold dilution was reduced using the automated method. Conclusion Ours was a proof-of-concept study in which we suggest that TXA may have a synergistic effect when combined with both vancomycin and gentamicin, especially at 10 mg/ml, which is the concentration generally used in clinical practice.
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Affiliation(s)
- Antonio Benjumea
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Díaz-Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rama Hafian
- School of Biology, Universidad Complutense de Madrid, Madrid, Spain
| | - Emilia Cercenado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Mar Sánchez-Somolinos
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Vaquero
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Chana
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Gkiatas I, Kontokostopoulos AP, Tsirigkakis SE, Kostas-Agnantis I, Gelalis I, Korompilias A, Pakos E. Topical use of tranexamic acid: Are there concerns for cytotoxicity? World J Orthop 2022; 13:555-563. [PMID: 35949709 PMCID: PMC9244960 DOI: 10.5312/wjo.v13.i6.555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/23/2022] [Accepted: 06/14/2022] [Indexed: 02/06/2023] Open
Abstract
Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.
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Affiliation(s)
- Ioannis Gkiatas
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | | | - Spyridon E Tsirigkakis
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | | | - Ioannis Gelalis
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | - Anastasios Korompilias
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
| | - Emilios Pakos
- Department of Orthopaedic Surgery, University of Ioannina, Ioannina 45500, Epirus, Greece
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Bolam SM, O’Regan-Brown A, Konar S, Callon KE, Coleman B, Dalbeth N, Monk AP, Musson DS, Cornish J, Munro JT. Cytotoxicity of tranexamic acid to tendon and bone in vitro: Is there a safe dosage? J Orthop Surg Res 2022; 17:273. [PMID: 35570313 PMCID: PMC9107642 DOI: 10.1186/s13018-022-03167-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Tranexamic acid (TXA) has been shown to be effective at reducing peri-operative blood loss and haemarthrosis in arthroplasty and arthroscopic soft tissue reconstructions. Intra-articular application, as an injection or peri-articular wash, is becoming increasingly common. Recent studies have shown TXA has the potential to be cytotoxic to cartilage, but its effects on human tendon and bone remain poorly understood. The aim of this study was to investigate whether TXA has any detrimental effects on tendon-derived cells and osteoblast-like cells and determine whether there is a safe dosage for clinical application.
Materials and methods
Primary tendon-derived cells and osteoblast-like cells were harvested from hamstring tendons and trabecular bone explants, respectively, and analysed in vitro with a range of TXA concentrations (0 to 100 mg/ml) at time points: 3 and 24 h. The in vitro toxic effect of TXA was investigated using viability assays (alamarBlue), functional assays (collagen deposition), fluorescent microscopy and live/apoptosis/necrosis staining for cell death mechanisms in 2D monolayer and 3D collagen gel cell culture.
Results
There was a significant (P < 0.05) decrease in tendon-derived cell and osteoblast-like cell numbers following treatment with TXA ≥ 50 mg/ml after 3 h and ≥ 20 mg/ml after 24 h. In tendon-derived cells, increasing concentrations > 35 mg/ml resulted in significantly (P < 0.05) reduced collagen deposition. Fluorescence imaging confirmed atypical cellular morphologies with increasing TXA concentrations and reduced cell numbers. The mechanism of cell death was demonstrated to be occurring through apoptosis.
Conclusions
Topical TXA treatment demonstrated dose- and time-dependent cytotoxicity to tendon-derived cells and osteoblast-like cells with concentrations 20 mg/ml and above in isolated 2D and 3D in vitro culture. On the basis of these findings, concentrations of less than 20 mg/ml are expected to be safe. Orthopaedic surgeons should show caution when considering topical TXA treatments, particularly in soft tissue and un-cemented arthroplasty procedures.
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Fan D, Ma J, Liu X, Zhang L. Peri-articular administration of tranexamic acid is an alternative route in total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:211. [PMID: 35392961 PMCID: PMC8991716 DOI: 10.1186/s13018-022-03095-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background As an antifibrinolytic agent, tranexamic acid (TXA) is increasingly used in total knee arthroplasty (TKA) to reduce blood loss. The administration of intravenous and intra-articular TXA has been well explored, but the most efficient way to administer TXA remains in question. Peri-articular injection (PAI) of TXA is a recently mentioned method. A meta-analysis of the efficacy of PAI TXA in patients after TKA should be performed.
Methods A systematic search was performed within PubMed, Embase, and the Cochrane Library up to November 8, 2021. Two authors independently screened studies for eligibility and extracted data for analysis. The primary outcome was haemoglobin change. The secondary outcomes were haematocrit change, total drainage volume, thromboembolic events, and blood transfusion. Results A total of ten studies were included in this meta-analysis. The results indicated that there was a significant decrease in haemoglobin change when using PAI TXA compared with no TXA (mean difference − 1.05; 95% CI − 1.28 to − 0.81; P < 0.00001; I2 = 0%), but it had no significant differences compared with IA and IV (mean difference − 0.01; 95% CI − 0.17 to − 0.14; P = 0.85; I2 = 39%). There were no significant differences between the TXA < 1.5 g subgroup (0.10, 95% CI − 0.27 to 0.46; P = 0.60; I2 = 0%) and the TXA ≥ 1.5 g subgroup (0.18, 95% CI − 0.12 to 0.48; P = 0.24; I2 = 74%). In addition, the combined group (PAI plus IV or IA) was superior to the IV or IA group in terms of haemoglobin change (mean difference − 0.51; 95% CI − 0.76 to − 0.27; P < 0.0001; I2 = 19%). Regarding haematocrit change, the pooled result showed it was significantly less in the PAI group than the non-TXA group. Similarly, comparing it against the IV subgroup, the result revealed a difference in favour of the PAI group, with a mean difference of − 1.89 g/dL (95% CI − 2.82 to − 0.95; P < 0.0001; I2 = 67%). For total drainage volume, the pooled result was in favour of PAI TXA over no TXA (297 ml, 95% CI − 497.26 to − 97.23; P = 0.004; I2 = 87%), but it had no significant difference compared with IA and IV (mean difference − 37.98; 95% CI − 115.68 to 39.71; P = 0.34; I2 = 95%). There was no significant difference in thromboembolic events (OR 0.74; 95% CI 0.25 to 2.21; P = 0.59; I2 = 0%). Blood transfusion was not significantly different between the PAI group and the non-TXA group (OR 0.50; 95% CI 0.23 to 1.06; P = 0.07; I2 = 21%), and there was no significant difference between PAI and the other two TXA injection methods (OR 0.72; 95% CI 0.41 to 1.25; P = 0.24; I2 = 19%). Conclusion PAI has comparable effects to IV and IA injections. PAI is an alternative injection route of TXA for patients who have undergone TKA.
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Affiliation(s)
- DingYuan Fan
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China.,Beijing University of Chinese Medicine (BUCM), Beijing, People's Republic of China
| | - Jia Ma
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China
| | - XiaoHua Liu
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China
| | - Lei Zhang
- Department of Joint Surgery and Sports Medicine, Wangjing Hospital, China Academy of Chinese Medical Sciences, No. 6, South Zhonghuan Road, Chaoyang district, Beijing, 100102, People's Republic of China.
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Goldstein K, Jones C, Kay J, Shin J, de Sa D. Tranexamic Acid Administration in Arthroscopic Surgery Is a Safe Adjunct to Decrease Postoperative Pain and Swelling: A Systematic Review and Meta-analysis. Arthroscopy 2022; 38:1366-1377.e9. [PMID: 34655767 DOI: 10.1016/j.arthro.2021.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 10/03/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model. RESULTS There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: -1.65, 95% confidence interval [CI] -3.41 to 0.10, P = .06, I2 = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I2 = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: -61.14 mL, 95% CI -104.43 to -17.85, I2 = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: -0.76, 95% CI -0.97 to -0.54, I2 = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI -3.43 to 4.50, I2 = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups. CONCLUSIONS This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kyle Goldstein
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Conor Jones
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario
| | - Jason Shin
- Department of Orthopaedic Surgery. University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario.
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Safety and Efficacy of Local Tranexamic Acid for the Prevention of Surgical Bleeding in Soft-Tissue Surgery: A Review of the Literature and Recommendations for Plastic Surgery. Plast Reconstr Surg 2022; 149:774-787. [PMID: 35196701 PMCID: PMC8860217 DOI: 10.1097/prs.0000000000008884] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Although high-bleed surgery routinely utilizes the antifibrinolytic drug tranexamic acid, most plastic surgical procedures are conducted in soft tissue with low-volume bleeding. Unease regarding possible systemic adverse effects prevents widespread systemic use, but local use of tranexamic acid is gaining popularity among plastic surgeons. Randomized controlled trials on topical use of tranexamic acid are mainly from high-bleed surgeries, and few studies address the effect in soft tissue. This article reviews the scientific evidence regarding local use of tranexamic acid in soft-tissue surgery, discusses pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery. Methods: A systematic search of databases for studies on local use of tranexamic acid in soft-tissue surgery was performed. Randomized controlled trials were included for a systematic review on effect; a narrative review regarding other clinically relevant aspects is based on extensive literature searches combined with the authors’ own research. Results: Fourteen randomized controlled trials, including 1923 patients, were included in the systematic review on local use of tranexamic acid in soft-tissue surgery. Conclusions: Local use of tranexamic acid may reduce blood loss comparably to intravenous prophylactic use with negligible risk of systemic adverse effects, but high-quality randomized controlled trials are few. Prolonged exposure to high local concentrations is discouraged, and direct contact with the central nervous system may cause seizures. No single superior means of administration or dosage is supported in the literature, and lowest effective dose is unknown. There may not be one single ideal dosing regimen, but rather many possibilities adaptable for different surgical situations.
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Na Y, Jia Y, Shi Y, Liu W, Han C, Hua Y. Administration of Tranexamic Acid to Reduce Intra-articular Hemarthrosis in ACL Reconstruction: A Systematic Review. Orthop J Sports Med 2022; 10:23259671211061726. [PMID: 35111862 PMCID: PMC8801653 DOI: 10.1177/23259671211061726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Although tranexamic acid (TXA) has been shown to reduce bleeding in joint replacement procedures, its effectiveness for anterior cruciate ligament reconstruction (ACLR) has not been widely reported. Purpose: To evaluate the effectiveness of TXA to reduce postoperative hemarthrosis and improve clinical outcomes after ACLR. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review of the literature following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was performed; literature retrieval was carried out using the MEDLINE, Embase, and Cochrane Library electronic databases. The inclusion criteria were comparative studies in English that reported the administration of intravenous or intra-articular TXA versus other modalities or placebo in patients undergoing ACLR. Results: Six studies comprising 418 patients who were treated with TXA were included. Heterogeneity among studies did not allow for the pooling of data. Five studies showed decreased drainage volume in the first 24 or 48 hours postoperatively as compared with control (ACLR with no TXA). Four studies showed lower hemarthrosis grades and visual analog scale scores in TXA versus control in the early postoperative period, although this difference was not evident at 4 weeks postoperatively. No studies showed differences in infection, deep venous thrombosis, or adverse events between the TXA and control groups. Conclusion: The current best available evidence suggests that TXA administration at the time of ACLR results in decreased intra-articular bleeding (measured using a drainage system), hemarthrosis grade, and pain when compared with control.
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Affiliation(s)
- Yuyan Na
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanbo Jia
- Department of Arthroscopy and Sports Medicine, the Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Yuting Shi
- Cardiac Function Department, Cadre Health Care Center, Inner Mongolia Autonomous Region People’s Hospital, Hohhot, Inner Mongolia Autonomous Region, China
| | - Wanlin Liu
- Department of Pediatric Orthopedics, the Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Changxu Han
- Department of Arthroscopy and Sports Medicine, the Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Morris JL, Letson HL, McEwen P, Biros E, Dlaska C, Hazratwala K, Wilkinson M, Dobson GP. Comparison of intra-articular administration of adenosine, lidocaine and magnesium solution and tranexamic acid for alleviating postoperative inflammation and joint fibrosis in an experimental model of knee arthroplasty. J Orthop Surg Res 2021; 16:726. [PMID: 34930351 PMCID: PMC8686251 DOI: 10.1186/s13018-021-02871-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dysregulated inflammatory responses are implicated in the pathogenesis of joint stiffness and arthrofibrosis following total knee arthroplasty (TKA). The purpose of this study was to compare the effects of intra-articular (IA) administration of tranexamic acid (TXA), an anti-fibrinolytic commonly used in TKA, and ALM chondroprotective solution on postoperative inflammation and joint tissue healing in a rat model of knee implant surgery. METHODS Male Sprague-Dawley rats (n = 24) were randomly divided into TXA or ALM treatment groups. The right knee of each rat was implanted with titanium (femur) and polyethylene (tibia) implants. An IA bolus (0.1 ml) of TXA or ALM was administered after implantation and capsule closure, and before skin closure. Postoperative coagulopathy, haematology and systemic inflammatory changes were assessed. Inflammatory and fibrotic markers were assessed in joint tissue, 28 days after surgery. RESULTS Haemostasis was comparable in animals treated with TXA or ALM after knee implant surgery. In contrast to ALM-treated animals, systemic inflammatory markers remained elevated at day 5 (IL-6, IL-12, IL-10, platelet count) and day 28 (IL-1β, IL-10) following surgery in TXA-treated animals. At day 28 following surgery, the extension range of motion of operated knees was 1.7-fold higher for ALM-treated animals compared to the TXA group. Key inflammatory mediators (NF-κB, IL-12, IL-2), immune cell infiltration (CD68+ cells) and markers of fibrosis (α-SMA, TGF-β) were also lower in capsular tissue of ALM-treated knees at day 28. CONCLUSION Data suggest that IA administration of ALM is superior to TXA for reducing postoperative systemic and joint inflammation and promoting restoration of healthy joint tissue architecture in a rat model of TKA. Further studies are warranted to assess the clinical translational potential of ALM IA solution to improve patient outcomes following arthroplasty.
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Affiliation(s)
- Jodie L Morris
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Peter McEwen
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Erik Biros
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Constantin Dlaska
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Kaushik Hazratwala
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Geoffrey P Dobson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
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Johns WL, Walley KC, Hammoud S, Gonzalez TA, Ciccotti MG, Patel NK. Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:4030-4041. [PMID: 33630652 DOI: 10.1177/0363546521988943] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study. PURPOSE To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures. STUDY DESIGN Meta-analysis. METHODS A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis. RESULTS Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, -95.51 to -27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (-1.96 points; 95% CI, -2.19 to -1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups. CONCLUSION The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Sommer Hammoud
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Medical College of Virginia at Virginia Commonwealth University, Richmond, Virginia, USA
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27
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Bozkurt O, Bağır M, Mirioğlu A, Tekin M, Biçer ÖS, Özkan C, Erdoğan K. The histological effect of tranexamic acid on tendon-to-bone healing histologically in rats. Jt Dis Relat Surg 2021; 32:688-697. [PMID: 34842101 PMCID: PMC8650670 DOI: 10.52312/jdrs.2021.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022] Open
Abstract
Objectives
In this study, we aimed to investigate the effect of tranexamic acid (TXA) on osteotendinous junction healing in a rat model, both biomechanically and histologically. Materials and methods
Sixty-four male Wistar-Albino rats weighing 450 to 600 g were used in this study. The rats were divided into two groups as the experimental (n=16) and control (n=16) groups. Achillotomy and subsequent repair site was exposed to 1 mL of TXA in the experimental group, while 1 mL of saline was given to the control group. For biomechanical and histopathological investigation, each group was further divided into two subgroups. At the end of four weeks, all rats were sacrificed. Biomechanical tests were performed using the M500-50CT device. The Bonar, Movin, and Nourissat bone-tendon junction scoring systems were used for histopathological evaluation. Results
There was no statistically significant difference in the elongation at a maximum point, maximum loading, and maximum stress variables in the biomechanical study (p=0.558 p=0.775, and p=0.558, respectively). In the histopathological evaluation, the collagen content and layout were close to the native tissue in the experimental group (p=0.047 and p=0.008, respectively). Vascularity, hyalinization, and glycosaminoglycan content were significantly lower in the experimental group (p=0.004, p=0.014, and p=0.026, respectively). The total Bonar and Movin scores were more favorable in the experimental group (p<0.001). Conclusion
This experimental study showed that local administration of TXA accelerated bone-tendon junction healing in rats.
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Affiliation(s)
| | - Melih Bağır
- Çukurova Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 01330 Sarıçam, Adana, Türkiye.
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28
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Pape E, Parent M, Pinzano A, Sapin-Minet A, Henrionnet C, Gillet P, Scala-Bertola J, Gambier N. Rapamycin-loaded Poly(lactic-co-glycolic) acid nanoparticles: Preparation, characterization, and in vitro toxicity study for potential intra-articular injection. Int J Pharm 2021; 609:121198. [PMID: 34662644 DOI: 10.1016/j.ijpharm.2021.121198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 12/11/2022]
Abstract
Osteoarthritis (OA) is the most common degenerative joint disease. Rapamycin is a potential candidate for OA treatment by increasing the autophagy process implicated in its physiopathology. To optimize Rapamycin profit and avoid systemic side effects, intra-articular (i.a.) administration appeared helpful. However, Rapamycin's highly hydrophobic nature and low bioavailability made it challenging to develop purpose-made drug delivery systems to overcome these limitations. We developed Rapamycin-loaded nanoparticles (NPs) using poly (lactic-co-glycolic acid) by emulsion/evaporation method. We evaluated these NPs' cytocompatibility towards cartilage (chondrocytes) and synovial membrane cells (synoviocytes) for a potential i.a. administration. The in vitro characterization of Rapamycin-loaded NPs had shown a suitable profile for an i.a. administration. In vitro biocompatibility of NPs was highlighted to 10 µM of Rapamycin for both synoviocytes and chondrocytes, but significant toxicity was observed with higher concentrations. Besides, synoviocytes are more sensitive to Rapamycin-loaded NPs than chondrocytes. Finally, we observed in vitro that an adapted formulated Rapamycin-loaded NPs could be safe at suitable i.a. injection concentrations. The toxic effect of Rapamycin encapsulated in these NPs on both articular cells was dose-dependent. After Rapamycin-loaded NPs i.a. administration, local retention, in situ safety, and systemic release should be evaluated with experimental in vivo models.
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Affiliation(s)
- Elise Pape
- Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France; Laboratoire de Pharmacologie, Toxicologie et Pharmacovigilance, Bâtiment de Biologie Médicale et de Biopathologie, CHRU de Nancy-Brabois, 5 Rue du Morvan, F54511 Vandœuvre-Lès-Nancy, France.
| | | | - Astrid Pinzano
- Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France.
| | | | | | - Pierre Gillet
- Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France; Laboratoire de Pharmacologie, Toxicologie et Pharmacovigilance, Bâtiment de Biologie Médicale et de Biopathologie, CHRU de Nancy-Brabois, 5 Rue du Morvan, F54511 Vandœuvre-Lès-Nancy, France.
| | - Julien Scala-Bertola
- Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France; Laboratoire de Pharmacologie, Toxicologie et Pharmacovigilance, Bâtiment de Biologie Médicale et de Biopathologie, CHRU de Nancy-Brabois, 5 Rue du Morvan, F54511 Vandœuvre-Lès-Nancy, France.
| | - Nicolas Gambier
- Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France; Laboratoire de Pharmacologie, Toxicologie et Pharmacovigilance, Bâtiment de Biologie Médicale et de Biopathologie, CHRU de Nancy-Brabois, 5 Rue du Morvan, F54511 Vandœuvre-Lès-Nancy, France.
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Haratian A, Shelby T, Hasan LK, Bolia IK, Weber AE, Petrigliano FA. Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations. Orthop Res Rev 2021; 13:187-199. [PMID: 34703327 PMCID: PMC8541761 DOI: 10.2147/orr.s321881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023] Open
Abstract
Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.
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Affiliation(s)
- Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Tara Shelby
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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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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Wang F, Wang SG, Yang Q, Nan LP, Cai TC, Wu DS, Zhang L. Cytotoxicity and Effect of Topical Application of Tranexamic Acid on Human Fibroblast in Spine Surgery. World Neurosurg 2021; 153:e380-e391. [PMID: 34224885 DOI: 10.1016/j.wneu.2021.06.125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In spinal surgery, considerable blood loss is increasingly treated with the local application of tranexamic acid (TXA). However, little is known about its cytotoxicity and effect on human fibroblasts. This study was to identify the effect of TXA solution on human fibroblast at different concentrations and exposure times in vitro. METHODS To mimic the actual clinical situation, human fibroblasts were subjected to both limited and chronic exposure to various clinically relevant concentrations of TXA to mimic different ways of topical administration. At time points after treatment, the viability, proliferation, apoptosis, collagen synthesis, adhesion, and migration of fibroblasts were analyzed in vitro. RESULTS Limited exposure (10 minutes) to a high concentration of TXA (100 mg/mL) did not affect the viability, proliferation, and apoptosis of fibroblasts, and chronic exposure to low concentration of TXA (≤12.5 mg/mL) exerted little effect on viability, proliferation, apoptosis, collagen synthesis, adhesion, and migration of human fibroblasts (P > 0.05). However, the chronic exposure to a high concentration of TXA (≥25 mg/mL) can inhibit the viability, proliferation, collagen synthesis, adhesion and migration, and induce apoptosis of fibroblasts. CONCLUSIONS Although limited exposure to high concentration of TXA and chronic exposure to low concentration of TXA exerted little effect on fibroblasts, chronic exposure to high concentration of TXA can lead to fibroblast injury.
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Affiliation(s)
- Feng Wang
- Department of Orthopedic, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shu-Guang Wang
- Department of Orthopedic, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qian Yang
- Department of Ophthalmology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Li-Ping Nan
- Department of Orthopedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tong-Chuan Cai
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - De-Sheng Wu
- Department of Orthopedic, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Luo Y, Zhao X, Yang Z, Yeersheng R, Kang P. Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty. Bone Joint Res 2021; 10:354-362. [PMID: 34096338 PMCID: PMC8242685 DOI: 10.1302/2046-3758.106.bjr-2020-0357.r2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIMS The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA. METHODS This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo). RESULTS Mean total blood loss (TBL) in groups A (605.0 ml (SD 235.9)), B (790.9 ml (SD 280.7)), and C (844.8 ml (SD 248.1)) were lower than in group D (1,064.9 ml (SD 318.3), p < 0.001). We also found that compared with group D, biomarker level of inflammation, transfusion rate, pain score, and hip range of motion at discharge in groups A, B, and C were significantly improved. There were no differences among the four groups in terms of intraoperative blood loss (IBL), intramuscular venous thrombosis (IMVT), and length of hospital stay (LOS). CONCLUSION The combined application of CSS and TXA is more effective than TXA alone in reducing perioperative blood loss and transfusion rates, inflammatory response, and postoperative hip pain, results in better early hip flexion following THA, and did not increase the associated venous thromboembolism (VTE) events. Intravenous combined with topical injection of CSS was superior to intravenous or topical injection of CSS alone in reducing perioperative blood loss. Cite this article: Bone Joint Res 2021;10(6):354-362.
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Affiliation(s)
- Yue Luo
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Zhao
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhouyuan Yang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Releken Yeersheng
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Pengde Kang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Chiang ER, Chen KH, Ma HL. Editorial Commentary: Tranexamic Acid Is Beneficial in the Very Early Postoperative Period in Anterior Cruciate Ligament Reconstruction Patients. Arthroscopy 2021; 37:1890-1891. [PMID: 34090572 DOI: 10.1016/j.arthro.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
Tranexamic acid (TXA) has been administrated in many orthopaedic surgical procedures to decrease perioperative and postsurgical bleeding. Relatively scant literature exists regarding the effect of TXA in patients after anterior cruciate ligament reconstruction. Currently, most evidence shows that within about 1 month after anterior cruciate ligament reconstruction, TXA can effectively reduce postoperative joint swelling and pain, as well as the aspiration rate. However, there are still controversies regarding the optimal dosage, timing, and route of administration of TXA in these patients. In addition, the potential chondrotoxic effect of TXA needs to be further clarified with longer clinical follow-up.
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Bolam SM, O'Regan-Brown A, Paul Monk A, Musson DS, Cornish J, Munro JT. Toxicity of tranexamic acid (TXA) to intra-articular tissue in orthopaedic surgery: a scoping review. Knee Surg Sports Traumatol Arthrosc 2021; 29:1862-1871. [PMID: 32860523 DOI: 10.1007/s00167-020-06219-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/06/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Intra-articular administration of tranexamic acid (TXA) in orthopaedic arthroplasty and arthroscopic procedures has become increasingly common over the past decade. However, several recent reports have shown that TXA has the potential to be cytotoxic to cartilage, tendon and synovium. Our aim was to review the literature for evidence of toxic effects from TXA exposure to intra-articular tissue. METHODS A scoping review methodology was used to search for studies assessing the toxic effects of TXA exposure to intra-articular tissues. MEDLINE, EMBASE, SCOPUS and The Cochrane Library were searched. Relevant information was extracted and synthesis of the retrieved data followed a basic content analytical approach. RESULTS A total of 15 laboratory studies were retrieved. No clinical studies reporting a toxic effect of TXA on intra-articular tissue were identified in our search. Studies were analysed according to species of origin, tissue of origin and study setting (in vitro, ex vivo, or in vivo). There was increasing cytotoxicity to chondrocytes, tenocytes, synoviocytes and periosteum-derived cells with TXA concentrations beyond 20 mg/ml. Monolayer cell cultures appear more susceptible to TXA exposure, than three-dimensional and explant culture models. In vivo studies have not demonstrated a major toxic effect. CONCLUSIONS Current evidence suggests a dose-dependent toxic effect on cartilage, tendon, and synovial tissue. Concentrations of 20 mg/ml or less are expected to be safe. There is a significant body of evidence to suggest the need for caution with intraarticular administration of TXA. There is a need for further human clinical trials in order to clarify the long-term safety of TXA topical application.
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Affiliation(s)
- Scott M Bolam
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand.
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton, New Zealand.
| | - Arama O'Regan-Brown
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
| | - A Paul Monk
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton, New Zealand
- Auckland Bioengineering Institute, University of Auckland, 70 Symonds St, Grafton, 1010, New Zealand
| | - David S Musson
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
| | - Jillian Cornish
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
| | - Jacob T Munro
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton, New Zealand
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Belk JW, McCarty EC, Houck DA, Dragoo JL, Savoie FH, Thon SG. Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies. Arthroscopy 2021; 37:1323-1333. [PMID: 33278534 DOI: 10.1016/j.arthro.2020.11.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder. METHODS A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores). RESULTS Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05). CONCLUSION Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients. LEVEL OF EVIDENCE II, systematic review of level I and II studies.
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Affiliation(s)
- John W Belk
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A..
| | - Eric C McCarty
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Darby A Houck
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Jason L Dragoo
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Felix H Savoie
- Department of Orthopaedics, Tulane University, New Orleans, Louisiana, U.S.A
| | - Stephen G Thon
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
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The Topical Tranexamic Acid Have Potential Hazard of Promoting Biofilm Formation of Staphylococcus aureus in Microenvironment of the Prosthetic Joint. BIOMED RESEARCH INTERNATIONAL 2021. [DOI: 10.1155/2021/5748069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background. Perioperative topical tranexamic acid as antifibrinolytic agent is often used for total joint replacement to reduce bleeding currently. Staphylococcus aureus was the most common isolates from perioperative infection of prosthetic joint. The influence of topical application with tranexamic acid on the incidence of acute prosthetic joint infection of Staphylococcus aureus has not been clarified. Methods. Mouse model of Staphylococcus aureus knee prosthesis infection was constructed. Tranexamic acid was intra-articular injected during the perioperative period. CFU counting from tissue and implant sample was evaluated 3 days and 7 days after inoculating of Staphylococcus aureus. Bacterial growth curve, biofilm formation, aggregation, and plasmin inhibition of Staphylococcus aureus were tested with tranexamic acid added to the synovial culture medium. Results. There were no significant differences of CFU counting from tissue and implant samples in knee prosthesis infection after a single local injection of tranexamic acid at the postoperative 3 or 7 days. The amount of bacterial colonization on the surface of implant increased after 3 days’ continuous local injection of tranexamic acid. Tranexamic acid has no effect on bacterial growth at the concentration (10 mg/ml) of clinical application, but it can inhibit bacterial aggregation and mildly inhibit biofilm formation. Plasmin can significantly inhibit biofilm formation which can be revised by adding tranexamic acid. Conclusion. Although continuous local injection of tranexamic acid can promote the biofilm formation of Staphylococcus aureus on the surface of articular implant, it has clinical safety for using one single local injection of tranexamic acid during the perioperative period.
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Comparison of the efficacy of irrigation with epinephrine or tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A double-blind, randomized-controlled study. Jt Dis Relat Surg 2021; 32:115-121. [PMID: 33463426 PMCID: PMC8073435 DOI: 10.5606/ehc.2021.78393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/18/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES This study aims to investigate whether there was a difference between epinephrine (EPN) and tranexamic acid (TXA) in providing visual clarity during arthroscopic rotator cuff tear repair. PATIENTS AND METHODS This double-blind, prospective, randomized-controlled clinical study included a total of 90 patients (42 males, 48 females; mean age: 55.6±8.3 years; range, 18 to 69 years) in whom either EPN (EPN group, n=47) or TXA-diluted irrigation solutions (TXA group, n=43) were used during rotator cuff tear arthroscopy between December 2017 and November 2019. Arthroscopy was performed using irrigation fluid containing 0.33 mg of EPN per 1 L of saline in the EPN group and 0.42 mg of TXA per 1 L of saline in the TXA group. All procedures were performed by two specialized shoulder surgeons. Visual clarity (primary endpoint) was rated by the operating surgeon using the Visual Analog Scale (VAS) in the immediate postoperative period. Secondary endpoints included total operating time (TOT), potential thrombotic or thromboembolic side effects, mean arterial pressure (MAP), and total amount of irrigation fluid used. RESULTS There was no significant difference in the surgeon rated- VAS scores between the groups. The mean VAS score was 7.6±1.62 (range, 4 to 10) in the EPN group and 7.1±1.74 (range, 3 to 10) in the TXA group (p=0.59). No cardiac, thrombotic, or thromboembolic complications were observed in any of the groups. CONCLUSION Adding TXA to the irrigation fluid during the arthroscopic rotator cuff repair may provide similar visual quality to the EPN, as measured by VAS.
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Bozorgomid A, Bashiri H, Hamzeii M. Effect of tranexamic acid on the treatment of patients with upper gastrointestinal bleeding: A double-blinded randomized controlled clinical trial. JOURNAL OF ACUTE DISEASE 2021. [DOI: 10.4103/2221-6189.312153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Impact of Tranexamic Acid on Chondrocytes and Osteogenically Differentiated Human Mesenchymal Stromal Cells (hMSCs) In Vitro. J Clin Med 2020; 9:jcm9123880. [PMID: 33260331 PMCID: PMC7760070 DOI: 10.3390/jcm9123880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations of TXA on proliferation rates, gene expression and differentiation capacity of chondrocytes and human mesenchymal stromal cells (hMSCs), which underwent osteogenic differentiation. Chondrocytes and hMSCs were isolated and multiplied in monolayer cell cultures. Osteogenic differentiation of hMSCs was induced for 21 days using a differentiation medium containing specific growth factors. Cell proliferation was analyzed using ATP assays. Effects of TXA on cell morphology were examined via light microscopy and histological staining, while expression levels of tissue-specific genes were measured using semiquantitative RT-PCR. After treatment with 50 mg/mL of TXA, a decrease in cell proliferation rates was observed. Furthermore, treatment with concentrations of 20 mg/mL of TXA for at least 48 h led to a visible detachment of chondrocytes. TXA treatment with 50 mg/mL for at least 24 h led to a decrease in the expression of specific marker genes in chondrocytes and osteogenically differentiated hMSCs. No significant effects were observed for concentrations beyond 20 mg/mL of TXA combined with exposure times of less than 24 h. This might therefore represent a safe limit for topical application in vivo. Further research regarding in vivo conditions and effects on hMSC functionality are necessary to fully determine the effects of TXA on articular and periarticular tissues.
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Palmer AJR, Gagné S, Fergusson DA, Murphy MF, Grammatopoulos G. Blood Management for Elective Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:1552-1564. [PMID: 32558663 DOI: 10.2106/jbjs.19.01417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | | | | | - Michael F Murphy
- NHS Blood and Transplant and Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Lee JW, Kim SG, Kim SH, Cho HW, Bae JH. Intra-articular Administration of Tranexamic Acid Has No Effect in Reducing Intra-articular Hemarthrosis and Postoperative Pain After Primary ACL Reconstruction Using a Quadruple Hamstring Graft: A Randomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967120933135. [PMID: 32743011 PMCID: PMC7376302 DOI: 10.1177/2325967120933135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/01/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Insufficient data are available to support the routine use of tranexamic acid
(TXA) in anterior cruciate ligament (ACL) surgeries with respect to
administration method and frequency, exposure duration, dose, and adverse
effects. Purpose: To investigate whether intra-articular (IA) administration of TXA could
reduce hemarthrosis and postoperative pain in patients after ACL
reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 47 patients were included in this study, which was performed
between July 2017 and May 2019. Single-bundle reconstructions using
autologous hamstring tendon grafts were performed in all patients. The
patients were randomized into 2 groups: the TXA group (received the index
procedure with 100-mL IA injection of TXA [30 mg/mL]) and a control group
(did not receive IA injection of TXA). No patients received a drain. Blood
loss was calculated on the basis of hemoglobin balance at postoperative day
(PD) 2. The visual analog scale (VAS) for pain score was assessed at PD 3.
The midpatellar circumference was measured at PD 2 and PD 5. Knee range of
motion (ROM) was evaluated 6 weeks after surgery. Results: The mean ± SD blood loss was 467 ± 242 mL in the TXA group and 558 ± 236 mL
in the control group. No significant differences were found for blood loss
(P = .20), VAS pain scores (P = .28),
ROM at postoperative week 6 (P = .61), or patellar
circumference at PD 2 (P = .75) and PD 5
(P = .84). Conclusion: This study showed that IA administration of 3.0 g of TXA had no effect in
reducing blood loss and postoperative pain after primary anatomic
single-bundle ACL reconstruction using quadruple hamstring autografts. Registration: NCT04042688 (ClinicalTrials.gov
identifier).
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Affiliation(s)
- Ja-Woon Lee
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Su-Hyun Kim
- Department of Orthopedic Surgery, Naval Maritime Medical Center, Jinju, Republic of Korea
| | - Hyun-Woo Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Bae
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Lloyd TD, Neal‐Smith G, Fennelly J, Claireaux H, Bretherton C, Carr AJ, Murphy M, Kendrick BJ, Palmer AJR, Wong J, Sharma P, Osei‐Bonsu PK, Ashcroft G, Baigent T, Shirland E, Espey R, Stokes M, Liew I, Dhawal A, Watchorn D, Lum J, Qureshi M, Khaled AS, Kauser S, Hodhody G, Rogers S, Haywood‐Alexander B, Sheikh G, Mahapatra P, Twaij H, Chicco M, Arnaout F, Atherton T, Mutimer J, Sinha P, Oliver E, Stedman T, Gadd R, Kutuzov V, Sattar M, Robiati L, Plastow R, Howe T, Hassan A, Lau B, Collins J, Doshi A, Tan G, Baskaran D, Hari Sunil Kumar K, Agarwal R, Horner M, Gwyn R, Masud S, Beaumont O, Pilarski A, Lebe M, Dawson‐Bowling S, Nolan D, Tsitskaris K, Beamish RE, Jordan C, Alsop S, Hibbert E, Deshpande G, Gould A, Briant‐Evans T, Kilbane L, Crowther I, Ingoe H, Naisbitt A, Gourbault L, Muscat J, Goh EL, Gill J, Elbashir M, Modi N, Archer J, Ismael S, Petrie M, O'Brien H, McCormick M, Koh NP, Lloyd T, King A, Ikram A, Peake J, Yoong A, Rye DS, Newman M, Naraen A, Myatt D, Kapur R, Sgardelis P, Kohli S, Culverhouse‐Mathews M, Haynes S, Boden H, Purmah A, Shenoy R, Raja S, Koh NP, Donovan R, Yeomans D, Ritchie D, Larkin R, Aladwan R, Hughes K, Unsworth R, Cooke R, Samra I, Barrow J, Michael K, Byrne F, Anwar R, Karatzia L, Drysdale H, Wilson H, Jones R, Dass D, Liaw F, Aujla R, Kheiran A, Bell K, Ramavath AL, Telfer R, Nachev K, Lawrence H, Garg V, Shenoy P, Lacey A, Byrom I, Simons M, Manning C, Cheyne N, Williams J. Peri‐operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study. Anaesthesia 2020; 75:1050-1058. [DOI: 10.1111/anae.15056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 12/20/2022]
Affiliation(s)
- T. D. Lloyd
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - G. Neal‐Smith
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - J. Fennelly
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - H. Claireaux
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - C. Bretherton
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
- Oxford Surgical Collaborative for Audit and Research Oxford UK
| | - A. J. Carr
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - M. Murphy
- University of Oxford UK
- NHS Blood and Transplant Oxford UK
| | - B. J. Kendrick
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - A. J. R. Palmer
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
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Wurtz JW, Wurtz LD, Ziemba-Davis M, Deckard ER, Meneghini RM. Topical Tranexamic Acid Increases Early Postoperative Pain After Total Hip Arthroplasty. J Arthroplasty 2020; 35:S219-S225. [PMID: 32098737 DOI: 10.1016/j.arth.2020.01.069] [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] [Received: 12/02/2019] [Revised: 01/14/2020] [Accepted: 01/24/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) has reduced blood transfusion following total hip arthroplasty (THA). However, non-human studies have linked TXA exposure with increased pain and decreased periarticular cell viability and cell death. This study evaluated early pain following THA performed with and without topical TXA. METHODS A consecutive series of 213 THAs performed without TXA were compared to 169 THAs performed with topical TXA. A single surgeon using identical perioperative medical and pain control protocols performed procedures. Prospectively collected inpatient pain scores, time to first opioid, and opioid consumption in morphine milligram equivalents were evaluated in relation to TXA use and 10 additional covariates. Univariate relationships between independent and dependent variables with P ≤ .20 were entered into multivariate analysis using the General Linear Model. RESULTS Patients who received topical TXA reported higher mean 24-hour pain scores compared to patients who did not receive TXA (P = .006). Patients with topical TXA requested opioids significantly sooner (means of 152 vs 246 minutes, P = .033). An average of 56.07 morphine milligram equivalents were consumed during the first 24 hours after post-acute care unit discharge by patients who received topical TXA compared to 31.26 by patients who did not receive TXA (P < .001). CONCLUSION Topical TXA use was associated with greater early postoperative pain and opioid consumption in primary THA patients. Findings were supported by the magnitude of observed effects and the likelihood of clinical relevance. Replication and consideration of potential adverse consequences of TXA use in elective settings is encouraged.
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Affiliation(s)
| | - L Daniel Wurtz
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mary Ziemba-Davis
- IU Health Hip & Knee Center, IU Health Physicians, Orthopedics & Sports Medicine, Fishers, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; IU Health Hip & Knee Center, IU Health Physicians, Orthopedics & Sports Medicine, Fishers, IN
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Fatahian R, Mirjalili M, Khajavi R, Rahimi MK, Nasirizadeh N. A novel hemostat and antibacterial nanofibrous scaffold based on poly(vinyl alcohol)/poly(lactic acid). J BIOACT COMPAT POL 2020. [DOI: 10.1177/0883911520913900] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Today, an advanced wound dressing with the ability of blood clotting and antibacterial activity is the main subject of many studies to consider their necessity in modern society. In this study, it was aimed to present a novel scaffold with both abilities simultaneously. Poly(vinyl alcohol)/poly(lactic acid) nanofibrous scaffolds containing ceftriaxone antimicrobial agent (PVA-CTX/PLA) and tranexamic acid coagulant (PVA-CTX-TXA/PLA) were fabricated by electrospinning method. Morphology, antimicrobial activity, blood coagulation and bioavailability indexes, and swelling ability (gel formation) of produced samples were determined. Morphological results showed that the hybrid nanofibers were form successfully. The antibacterial efficiency of them against Gram-negative ( Escherichia coli) and Gram-positive ( Staphylococcus aureus) bacteria was more than 90% for PVA-CTX/PLA and it reached 100% for PVA-CTX-TXA/PLA. Both PVA-CTX-TXA/PLA and PVA-TXA/PLA scaffolds showed acceptable blood coagulation ability with an average absorption of 0.043 and 0.036 nm, respectively. PVA-CTX-TXA/PLA scaffolds had a gel formation ability of about 45 min. All scaffolds were successful in cell proliferation (L929 fibroblast cell) after 48 h.
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Affiliation(s)
- Reyhaneh Fatahian
- Department of Textile Engineering, Yazd Branch, Islamic Azad University, Yazd, Iran
| | - Mohammad Mirjalili
- Department of Textile Engineering, Yazd Branch, Islamic Azad University, Yazd, Iran
| | - Ramin Khajavi
- Department of Polymer and Textile Engineering, South Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Karim Rahimi
- Department of Medical Sciences, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Navid Nasirizadeh
- Department of Textile Engineering, Yazd Branch, Islamic Azad University, Yazd, Iran
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Jacob B, Kloss N, Böhle S, Kirschberg J, Zippelius T, Heinecke M, Matziolis G, Röhner E. Tranexamic acid is toxic on human chondrocytes, in vitro. J Orthop 2019; 20:1-5. [PMID: 32021047 DOI: 10.1016/j.jor.2019.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/11/2019] [Indexed: 01/20/2023] Open
Abstract
The aim of this study was to examine toxic effects of tranexamic acid (TXA) on the viability of human chondrocytes. Our hypothesis was that TXA damages human chondrocytes. Chondrocytes were cultured from donated human knee joints. TXA was added to these cultures. Toxicity were analyzed by using LDH und XTT Elisa assays, light microscopy and fluorescence microscopy. The results show that TXA damages human chondrocytes in vitro. We cannot recommend the use of TXA in hemiarthroplasty of the hip or unicompartmental knee arthroplasty in higher concentrations.
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Affiliation(s)
- Benjamin Jacob
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Nadja Kloss
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Sabrina Böhle
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Julia Kirschberg
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Timo Zippelius
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Markus Heinecke
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Georg Matziolis
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
| | - Eric Röhner
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, 07607, Eisenberg, Germany
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47
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Siegel MG. The Dangers and Concerns of Intra-articular Tranexamic Acid. Arthroscopy 2019; 35:2973-2974. [PMID: 31699244 DOI: 10.1016/j.arthro.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/10/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Mark G Siegel
- Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, Ohio, U.S.A
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48
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Author Reply to "The Dangers and Concerns of Intra-articular Tranexamic Acid" and "Regarding 'Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study'". Arthroscopy 2019; 35:2975-2976. [PMID: 31699246 DOI: 10.1016/j.arthro.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 02/02/2023]
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49
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Xie J, Zhang S, Chen G, Xu H, Zhou Z, Pei F. Optimal route for administering tranexamic acid in primary unilateral total hip arthroplasty: Results from a multicenter cohort study. Br J Clin Pharmacol 2019; 85:2089-2097. [PMID: 31236973 DOI: 10.1111/bcp.14018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/22/2019] [Accepted: 05/15/2019] [Indexed: 02/05/2023] Open
Abstract
AIM This study aimed to compare the efficacy and safety of different tranexamic acid (TXA) routes following primary total hip arthroplasty (THA). METHODS We collected data from the National Health Database on patients registered from January 2013 to September 2017. The patients were divided based on TXA administration route into a control group (without TXA), intravenous group, topical group and combined group. The primary outcome was transfusion; secondary outcomes were total blood loss, haemoglobin level, decrease in haemoglobin on postoperative day 3, and incidence of complications. RESULTS Data were collected on 7667 primary THA, 4662 with TXA and 3005 without TXA. The transfusion rate was 28.7% in the control group, 12.7% in the topical group, 8.9% in the intravenous group, and 6.1% in the combined group, and the inter-group differences were significant (P < .01). The combined group showed significantly smaller total blood loss (1.23 ± 0.52 L), smaller reduction in haemoglobin level (26.5 ± 11.1 g/L) and higher haemoglobin level on postoperative day 3 (107.0 ± 15.5 g/L) than the other three groups (P < .05). The three TXA groups showed significantly lower incidence of deep vein thrombosis than the control group (0.08% vs 0.47%, P = .001) as well as a lower rate of other complications (0.34% vs 0.67%, P = .044). CONCLUSION TXA is effective and safe to decrease blood loss and transfusion following primary THA, regardless of whether it is administered intravenously, topically or both. Intravenous or combined routes may produce better haemostatic effects, so they may be suggested in the absence of contraindications.
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Affiliation(s)
- Jinwei Xie
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Chengdu, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Mianyang, Mianyang, People's Republic of China
| | - Guo Chen
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Chengdu, People's Republic of China
| | - Hong Xu
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Chengdu, People's Republic of China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Chengdu, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Chengdu, People's Republic of China
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Karaaslan F. Editorial Commentary: Tranexamic Acid: Okay, It Reduces the Bleeding, but Are We Sure Topical Use Is Not Harmful to the Cartilage? Arthroscopy 2019; 35:2133-2135. [PMID: 31272632 DOI: 10.1016/j.arthro.2019.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/12/2019] [Indexed: 02/02/2023]
Abstract
Numerous studies have estimated the role of hemarthrosis and intra-articular drains in anterior cruciate ligament (ACL) reconstructive procedures. Long-standing hemarthrosis and related pain can disrupt rehabilitation and lead to arthrofibrosis. A significant number of orthopaedic surgeons use intra-articular suction drains following arthroscopic ACL reconstruction. Hemarthrosis and pain have undesirable effects on the functional outcomes of ACL reconstruction in the early postoperative period.
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