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Pinsornsak P, Thaveekitikul R, Pinsornsak P, Tanariyakul Y. Comparative effectiveness of combined peri-articular and intra-articular injection versus intravenous and intra-articular injection of tranexamic acid in total knee arthroplasty: a randomized controlled trial study. Arch Orthop Trauma Surg 2024; 144:2753-2759. [PMID: 38662002 DOI: 10.1007/s00402-024-05337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) administration is supported by numerous evidence in reducing blood loss after total knee arthroplasty (TKA). The combination of intravenous (IV) and intra-articular (IA) TXA administration revealed good result in blood loss reduction with less evidence of venous thromboembolism event (VTE). Several literature reviews portray that peri-articular (PA) administration yields similar hemostasis in comparison to IV route. However, there is no report on the clinical effect of combining PA + IA TXA in blood loss reduction and its complications, compared to combining IV + IA TXA after TKA. MATERIALS AND METHODS We conducted a double-blind, randomized controlled trial comparing the use of PA + IA TXA administration and IV + IA TXA administration in 70 patients who were scheduled for unilateral primary TKA. Thirty-five patients were assigned for PA + IA injection (Group 1) and anoter 35 patients were assigned for IV + IA injection (Group 2). Primary outcomes included total blood loss at 48 h, and the need for blood transfusion. Secondary outcomes included thigh and leg circumference, degree of knee flexion, and postoperative complications. RESULTS The calculated blood loss at 48 h showed no difference between Groups 1 and 2 (617 ml vs. 632 ml, p = 0.425). The total hemoglobin and hematocrit changes were not different (1.89 g/dL vs. 1.97 g/dL, p = 0.371 and 5.66% vs. 5.87%, p = 0.391). There was no need for blood transfusion in either group. However, lower thigh swelling was significant in Group 1 (2.15 cm vs. 2.79 cm, p = 0.04). Leg circumferences at 48 h was also lower in Group 1 (42.12 cm vs. 42.77 cm, p = 0.04). There was no significant difference in knee flexion decrease between the two groups (38° vs. 37°, p = 0.425). There were no VTE complications or infections found in either group. CONCLUSIONS Combined PA + IA TXA administration had similar efficacy in blood loss reduction and blood transfusion when compared to combined IV + IA TXA. The first group displayed less soft tissue swelling. The combination of PA + IA TXA administration can be used as an alternative regimen to avoid IV TXA administration.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18 Phaholyothin Rd, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Ranet Thaveekitikul
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18 Phaholyothin Rd, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Prem Pinsornsak
- Kasetsart University Laboratory School Center for Educational Research and Development, 50 Ngamwongwan Rd, Chatuchak, Bangkok, 10900, Thailand
| | - Yot Tanariyakul
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18 Phaholyothin Rd, Khlong Luang, Pathum Thani, 12120, Thailand.
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Fakharian M, Fakharian A, Keshmiri Z, Khorrami AM. Comparison of the effect of combined administration of intravenous and intra-articular tranexamic acid versus their administration alone in the management of blood loss in total knee arthroplasty: a prospective, multicenter study in Iran. BMC Musculoskelet Disord 2023; 24:974. [PMID: 38104059 PMCID: PMC10724898 DOI: 10.1186/s12891-023-07089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with significant blood loss. Antifibrinolytic agents such as tranexamic acid (TXA) are widely used to manage blood loss during TKA. This study aimed to compare the efficacy of three different administration approaches of TXA in TKA. METHODS In a prospective, multicenter study, 285 patients with end-stage osteoarthritis who underwent TKA between 2020 and 2022 in three orthopedic surgery centers were included in the study. To manage bleeding during TKA, one of the three methods of intravenous administration (IV), intra-articular injection (IA), and combination administration of TXA was performed for the patients. Postoperative blood loss was calculated using blood volume and change in hemoglobin level from preoperative measurement to postoperative day 3. RESULTS The mean baseline Hemoglobin (Hb) was not significantly different between the three study groups (p > 0.05). The mean postoperative Hb of 12 h, 24 h, and 48 h after the surgery was not significantly different between the three stud groups (p > 0.05). The mean intraoperative blood loss in the combined TXA group was significantly lower compared to the IV and IA groups (0.025). The number of blood transfusions in the three study groups was not statistically significant (p > 0.05). No side effect was recorded in any group, as well. CONCLUSION Blood loss in the combination TXA group was significantly less than in the other two groups. Combination TXA can help reduce blood loss after TKA surgery.
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Affiliation(s)
- Mohammadali Fakharian
- Orthopedic Surgeon Department, Mostafa Khomeni Hospital, Shahed University of Medical Sciences, Tehran, Iran
| | - Arman Fakharian
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | | | - Amir Mohsen Khorrami
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Baharestan Square, Tehran, 1157637131, Iran.
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Tsukada S, Wakui M, Kurosaka K, Saito M, Nishino M, Hirasawa N. Predeposited Autologous Blood Transfusion in Single-Anesthetic Bilateral Total Knee Arthroplasty with Modern Blood Conservation Strategy. JB JS Open Access 2023; 8:JBJSOA-D-22-00125. [PMID: 36698982 PMCID: PMC9851708 DOI: 10.2106/jbjs.oa.22.00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This study was performed to examine the hypothesis that the rate of allogeneic blood transfusion in patients who did not predeposit an autologous blood transfusion before single-anesthetic bilateral total knee arthroplasty (TKA) would be noninferior to that in patients who did predeposit blood. Methods We assessed the number of allogeneic transfusions required in 338 patients undergoing single-anesthetic bilateral TKA with a preoperative hemoglobin level of ≥11.0 g/dL. All TKAs were performed by a single surgeon according to the same operative and postoperative protocol. All patients received a combination of intravenous and intra-articular tranexamic acid. Neither a pneumonic tourniquet nor a drain was used. The difference in the risk of allogeneic transfusion between patients without and with autologous blood predeposit was compared with a noninferiority margin of 10 percentage points. Results Allogeneic transfusion was required in 1 (0.5%) of 194 patients who predeposited autologous blood and 3 (2.1%) of 144 patients who did not predeposit blood. The difference in risk was -1.6 percentage points (95% confidence interval, -4.1 to 1.0 percentage points); the confidence interval did not include the noninferiority margin and included zero. Conclusions In single-anesthetic bilateral TKA, allogeneic transfusion requirements in patients who did not predeposit autologous blood were noninferior to those in patients who predeposited blood. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan,Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan,Email for corresponding author:
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Kenji Kurosaka
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Masayoshi Saito
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Masahiro Nishino
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Naoyuki Hirasawa
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
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Bagheri N, Amini MA, Pourahmad A, Vosoughi F, Moharrami A, Mortazavi SMJ. Comparison of Combined Intraarticular and Intravenous Administration of Tranexamic Acid with Intraarticular and Intravenous Alone in Patients Undergoing Total Knee Arthroplasty without Drainage Catheter: A Clinical Trial Study. THE ARCHIVES OF BONE AND JOINT SURGERY 2023; 11:570-576. [PMID: 37868132 PMCID: PMC10585483 DOI: 10.22038/abjs.2022.64446.3097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 10/02/2022] [Indexed: 10/24/2023]
Abstract
Objectives We aimed to assess the most effective route for Tranexamic acid (TXA) administration among Intraarticular (IA), Intravenous (IV), and combined IA/IV for Total Knee Arthroplasty (TKA) surgeries. Methods A double-blinded clinical trial was run on 147 TKA candidates. Blood loss and hemoglobin (Hb) drop were evaluated using the Gross and Nadler formula in three matched case groups administered TXA during the TKA through IV, IA, or combined IA/IV route. Tourniquet was used on all operations for controlling intraoperative blood loss. No drainage catheter was used for the cases. Results The combined group showed an average blood loss of 630±252 ml, which was significantly lower than that in the IV group (878±268 ml, P<0.01) and the IA group (774±288 ml, P=0.03). Furthermore, the mean Hb and hematocrit drop were significantly lower in the combined group, compared to the other two groups, 48 and 72 h postoperatively (P<0.05). Conclusion The combined IA/IV route had a 28% and 19% reduction of blood loss, compared to the IV or IA methods, respectively. Therefore, using TXA via the combined IA/IV route may be more effective for reducing perioperative blood loss following TKA surgery using a tourniquet without drain placement.
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Affiliation(s)
- Nima Bagheri
- Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Amini
- Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezu Pourahmad
- Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Vosoughi
- Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Moharrami
- Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - SM Javad Mortazavi
- Joint Reconstruction Research Center, Imam Khomeini hospital, Tehran University of Medical Sciences, Tehran, Iran
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Wilde JM, Copp SN, Ezzet KA, Rosen AS, Walker RH, McCauley JC, Evans AS, Bugbee WD. No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA. Clin Orthop Relat Res 2022; 480:702-711. [PMID: 35302971 PMCID: PMC8923576 DOI: 10.1097/corr.0000000000002037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/05/2021] [Accepted: 10/11/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained. QUESTIONS/PURPOSES We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery. METHODS Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism. RESULTS With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction. CONCLUSION The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jeffrey M. Wilde
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Steven N. Copp
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Kace A. Ezzet
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Adam S. Rosen
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Richard H. Walker
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Julie C. McCauley
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
| | - Audree S. Evans
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
| | - William D. Bugbee
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
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Öztürk A, Akalin Y, Çevik N, Avcı Ö, Çetin O, Sağlicak H. Tranexamic acid use in simultaneous bilateral total knee arthroplasty : a comparison of intravenous and intra-articular applications, which is more effective? Acta Orthop Belg 2021. [DOI: 10.52628/87.3.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patients applied with simultaneous bilateral total knee arthroplasty (SBTKA) with the administration of intravenous or intra-articular tranexamic acid (TXA) were compared in respect of blood loss and the need for allogenic blood transfusion.
Of a total 53 patients applied with SBTKA, 32(60%) were administered intravenous TXA and 21(40%) intra-articular TXA. The patients were evaluated in respect of age, gender, height, weight, body mass index (BMI), body blood volume, preoperative and 1,2,3 and 4 days postoperative levels of hemoglobin (Hb) and hematocrit (Htc) and the change in Hb levels, estimated blood loss, mean actual blood loss, the need for allogenic blood transfusion (ABT) and the use or not of a drain.
No difference was determined between the intravenous and intra-articular groups in respect of mean age, gender, height, weight, and body blood volume. No difference was determined between the groups in preoperative and postoperative mean Hb and Hct values, the reduction in mean Hb postoperatively, estimated blood loss, or the need for ABT. No deep vein thrombosis or pulmonary embolism was determined in any patient.
In the application of SBTKA, TXA can be safely administered by the intravenous or intra-articular route to reduce the need for ABT. The results of this study determined no difference in efficacy between the routes of application. For patients with a risk of intravenous use, intra-articular application can be preferred.
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Ma Q, Sun CJ, Wu S, Cai X. Comparison of Blood Loss between Open-Box Prosthesis and Closed-Box Prosthesis after Primary Total Knee Arthroplasty. Orthop Surg 2021; 13:768-777. [PMID: 33666377 PMCID: PMC8126935 DOI: 10.1111/os.12952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/26/2020] [Accepted: 01/20/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To compare the blood loss after procedures of primary unilateral or one‐stage bilateral total knee arthroplasty (TKA) caused by open‐box prosthesis and closed‐box prosthesis. Methods This was a retrospective study. Patients undergoing procedures of primary TKA between January 2017 and July 2020 in our institution were assessed for eligibility for this study. Those who were diagnosed with knee osteoarthritis and underwent primary unilateral or one‐stage bilateral TKA by using PFC Sigma PS150 (closed‐box prosthesis) or Vanguard (open‐box prosthesis) knee systems and had complete data of laboratory indexes on postoperative day (POD) 1, POD 3, and POD 5 were the interested population. At last 243 patients were enrolled, among which 88 patients were classified into the unilateral closed‐box group, 66 patients into the unilateral open‐box group, 47 patients into the one‐stage bilateral closed‐box group, and 42 patients into the one‐stage bilateral open‐box group. The perioperative management and operative techniques were almost the same for each patient, except the selection of prosthesis, which was decided according to surgeon's preference. The baseline information, postoperative laboratory indexes tested on POD 1, POD 3, and POD 5 including hemoglobin, hematocrit, platelet, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT), and international normalized ratio (INR), the primary outcome measurements including the maximum decreased value of hemoglobin and the volume of total blood loss, and the secondary outcome measurements including the transfusion rate and the average transfused red blood cell (RBC) units were well compared between the open‐box group and the closed‐box group. Results The baseline was comparable between groups, except higher preoperative levels of hemoglobin (134.43 g/L vs 126.51 g/L, P = 0.003) and hematocrit (39.92% vs 37.37%, P = 0.000) observed in the one‐stage bilateral open‐box group. The differences of postoperative coagulation function monitored by TT, PT, APTT, and INR were clinically irrelevant between groups. For patients receiving unilateral TKA, significantly higher value of decreased hemoglobin (26.06 g/L vs 21.05 g/L, P = 0.025) and significantly larger amount of total blood loss (920.34 mL vs 723.19 mL, P = 0.013) were observed in the open‐box group. For patients receiving one‐stage bilateral TKA, the open‐box prosthesis was observed to cause more hemoglobin drop (37.81 g/L vs 32.02 g/L, P = 0.071) and total blood loss (1327.26 mL vs 1177.42 mL, P = 0.247) compared to the closed‐box prosthesis, though the differences were not significant. The transfusion rate and the average transfused RBC units were not significantly different between the open‐box group and the closed‐box group no matte whether the patients were from the unilateral TKA group or from one‐stage bilateral TKA group. Conclusion The use of open‐box prosthesis caused more hemoglobin drop and total blood loss than closed‐box prosthesis after primary unilateral or one‐stage bilateral TKA, resulting in comparable transfusion rate and average transfused RBC units between groups.
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Affiliation(s)
- Qi Ma
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Chang-Jiao Sun
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Sha Wu
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xu Cai
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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Tsukada S, Kurosaka K, Nishino M, Maeda T, Hirasawa N, Matsue Y. Intraoperative Intravenous and Intra-Articular Plus Postoperative Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Placebo-Controlled Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102:687-692. [PMID: 32053522 DOI: 10.2106/jbjs.19.01083] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Combined intraoperative intravenous and intra-articular tranexamic acid (TXA) is 1 of the most effective administration routes to decrease the amount of perioperative blood loss during total knee arthroplasty (TKA). However, the additive effect of postoperative intravenous TXA administration remains unclear. We hypothesized that the postoperative repeated-dose intravenous administration of TXA would provide lower perioperative blood loss. METHODS We performed a double-blinded, placebo-controlled trial involving patients undergoing primary TKA. A total of 100 patients who were managed with combined intraoperative intravenous and intra-articular TXA were randomly assigned to receive 3 postoperative 1,000-mg doses of intravenous TXA (TXA group) or 3 postoperative doses of intravenous normal saline solution (placebo group) in a 1:1 ratio. The prespecified primary outcome was perioperative blood loss calculated from patient blood volume and the difference in hemoglobin from preoperatively to postoperative day 3. A post hoc power analysis showed that the number of patients allocated to either the TXA group (n = 46) or the placebo group (n = 54) possessed >80% power to detect a 200-mL difference in perioperative blood loss. RESULTS In the intention-to-treat analysis, we found no significant differences in perioperative blood loss between the TXA group and the placebo group through postoperative day 3 (578 ± 229 compared with 640 ± 276 mL, respectively; 95% confidence interval for the difference, -40 to 163 mL; p = 0.23). The prevalence of postoperative thrombotic events did not differ between the 2 groups (4.3% compared with 3.7%, respectively; p > 0.99). CONCLUSIONS Postoperative intravenous TXA had no additive effect in reducing perioperative blood loss in patients receiving intraoperative combined intravenous and intra-articular TXA. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sachiyuki Tsukada
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Mito, Japan
| | - Kenji Kurosaka
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Mito, Japan
| | - Masahiro Nishino
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Mito, Japan
| | - Tetsuyuki Maeda
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Mito, Japan
| | - Naoyuki Hirasawa
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Mito, Japan
| | - Yuya Matsue
- Department of Cardiovascular Medicine, Juntendo University, Tokyo, Japan.,Department of Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Juntendo University School of Medicine, Tokyo, Japan
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Yang Y, Wang Z, Jin Q. Letter to the Editor on "A Prospective Double-Blind Placebo Controlled Trial of Topical Tranexamic Acid in Total Knee Arthroplasty". J Arthroplasty 2020; 35:1161. [PMID: 31959417 DOI: 10.1016/j.arth.2019.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/10/2019] [Indexed: 02/01/2023] Open
Affiliation(s)
- Yong Yang
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Zheng Wang
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Qunhua Jin
- Department of orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
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Tsukada S, Kurosaka K, Nishino M, Maeda T, Yonekawa Y, Hirasawa N. Intra-articular tranexamic acid as an adjunct to intravenous tranexamic acid for simultaneous bilateral total knee arthroplasty: a randomized double-blind, placebo-controlled trial. BMC Musculoskelet Disord 2019; 20:464. [PMID: 31638960 PMCID: PMC6805302 DOI: 10.1186/s12891-019-2890-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/10/2019] [Indexed: 12/21/2022] Open
Abstract
Background Intra-articular tranexamic acid (TXA) as an adjunct to intravenous TXA was reported to decrease perioperative blood loss during unilateral total knee arthroplasty (TKA). However, there have been no randomized controlled trials comparing intravenous versus combined intravenous and intra-articular TXA administration in patients undergoing simultaneous bilateral TKA. Methods We randomly assigned 77 patients with 154 involved knees undergoing simultaneous bilateral TKA to the intravenous TXA group (intra-articular placebo for each knee) or combined TXA group (1000 mg of intra-articular TXA for each knee) with 1:1 treatment allocation. In both groups, 1000 mg of TXA was given intravenously twice, just before surgery and 6 h after the initial administration. Other perioperative medications, surgical procedures, and blood management strategies were the same for all patients. The primary outcome was perioperative blood loss calculated from blood volume and change in hemoglobin from preoperative to postoperative day 3. Results Intention-to-treat analysis showed no statistically significant differences in perioperative blood loss until postoperative day 3 (1067 ± 403 mL in the intravenous TXA group vs. 997 ± 345 mL in the combined TXA group [95% CI, − 240 to 100 mL], P = 0.42). No patients required allogenic blood transfusion. The incidence of thrombotic events did not differ between groups (12% in the intravenous TXA group vs. 9% in the combined TXA group; P = 0.73). Conclusions The addition of intra-articular TXA did not reduce perioperative blood loss in patients undergoing simultaneous bilateral TKA compared with placebo. Trial registration University Hospital Medical Information Network UMIN000026137. Registered 14 February 2017.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashihara, Mito, Ibaraki, 310-0035, Japan.
| | - Kenji Kurosaka
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashihara, Mito, Ibaraki, 310-0035, Japan
| | - Masahiro Nishino
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashihara, Mito, Ibaraki, 310-0035, Japan
| | - Tetsuyuki Maeda
- Department of Anesthesiology, Hokusuikai Kinen Hospital, Mito, Japan
| | | | - Naoyuki Hirasawa
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashihara, Mito, Ibaraki, 310-0035, Japan
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Tsukada S, Kurosaka K, Nishino M, Maeda T, Hirasawa N. A Strategy of Continued Antiplatelet Agents, Vitamin K Antagonists, and Direct Oral Anticoagulants Throughout the Perioperative Period of Total Knee Arthroplasty in Patients Receiving Chronic Antithrombotic Therapy. JB JS Open Access 2019; 4:JBJSOA-D-18-00057. [PMID: 31592500 PMCID: PMC6766380 DOI: 10.2106/jbjs.oa.18.00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Although continuing antithrombotic therapy is desirable to prevent perioperative cardiovascular and cerebrovascular diseases, perioperative blood loss remains a concern in patients undergoing total knee arthroplasty. The purpose of this study was to assess the impact of continuing chronic antithrombotic therapy on blood loss and major bleeding events. Methods We classified 201 consecutive patients undergoing total knee arthroplasty into 2 groups: (1) patients taking antiplatelet agents, vitamin K antagonists, and/or direct oral anticoagulants, referred to as the continuing antithrombotic therapy group (n = 32); and (2) patients not receiving these agents, referred to as the no antithrombotic therapy group (n = 169). During the study period, antithrombotic agents were continued perioperatively in all patients receiving antithrombotic therapy. Surgical procedures were performed without the use of a pneumatic tourniquet or drain. Screening for deep vein thrombosis was routinely performed before and after total knee arthroplasty. The total perioperative blood loss was calculated from blood volume and change in hemoglobin from preoperatively to postoperative days 1, 3, and 7. Results The perioperative blood loss after total knee arthroplasty did not differ significantly between the continuing antithrombotic therapy group and the no antithrombotic therapy group at 1 day postoperatively (448 ± 213 compared with 495 ± 345 mL [95% confidence interval (CI) of the difference, -172 to 77 mL]; p = 0.45), 3 days postoperatively (841 ± 308 compared with 826 ± 328 mL [95% CI, -108 to 139 mL]; p = 0.81), and 7 days postoperatively (855 ± 313 compared with 861 ± 245 mL [95% CI, -122 to 108 mL]; p = 0.91). No patients in the continuing antithrombotic therapy group and 2 patients (1.2%) in the no antithrombotic therapy group had allogeneic blood transfusion (p = 1). No major bleeding events occurred in the continuing antithrombotic therapy group. Conclusions Perioperative blood loss in patients continuing chronic antithrombotic therapy during total knee arthroplasty was not significantly different from that in patients receiving no chronic antithrombotic therapy. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sachiyuki Tsukada
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Ibaraki, Japan
| | - Kenji Kurosaka
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Ibaraki, Japan
| | - Masahiro Nishino
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Ibaraki, Japan
| | - Tetsuyuki Maeda
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Ibaraki, Japan
| | - Naoyuki Hirasawa
- Departments of Orthopaedic Surgery (S.T., K.K., M.N., and N.H.) and Anesthesiology (T.M.), Hokusuikai Kinen Hospital, Ibaraki, Japan
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12
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Iseki T, Tsukada S, Wakui M, Yoshiya S. Intravenous tranexamic acid only versus combined intravenous and intra-articular tranexamic acid for perioperative blood loss in patients undergoing total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1397-1402. [PMID: 29693237 DOI: 10.1007/s00590-018-2210-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/18/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE This study was performed to assess the effectiveness of the combined intravenous and intra-articular tranexamic acid (TXA) regimen in total knee arthroplasty (TKA). METHODS The perioperative blood loss in 75 consecutive patients undergoing unilateral TKA that received both 1000 mg of TXA intravenously and 1000 mg of intra-articular TXA (combined TXA group) was compared with a consecutive series of 77 patients that received 1000 mg of TXA intravenously (intravenous TXA group). An additional 1000 mg of intravenous TXA was administered 6 h after the initial administration in both groups. Neither a pneumatic tourniquet nor drain was used. The primary outcome was the perioperative blood loss at 3 days after TKA calculated using the blood volume and change in haemoglobin from the preoperative value. RESULTS The perioperative blood loss was significantly lower in the combined TXA group at 3 days after TKA than the intravenous TXA group (686 ± 303 vs. 830 ± 317 mL; 95% CI 44-244 mL; p = 0.0049). The perioperative blood loss was also lower in the combined TXA group at 1 and 7 days after TKA (374 ± 265 vs. 459 ± 226 mL; 95% CI 7-165 mL; p = 0.034 and 751 ± 320 vs. 871 ± 327 mL; 95% CI 16-224 mL; p = 0.024, respectively). No thrombotic events were observed during the study periods. CONCLUSIONS Combined intra-articular and intravenous TXA regimen significantly reduced perioperative blood loss compared with only intravenous TXA until 7 days after TKA.
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Affiliation(s)
- Takuya Iseki
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, 14-7 Konan, Chuo-ku, Niigata, Niigata, 950-1151, Japan.,Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, 14-7 Konan, Chuo-ku, Niigata, Niigata, 950-1151, Japan. .,Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashihara, Mito, Ibaraki, 310-0035, Japan.
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, 14-7 Konan, Chuo-ku, Niigata, Niigata, 950-1151, Japan
| | - Shinichi Yoshiya
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo, 663-8501, Japan
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13
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Tsukada S, Wakui M. Continuing versus discontinuing antiplatelet drugs, vasodilators, and/or cerebral ameliorators on perioperative total blood loss in total knee arthroplasty without pneumatic tourniquet. Arthroplast Today 2017; 4:89-93. [PMID: 29560402 PMCID: PMC5859674 DOI: 10.1016/j.artd.2017.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/24/2017] [Accepted: 07/04/2017] [Indexed: 12/19/2022] Open
Abstract
Background Although studies have supported the utility of perioperative continuation of antiplatelet drugs, vasodilators, and cerebral ameliorators in most procedures, no study compared total volume of blood loss after total knee arthroplasty (TKA) in patients continuing and discontinuing these drugs. Methods We retrospectively reviewed 266 consecutive patients undergoing TKA, and included 67 patients (25.2%) taking antiplatelet drugs, vasodilators, or cerebral ameliorators in this study. All TKAs were performed without a pneumatic tourniquet. The primary outcome was perioperative total blood loss calculated from blood volume and change in hemoglobin. As subgroup analysis, we compared perioperative total blood loss in patients taking antiplatelet drugs. Results There was no significant difference between the continuing group (n = 38) and discontinuing group (n = 29) in terms of the perioperative total blood loss (1025 ± 364 vs 1151 ± 327 mL, respectively; mean difference 126 mL; 95% confidence interval -45 to 298 mL; P = .15). No major bleeding or thrombotic events occurred in either group until postoperative 3-month follow-up. In patients taking antiplatelet drugs (n = 51), no significant difference was observed in the total blood loss between the continuing group (n = 30) and discontinuing group (n = 21) (1056 ± 287 vs 1151 ± 305 mL, respectively; mean difference 95 mL; 95% confidence interval -75 to 264 mL; P = .27). Conclusions No significant differences in terms of perioperative total blood loss were observed between patients continuing and discontinuing study drugs. Continuing these drugs may be preferable in the perioperative period of TKA.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
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