The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty

Evaluation of efficacy and safety of perioperative tranexamic acid during Primary Total Knee Arthroplasty: A randomized, Clinical trial

Background

Primary total knee arthroplasty (TKA) is the gold standard treatment for degenerative joint disease, but it carries a significant risk of blood loss that may require transfusion. Various techniques are implemented to reduce the possibility of the need for allogeneic blood transfusion (ABT). To this end, this study aims to assess the effectiveness of tranexamic acid (TXA) in decreasing blood loss following primary TKA.

Materials and methods

This study is a randomized controlled study of 100 cases of primary total knee arthroplasty conducted in Damascus from July 2021 to September 2022, followed up with every patient for six months. The patients were randomized into two groups. We compared intraoperative, postoperative, total, and hidden blood loss and perioperative complications.

Results

We observed a statistically significant difference between the two groups in total calculated, hidden, and postoperative blood loss. However, this difference does not seem clinically significant, as we didn't find a significant difference in allogeneic blood transfusion between the groups. Regarding complications, the TXA group had five cases of superficial wound infection and six cases of deep venous thrombosis. In contrast, the control group had eight cases of superficial wound infection and five cases of deep venous thrombosis.

Conclusion

Our study suggests that the role of TXA in primary unilateral total knee arthroplasty in the hands of an experienced surgeon might be overrated. The reduced blood loss did not seem to have clinical importance and didn't affect the transfusion rates.

Total blood loss and early clinical outcomes under different tranexamic acid regimes in total knee arthroplasty

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.

Intravenous Versus Locally Injected Tranexamic Acid in a Fragility Hip Fracture Population: A Retrospective Review

OBJECTIVES

Evaluate differences between blood transfusion and complication rates among fragility hip fracture patients treated with locally injected (Local) versus intravenous (IV) tranexamic acid (TXA).

METHODS

Design: Retrospective comparative cohort.

SETTING

Tertiary referral orthopaedic specialty hospital; Level I trauma center.

PATIENT SELECTION CRITERIA

Patients aged 50 years and over who underwent surgical treatment for a proximal femur fragility fracture (Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 31A and 31B). Between March 2018 and April 2022 with or without the use of local TXA during wound closure or IV TXA.

OUTCOME MEASURES AND COMPARISONS

Postoperative blood transfusion, venous thromboembolism, surgical site infections, and 30-day readmissions compared between those who received IV TXA, Local TXA, and controls that did not receive any TXA.

RESULTS

Seven hundred forty-six patients (258 received IV TXA, 252 received Local TXA, and 236 controls that did not receive any TXA) were studied. Both Local and IV TXA groups received fewer blood transfusion versus controls. IV TXA was associated with a transfusion rate reduction of 12% compared with Local TXA ( P < 0.001). Regression analysis indicated that IV TXA reduced the odds of a postoperative blood transfusion by 48% compared with Local TXA ( P = 0.017). There were no differences in complication rates among the groups; however, patients receiving IV TXA had a significantly lower 30-day readmission rate (5%) than the control (13.9%) or Local (13.8%) TXA groups ( P = 0.001).

CONCLUSIONS

IV TXA significantly reduced the risk of postoperative transfusion compared with controls and patients receiving Local TXA. There was no increased risk of complications, and a lower 30-day readmission was observed for the IV TXA group. IV TXA seems to be a safe and effective way to reduce postoperative blood transfusion in patients with fragility hip fractures.

LEVEL OF EVIDENCE

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

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

The Efficacy and Safety of Tranexamic Acid in Total Hip and Knee Arthroplasty: A Literature Review

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.

Do 'Surgeon Champions' and High-Volume Surgeons Have Lower Rates of Periprosthetic Femur Fracture? Perspective from a State-wide Quality Improvement Registry

BACKGROUND

Recently, a state-wide registry identified fracture as a major cause of total hip arthroplasty revision. There were 52.8% of revisions occurring within 6 months (fracture leading cause). Registry sites have a 'Surgeon Champion' who acts as liaison and advocate. This study evaluated the effect of surgeon volume and role of 'surgeon champion' on fracture rates.

METHODS

There were 95,948 cases from 2012 to 2019 queried with peri-implant femoral fractures identified (within 6 months). Funnel plots were generated to compare individual surgeon-specific fracture rates. Surgeons who had a fracture rate below the confidence interval were labeled 'green' (lower than mean), within were 'yellow' (no difference), and above were 'red' (significantly higher).

RESULTS

For all surgeons, 19.6% were red, 72.1% yellow, and 8.3% green. There were 17.2% 'Surgeon Champions' and 6.2% 'Non-Champions' that were green (P=0.01), while 20.7 and 19.3% were red (P=0.82). There was a significant association between volume and performance (P<0.01). No surgeons in the lower two quartiles (<84; 84 to 180 cases), while 4 and 29% of higher-volume surgeons (181 to 404; >404 cases) were green. There was no statistical difference in red status by volume (P=0.53).

CONCLUSION

'Surgeon champions' and high-volume surgeons were more likely to be high performers, but not less-likely to be low performers. Active involvement in quality improvement and/or high-volume was associated with better outcomes, but did not impart complication immunity. 'Green' surgeons should mentor colleagues to help reduce fractures by re-evaluating modifiable factors. Analyzing outcomes to promote quality and decrease complications is paramount.

Femoral and tibial cementless fixation neither increases blood loss nor impedes early functional recovery: A randomized controlled trial

Background

Whether cementless fixation on femoral and tibial components increases blood loss during total knee arthroplasty (TKA) is unclear. The purpose of this randomized controlled trial was to compare blood loss and early functional recovery between patients who underwent cementless or cemented TKA.

Methods

Between November 2021 and April 2022, sixty-one eligible patients at our medical center were randomized to cementless and cemented group. The primary outcome was total blood loss (TBL). Secondary outcomes were drainage, knee swelling, anemia, transfusion, hematological indicators, early functional recovery, and postoperative complications. The early functional recovery included range of motion (ROM), Hospital for Special Surgery (HSS) score, walking distance.

Results

A total of 61 patients were analyzed, of whom 30 underwent cementless fixation. On postoperative day 1, the mean TBL was 394.39 ml (SD 182.97 ml) in the cementless group and 382.41 ml (SD 208.67 ml) in the cemented group (P = 0.863). By postoperative day 3, the corresponding mean TBL was higher at 593.48 ml (SD 230.04 ml) and 603.80 ml (SD 213.16 ml) (P = 0.751). The two groups did not differ significantly in drainage, knee swelling, anemia, levels of hemoglobin or hematocrit or platelets, ROM, HSS score, walking distance, or rates of transfusion or postoperative complications.

Conclusions

Cementless fixation on femoral and tibial components during TKA does not increase blood loss or impede early functional recovery, which suggests that clinicians need not worry about blood loss and early functional recovery when deciding what type of fixation to perform during TKA.

Trial registration

Number: ChiCTR2100052857; Date: November 6, 2021.

Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?

BACKGROUND

Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data.

RESULTS

Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis.

CONCLUSION

Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.

No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA

BACKGROUND

Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained.

QUESTIONS/PURPOSES

We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery.

METHODS

Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism.

RESULTS

With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction.

CONCLUSION

The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Simultaneous Bilateral Total Hip Arthroplasty With Contemporary Blood Management is Associated With a Low Risk of Allogeneic Blood Transfusion

BACKGROUND

There is a paucity of data on blood loss and the risk of allogeneic blood transfusion after simultaneous bilateral total hip arthroplasty (SBTHA) with contemporary blood management including neuraxial anesthesia, routine tranexamic acid use, and a restrictive transfusion protocol. As such, we sought to determine the in-hospital outcomes of SBTHA, specifically analyzing blood loss and the rate and risk factors for transfusion.

METHODS

We identified 191 patients who underwent SBTHA at a single institution from 2016 to 2019. No drains were utilized and no patients donated blood preoperatively. Mean age was 59 years with 96 females (50.3%). The surgical approach was posterior in 138 (72.3%) and direct anterior in 53 (27.7%) patients. We analyzed blood loss, the rate of allogeneic blood transfusions, and in-hospital thromboembolic complications. We analyzed risk factors for transfusion with a logistic regression analysis.

RESULTS

Twenty-two patients (11.5%) underwent allogeneic blood transfusion. All transfused patients were female. Univariate analysis revealed female gender as a transfusion risk factor since it had statistically significant higher proportion in the transfusion group than the nontransfusion group (100% vs 43.5%, respectively, P < .001). We did not identify any other singular significant risk factors for transfusion in a multivariable regression analysis. However, females with a preoperative Hb <12 had an elevated risk of transfusion at 37.5% (15/40 patients).

CONCLUSION

With contemporary perioperative blood management protocols, there is a relatively low (11.5%) risk of a blood transfusion after SBTHA. Females with a lower preoperative Hb (<12 g/dL) had the highest risk of transfusion at 37.5%.

Effectiveness of Primary Total Hip Arthroplasty Combined with Intra-articular and Intravenous Tranexamic Acid: A Retrospective Analysis of Number of Doses and Dose Strength

Introduction

Total hip arthroplasty is a very effective reconstructive surgery but is often associated with massive perioperative bleeding, which leads to anemia. Tranexamic acid (TXA) minimizes bleeding and the need for blood transfusion. However, no universal standard TXA dosing regimen has been established. The objectives of this study were (1) whether there was a difference in the amount of decrease in perioperative mean hemoglobin (Hb) level between a single topical administration of TXA and intravenous and topical combination administration, and we also investigated whether there was a difference in the amount of decrease in the perioperative mean Hb level due to the difference in the local dose of TXA.

Methods

We retrospectively reviewed 292 hips between June 2013 and October 2020. The decrease in Hb level (difference between the preoperative value and the 7-day postoperative value) was used to estimate total perioperative blood loss. The mean perioperative reduction in Hb was compared between hips that received intravenous TXA preoperatively and intra-articular TXA at wound closure (combination administration group) and those that received only intra-articular TXA (single dose group). It was also compared by different local doses of tranexamic acid.

Results

The mean reduction in Hb was significantly smaller in the combination administration group than in the single dose group. However, no significant difference was observed due to the difference in the local dose of TXA administered at the time of wound closure.

Conclusion

Reducing perioperative bleeding decreases the invasiveness of surgery, which is important from the perspective of medical safety.

Effects of carbazochrome sodium sulfonate combined with tranexamic acid on hemostasis and inflammation during perioperative period of total hip arthroplasty: A randomized controlled trial

BACKGROUND

The hemostatic effect of tranexamic acid (TXA) combined with carbazochrome sodium sulfonate (CSS) in total hip arthroplasty (THA) has not been determined. Therefore we performed a randomized study aiming to evaluate the effects of CSS combined with TXA on perioperative blood loss and inflammatory response of THA.

HYPOTHESIS

CSS combined with TXA can effectively reduce perioperative blood loss and immune response compared to TXA.

MATERIAL AND METHODS

This randomized placebo-controlled trial assigned 150 patients undergoing unilateral primary total hip arthroplasty who underwent direct anterior approach surgery to 3 groups: group A received TXA plus topical CSS; group B received TXA only; and group C received placebo. The main outcome was total blood loss. Secondary outcomes included reduction in hemoglobin concentration, coagulation parameters, inflammatory marker levels, perioperative visual analog scale (VAS) pain score, transfusion rates, postoperative hospital stay, and incidence of thromboembolic events.

RESULTS

Total blood loss in group A (668.84±230.95ml) was lower than in group B (940.96±359.22ml) and C (1166.52±342.85ml, p<0.05). We also found that compared with group B, postoperative hip pain, biomarker level of inflammation, visual analogue score (VAS) pain score in group A were significantly improved. The transfusion rate and unit of group A were significantly lower than group C (8 patients; 17.5 units), but there was no statistical difference between group A (no transfusion) and group B (2 patients; 4 units). No differences were observed in thromboembolic and other outcomes among the groups.

DISCUSSION

The combined application of topic CSS and TXA is more effective than TXA alone following THA in regard of reducing total blood loss. In addition, CSS combined with TXA is better than TXA alone in terms of improving postoperative hip pain and reducing the level of inflammatory factors.

LEVEL OF EVIDENCE

I; randomized controlled study.

Safety of Tranexamic Acid in Hip and Knee Arthroplasty in High-risk Patients

BACKGROUND

With increasing use of tranexamic acid in total hip and knee arthroplasties, safety concerns remain. Using national claims data, this study examined tranexamic acid use in patients with preexisting comorbidities. The hypothesis was that tranexamic acid use is not associated with increased complication risk in hip and knee arthroplasty patients with comorbidities.

METHODS

Among 765,011 total hip/knee arthroplasties (2013 to 2016, Premier Healthcare claims), tranexamic acid use was assessed in three high-risk groups: group I with patients with a history of venous thromboembolism, myocardial infarction, seizures, or ischemic stroke/transient ischemic attack (n = 27,890); group II with renal disease (n = 44,608); and group III with atrial fibrillation (n = 45,952). The coprimary outcomes were blood transfusion and new-onset "composite complications" (venous thromboembolism, myocardial infarction, seizures, and ischemic stroke/transient ischemic attack). Associations between tranexamic acid use and outcomes were measured separately by high-risk group. The odds ratios and Bonferroni-adjusted 99.9% CIs are reported.

RESULTS

Overall, 404,974 patients (52.9%) received tranexamic acid, with similar frequencies across high-risk groups I (13,004 of 27,890 [46.6%]), II (22,424 of 44,608 [50.3%]), and III (22,379 of 45,952 [48.7%]). Tranexamic acid use was associated with decreased odds of blood transfusion in high-risk groups I (721 of 13,004 [5.5%] vs. 2,293 of 14,886 [15.4%]; odds ratio, 0.307; 99.9% CI, 0.258 to 0.366), group II (2,045 of 22,424 [9.1%] vs. 5,159 of 22,184 [23.3%]; odds ratio, 0.315; 99.9% CI, 0.263 to 0.378), and group III (1,325 of 22,379 [5.9%] vs. 3,773 of 23,573 [16.0%]; odds ratio, 0.321; 99.9% CI, 0.266 to 0.389); all adjusted comparisons P < 0.001. No increased odds of composite complications were observed in high-risk group I (129 of 13,004 [1.0%] vs. 239 of 14,886 [1.6%]; odds ratio, 0.89, 99.9% CI, 0.49 to 1.59), group II (238 of 22,424 [1.1%] vs. 369 of 22,184 [1.7%]; odds ratio, 0.98; 99.9% CI, 0.58 to 1.67), and group III (187 of 22,379 [0.8%] vs. 290 of 23,573 [1.2%]; odds ratio, 0.93; 99.9% CI, 0.54 to 1.61); all adjusted comparisons P > 0.999.

CONCLUSIONS

Although effective in reducing blood transfusions, tranexamic acid is not associated with increased complications, irrespective of patient high-risk status at baseline.

EDITOR’S PERSPECTIVE

Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty

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.

One Versus Two Doses of Intravenous Tranexamic Acid in Total Knee Arthroplasty

Tranexamic acid (TXA) has been shown to reduce blood loss and postoperative transfusions in total knee arthroplasty (TKA). There is no consensus on the ideal dosing regimen in the literature, although there is a growing body of literature stating there is little benefit to additional doses. Our study compared one versus two doses of TXA in primary TKA and its effect on postoperative transfusion rate. We retrospectively reviewed patients undergoing primary TKA at our two high-volume arthroplasty centers between 2013 and 2016. Patients were included if they underwent unilateral primary TKA, and received one or two doses of intravenous TXA. Patients receiving therapeutic anticoagulation were excluded. Our primary outcome was postoperative transfusion rate. Secondary outcomes included blood loss, length of stay, rate of deep vein thrombosis or pulmonary embolism (DVT/PE), readmission and reoperation.A total of 1,191 patients were included: 891 received one dose and 300 received two doses. There was no significant difference in rate of transfusion, deep vein thrombosis or pulmonary embolism (DVT/PE), blood volume loss, and reoperation. There was a significantly higher risk of readmission (6.7 vs. 2.4%, odds ratio [OR] 2.96, p < 0.001) and reoperation (2.0 vs. 0.6%, OR 3.61, p = 0.024) in patients receiving two doses. These findings were similar with subgroup analysis of patients receiving only aspirin prophylaxis.In unilateral TKA, there is no difference in transfusion rate with one or two doses of perioperative TXA. There was no increased risk of thromboembolic events between groups, although the two-dose group had a higher rate of readmission and reoperation. Given the added cost without clear benefit, these findings may support administration of one rather than two doses of TXA during primary TKA.

Simultaneous Bilateral Primary Total Knee Arthroplasty With TXA and Restrictive Transfusion Protocols: Still a 1 in 5 Risk of Allogeneic Transfusion

BACKGROUND

Historically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).

METHODS

We retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/m². Drains were utilized in 143 patients (30%). Mean preoperative hemoglobin (Hgb) was 13.7 g/dL. Multivariate logistic regression analysis adjusting for age ≥70 years, sex, body mass index, drain use, and preoperative Hgb of <12.5 g/dL was utilized to identify risk factors for transfusion.

RESULTS

One hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb <12.5 (OR = 3.99, P < .0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb <12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P < .001).

CONCLUSION

Patients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb <12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization.

Is There a Synergistic Effect of Topical Plus Intravenous Tranexamic Acid Versus Intravenous Administration Alone on Blood Loss and Transfusions in Primary Total Hip and Knee Arthroplasties?

Background

The optimal route and dosing regimen of tranexamic acid (TXA) in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unclear. As such, we sought to analyze if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and transfusions.

Methods

We retrospectively analyzed 6720 primary TKAs and 6559 THAs performed from February 1, 2016 to December 31, 2019 at a single institution in patients who received a double IV dose (6159 TKAs and 6276 THAs) compared with a combined single IV and topical dose (561 TKAs and 283 THAs) of TXA. Multivariate logistic regression models, adjusting for age, body mass index, American Society of Anesthesiologists class, preoperative hemoglobin, and TXA administration, were performed for significant variables from a univariate analysis.

Results

In the TKA cohort, the mean total blood loss was statistically similar for double IV (305 mL, 95% confidence interval [CI] = 301-310 mL) TXA compared with combined TXA (310 mL, 95% CI = 299-321 mL) (P = .43). Furthermore, there was no difference in the rate of transfusion (odds ratio = 1.23, 95% CI = 0.57-2.67, P = .598). In the THA cohort, there was statistically higher blood loss with double IV (328 mL, 95% CI = 323-333 mL) TXA than in the combined group (295 mL, 95% CI = 280-310 mL) (P < .001). The rate of transfusion was statistically similar at ~2% (P = .970).

Conclusions

A double IV TXA dose and a combined single IV and topical TXA dose were equally effective in minimizing blood transfusions (~2%) at primary TKA and THA. We did not find a synergistic effect when combining a systemic IV TXA with a topical TXA.

Level of Evidence

Level III.

Can an outpatient risk assessment tool predict who needs postoperative haemoglobin monitoring?

AIMS

Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement.

METHODS

We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score.

RESULTS

A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold.

CONCLUSION

Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65-70.

Meaningful Clinical Applications of Patient-Reported Outcome Measures in Orthopaedics

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Patient-reported outcome measures (PROMs) comprise valuable data, when combined with traditional clinical information, for patient-centered health outcome assessment.

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While PROMs form the foundation of orthopaedic clinical research, they are invaluable tools for clinical care.

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PROMs play a critical role in shared decision-making with patients, as they are quantitative measures of patient health (function, pain, and satisfaction).

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PROMs should be incorporated into routine postoperative care for effective clinical monitoring and understanding of the response to surgery.

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PROMs can be additionally utilized for meaningful clinical research, predictive analytics, and value-based care delivery pathways.

Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty

BACKGROUND

The optimal dosage and administration approach of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains controversial. In light of recently published 14 randomized controlled trials (RCTs), the study aims to incorporate the newly found evidence and compare the efficacy and safety of intra-articular (IA) vs. intravenous (IV) application of TXA in primary TKA.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for RCTs comparing IA with IV TXA for primary TKA. Primary outcomes included total blood loss (TBL) and drain output. Secondary outcomes included hidden blood loss (HBL), hemoglobin (Hb) fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time.

RESULT

In all, 34 RCTs involving 3867 patients were included in our meta-analysis. Significant advantages of IA were shown on TBL (MD = 33.38, 95% CI = 19.24 to 47.51, P < 0.001), drain output (MD = 28.44, 95% CI = 2.61 to 54.27, P = 0.03), and postoperative day (POD) 3+ Hb fall (MD = 0.24, 95% CI = 0.09 to 0.39, P = 0.001) compared with IV. There existed no significant difference on HBL, POD1 and POD2 Hb fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time between IA and IV.

CONCLUSION

Intra-articular administration of TXA is superior to intravenous in primary TKA patients regarding the performance on TBL, drain output, and POD3+ Hb fall, without increased risk of perioperative complications. Therefore, intra-articular administration is the recommended approach in clinical practice for primary TKA.

In the Era of Tranexamic Acid, are Type and Screens for Primary Total Joint Arthroplasty Obsolete?

BACKGROUND

Advances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion.

METHODS

Prospectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA.

RESULTS

A total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27.

CONCLUSION

In our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice.

Effectiveness of administering tranexamic acid to high-risk hip and knee arthroplasty patients: a systematic review protocol

OBJECTIVE

The objective of this review is to assess the safety and effectiveness in administering tranexamic acid in high-risk hip and knee arthroplasty patients.

INTRODUCTION

Arthroplasty surgery is associated with a significant amount of perioperative blood loss. Tranexamic acid is an antifibrinolytic used to counteract blood loss. Although various studies have demonstrated the effectiveness of tranexamic acid without significant adverse effects, a majority of these studies have excluded high-risk patients. Due to this selection bias there is a lack of clear evidence of the safety of administering tranexamic acid in high-risk patients.

INCLUSION CRITERIA

This review will consider studies that included high-risk patients aged >18 years who had previous myocardial infarction including cardiac stents, deep vein thrombosis and/or pulmonary embolism, transient ischemic attacks and/or stroke and clotting disorders. No exclusions will be made for the dosing route of tranexamic acid. The outcomes measured will be 1) thromboembolic complications of deep vein thrombosis, pulmonary embolism, transient ischemic attacks, stroke, myocardial infarction and death; 2) requirements of blood transfusion and 3) the amount of blood loss.

METHODS

A search will be conducted in PubMed, Embase, Scopus and Web of Science databases with the results being reported in a PRISMA flow diagram. Selected studies will be critically appraised by two independent reviewers for methodological quality. Study and outcome quality will be reported using the GRADE approach. Data will be extracted using a standardized data extraction tool. Studies will, where possible, be pooled in statistical meta-analysis. Effect sizes will be expressed as either odds ratios (for dichotomous data) or standardized mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis.

Development and early findings of a semiautomated arthroplasty registry in a multi-institutional healthcare network

AIMS

The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR's data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019.

METHODS

Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network's electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019.

RESULTS

The PAR captured 16,163 THAs and TKAs between April 2016 and March 2019, performed in seven hospitals by 110 surgeons. Manual comparison to operating schedules showed a 100% capture rate. Review of the records was performed for 2,603 random operations; 2,298 (88.3%) had complete and accurate data. The PAR provided the data for three abstracts presented at international conferences and has led to preoperative mental health treatment as a quality improvement initiative in the participating institutions. For primary THA and TKA surgeries, the LOS decreased significantly (p < 0.001) and the rate of home discharge increased significantly (p < 0.001) between 2016 and 2019. Readmission rates did not correlated with the date of surgery (p = 0.953).

CONCLUSION

The PAR has high rates of coverage (the number of patients treated within the Partners healthcare network) and data completion and can be used for both research purposes and quality improvement. The same method of creating a registry that was used in the PAR can be applied to hospitals using similar EMR systems. Cite this article: Bone Joint J 2020;102-B(7 Supple B):90-98.

Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study

BACKGROUND

There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.

METHODS

We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.

RESULTS

We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.

CONCLUSION

Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.

Hemostatic and Anti-Inflammatory Effects of Carbazochrome Sodium Sulfonate in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Postoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.

METHODS

This study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.

RESULTS

Total blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).

CONCLUSION

CSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications.

Association of Aspirin With Prevention of Venous Thromboembolism in Patients After Total Knee Arthroplasty Compared With Other Anticoagulants: A Noninferiority Analysis

Importance

There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA).

Objective

To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA.

Design, Setting, and Participants

Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan. The study included 41 537 patients who underwent primary TKA between April 1, 2013, and October 31, 2015. Clinical events were monitored for 90 days after surgery. Data were analyzed between September and October 2016.

Exposures

The method of pharmacologic prophylaxis: neither aspirin nor anticoagulants for 668 patients (1.6%), aspirin only for 12 831 patients (30.9%), anticoagulant only (eg, low-molecular-weight heparin, warfarin, and Xa inhibitors) for 22 620 patients (54.5%), and both aspirin/anticoagulant for 5418 patients (13.0%). Most patients were also using intermittent pneumatic compression stockings.

Main Outcome and Measures

The primary composite outcome was the first occurrence of VTE or death. The noninferiority margin was specified as 0.3. The secondary outcome was bleeding events.

Results

Of the 41 537 patients, 14 966 were men (36%), and the mean age was 65.8 years. A VTE event occurred in 573 of 41 537 patients (1.38%); 32 of 668 (4.79%) who received no pharmacologic prophylaxis, 149 of 12 831 (1.16%) treated with aspirin alone, 321 of 22 620 (1.42%) with anticoagulation alone, and 71 of 5418 (1.31%) prescribed both aspirin and anticoagulation. Aspirin only was noninferior for the composite VTE outcome compared with those receiving other chemoprophylaxis (adjusted odds ratio, 0.85; 95% CI, 0.68-1.07, P for inferiority = .007). Bleeding occurred in 457 of 41 537 patients (1.10%), 10 of 668 (1.50%) without prophylaxis, 116 of 12 831 (0.90%) in the aspirin group, 258 of 22 620 (1.14%) with anticoagulation, and 73 of 5418 (1.35%) of those receiving both. Aspirin alone was also noninferior for bleeding complications (adjusted odds ratio, 0.80; 95% CI, 0.63-1.00, P for inferiority <.001).

Conclusions and Relevance

In this study of patients undergoing TKA, aspirin was not inferior to other anticoagulants in the postoperative rate of VTE or death. Aspirin alone may provide similar protection from postoperative VTE compared with other anticoagulation treatments.

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti

BACKGROUND

Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA.

METHODS

Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18-65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit.

RESULTS

One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group "before" (adjusted odds ratio 0.3, 95%confidence interval 0.1-0.8). They also had a significantly shorter hospital length of stay (p = 0.02).

CONCLUSIONS

Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review

OBJECTIVES

For many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of perioperative care may be associated with the adverse event of chronic pain 6 months or longer after surgery; effects may be direct, for example, through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical perioperative interventions prevent long-term pain after TKR.

METHODS

We conducted a systematic review of perioperative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searched The Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL until February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included.

INTERVENTIONS

Perioperative non-surgical interventions; control receiving no intervention or alternative treatment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Pain or score with pain component assessed at 6 months or longer postoperative.

RESULTS

44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (three studies), ketamine infusion (one study), pregabalin (one study) and supported early discharge (one study) compared with no intervention. For electric muscle stimulation (two studies), anabolic steroids (one study) and walking training (one study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes.

CONCLUSIONS

To prevent chronic pain after TKR, several perioperative interventions show benefits and merit further research. Good-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.

Topical and Intravenous Tranexamic Acid Are Equivalent in Decreasing Blood Loss in Total Shoulder Arthroplasty

INTRODUCTION

Tranexamic acid (TXA) has been shown to be an effective modality to decrease blood loss in total shoulder arthroplasty (TSA). However, the most effective method of TXA administration remains controversial. The purpose of this study was to directly compare the use intravenous and topical TXA to determine which regimen was more effective in improving postoperative hemoglobin (Hb), transfusion rates, and patient outcomes after primary TSA.

METHODS

We conducted a retrospective review of 3 sequential cohorts of patients undergoing primary TSA with no TXA, intravenous TXA, or topical TXA. Postoperative data collection included daily Hb levels (g/dL), transfusions, thromboembolic events, length of stay, and discharge disposition. One-way analysis of variance was used to compare data between the 3 groups with post hoc Tukey honestly significant difference test for differences between pairs.

RESULTS

Average change in Hb was 2.36 g/dL in the IV TXA group and 2.27 g/dL in the Topical TXA group which was not statistically significant (P = .69). Average change in Hb in the control group was 3.27 g/dL which was significant when compared to both TXA groups (P < .01). There were no transfusions or thromboembolic events in either TXA group. In the control group, there were 2 transfusions which was not statistically significant (P = .09). There was no significant difference in the discharge disposition or days in hospital between the 2 groups receiving TXA (P = .33).

CONCLUSION

Intravenous and topical TXA are equivalent in improving postoperative Hb in TSA.

Transfusions and cost-benefit of oral versus intravenous tranexamic acid in primary total hip arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to assess the cost benefit and transfusions of oral and IV tranexamic acid (TXA) in primary total hip arthroplasty (THA).

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) comparing oral and IV TXA in primary THA. Primary outcomes were total blood loss, maximum hemoglobin drop, transfusion requirements, and cost benefit. Secondary outcomes were length of stay, deep venous thrombosis (DVT) and/or pulmonary embolism (PE).

RESULTS

Four independent RCTs were included involving 391 patients. There was no difference in the total blood loss (P = .99), maximum hemoglobin drop (P = .73), and the length of stay (P = .95) between the 2 groups. Transfusion requirements (P = .97) were similar. The total mean cost was the US $75.41 in oral TXA group and the US $580.83 in IV TXA group. The incidence of DVT (P = .3) did not differ significantly between the 2 groups, and no PE was reported in all studies.

CONCLUSION

Oral TXA shows similar efficacy and safety as IV TXA in reducing total blood loss, maximum hemoglobin drop and transfusion requirements in primary THA. However, oral TXA may be more cost-benefit than IV TXA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Dose optimization of topical tranexamic acid for primary total hip arthroplasty: A prospective cohort study

BACKGROUND

Recently, the topical application of tranexamic acid has become widespread, and it is effective in reducing postoperative blood loss and transfusion rate in total hip arthroplasty. There is no consensus on the optimal dose of topical tranexamic acid. This study aimed to assess the efficacy and safety of topical tranexamic acid on postoperative blood loss and determine the optimal topical dose for primary total hip arthroplasty.

METHODS

This prospective cohort study with a robust protocol enrolled 79 patients who received either 1 or 2 g of topical tranexamic acid in 30 mL normal saline solution or an equivalent volume of normal saline at the end of surgery. The primary outcomes were postoperative drain blood loss and hemoglobin decrease on postoperative day 7. The secondary outcomes were transfusion rate, d-dimer level on postoperative day 7, symptomatic deep vein thrombosis rate, and duration of hospital stay.

RESULTS

Both 1 and 2 g tranexamic acid significantly reduced postoperative drain blood loss (p < 0.001). These doses also reduced the hemoglobin concentration decrease on postoperative day 7, but not significantly. Furthermore, 1 and 2 g doses of tranexamic acid had similar effects on postoperative blood loss and hemoglobin concentration decrease. There was no difference in the transfusion rate, d-dimer level, symptomatic deep vein thrombosis rate, and length of hospital stay.

CONCLUSIONS

The use of topical tranexamic acid at the end of surgery is effective and safe for reducing postoperative blood loss in primary total hip arthroplasty. Topical tranexamic acid at a dose of 1 g may be sufficient and cost-effective, with fewer side effects than the higher dose.

The Michigan Arthroplasty Registry Collaborative Quality Initiative Experience: Improving the Quality of Care in Michigan

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a regional quality improvement effort that is focused on hip and knee arthroplasty. From its inception in 2012, MARCQI has grown to include data from 66 hospitals and surgery centers, and contains over 209,000 fully abstracted cases in its database. Using high-quality risk-standardized outcomes data, MARCQI drives quality improvement through a collaborative and nonpunitive structure. Quality improvement initiatives have included transfusion reduction, infection prevention, venous thromboembolism reduction, and reduction of discharge to nursing homes. In addition, MARCQI focuses on postmarket surveillance of implants by computing revision-risk estimates based on the cases that were registered prior to the end of 2016. This paper describes the impact of MARCQI on the quality of hip and knee arthroplasty care in the state of Michigan since its inception in 2012, and it briefly summarizes the recently released 5-year report.

Hip replacement

Total hip replacement is a frequently done and highly successful surgical intervention. The procedure is undertaken to relieve pain and improve function in individuals with advanced arthritis of the hip joint. Symptomatic osteoarthritis is the most common indication for surgery. In paper 1 of this Series, we focus on how patient factors should inform the surgical decision-making process. Substantial demands are placed upon modern implants, because patients expect to remain active for longer. We discuss the advances made in implant performance and the developments in perioperative practice that have reduced complications. Assessment of surgery outcomes should include patient-reported outcome measures and implant survival rates that are based on data from joint replacement registries. The high-profile failure of some widely used metal-on-metal prostheses has shown the shortcomings of the existing regulatory framework. We consider how proposed changes to the regulatory framework could influence safety.

Optimal use of tranexamic acid for total hip arthroplasty: A network meta-analysis

Background

Tranexamic acid (TXA) has been demonstrated to minimize blood loss after total hip arthroplasty. There are three main routes: intravenous (IV), intra-articular (topical), and combined (IV and topical) but little consensus support which is most effective and safe. We performed network meta-analysis.to assess the comparative efficacy and safety of three different administration routes of TXA.

Methods

Twenty-five randomized controlled trials (RCT) were evaluated. Interventions were classified as: combined, IV multiple, IV single, topical and placebo. The primary outcome was effectiveness (transfusion rate, total blood loss, and total drain out). The secondary outcome was safety, based on the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE).

Results

A total of 2227 patients were included in the 5 categories: 564 IV single, 319 IV multiple, 398 topical, 120 combined, and 826 placebo. A network meta-analysis identified the most effective interventions in terms of reducing the need for transfusion as follows: combined = 98.2%, IV single = 54.0%, IV multiple = 78.6%, topical = 66.1%, placebo = 0.0%. Compared with placebo, the IV single, IV multiple, topical, and combined interventions showed no difference in the rate of occurrence of DVT and PE.

Conclusions

A network meta-analysis indicated that combined administration of TXA (IV and topical) was effective in reducing the transfusion rate after hip arthroplasty compared with IV or topical alone. As no high-risk patients were evaluated in the RCTs, it is not known whether the combined method is safer for patients susceptible to DVT or PE.

Perioperative Tranexamic Acid Treatment and Risk of Cardiovascular Events or Death After Total Hip Arthroplasty: A Population-Based Cohort Study from National Danish Databases

BACKGROUND

There have been concerns that the antifibrinolytic drug tranexamic acid (TXA) might increase the postoperative risk of cardiovascular events. Our objective was to determine whether perioperative TXA use is associated with cardiovascular events and death within 30 days after primary total hip arthroplasty (THA).

METHODS

We conducted a nationwide cohort study of cardiovascular outcomes after perioperative exposure to tranexamic acid during THA. We included 45,290 patients who had a THA in the study period of 2006 to 2013; 38,586 received perioperative TXA, and 6,704 did not. Propensity scores were calculated on the basis of age, sex, income, year of surgery, Elixhauser comorbidity index, and a variety of comorbidities and coprescribed medications. The primary outcome was venous thromboembolism. The secondary outcomes were deep venous thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke, and all-cause mortality. Data were analyzed using Cox regression, either in a multivariable model with inclusion of covariates (full cohorts) or in propensity-score-matched cohorts.

RESULTS

After propensity score matching, all prognostic covariates balanced well. In the matched cohort, TXA use was not found to significantly increase the risk of venous thromboembolism (hazard ratio [HR] = 1.18; 95% confidence interval [CI] = 0.83 to 1.68), deep vein thrombosis (HR = 1.15; CI = 0.78 to 1.68), pulmonary embolism (HR = 1.50; CI = 0.60 to 3.78), myocardial infarction (HR = 0.83; CI = 0.46 to 1.50), ischemic stroke (HR = 0.89; CI = 0.39 to 2.01), or all-cause mortality (HR = 0.73; CI = 0.41 to 1.28). Similar results were found in the multivariable Cox regression analyses.

CONCLUSIONS

Our data do not support a detrimental effect of TXA on the risk of cardiovascular events or death following THA.

LEVEL OF EVIDENCE

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

One Dose of Intravenous Tranexamic Acid Is Equivalent to Two Doses in Total Hip and Knee Arthroplasty

BACKGROUND

Tranexamic acid (TXA) helps to prevent excessive blood loss during total hip arthroplasty (THA) and total knee arthroplasty (TKA), but the most efficacious dosing protocol has not been ascertained. The purpose of this study was to identify whether 1 dose of intravenous TXA is equivalent to 2 doses for reducing blood loss and transfusion rates following THA and TKA without an increase in complications.

METHODS

We identified 1,736 patients who underwent THA (592 who did not receive TXA, 454 who received 1 dose of TXA, and 690 who received 2 doses) and 2,042 patients who underwent TKA (744 who did not receive TXA, 499 who received 1 dose, and 799 who received 2 doses) from 2012 to 2016. The differences among groups with regard to the change in hemoglobin levels, rate of allogeneic blood transfusions, and rate of complications were assessed.

RESULTS

Patients who underwent THA and received 1 dose or 2 doses of TXA had similar drops in the mean hemoglobin levels postoperatively (2.9 g/dL and 3.1 g/dL, respectively; p = 0.197) and both had a smaller drop than the control group (3.6 g/dL; p < 0.001 compared with the 1 and 2-dose groups). These findings were confirmed by a multivariate analysis that controlled for age, sex, and preoperative hemoglobin level. Transfusion was required for 12.5% of the patients who underwent THA without receiving TXA, no patient who received 1 dose, and 0.7% of the patients who received 2 doses. The patients who underwent TKA and received 1 dose or 2 doses of TXA had similar mean drops in the hemoglobin level postoperatively (2.4 g/dL and 2.4 g/dL, respectively; p = 0.891), and both had less of a drop than the control group (2.9 g/dL; p < 0.001 compared with the 1 and 2-dose groups). These findings were also confirmed by a multivariate analysis that controlled for age, sex, and preoperative hemoglobin level. Transfusion was required for 4.3% of the patients who underwent TKA without receiving TXA, 0.4% of those who received 1 dose, and 0.3% of those who received 2 doses. Similar rates of perioperative complications occurred among all groups.

CONCLUSIONS

One dose of TXA was as effective as 2 doses for decreasing blood loss and transfusion rates after THA and TKA without an increase in complications.

LEVEL OF EVIDENCE

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

Oral vs Intravenous vs Topical Tranexamic Acid in Primary Hip Arthroplasty: A Prospective, Randomized, Double-Blind, Controlled Study

BACKGROUND

Tranexamic acid (TXA) has demonstrated efficacy in reducing blood loss, reduction in hemoglobin, and blood transfusion requirements in primary total hip arthroplasty (THA). The optimal mode of TXA administration for patients undergoing primary THA is unclear. The purpose of this randomized controlled trial is to determine whether oral administration of TXA was superior to intravenous or topical routes in these patients.

METHODS

In this double-blinded, placebo-controlled trial, patients undergoing primary THA were randomized to oral (2 g TXA orally 2 hours preoperatively), intravenous (20 mg/kg intravenous TXA bolus 5 minutes before the incision), or topical (2 g TXA applied topically) TXA groups. The primary outcome was the reduction in hemoglobin. Secondary outcomes included blood loss, transfusion rate, cost of TXA (Chinese yuan (¥); in 2017, ¥1 = $0.147), and adverse events.

RESULTS

One hundred eighty patients were randomized into the 3 groups. Demographic characteristics were similar among the groups. The mean reduction in hemoglobin was similar among the oral, intravenous, and topical groups (3.48 ± 1.32, 3.58 ± 1.07, and 3.66 ± 1.26 g/dL, respectively). Similarly, the mean total blood loss did not differ significantly among the 3 groups. The oral group incurred the lowest TXA cost (¥480) compared with that in the intravenous (¥3329.28) and topical (¥3540) groups (P = .01). None of the patients sustained a deep venous thrombosis, pulmonary embolism, or an infection.

CONCLUSION

The blood-sparing efficacy of oral TXA is comparable to that of the intravenous and topical forms. Oral TXA is recommended because of its cost-benefit superiority and ease of administration.

Primary lower limb joint replacement and tranexamic acid: an observational cohort study

Background

This work aimed to evaluate the efficacy and safety of routine tranexamic acid (TXA) use in elective orthopaedic lower limb joint replacement surgery.

Methods

This retrospective cohort study included all primary hip or knee replacement procedures by a single surgeon over a 6-year period. TXA was introduced during the study period as part of an enhanced recovery after surgery strategy.

Results

Of the 673 procedures, 446 cases (66.3%) received TXA. The median length of stay was 5 days (2-69) and 6 days (3-28) for the TXA and control groups, respectively (P < .001). Blood transfusion was required for 28 (6.3%) of the TXA cases versus 40 (17.6%) controls (P < .001). Complication rates were similar irrespective of TXA status. At multivariate analysis, TXA was significantly and independently associated with fewer blood transfusions (hazard ratio 0.309, 95% confidence interval: 0.168-0.568, P < .001), with a number needed to treat of 9 cases. TXA use was estimated to save between £67.89 and £155.90 per case.

Conclusions

Routine prophylactic TXA administration for elective primary hip and knee replacement reduces the likelihood of postoperative transfusion with a number needed to treat of 9. Cost savings may be as high as £155.90 per case, and no safety concerns were noted.

Effects of low-dose epinephrine on perioperative hemostasis and inflammatory reaction in major surgical operations: a randomized clinical trial

Essentials Blood loss and immune reaction are closely related to morbidity and recovery after surgery. We studied the effect of epinephrine plus tranexamic acid on blood loss and immune reaction. Epinephrine plus tranexamic acid reduced postoperative total blood loss and immune reaction. Epinephrine plus tranexamic acid did not increase the incidence of complications.

SUMMARY

Background Hemostasis, thrombosis and surgical stress-induced immune reactions are important for perioperative morbidity and recovery after major surgical operations. Objectives To evaluate the effects of combined administration of low-dose epinephrine (LDEPI) and tranexamic acid (TXA) on perioperative blood loss, thromboembolic complications and inflammatory responses in patients undergoing total hip arthroplasty (THA). Patients/Methods Patients scheduled for THA (n = 195) were randomized into three interventions: intravenous LDEPI plus TXA (group IV); topical diluted epinephrine plus TXA (group TP); and TXA alone as control (group CT). The primary outcome was perioperative blood loss on postoperative day (POD) 1. Secondary outcomes included perioperative blood loss on POD 3, intraoperative blood loss, volume of drainage, transfusion values, coagulation and fibrinolysis parameters, inflammatory cytokine levels, cases of thrombosis, intravenous fluid on the operation day, and length of hospital stay. Results The mean calculated amounts of total blood loss in groups IV, TP and CT were 631.2 mL, 760.5 mL, and 825.6 mL, respectively, on POD 1; treatment effects (differences) were 194.4 mL (95% confidence interval [CI] 146.7-242.0) and 65.0 mL (95% CI 17.4-112.7). Groups IV and TP had lower levels of proinflammatory cytokines (tumor necrosis factor-α and interleukin [IL]-1β) and higher levels of the anti-inflammatory cytokine IL-10, and showed faster development of coagulation and fibrinolysis (without change in peak levels), than group CT early postoperation. No differences were observed in transfusion, thromboembolic and other outcomes among the groups. Conclusion The combined administration of LDEPI and TXA was more effective in reducing perioperative blood loss and alleviating the inflammatory response than TXA alone, without increasing the incidence of thromboembolic and other complications.

Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database

BACKGROUND

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid.

METHODS

All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits.

RESULTS

For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of "unnecessary" transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits.

CONCLUSION

A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.

Comparison of oral versus intravenous application of tranexamic acid in total knee and hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is regarded as one of the most important drugs in reducing blood loss and hemoglobin (Hb) drop after total knee arthroplasty (TKA) or total hip arthroplasty (THA). Treatment with tranexamic acid (TXA) by intravenous application has been discussed extensively. Recently, several studies have reported that oral administration has an effect on blood sparing. Therefore, we performed a meta-analysis to investigate the efficacy and safety between oral TXA and intravenous TXA (IV-TXA) for blood sparing in total knee and hip arthroplasty.

METHODS

Randomized controlled trials (RCTs) or retrospective cohort studies (RCSs) about relevant research were searched for by using PubMed (1996-April 2017), Embase (1980-April 2017), and the Cochrane Library (CENTRAL, April 2017). Five studies that compared oral with IV administration of TXA were included in our meta-analysis. Meta-analysis results were collected and analyzed by the software Review Manager 5.3 (Copenhagen: The Nordic Cochrane Center, The Collaboration, 2014).

RESULTS

Five studies containing 3474 patients met the inclusion criteria. Our pooled data analysis indicated that oral TXA was as effective as the IV-TXA in terms of the average Hb drop (P = 0.88), total Hb loss (P = 0.57), total blood loss (P = 0.42), transfusion rate (P = 0.16), complications (P = 0.61), and length of hospital stay (P = 1.00).

CONCLUSIONS

Compared with the IV-TXA method, oral TXA shows similar blood-sparing efficacy for preventing hemoglobin drop, total hemoglobin loss, and total blood loss following TKA or THA. In addition, no significant differences of transfusion rate, complications, or length of hospital stay were found between the 2 groups. However, because of the limited number of included studies, more studies of high quality are needed to further identify the optimal administration time for oral TXA.

Is combined topical and intravenous tranexamic acid superior to intravenous tranexamic acid alone for controlling blood loss after total hip arthroplasty?: A meta-analysis

BACKGROUND

We performed a meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of combined intravenous (IV) and topical tranexamic acid (TXA) with IV-TXA alone for controlling blood loss in patients following primary total hip arthroplasty (THA).

METHODS

PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, the Google database, the Chinese Wanfang database, and the China National Knowledge Infrastructure database were searched to identify studies comparing combined IV and topical TXA with IV-TXA alone in patients who were prepared for THA. The weighed mean differences for total blood loss, hemoglobin drop, intraoperative blood loss, and the length of hospital stay were calculated. We calculated risk ratios for the need for transfusion and the occurrence of deep venous thrombosis (DVT) in the combined TXA and IV-TXA alone groups. Relevant data were analyzed using Reviewer Manager 5.3.0.

RESULTS

Eight RCTs with a total of 850 patients (combined TXA: n = 471; IV-TXA: n = 479) were included in this meta-analysis. Pooled results indicated that compared with the IV-TXA alone group, the combined TXA group was associated with a lesser need for transfusion, total blood loss, intraoperative blood loss, and hemoglobin drop (P < .05). There was no significant difference between the 2 groups for the length of hospital stay and the occurrence of DVT (P > .05).

CONCLUSIONS

The current meta-analysis indicated that combined topical and IV-TXA was a relatively effective hemostasis method compared with IV-TXA alone. The number of studies included in this meta-analysis is limited, and more studies are needed to verify the effects of combined IV and topical TXA in THA patients.

Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database

BACKGROUND

As outpatient total hip (THA) and knee arthroplasties (TKA) increase in popularity, concerns exist about the safety of discharging patients home the same day. The purpose of this study is to determine the complications associated with outpatient total joint arthroplasty (TJA) and to identify high-risk patients who should be excluded from these protocols.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary TKA or THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between outpatient and traditional inpatient procedures. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes.

RESULTS

Of the total 169,406 patients who underwent TJA, 1220 were outpatient (0.7%). The outpatient and inpatient groups had an overall complication rate of 8% and 16%, respectively. Patients aged more than 70 years, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for readmission and complications after THA and TKA (all P < .05). Surprisingly, outpatient TJA alone did not increase the risk of readmission (OR 0.652, 95% CI 0.243-1.746, P = .395) or reoperation (OR 1.168, 95% CI 0.374-3.651, P = .789), and was a negative independent risk factor for complications (OR 0.459, 95% CI 0.371-0.567, P < .001).

CONCLUSION

With the resources available in a hospital setting, outpatient TJA may be a safe option, but only in select, healthier patients. Care should be taken to extrapolate these results to an outpatient facility, where complications may be more difficult to manage.