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Li X, Xie H, Liu S, Wang J, Shi Z, Yao Q, Yang Q, Li Q, Bao L. Analysis of the incidence and risk factors of blood transfusion in total knee revision: a retrospective nationwide inpatient sample database study. BMC Musculoskelet Disord 2024; 25:225. [PMID: 38509493 PMCID: PMC10953239 DOI: 10.1186/s12891-024-07331-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE This study sought to determine the incidence and risk factors of blood transfusion among patients undergoing total knee revision (TKR) using a nationwide database. METHODS A retrospective data analysis was conducted based on the Nationwide Inpatient Sample (NIS), enrolling patients who underwent TKR from 2010 to 2019 with complete information. The patients were divided into two groups based on whether they received blood transfusion or not. The demographic characteristics (race, sex, and age), length of stay (LOS), total charge of hospitalization, hospital characteristics (admission type, insurance type, bed size, teaching status, location, and region of hospital), hospital mortality, comorbidities, and perioperative complications were analyzed. Finally, we conducted univariate and multivariate logistic regression to identify factors that were associated with TKR patients to require blood transfusion. RESULTS The NIS database included 115,072 patients who underwent TKR. Among them, 14,899 patients received blood transfusion, and the incidence of blood transfusion was 13.0%. There was a dramatic decrease in the incidence over the years from 2010 to 2019, dropping from 20.4 to 6.5%. TKR patients requiring transfusions had experienced longer LOS, incurred higher total medical expenses, utilized Medicare more frequently, and had increased in-hospital mortality rates (all P < 0.001). Independent predictors for blood transfusion included advanced age, female gender, iron-deficiency anemia, rheumatoid disease, chronic blood loss anemia, congestive heart failure, coagulopathy, uncomplicated diabetes, lymphoma, fluid and electrolyte disorders, metastatic carcinoma, other neurological diseases, paralysis, peripheral vascular disorders, pulmonary circulation disorders, renal failure, valvular disease, and weight loss. In addition, risk factors for transfusion in TKR surgery included sepsis, acute myocardial infarction, deep vein thrombosis, pulmonary embolism, gastrointestinal bleeding, heart failure, renal insufficiency, pneumonia, wound infection, lower limb nerve injury, hemorrhage/seroma/hematoma, wound rupture/non healing, urinary tract infection, acute renal failure, and postoperative delirium. CONCLUSIONS Our findings highlight the importance of recognizing the risk factors of blood transfusion in TKR to reduce the occurrence of adverse events.
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Affiliation(s)
- Xiaoyin Li
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Hao Xie
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shuxia Liu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Jian Wang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhanjun Shi
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Qiaobing Yao
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Qinfeng Yang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Qiuhong Li
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Liangxiao Bao
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
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Gibbs VN, Champaneria R, Sandercock J, Welton NJ, Geneen LJ, Brunskill SJ, Dorée C, Kimber C, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD013295. [PMID: 38226724 PMCID: PMC10790339 DOI: 10.1002/14651858.cd013295.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Hip and knee replacement surgery is a well-established means of improving quality of life, but is associated with a significant risk of bleeding. One-third of people are estimated to be anaemic before hip or knee replacement surgery; coupled with the blood lost during surgery, up to 90% of individuals are anaemic postoperatively. As a result, people undergoing orthopaedic surgery receive 3.9% of all packed red blood cell transfusions in the UK. Bleeding and the need for allogeneic blood transfusions has been shown to increase the risk of surgical site infection and mortality, and is associated with an increased duration of hospital stay and costs associated with surgery. Reducing blood loss during surgery may reduce the risk of allogeneic blood transfusion, reduce costs and improve outcomes following surgery. Several pharmacological interventions are available and currently employed as part of routine clinical care. OBJECTIVES To determine the relative efficacy of pharmacological interventions for preventing blood loss in elective primary or revision hip or knee replacement, and to identify optimal administration of interventions regarding timing, dose and route, using network meta-analysis (NMA) methodology. SEARCH METHODS We searched the following databases for randomised controlled trials (RCTs) and systematic reviews, from inception to 18 October 2022: CENTRAL (the Cochrane Library), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Transfusion Evidence Library (Evidentia), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA We included RCTs of people undergoing elective hip or knee surgery only. We excluded non-elective or emergency procedures, and studies published since 2010 that had not been prospectively registered (Cochrane Injuries policy). There were no restrictions on gender, ethnicity or age (adults only). We excluded studies that used standard of care as the comparator. Eligible interventions included: antifibrinolytics (tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid (EACA)), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants and non-fibrin sealants. DATA COLLECTION AND ANALYSIS We performed the review according to standard Cochrane methodology. Two authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using CINeMA. We presented direct (pairwise) results using RevMan Web and performed the NMA using BUGSnet. We were interested in the following primary outcomes: need for allogenic blood transfusion (up to 30 days) and all-cause mortality (deaths occurring up to 30 days after the operation), and the following secondary outcomes: mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), length of hospital stay and adverse events related to the intervention received. MAIN RESULTS We included a total of 102 studies. Twelve studies did not report the number of included participants; the other 90 studies included 8418 participants. Trials included more women (64%) than men (36%). In the NMA for allogeneic blood transfusion, we included 47 studies (4398 participants). Most studies examined TXA (58 arms, 56%). We found that TXA, given intra-articularly and orally at a total dose of greater than 3 g pre-incision, intraoperatively and postoperatively, ranked the highest, with an anticipated absolute effect of 147 fewer blood transfusions per 1000 people (150 fewer to 104 fewer) (53% chance of ranking 1st) within the NMA (risk ratio (RR) 0.02, 95% credible interval (CrI) 0 to 0.31; moderate-certainty evidence). This was followed by TXA given orally at a total dose of 3 g pre-incision and postoperatively (RR 0.06, 95% CrI 0.00 to 1.34; low-certainty evidence) and TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively (RR 0.10, 95% CrI 0.02 to 0.55; low-certainty evidence). Aprotinin (RR 0.59, 95% CrI 0.36 to 0.96; low-certainty evidence), topical fibrin (RR 0.86, CrI 0.25 to 2.93; very low-certainty evidence) and EACA (RR 0.60, 95% CrI 0.29 to 1.27; very low-certainty evidence) were not shown to be as effective compared with TXA at reducing the risk of blood transfusion. We were unable to perform an NMA for our primary outcome all-cause mortality within 30 days of surgery due to the large number of studies with zero events, or because the outcome was not reported. In the NMA for deep vein thrombosis (DVT), we included 19 studies (2395 participants). Most studies examined TXA (27 arms, 64%). No studies assessed desmopressin, EACA or topical fibrin. We found that TXA given intravenously and orally at a total dose of greater than 3 g intraoperatively and postoperatively ranked the highest, with an anticipated absolute effect of 67 fewer DVTs per 1000 people (67 fewer to 34 more) (26% chance of ranking first) within the NMA (RR 0.16, 95% CrI 0.02 to 1.43; low-certainty evidence). This was followed by TXA given intravenously and intra-articularly at a total dose of 2 g pre-incision and intraoperatively (RR 0.21, 95% CrI 0.00 to 9.12; low-certainty evidence) and TXA given intravenously and intra-articularly, total dose greater than 3 g pre-incision, intraoperatively and postoperatively (RR 0.13, 95% CrI 0.01 to 3.11; low-certainty evidence). Aprotinin was not shown to be as effective compared with TXA (RR 0.67, 95% CrI 0.28 to 1.62; very low-certainty evidence). We were unable to perform an NMA for our secondary outcomes pulmonary embolism, myocardial infarction and CVA (stroke) within 30 days, mean number of transfusion episodes per person (up to 30 days), re-operation due to bleeding (within seven days), or length of hospital stay, due to the large number of studies with zero events, or because the outcome was not reported by enough studies to build a network. There are 30 ongoing trials planning to recruit 3776 participants, the majority examining TXA (26 trials). AUTHORS' CONCLUSIONS We found that of all the interventions studied, TXA is probably the most effective intervention for preventing bleeding in people undergoing hip or knee replacement surgery. Aprotinin and EACA may not be as effective as TXA at preventing the need for allogeneic blood transfusion. We were not able to draw strong conclusions on the optimal dose, route and timing of administration of TXA. We found that TXA given at higher doses tended to rank higher in the treatment hierarchy, and we also found that it may be more beneficial to use a mixed route of administration (oral and intra-articular, oral and intravenous, or intravenous and intra-articular). Oral administration may be as effective as intravenous administration of TXA. We found little to no evidence of harm associated with higher doses of tranexamic acid in the risk of DVT. However, we are not able to definitively draw these conclusions based on the trials included within this review.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Nicky J Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Sivasubramanian H, Tan CMP, Wang L. Effects of local infiltration of analgesia and tranexamic acid in total knee replacements: safety and efficacy in reducing blood loss and comparability to intra-articular tranexamic acid. Singapore Med J 2024; 65:16-22. [PMID: 34617694 PMCID: PMC10863735 DOI: 10.11622/smedj.2021130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The use of periarticular (PA) tranexamic acid (TXA) and its efficacy in comparison with intra-articular (IA) TXA have not been well explored in the literature. This retrospective cohort study aimed to compare the effects of IA and PA TXA with analgesic components in reducing blood loss and improving immediate postoperative pain relief and functional outcomes in patients after unilateral primary total knee arthroplasty (TKA). METHODS A total of 63 patients underwent TKA, and they were divided into the IA TXA delivery group ( n = 42) and PA TXA delivery group ( n = 21). All patients were administered 1 g of TXA. They also received pericapsular infiltration consisting of 0.5 mL of adrenaline, 0.4 mL of morphine, 1 g of vancomycin, 1 mL of ketorolac and 15 mL of ropivacaine. Outcomes for blood loss and surrogate markers for immediate functional recovery were measured. RESULTS Of the 63 patients, 54% were female and 46% male. The mean drop in postoperative haemoglobin levels in the PA and IA groups was 2.0 g/dL and 1.6 g/dL, respectively, and this was not statistically significant ( P = 0.10). The mean haematocrit drop in the PA and IA groups was 6.1% and 5.3%, respectively, and this was also not statistically significant ( P = 0.58). The postoperative day (POD) 1 and discharge day flexion angles, POD 1 and POD 2 visual analogue scale (VAS) scores, gait distance on discharge and length of hospitalisation stay were largely similar in the two groups. CONCLUSION Our study showed that both IA and PA TXA with analgesic components were equally efficient in reducing blood loss and improving immediate postoperative pain relief and functional outcomes.
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Affiliation(s)
- Harish Sivasubramanian
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
| | - Cheryl Marise Peilin Tan
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
| | - Lushun Wang
- Department of Orthopaedic Surgery, Ng Teng Fong Hospital, National University Health System, Singapore
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Gibbs VN, Geneen LJ, Champaneria R, Raval P, Dorée C, Brunskill SJ, Novak A, Palmer AJ, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures. Cochrane Database Syst Rev 2023; 6:CD013499. [PMID: 37272509 PMCID: PMC10241722 DOI: 10.1002/14651858.cd013499.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications. OBJECTIVES To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones. SEARCH METHODS We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data. MAIN RESULTS We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence). It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence). We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect. Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants). All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here. AUTHORS' CONCLUSIONS We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration). We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.
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Affiliation(s)
- Victoria N Gibbs
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Rita Champaneria
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Parag Raval
- Trauma and Orthopaedic Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx), Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Gbejuade H, Sambhwani S, Ubsdell RM, Dungey M, Kandiah A, Shyamsundar S. Predicting Factors for Requiring Routine Postoperative Blood Analysis in Primary Hip and Knee Arthroplasty: A Prospective Study. Cureus 2023; 15:e39283. [PMID: 37346220 PMCID: PMC10280489 DOI: 10.7759/cureus.39283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Background Minimising unnecessary expenditure is essential to cope with high demands on the health sector. A set of full blood count, electrolyte, creatinine and urea tests cost £12 in the National Health Service (NHS). Identifying selected patients requiring postoperative blood tests following primary knee and hip arthroplasty will avoid unnecessary tests and help to reduce expenditure. The aim of our study is to propose criteria for requesting postoperative blood tests that are safe and do not miss patients. Materials and methods We prospectively evaluated 126 patients (72 in the total knee replacement (TKR) group and 54 in the total hip replacement (THR) group) who underwent either an elective primary THR or a TKR. The mean patient age was 71 years. Patient demographics as well as in-patient events throughout each patient's hospital stay were recorded. Hospital readmissions were also monitored for up to 90 days postoperatively. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY) with paired t-tests / Wilcox and mixed measures analysis of variance. Binary logistic regression was used to identify predictors of patients requiring a postoperative blood test. Results Analysis of our data identified the following as risk factors for requiring postoperative full blood count tests, including pre-operative Hb of ≤ 110 g/L, cardiac disease, clinical features of anaemia postoperatively and intraoperative blood loss of > 500 mL. The additional risk factors identified for requiring postoperative electrolyte and urea tests are deranged pre-operative electrolytes and clinical signs or symptoms of electrolyte/renal disturbance such as anuria. No patient was readmitted within 90 days of discharge. Conclusion Overall, applying the criteria we have devised would have saved 74 blood tests in the cohort of 126 patients. This provides an odds ratio of 14.0 (95% confidence interval: 1.77-110, p=0.012) of an abnormal result in the patients that would have been tested, compared to those that would not have been tested.
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Affiliation(s)
| | | | | | - Maurice Dungey
- Orthopaedics, Kettering General Hospital, Kettering, GBR
| | - Ashan Kandiah
- Orthopaedics, Kettering General Hospital, Kettering, GBR
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Resch EDS, Lemos LS, Santos JSPD, Pozzi JFA, Konkevicz ER. Comparison of Blood Loss with the Use of Intravenous and Intraarticular Tranexamic Acid Versus Isolated Intraarticular in Primary Knee Arthroplasty. Rev Bras Ortop 2023; 58:320-325. [PMID: 37252309 PMCID: PMC10212634 DOI: 10.1055/s-0042-1757958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 09/12/2022] [Indexed: 05/31/2023] Open
Abstract
Objective The objective of this work is to compare blood loss during primary knee arthroplasty with the use of intravenous and intraarticular (IV + IA) tranexamic acid versus intraarticular (IA) tranexamic acid alone. Methods This is a randomized, double-blind clinical trial. Patients with indication for primary total knee arthroplasty were recruited in a specialized clinic, where they were operated by the same surgeon, always using the same surgical technique. Thirty patients were allocated in the IV + IA tranexamic acid group and 30 patients in the IA tranexamic acid group, according to randomization. Blood loss was compared through hemoglobin, hematocrit, drain volume, and blood loss estimation (Gross and Nadler calculus). Results After collection, data from 40 patients were analyzed, 22 in the IA group and 18 in the IV + IA group. There were 20 losses due to collection error. Between groups IA and IV + IA, there were no significant differences in 24 hours between hemoglobin levels (10.56 vs. 10.65 g/dL; F 1.39 = 0.63, p = 0.429), erythrocyte (3.63 vs. 3.73 million/mm 3 ; F 1.39 = 0.90, p = 0.346); hematocrit (32.14 vs. 32.60%; F 1.39 = 1.39, p = 0.240); drainage volume (197.0 vs. 173.6 mL; F 1.39 = 3.38 p = 0.069); and estimated blood loss (1,002.5 vs. 980.1; F 1.39 = 0.09, p = 0.770). The same occurred in comparisons conducted after 48 hours postoperatively. Time was a significant factor for the change of all outcome variables. However, the treatment did not modify the effect of time on these outcomes. No individual presented any thromboembolic event during the work period. Conclusions The use of IV + IA tranexamic acid showed no advantage in reducing blood loss when compared to the use of IA tranexamic acid alone in primary knee arthroplasties. This technique proved to be safe, since no thromboembolic event occurred during the development of the work.
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Affiliation(s)
- Elemar da Silva Resch
- Departamento de Ortopedia e Traumatologia, Hospital Universitário de Santa Maria, Santa Maria, RS, Brasil
| | - Leandro Silvestro Lemos
- Departamento de Ortopedia e Traumatologia, Clínica Millenarium Multi Especialidades, Porto Alegre, RS, Brasil
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Masada KM, Blumenthal SR, Cipriano CA. Fixation Principles for Pathologic Fractures in Metasatic Disease. Orthop Clin North Am 2023; 54:47-57. [PMID: 36402510 DOI: 10.1016/j.ocl.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The management of pathologic fractures differs from nonpathologic fractures with respect to preoperative evaluation, surgical strategies, adjuvant therapies, and complication rates. These issues must be understood to provide appropriate musculoskeletal care for patients with metastatic disease.
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Affiliation(s)
- Kendall M Masada
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
| | - Sarah R Blumenthal
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Cara A Cipriano
- Hospital of the University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
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8
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Erasu V, Novak A, Gibbs VN, Champaneria R, Dorée C, Hafeez A, Moy R, Sandercock J, Brunskill SJ, Estcourt LJ. Pharmacological interventions for the treatment of bleeding in people treated for blunt force or penetrating injury in an emergency department: a systematic review and network meta-analysis. Hippokratia 2022. [DOI: 10.1002/14651858.cd014600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vishakha Erasu
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Victoria N Gibbs
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Rita Champaneria
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Carolyn Dorée
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Aqib Hafeez
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Ross Moy
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Josie Sandercock
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | | | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Tsantes AG, Trikoupis IG, Papadopoulos DV, Goumenos S, Piovani D, Nikolopoulos GK, Gialeraki A, Bonovas S, Papagelopoulos PJ, Kontogeorgakos VA, Tsantes AE. The Safety and Efficacy of Tranexamic Acid in Oncology Patients Undergoing Endoprosthetic Reconstruction and a ROTEM-Based Evaluation of Their Hemostatic Profile: A Pilot Study. Cancers (Basel) 2021; 13:cancers13163951. [PMID: 34439106 PMCID: PMC8392365 DOI: 10.3390/cancers13163951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Tranexamic acid can be an effective and safe way to reduce perioperative bleeding following an endoprosthetic reconstruction of a lower limb after a bone tumor resection. Tranexamic acid does not result in a complete shutdown of the fibrinolysis, supporting its safe use without increasing the risk of thromboembolic complications. Abstract Background: An endoprosthetic reconstruction in musculoskeletal oncology patients is associated with significant blood loss. The purpose of this study is to evaluate the safety and efficacy of tranexamic acid (TXA) for these patients and to assess any changes in their hemostatic profile using rotational thromboelastometry (ROTEM). Methods: A retrospective observational study was performed including 61 patients with primary or metastatic bone tumors who underwent surgery. Group A (n = 30) received both intravenous and local TXA whereas Group B (n = 31) was the control group. The primary outcomes were perioperative blood loss and blood unit transfusions and the secondary outcomes included the incidence of thromboembolic complications and a change in blood coagulability as reflected by ROTEM parameters. Results: The median difference in blood loss between the two groups was 548.5 mL, indicating a 29.2% reduction in the 72 h blood loss following TXA administration (p < 0.001). TXA also led to a reduced transfusion of 1 red blood cell (RBC) unit per patient (p < 0.001). The two groups had similar rates of thromboembolic complications (p = 0.99). The antifibrinolytic properties of TXA were confirmed by the significantly higher INTEM, FIBTEM and EXTEM LI60 (p < 0.001, p = 0.005 and p < 0.001, respectively) values in the TXA group. Conclusion: Tranexamic acid was associated with a significant reduction in perioperative blood loss and transfusion requirements without a complete shutdown of the fibrinolysis. Larger studies are warranted to assess the frequency of these outcomes in musculoskeletal oncology patients.
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Affiliation(s)
- Andreas G. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.G.); (A.E.T.)
- Correspondence: (A.G.T.); (V.A.K.); Tel.: +30-697221978 (V.A.K.)
| | - Ioannis G. Trikoupis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (I.G.T.); (S.G.); (P.J.P.)
| | - Dimitrios V. Papadopoulos
- Department of Orthopaedic Surgery, University of Pittsburgh, Orthopedic Specialists-UPMC, Pittsburgh, PA 15237, USA;
| | - Stavros Goumenos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (I.G.T.); (S.G.); (P.J.P.)
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.P.); (S.B.)
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | | | - Argyri Gialeraki
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.G.); (A.E.T.)
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.P.); (S.B.)
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Panayiotis J. Papagelopoulos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (I.G.T.); (S.G.); (P.J.P.)
| | - Vasilios A. Kontogeorgakos
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (I.G.T.); (S.G.); (P.J.P.)
- Correspondence: (A.G.T.); (V.A.K.); Tel.: +30-697221978 (V.A.K.)
| | - Argirios E. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.G.); (A.E.T.)
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11
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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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12
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Taeuber I, Weibel S, Herrmann E, Neef V, Schlesinger T, Kranke P, Messroghli L, Zacharowski K, Choorapoikayil S, Meybohm P. Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression. JAMA Surg 2021; 156:e210884. [PMID: 33851983 PMCID: PMC8047805 DOI: 10.1001/jamasurg.2021.0884] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/14/2021] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use. OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines. DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020. STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded. DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality. RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53). CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.
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Affiliation(s)
- Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Leila Messroghli
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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13
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Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6961540. [PMID: 33532495 PMCID: PMC7834786 DOI: 10.1155/2021/6961540] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
Objective Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. Design A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. Results A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. Conclusions There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.
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14
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Comparison of Effects of a Thrombin-Based Hemostatic Agent and Topical Tranexamic Acid on Blood Loss in Patients with Preexisting Thromboembolic Risk Undergoing a Minimally Invasive Total Knee Arthroplasty. A Prospective Randomized Controlled Trial. BIOMED RESEARCH INTERNATIONAL 2021; 2021:2549521. [PMID: 33511201 PMCID: PMC7822658 DOI: 10.1155/2021/2549521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 11/25/2020] [Accepted: 01/05/2021] [Indexed: 11/17/2022]
Abstract
Background The efficacy of a thrombin-based hemostatic agent (Floseal®) on reducing postoperative blood loss after total knee arthroplasty (TKA) was still unclear. The aim of our study was to conduct a prospective randomized controlled study to compare the blood conservation effects of Floseal® and topical TXA in patients with preexisting thromboembolic risk undergoing primary minimally invasive TKA. Methods Our power analysis of this study was based upon the following description, to obtain a statistical power of 0.90 and an alpha error of 0.05, 30 patients were required in each group. Therefore, we enrolled a total of 103 patients with at least one of the risk factors for thromboembolism who underwent unilateral primary minimally invasive TKA, and the participants were randomly divided into the topical TXA group (n = 34), receiving intra-articular injection of 3 g of TXA in 100 mL saline after TKA, the topical Floseal® group (n = 34), receiving 10 mL of Floseal® intra-articularily during surgery, and the placebo group (n = 35), receiving an intra-articular saline injection only. The total blood loss (TBL) and hemoglobin (Hb) drop were compared among the 3 groups. Results The TXA group had a lower TBL of 645 mL (227 to 1090) in comparison with 1145 mL (535 to 1942) in the Floseal® group and 1103 mL (424 to 1711) in the placebo (p < 0.001, respectively). The TBL was similar between the Floseal® group and the placebo group (p = 0.819). No patients in any group had symptoms of venous thromboemblism. Conclusion Our prospective randomized controlled study showed that intra-articular application of TXA was superior to hemostatic matrix (Floseal®) in terms of blood conservation in patients with preexisting thromboembolic risk undergoing minimally invasive TKA. This trial is registered with Clinicaltrials.gov (NCT02865174) on 08/09/2016.
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15
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Smith CS, Mollon B, Vannabouathong C, Fu JM, Sales B, Bhandari M, Whelan DB. An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013. J Bone Joint Surg Am 2020; 102:e116. [PMID: 33086352 DOI: 10.2106/jbjs.18.00653] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.
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Affiliation(s)
| | - Brent Mollon
- Soldiers' Memorial Hospital, Orillia, Ontario, Canada
| | | | - Joyce M Fu
- Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Bhandari
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel B Whelan
- University of Toronto Orthopaedic Sports Medicine, St. Michael's and Women's College Hospitals, Toronto, Ontario, Canada
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Totlis T, Paparoidamis G, Terzidis I, Piagkou M, Tsiridis E, Natsis K. Surgical anatomy of the lateral circumflex femoral artery branches: Contribution to the blood loss control during hip arthroplasty. Ann Anat 2020; 232:151566. [PMID: 32603828 DOI: 10.1016/j.aanat.2020.151566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The lateral circumflex femoral artery (LCFA) branches encountered during anterior and lateral hip approaches; although vessels' haemostasis is suggested in surgical textbooks, literature is scarce regarding their topography. The current study defines the exact location of the LCFA and its branches, based on osseous landmarks, as well as their size and possible variants, providing helpful information for intraoperative identification and demonstrating the magnitude of potential haemorrhage during hip surgery. METHODS Twenty-three human cadavers (46 lower limbs) were dissected. The LCFA branching pattern was recorded. The distances of the LCFA origin and its first branch from the anterior superior iliac spine (ASIS) were measured. Length and width of the LFCA, LCFA ascending and transverse branches (LCFAab and LCFAtb) were calculated and compared to the ipsilateral ulnar artery (UA) width, which was served as a comparative guide. RESULTS The LFCA origin was located 106.9 ± 17.5 mm distal and 65.6 ± 14.7 mm medial to the ASIS, while the LFCA first branch origin was 115.1 ± 24.3 mm distal and 48.2 ± 14.3 mm medial to the ASIS. The mean lengths of the LCFA, LCFAab and LCFAtb were 23.2 ± 12.6 mm, 44.8 ± 14.9 mm and 42.3 ± 13.6 mm, respectively. Their mean widths were 4.3 ± 1.0 mm, 2.9 ± 0.9 mm and 2.7 ± 0.7 mm, respectively, while the mean UA width was 2.7 ± 0.4 mm. CONCLUSION The surgeon may detect the LCFA and its branching, at a mean distance of 110 mm (range 100-126 mm), distal to the ASIS. The LCFAab and LCFAtb widths are similar to the UA width. Meticulous knowledge of the branching pattern topography and vessels' size may contribute to a successful management of the intraoperative blood loss.
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Affiliation(s)
- T Totlis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece; TheMIS Orthopaedic Center, St. Luke's Hospital, Thessaloniki, Greece.
| | - G Paparoidamis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece; Academic Orthopaedic Department, "Papageorgiou" General Hospital, Aristotle University Medical School Faculty of Health Sciences, and CORE Lab, CIRI-AUTh, Thessaloniki, Greece
| | - I Terzidis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece; TheMIS Orthopaedic Center, St. Luke's Hospital, Thessaloniki, Greece
| | - M Piagkou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Greece
| | - E Tsiridis
- Academic Orthopaedic Department, "Papageorgiou" General Hospital, Aristotle University Medical School Faculty of Health Sciences, and CORE Lab, CIRI-AUTh, Thessaloniki, Greece; ICAROS International Center for Arthroplasty & Robotic Orthopaedic Surgery, European Interbalkan Medical Center, Thessaloniki, Greece
| | - K Natsis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece; European Interbalkan Medical Center, Thessaloniki, Greece
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17
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Drain NP, Gobao VC, Bertolini DM, Smith C, Shah NB, Rothenberger SD, Dombrowski ME, O'Malley MJ, Klatt BA, Hamlin BR, Urish KL. Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty. J Arthroplasty 2020; 35:S201-S206. [PMID: 32209286 PMCID: PMC7239733 DOI: 10.1016/j.arth.2020.02.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE Level III, Observational Cohort Study.
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Affiliation(s)
| | | | | | - Clair Smith
- Department of Physical Therapy and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Scott D Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Michael J O'Malley
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brian A Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brian R Hamlin
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA
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18
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Turnikesiz Unilateral Total Diz Artoplastisi Sonrası Kanama Kontrolünde Topikal Uygulanan Traneksamik Asitin Etkinliği. JOURNAL OF CONTEMPORARY MEDICINE 2020. [DOI: 10.16899/jcm.655991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Tranexamic Acid in Patients With Cancer Undergoing Endoprosthetic Reconstruction: A Retrospective Review. J Am Acad Orthop Surg 2020; 28:248-255. [PMID: 32142488 DOI: 10.5435/jaaos-d-18-00798] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Endoprosthetic reconstruction presents a significant risk of perioperative blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent used to reduce blood loss in orthopaedic procedures. The safety and efficacy of TXA in arthroplasty are well documented. There is, however, a dearth of literature exploring the safety and efficacy of TXA in musculoskeletal oncology patients. This retrospective, comparative study explores the effects of TXA on perioperative blood loss, blood transfusion rates, venous thromboembolism (VTE) occurrence, and hospital stay in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction. METHODS For the study, charts from a total of 90 patients who underwent resection of an aggressive bone tumor and endoprosthetic reconstruction were reviewed; of these patients, 34 were in the TXA group and 56 in the non-TXA group. Study participants composed of a heterogeneous group of patients with primary bone sarcoma and metastatic osseous disease. Patients in the TXA group received 1 g of topical TXA administered into the wound bed before closure. The Hemoglobin Balance method was used to calculate blood loss. Patients were followed for 6 weeks. RESULTS Patients undergoing proximal femur replacement and distal femur replacement in the TXA group experienced a 796 and 687 mL reduction in 72-hour mean blood loss, respectively (P = 0.0003 and P = 0.006). Average blood transfusions decreased by 0.45 U of packed red blood cells per patient in the TXA group (P = 0.048) and transfusion incidence decreased by 21.1% compared with the non-TXA group (P = 0.04). Patients undergoing proximal femur replacement in the TXA group left the hospital 2.2 days earlier than those in the non-TXA group (P = 0.0004). No increase in VTE rate was observed with TXA use. DISCUSSION This study found results similar to total joint arthroplasty with regard to TXA's effect on perioperative blood loss, transfusion rates, hospital stay, and VTE occurrence. It provides initial data to support the efficacy of topical TXA use in this patient cohort. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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20
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Dao P, Massin P. Blood management in enhanced recovery after hip and knee replacement. Orthop Traumatol Surg Res 2020; 106:S1-S5. [PMID: 31836497 DOI: 10.1016/j.otsr.2019.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 04/30/2019] [Accepted: 05/10/2019] [Indexed: 02/02/2023]
Abstract
Enhanced recovery in orthopedic surgery is a global patient management strategy to achieve early functional recovery. Blood management is central to rehabilitation protocols after hip or knee replacement. Coagulation physiology in hip and knee replacement is now well described, showing aggravation of bleeding by hyperfibrinolysis. The present study approaches blood management via 3 questions. 1/How to anticipate and prevent transfusion risk preoperatively? Screening for predictive factors can target the at-risk population, enabling a strategy of preoperative hemoglobin level optimization. 2/How to improve intraoperative hemostasis so as to minimize blood loss? Anti-fibrinolytic and topical hemostatic agents have proven efficacy. Tranexamic acid plays a central role. The impact of the usual surgical techniques, such as pneumatic tourniquet and postoperative drainage, on bleeding needs assessment. 3/How to manage postoperative anemia? Anemia without signs of general intolerance is frequent at discharge, but has been little studied. This raises the question of the medical interest of correcting postoperative anemia. LEVEL OF EVIDENCE: Expert opinion, V.
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Affiliation(s)
- Pierre Dao
- CMC Ambroise-Paré, 25-27, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France.
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21
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Gibbs VN, Champaneria R, Novak A, Doree C, Palmer AJR, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation of hip, pelvic and long bone fractures: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Victoria N Gibbs
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Rita Champaneria
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Alex Novak
- John Radcliffe Hospital; Emergency Department; Headley Way Oxford Oxon UK OX39DU
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Antony JR Palmer
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; Botnar Research Centre Oxford Oxfordshire UK OX3 7LD
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
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22
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Hemostatic techniques to reduce blood transfusion after primary TKA: a meta-analysis and systematic review. Arch Orthop Trauma Surg 2019; 139:1785-1796. [PMID: 31541274 DOI: 10.1007/s00402-019-03271-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE To investigate the efficacy of non-tranexamic acid (TXA) on reducing blood loss and requirements of allogeneic blood transfusion (ABT) in total knee arthroplasty (TKA). METHODS The PubMed, EMBASE, and the Cochrane Library databases were researched since incipiency to June 2018. Only randomized controlled trials (RCTs) involved with non-TXA hemostatic techniques in TKA met the inclusion criteria. RESULTS A total of 36 RCTs, including 1511 patients, were recruited for analysis. The results of subgroup analysis revealed that hemostatic techniques, which could substantially decrease the rate of ABT, were cell salvage with the transfusion trigger of 9 mg/dl, fibrin sealant with a dosage of 10 ml, and postoperative flexion position. CONCLUSION The available evidence in this meta-analysis suggests that postoperative flexion position, fibrin sealant, and cell salvage can substantially decrease the rate of ABT in TKA. Further studies, including more hemostatic methods and high-quality research, are expected.
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23
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Blood Transfusion Trends in Primary and Revision Total Joint Arthroplasty: Recent Declines Are Not Shared Equally. J Am Acad Orthop Surg 2019; 27:e920-e927. [PMID: 30676513 DOI: 10.5435/jaaos-d-18-00205] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This study examined whether recent nationwide declines in the incidence of transfusion following total joint arthroplasty were equal across inpatient facilities. METHODS This analysis used the Premier database (2010 to 2015). Cohorts of primary total hip or knee arthroplasty (THA or TKA) and revision THA or TKA were defined. RESULTS Among 1,013,024 patients who met selection criteria, the overall incidence of transfusion declined from 2010 through 2015 (primary THA: 22.1% to 7.1%; primary TKA: 18.1% to 3.2%; revision THA: 30.6% to 18.5%; and revision TKA: 19.8% to 9.8%; all P < 0.001). However, patients older than 65 years were associated with lower odds of transfusion relative to those younger than 65 years (P < 0.05 for three of four cohorts); smaller hospitals were associated with higher odds versus large hospitals (P < 0.05 all cohorts), and academic hospitals were associated with higher odds of transfusion versus community facilities (P < 0.05 for three of four cohorts). DISCUSSION During this study period, a meaningful proportion of total joint arthroplasty procedures were performed at facilities with the most room to improve. Decreases in transfusion rates were dependent on specific hospital characteristics; these results may help direct targeted improvement initiatives. LEVEL OF EVIDENCE Level III.
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Tille E, Mysliwietz J, Beyer F, Postler A, Lützner J. Intraarticular use of tranexamic acid reduces blood loss and transfusion rate after primary total knee arthroplasty. BMC Musculoskelet Disord 2019; 20:341. [PMID: 31351459 PMCID: PMC6661102 DOI: 10.1186/s12891-019-2715-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/11/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is effective in reduction of hemorrhage after major surgical procedures. In total joint replacement it is commonly administered intravenously. Despite various studies regarding the safety of its antifibrinolytic effect there are contraindications for systemic use. In total knee arthroplasty (TKA) TXA can also be administered intraarticular. However, there is a lack of studies focusing on dosage, effectiveness and complications of this local treatment. This study aimed to evaluate if blood loss and transfusion rate can be reduced in primary TKA by local application of TXA. METHODS We included a total of 202 consecutive primary, unilateral TKA patients, 101 without and 101 with intraartricular application of 2 g TXA. Surgery was conducted after a standardized protocol. Blood loss, transfusion and complication rates were evaluated until three months after surgery. Blood loss was estimated using the hematocrit-value (Hk) prior and five days after surgery by Rosenecher's and Mercuriali's formula. RESULTS By the use of TXA a significant reduction of blood loss (Rosencher average 1220 ml vs 1900 ml, Mercuriali average 430 ml vs 700 ml p < 0,001) and transfusion rate (0% vs 24.75% of patients, p < 0,001) was observed. There were no differences regarding complication rates. Due to the lower cost of TXA compared to applied erythrocyte concentrates a side effect of the treatment was a cost reduction of € 1.609 within this cohort. CONCLUSIONS The intraarticular application of 2 g TXA resulted in a significant reduction of blood loss and transfusion rate after primary TKA without increased complication rates. This method therefore seems to be a safe and cost effective instrument to reduce perioperative blood loss. However, it has to be considered that this is an off-label use.
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Affiliation(s)
- Eric Tille
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Jonas Mysliwietz
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Anne Postler
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jörg Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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Gibbs VN, Champaneria R, Palmer A, Doree C, Estcourt LJ. Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Antony Palmer
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; Botnar Research Centre, Windmill Road Oxford Oxfordshire UK OX3 7LD
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; John Radcliffe Hospital Oxford UK OX3 9BQ
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
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Wang JQ, Chen ZX, Guo WJ, Zhao YM, Peng Luo. Comparison of plate and intramedullary nail fixation of extra-articular tibial fractures: A retrospective study exploring hidden blood loss. Injury 2019; 50:546-550. [PMID: 30580930 DOI: 10.1016/j.injury.2018.12.016] [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: 09/23/2018] [Accepted: 12/13/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To explore the hidden blood loss (HBL) in treatment of extra-articular tibial fractures with plate and intramedullary nail fixation. METHODS We conducted a retrospective study including 209 consecutive patients treated by plate (Group LCP) or intramedullary nail fixation (Group IMN) for extra-articular tibial fractures between January 2015 to December 2017. Demographics, intraoperative data, perioperative laboratory values, transfusion rate, and early complications were collected and analyzed. RESULTS Of 209 patients, 96 patients fixed with IMN and 113 fixed with LCP. The average HBL was 272.71 ± 57.88 ml in Group LCP and 507.66 ± 109.81 ml in Group IMN, and there was statistical difference in the HBL between two groups (p < 0.001). The Hb and Hct loss, surgical duration, and postoperative number of anemic patients in Group IMN were significantly higher than in Group LCP (p < 0.001), and IMN fixation has a significantly higher rate of transfusion (p = 0.027), whereas patients in group IMN has significantly less VBL (p < 0.001), shorter postoperative hospital stay (p < 0.001), and less superficial infection (p = 0.014). CONCLUSIONS There was a significant amount of hidden blood loss after reamed intramedullary nail fixation for extra-articular tibial fractures, which was much higher than expected. In view of the morbidity of acute anaemia and transfusion, we suggest that for patients who suffer from extra-articular tibial fractures with multiple injuries, or those with low haemoglobin preoperatively, plates might be more suitable than nail fixation.
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Affiliation(s)
- Ji-Qi Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Ze-Xin Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Wei-Jun Guo
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - You-Ming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Peng Luo
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China.
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Greco NJ, Manocchio AG, Lombardi AV, Gao SL, Adams J, Berend KR. Should postoperative haemoglobin and potassium levels be checked routinely following blood-conserving primary total joint arthroplasty? Bone Joint J 2019; 101-B:25-31. [PMID: 30648494 DOI: 10.1302/0301-620x.101b1.bjj-2018-0554.r1] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIMS Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. PATIENTS AND METHODS Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. RESULTS The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. CONCLUSION A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities.
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Affiliation(s)
- N J Greco
- Joint Implant Surgeons, Inc., White Fence Surgical Suites, and Mount Carmel Health System, New Albany, Ohio, USA
| | - A G Manocchio
- Department of Orthopedic Surgery, Grandview Medical Center, Dayton, Ohio, USA
| | - A V Lombardi
- Joint Implant Surgeons, Inc., White Fence Surgical Suites, and Mount Carmel Health System, New Albany, Ohio, USA and Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - S L Gao
- Department of Orthopedic Surgery, Grandview Medical Center, Dayton, Ohio, USA
| | - J Adams
- Joint Implant Surgeons, Inc., New Albany, Ohio, USA
| | - K R Berend
- Joint Implant Surgeons, Inc., White Fence Surgical Suites, and Mount Carmel Health System, New Albany, Ohio, USA
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Safety of intravenous tranexamic acid in patients undergoing majororthopaedic surgery: a meta-analysis of randomised controlled trials. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018. [PMID: 29337665 DOI: 10.2450//2017.0219-17] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Among the various pharmacological options to decrease peri-operative bleeding, tranexamic acid appears to be one of the most interesting. Several trials have consistently documented the efficacy of this synthetic drug in reducing the risk of blood loss and the need for allogeneic blood transfusion in patients undergoing total hip and knee arthroplasty. The safety of intravenous tranexamic acid in major orthopaedic surgery, particularly regarding the risk of venous thromboembolism, was systematically analysed in this review. A systematic search of the literature identified 73 randomised controlled trials involving 4,174 patients and 2,779 controls. The raw overall incidence of venous thromboembolism was 2.1% in patients who received intravenous tranexamic acid and 2.0% in controls. A meta-analytic pooling showed that the risk of venous thromboembolism in tranexamic acid-treated patients was not significantly different from that of controls (risk difference: 0.01%, 95% confidence interval [CI]: -0.05%, 0.07%; risk ratio: 1.067, 95% CI: 0.760-1.496). Other severe drug-related adverse events occurred very rarely (0.1%). In conclusion, the results of this systematic review and meta-analysis show that intravenous tranexamic acid is a safe pharmacological treatment to reduce blood loss and transfusion requirements in patients undergoing major orthopaedic surgery.
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Yates J, Perelman I, Khair S, Taylor J, Lampron J, Tinmouth A, Saidenberg E. Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis. Transfusion 2018; 59:806-824. [PMID: 30516835 DOI: 10.1111/trf.15030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.
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Affiliation(s)
- Jeffrey Yates
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simonne Khair
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital, Ottawa, Ontario, Canada
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Zhou L, Ma J, Bao J. Effect of pharmacist intervention on blood conservation therapy in total knee arthroplasty: A retrospective, observational study. Basic Clin Pharmacol Toxicol 2018; 124:681-690. [PMID: 30472799 DOI: 10.1111/bcpt.13181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 11/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with blood loss and an increased risk of transfusion. Guidelines for antifibrinolytic drug tranexamic acid (TXA) treatment in TKA patients are available. We evaluated the effects of anticoagulant pharmacist intervention on perioperative blood conservation treatment in TKA patients. METHODS In a retrospective, observational experimental study, patients admitted for TKA were allocated into the control or pharmacist intervention group. In the intervention phase, multiple interventions of TXA treatment based on guidelines were implemented. The primary endpoint was blood loss. Other outcome included postoperative haemoglobin and haematocrit levels, allogeneic blood transfusion, cost savings and safety. RESULTS A total of 177 patients were included (88 and 89 in the control and intervention group, respectively). In the intervention group, 24.72% orders of TXA dosage, 20.22% orders of drug choice, 26.97% orders of TXA timing and 30.34% orders of TXA administration manner were adjusted. Eighty-nine (100%) patients received blood conservation therapy compared with 21 (23.86%) patients in the control group (P < 0.001). Total blood loss was 1133.31 ± 627.08 mL in the control group compared with 604.34 ± 459.09 mL in the intervention group (P < 0.001). Postoperative drops in haemoglobin and haematocrit in the control group were greater than in the intervention group (P < 0.001). The rate of allogeneic blood transfusion was 40.91% in the control group compared with 21.35% in the intervention group (P = 0.01). Pharmacist intervention was conducted to cost savings resulting from reduced transfusion, but with comparable safety profile. CONCLUSIONS Anticoagulant pharmacist intervention on blood conservation treatment of TKA patients leads to favourable clinical and economic outcome.
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Affiliation(s)
- Ling Zhou
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Jianan Bao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
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The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis. J Arthroplasty 2018; 33:3090-3098.e1. [PMID: 29805106 DOI: 10.1016/j.arth.2018.04.043] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty. METHODS We searched Ovid MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases for publications before July 2017 on TXA in primary total joint arthroplasty. All included studies underwent qualitative and quantitative homogeneity testing. Direct and indirect comparisons were performed as a network meta-analysis, and results were tested for consistency. RESULTS After critical appraisal of the available 2113 publications, 67 articles were identified as representing the best available evidence. Topical, intravenous (IV), and oral TXA formulations were all superior to placebo in terms of decreasing blood loss and risk of transfusion, while no formulation was clearly superior. Use of repeat IV and oral TXA dosing and higher doses of IV and topical TXA did not significantly reduce blood loss or risk of transfusion. Preincision administration of IV TXA had inconsistent findings with a reduced risk of transfusion but no effect on volume of blood loss. CONCLUSIONS Strong evidence supports the efficacy of TXA to decrease blood loss and the risk of transfusion after primary TKA. No TXA formulation, dosage, or number of doses provided clearly improved blood-sparing properties for TKA. Moderate evidence supports preincision administration of IV TXA to improve efficacy.
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Avoiding Postoperative Wound Complications in Total Joint Arthroplasty. J Arthroplasty 2018; 33:3109-3112. [PMID: 29475573 DOI: 10.1016/j.arth.2018.01.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/18/2018] [Indexed: 02/01/2023] Open
Abstract
Avoidance of early wound complications is critical to the success of total joint arthroplasty. The magnitude of postoperative complications can be as simple as quickly resolving wound drainage, to persistent wound drainage and full-thickness soft tissue necrosis. Persistent postoperative drainage and wound complications can lead to a devastating deep periprosthetic infection. Attention to several steps in the clinical and perioperative pathway should be addressed to avoid this complication including addressing modifiable patient risk factors, implementing meticulous surgical technique, and following an algorithmic approach in response to persistent wound drainage.
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DeRogatis MJ, Mahon AM, Lee P, Issack PS. Perioperative Considerations to Reduce Infection Risk in Primary Total Hip and Knee Arthroplasty. JBJS Rev 2018; 6:e8. [PMID: 29664871 DOI: 10.2106/jbjs.rvw.17.00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Edwards SJ, Crawford F, van Velthoven MH, Berardi A, Osei-Assibey G, Bacelar M, Salih F, Wakefield V. The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms. Health Technol Assess 2018; 20:1-224. [PMID: 28051764 DOI: 10.3310/hta20940] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use. OBJECTIVES To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults. DATA SOURCES Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms. REVIEW METHODS This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis. RESULTS We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I2 = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I2 = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays. LIMITATIONS It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available. CONCLUSIONS The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020710. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Lu Q, Peng H, Zhou G, Yin D. Perioperative Blood Management Strategies for Total Knee Arthroplasty. Orthop Surg 2018; 10:8-16. [PMID: 29424017 PMCID: PMC6594499 DOI: 10.1111/os.12361] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 01/28/2023] Open
Abstract
Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.
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Affiliation(s)
- Qiang Lu
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Hao Peng
- Department of OrthopaedicsRenmin Hospital of Wuhan UniversityWuhanChina
| | - Guan‐jin Zhou
- Department of Orthopaedics, Puai Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Dong Yin
- Department of OrthopaedicsThe People’s Hospital of Guangxi Zhuang Autonomous RegionNanningChina
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A Systematic Review and Meta-analysis of the Topical Administration of Fibrin Sealant in Total Hip Arthroplasty. Sci Rep 2018; 8:78. [PMID: 29311570 PMCID: PMC5758515 DOI: 10.1038/s41598-017-16779-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/15/2017] [Indexed: 11/14/2022] Open
Abstract
Patients who undergo total hip arthroplasty (THA) may experience a large amount of blood loss. The objective of our study is to include randomized controlled trials (RCTs) and compare the clinical outcomes of fibrin sealant (FS) versus placebo after a THA. In October 2015, we searched the following databases: Medline, Embase, PubMed, the Cochrane Controlled Trials Register, Web of Science, the China National Knowledge Infrastructure, the China Wanfang database and Google Scholar. Finally, seven studies that included 679 patients met the inclusion criteria. The meta-analysis indicated that the topical administration of FS was associated with a reduction of the need for transfusion compared to the control group (P = 0.05). And topical FS will reduce total blood loss after THA (P = 0.0003) and blood loss in drainage (P = 0.002). However, there was no significant difference in terms of the intraoperative blood loss (P = 0.62) and the rate of deep venous thrombosis (DVT), fever, pain, anemia, hematoma and oozing. In conclusion, the use of FS in patients who are undergoing THA may reduce perioperative blood loss and attenuate the decrease in Hb. Furthermore, FS do not decrease the intraoperative blood loss without an increase in the risk of postoperative DVT, fever, pain, anemia, hematoma and oozing.
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SADIGURSKY DAVID, ARAUJO LARISSAMARTINS, FERNANDES ROGÉRIOJAMILCARNEIRO. EFFICACY OF TRANEXAMIC ACID IN REDUCING BLOOD LOSS IN TOTAL KNEE ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2018; 26:63-66. [PMID: 29977148 PMCID: PMC6025505 DOI: 10.1590/1413-785220182601149210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the efficacy of tranexamic acid in reducing blood loss in total knee arthroplasty by examining the existing literature. METHOD This literature review investigated the use of tranexamic acid in knee arthroplasty. The search was performed in the Pubmed, Science Direct, Google Scholar, and Lilacs databases over a 20-year period using the keywords: "knee arthroplasty, tranexamic acid, and efficacy". Only randomized clinical trials published between 2000 and 2016 in English, Spanish, or Portuguese were accepted, and only trials which scored above 3 on the Jadad scale were selected. RESULTS A total of 7 randomized clinical trials met the inclusion criteria, with a sample of 948 patients. CONCLUSION The use of tranexamic acid in total knee arthroplasty (unilateral or bilateral) reduces perioperative and postoperative blood loss more than other available antifibrinolytics. With this reduction in total blood loss and the need for blood transfusions without any increase in side effects, the use of tranexamic acid can be considered safe and effective in controlling bleeding after knee arthroplasties. Level of Evidence II; Systematic review.
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Affiliation(s)
- DAVID SADIGURSKY
- Faculdade de Tecnologia e Ciências de Salvador, Brazil; Clínica Ortopédica Traumatológica, Brazil
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Kearns SM, Kuhar HN, Bohl DD, Levine BR. An Aprotinin Containing Fibrin Sealant Does Not Reduce Blood Loss in Total Hip Arthroplasty. J Arthroplasty 2017. [PMID: 28648705 DOI: 10.1016/j.arth.2017.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Fibrin sealants are topical agents used to reduce perioperative blood loss; however, their efficacy in total hip arthroplasty (THA) remains uncertain. The purpose of this study was to determine if a fibrin sealant containing aprotinin as an antifibrinolytic agent, TISSEEL (Baxter, Deerfield, IL), reduces postoperative blood loss and transfusion during THA when compared with intravenous (IV) tranexamic acid (TXA) and control groups. METHODS Three retrospective uniform cohorts of primary THA procedures were identified, from a prospectively maintained database: 1 group who received TISSEEL, 1 group who received 1 g IV TXA, and 1 group who received neither (control). There were 80 patients in each group. Outcome measures included the lowest measured hemoglobin during postoperative hospitalization, greatest decrease in hemoglobin from preoperative to postoperative values, and blood transfusion rates. RESULTS The minimum postoperative hemoglobin level was significantly lower for TISSEEL patients compared with that of IV TXA patients (P = .021) and no different when compared with that of control patients (P = .134). Patients receiving fibrin sealant had a greater hemoglobin level decrease compared with that of IV TXA (P = .029) and control (P = .036). Postoperative transfusion rates were no different for the group receiving TISSEEL compared with those of control (P = .375) and were statistically greater when compared with those of IV TXA (P = .002). CONCLUSION TISSEEL fibrin sealant does not reduce postoperative blood loss or transfusions; however, IV TXA reduced postoperative transfusions compared with TISSEEL and control. Therefore, TXA is recommended to reduce perioperative blood loss, while, utilization of a fibrin sealant requires further refinements before being adopted for routine use in THA.
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Affiliation(s)
- Sean M Kearns
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Hannah N Kuhar
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel D Bohl
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brett R Levine
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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Abstract
Normal wound healing with avoidance of early wound complications is critical to the success of total knee arthroplasty. The severity of acute complications includes less morbid problems, such as quickly resolved drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft-tissue coverage. To achieve proper healing, surgeons must respond to persistent drainage by addressing modifiable patient risk factors, using meticulous surgical technique, and implementing an algorithmic approach to treatment.
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Gonzalez-Osuna A, Videla S, Cánovas E, Urrútia G, Rojas S, López R, Murat J, Aguilera X. HESTAT: Study protocol for a phase II/III, randomized, placebo-controlled, single blind study to evaluate the new hemostatic agent TT-173 in total knee arthroplasty. Contemp Clin Trials 2017; 61:16-22. [PMID: 28687347 DOI: 10.1016/j.cct.2017.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several hemostatic treatments intended to reduce the bleeding associated to total knee arthroplasty have been investigated with varying degrees of success. TT-173 is a new topical agent based on recombinant tissue factor that activates the extrinsic pathway of coagulation. This trial aim is to evaluate the efficacy and safety of TT-173 in total knee arthroplasty. METHODS/DESIGN This is a phase II/III, sequential, simple blind, randomized, multicenter, placebo controlled and parallel clinical trial that will recruit 189 evaluable patients. Those randomized to treatment group will receive 2mg of TT-173 over the surgical surfaces of the knee. Control patients will receive physiologic saline. The follow up will consist in 6 visits during a period of 35 (±7) days. Primary endpoints will be the total blood loss and the incidence and severity of adverse events. Secondary and exploratory endpoints will include drainage production, decrease in hemoglobin level, transfusion ratio, analytical alterations, pain intensity, motion range, immunogenicity of TT-173 and the occurrence of systemic absorption. At the end of phase II, results will be evaluated by an independent committee that will recommend the continuation or the discontinuation of the trial. DISCUSSION The design proposed maximizes the safety of the participants, avoids the risk of bias derived from the limitations of masking and enable the eventual discontinuation of the trial if this is recommended by the Interim Analysis Committee. If TT-173 proves its efficacy and safety in this indication, it would become a useful tool to improve the bleeding control in total knee arthroplasty. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02687399. Registered the 9th of February 2016.
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Affiliation(s)
- Aránzazu Gonzalez-Osuna
- Orthopaedic Surgery and Traumatology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastián Videla
- Department of Experimental and Health Sciences, Faculty of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Esther Cánovas
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Gerard Urrútia
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Spain
| | - Santiago Rojas
- Thombotargets Europe, S.L. Parque Mediterráneo de la Tecnología, Castelldefels, Spain; Unit of Human Anatomy and Embryology, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Ramón López
- Thombotargets Europe, S.L. Parque Mediterráneo de la Tecnología, Castelldefels, Spain
| | - Jesús Murat
- Thombotargets Europe, S.L. Parque Mediterráneo de la Tecnología, Castelldefels, Spain
| | - Xavier Aguilera
- Orthopaedic Surgery and Traumatology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Themistoklis T, Theodosia V, Konstantinos K, Georgios DI. Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now? World J Orthop 2017; 8:441-454. [PMID: 28660135 PMCID: PMC5478486 DOI: 10.5312/wjo.v8.i6.441] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Total knee replacement (TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions (ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.
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Lee QJ, Ching WY, Wong YC. Blood Sparing Efficacy of Oral Tranexamic Acid in Primary Total Knee Arthroplasty: A Randomized Controlled Trial. Knee Surg Relat Res 2017; 29:57-62. [PMID: 28231650 PMCID: PMC5336374 DOI: 10.5792/ksrr.16.074] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/13/2017] [Accepted: 01/17/2017] [Indexed: 01/30/2023] Open
Abstract
Purpose Tranexamic acid (TXA) is effective in reducing blood loss in primary total knee replacement. Almost all studies used an intravenous form or a topical form. The aim of this study was to assess the blood sparing efficacy and the safety of oral TXA. Materials and Methods All patients with primary total knee replacement performed in our institute from January 2015 to October 2015 were eligible. Oral TXA group was given 1 g oral TXA 2 hours before induction of anesthesia and 6 hours and 12 hours postoperatively. The control group was not given TXA. Results There were 94 cases in the oral TXA group and 95 cases in the control group. There was no difference in the baseline characteristics. The oral TXA group had a significantly lower hemoglobin drop (1.7 g/dL vs. 2.5 g/dL), lower drain output (154 mL vs. 203 mL), lower hidden blood loss (244 mL vs. 423 mL) and lower total blood loss (398 mL vs. 626 mL). There was no difference in transfusion rate (1.1% vs. 3.2%) and thromboembolic complication. There was no infection or mortality in both groups. Conclusions Oral TXA is effective in reducing blood loss in primary total knee replacement. It is a safe alternative to the intravenous or topical form.
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Affiliation(s)
- Qunn Jid Lee
- Department of Orthopaedics & Traumatology, Joint Replacement Center, Yan Chai Hospital, Hong Kong, China
| | - Wai Yee Ching
- Department of Orthopaedics & Traumatology, Joint Replacement Center, Yan Chai Hospital, Hong Kong, China
| | - Yiu Chung Wong
- Department of Orthopaedics & Traumatology, Joint Replacement Center, Yan Chai Hospital, Hong Kong, China
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Triyudanto AN, Lubis AM. The effects of intra-articular tranexamic acid given intraoperatively and intravenous tranexamic acid given preoperatively on post surgical bleeding and transfusion rate post total knee arthroplasty. MEDICAL JOURNAL OF INDONESIA 2017. [DOI: 10.13181/mji.v25i4.1502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background: Despite the advances in the design and fixation of implants in total knee replacement (TKR). the amount of postoperative bleeding is still an important issue that has not been resolved. This study aimed to measure the effectiveness of various tranexamic acid administration.
Methods: This was a randomized controlled trial study, held from August 2014 to February 2016 at Cipto Mangunkusumo Hospital, Jakarta. Twenty two patients having TKR were divided into three groups: the control group, the tranexamic acid intra-articular-intraoperative group, and the intravenous preoperative group. Intraoperative bleeding, haemoglobin (Hb) level on preoperative to five-day-post-surgery, total drain production, total blood tranfusion needed and the drain removal timing were recorded and compared. Numerical data were analyzed by using parametric and non-parametric test, depended on the normality of the data.
Results: The amount of blood transfusion needed in both the intra-articular group (200±SD 100 mL) and the intravenous group (238±SD 53 mL) were significantly different compared to those in the control group (1,016±SD 308.2 mL) (p=0.001). Meanwhile, there was no significant difference between the amount of blood transfusion needed in the intra-articular group and the intravenous group. Total drain production in the intra-articular group (328±SD 193 mL) and intravenous group (391±SD 185 mL) was significantly different compared to the control group (652±SD 150 mL) (p=0.003). No significant difference between the levels of both preoperative and postoperative haemoglobin, the amount of intraoperative bleeding, and the duration of drain usage.
Conclusion: Intravenous and intra-articular tranexamic acid effectively decreased transfusion volume and drain production in patients undergoing TKR.
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Chen TP, Chen YM, Jiao JB, Wang YF, Qian LG, Guo Z, Ma Z, Han CY, Shi TH. Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2017; 12:11. [PMID: 28103911 PMCID: PMC5244538 DOI: 10.1186/s13018-017-0512-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/08/2017] [Indexed: 02/03/2023] Open
Abstract
Background This study aims to compare the effectiveness and safety of topical versus intravenous tranexamic acid (TXA) in reducing blood loss in primary total knee arthroplasty (TKA). Methods PubMed, Embase, the Cochrane Library, Web of Science, Chinese Biomedicine Literature (CBM), Wanfang Database and China National Knowledge Infrastructure (CNKI), and Google Scholar were searched for randomized controlled studies (RCTs) that compared topical versus intravenous TXA in terms of reducing blood loss during TKA from their inception to September 2015. This systematic review and meta-analysis was performed according to PRISMA criteria. Results Twelve studies reporting 12 RCTs comprising 1130 patients were included. Compared with the intravenous administration of TXA, the topical administration of TXA showed no significant differences in total blood loss (MD 2.08, 95% CI −68.43 to 72.60, P = 0.95), blood loss in drainage (MD 18.49, 95% CI −40.01 to 76.98, P = 0.54), hidden blood loss (MD 4.75, 95% CI −337.94 to 347.44, P = 0.99), need for transfusion (RR = 0.92, 95% CI 0.67~1.25, P = 0.58), hemoglobin (Hb) decline (MD −0.42, 95% CI −0.89 to 0.05, P = 0.08), and DVT occurrence (RR = 1.17, 95% CI 0.55~2.50, P = 0.68). Conclusions Compared with intravenous administration TXA, topical administration TXA exhibits comparable effectiveness and safety in terms of reducing blood loss during TKA. Due to the poor quality of the included studies, more high-quality RCTs are needed to identify the optimal method and dose of TXA after TKA.
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Affiliation(s)
- Tao-Ping Chen
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Yu-Min Chen
- Hebei University, Yuhua Dong Road, 342, Yuhua District, Baoding, Hebei Province, 071000, China.
| | - Jian-Bao Jiao
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Yun-Fei Wang
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Li-Gang Qian
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Zhao Guo
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Zheng Ma
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Cui-Yu Han
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
| | - Tong-Huan Shi
- Affiliated Hospital of Hebei University, Yuhua Dong Road, 212, Yuhua District, Baoding, Hebei Province, China
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Wang Z, Xiao L, Guo H, Zhao G, Ma J. The efficiency and safety of fibrin sealant for reducing blood loss in primary total hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2016; 37:50-57. [PMID: 27939268 DOI: 10.1016/j.ijsu.2016.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 12/01/2016] [Accepted: 12/04/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Total hip arthroplasty (THA) is associated with substantial blood loss. The objective of present systematic review and meta-analysis is to provide evidence from randomized controlled trials (RCTs) on the efficiency and safety of administration of fibrin sealant (FS) for reducing blood loss in patients undergoing primary THA. METHODS Potential relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect, web of science and Cochrane Library. Gray academic studies were also identified from the reference list of included studies. There was no language restriction. Pooling of data was carried out by using RevMan 5.1. RESULTS Six randomized controlled trials (RCTs) met the inclusion criteria. Current meta-analysis indicated that there were significant differences in terms of total blood loss (MD = -153.77, 95% CI: -287.21 to -20.34, P = 0.02), postoperative hemoglobin level (MD = -0.25, 95% CI: -0.46 to -0.05, P = 0.02) and transfusion rate (RD = -0.12, 95% CI: -0.22 to -0.03, P = 0.01) between groups. No significant differences were found regarding the incidence of deep venous thrombosis (DVT) (RD = 0.00, 95% CI: -0.01to 0.01, P = 0.51) or other side effects. CONCLUSION Administration of fibrin sealant in total hip arthroplasty may reduce total blood loss, postoperative hemoglobin decline and transfusion requirements. Moreover, no adverse effect was related to FS. Due to the limited quality of the evidence currently available, higher quality RCTs are required.
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Affiliation(s)
- Zhiyuan Wang
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Lin Xiao
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Hao Guo
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Guanghui Zhao
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China
| | - Jianbing Ma
- Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, 710054, PR China.
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Li J, Li HB, Zhai XC, Qin-lei, Jiang XQ, Zhang ZH. Topical use of topical fibrin sealant can reduce the need for transfusion, total blood loss and the volume of drainage in total knee and hip arthroplasty: A systematic review and meta-analysis of 1489 patients. Int J Surg 2016; 36:127-137. [DOI: 10.1016/j.ijsu.2016.10.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/15/2016] [Indexed: 10/20/2022]
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Fu Y, Shi Z, Han B, Ye Y, You T, Jing J, Li J. Comparing efficacy and safety of 2 methods of tranexamic acid administration in reducing blood loss following total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2016; 95:e5583. [PMID: 27977593 PMCID: PMC5268039 DOI: 10.1097/md.0000000000005583] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) were to gather data to evaluate the efficacy and safety of topical tranexamic acid (TXA) versus intravenous (IV) TXA for blood loss after a total knee arthroplasty (TKA). METHODS Electronic databases: Pubmed, Web of Science, Cochrane library, and Embase from inception to June 2016 were searched. RCTs that comparing topical with IV TXA for blood loss control in patients prepared for TKA were included in this meta-analysis. The Cochrane risk of bias tool was used to appraise risk of bias. The primary outcomes were needed for transfusion, total blood loss, and blood loss in drainage. Secondary outcomes are hemoglobin (Hb) value at 24-hour post TKA and complication (deep venous thrombosis [DVT] and infection). The efficacy of blood loss was tested by total blood loss, drainage volume, Hb drop, and the Hb value at 24 hours after TKA. The safety was measured by the occurrence of DVT and infection. Continuous outcomes were expressed as the mean difference with the respective 95% confidence intervals (CIs). Discontinuous outcomes were expressed as the relative risk with 95% CIs. Stata 12.0 software (Stata Corp., College Station, TX) was used for the meta-analysis. RESULTS A total of 14 articles involving 1390 patients were finally included for this meta-analysis. The pooled results revealed that there were no significant difference between the need for transfusion, total blood loss, blood loss in drainage, Hb value at 24-hour post TKA, the occurrence of complications (infection and DVT) between topical administration of TXA and IV TXA. CONCLUSION Topical TXA has similar efficacy for blood loss control to IV TXA without sacrificing safety in TKA. However, the dose of topical TXA and IV TXA is different, thus, optimal timing and dose of TXA are still needed to explore the maximum effect of TXA.
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Affiliation(s)
- Yu Fu
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Zhigang Shi
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Bing Han
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Yong Ye
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Tao You
- Department of Orthopaedics, The First Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Juehua Jing
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
| | - Jun Li
- Department of Orthopaedics, The Second Hospital of Anhui Medical University
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The Assessment of Blood Loss During Total Knee Arthroplasty When Comparing Intravenous vs Intracapsular Administration of Tranexamic Acid. J Arthroplasty 2016; 31:2452-2457. [PMID: 27259391 DOI: 10.1016/j.arth.2016.04.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 04/03/2016] [Accepted: 04/14/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Administration of tranexamic acid topically and intravenously has demonstrated effectiveness in decreasing blood loss and transfusion rates. METHODS We randomized 131 patients undergoing primary total knee arthroplasty to receive either intracapsular (69) or intravenous tranexamic acid (62). Postoperative blood loss was calculated using the formula derived by Nadler et al. The number of units transfused was recorded, as well as length of hospital stay. RESULTS We found no statistically significant difference on calculated blood loss (postoperative day [POD] 1: 624 ± 326 vs 644 ± 292; P = .71, POD 2: 806 ± 368 vs 835 ± 319; P = .64, and POD 3: 1076 ± 419 vs 978 ± 343; P = .55). There was no difference in number of blood transfusions, length of stay, or complications. CONCLUSION Intracapsular tranexamic acid is not inferior to intravenous tranexamic acid in decreasing blood loss and blood transfusion rate in primary total knee arthroplasty.
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Mao Z, Yue B, Wang Y, Yan M, Dai K. A comparative, retrospective study of peri-articular and intra-articular injection of tranexamic acid for the management of postoperative blood loss after total knee arthroplasty. BMC Musculoskelet Disord 2016; 17:438. [PMID: 27760536 PMCID: PMC5069893 DOI: 10.1186/s12891-016-1293-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/11/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Intra-articular injection of tranexamic acid (TXA) is known to be effective in controlling blood loss after total knee arthroplasty (TKA). However, this method has some disadvantages, such as TXA leakage due to soft tissue release. Peri-articular injection provides an alternative to intra-articular administration of TXA. This study aimed to evaluate the effects of peri-articular injection of TXA in reducing blood loss after TKA and compare them to those of intra-articular TXA injection. METHODS This was a retrospective analysis of 127 patients who underwent primary, unilateral TKA for knee osteoarthritis in our hospital between January 2014 and December 2014. Cases were classified into 3 comparison groups: 49 patients in the peri-articular TXA group, 36 in the intra-articular group, and 42 in the control group (TXA not administered). Demographic variables, hemoglobin (Hb) measured before and after surgery, operation time, total amount of drained volume, time of removing drains, units of blood transfused peri- and postoperatively, estimated volume of blood loss, and preoperative comorbidities were retrieved from the patients' medical charts. Statistical analyses were performed using SPSS 19.0 software. RESULTS There were no significant differences of demographic variables and operation time among three groups (P > 0.05). Compared to the control group, both TXA groups had a significantly reduced volume of blood loss, postoperative knee joint drainage, hemoglobin concentration, time of removing drains, and need for blood transfusion (P < 0.05). The effects of TXA were comparable for the two methods of injection (P > 0.05). There were no deep venous thrombosis or thromboembolic complications in any group. CONCLUSIONS Peri-articular injection of TXA is as effective as an intra-articular injection in reducing postoperative blood loss during TKA. Both methods had a statistically significant benefit in reducing the change in Hb concentration, volume of joint drainage, and estimated volume of blood loss when compared to the control group. Peri-articular injection of TXA can significantly reduce the blood transfusion rate compared to the control group.
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Affiliation(s)
- Zhenyang Mao
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.,Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Bing Yue
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China. .,Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China.
| | - You Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.,Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Mengning Yan
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.,Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
| | - Kerong Dai
- Shanghai Key Laboratory of Orthopaedic Implants, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.,Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, People's Republic of China
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Gao F, Ma J, Sun W, Guo W, Li Z, Wang W. Topical fibrin sealant versus intravenous tranexamic acid for reducing blood loss following total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2016; 32:31-7. [DOI: 10.1016/j.ijsu.2016.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/13/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
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