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Morris JL, Letson HL, McEwen P, Biros E, Dlaska C, Hazratwala K, Wilkinson M, Dobson GP. Comparison of intra-articular administration of adenosine, lidocaine and magnesium solution and tranexamic acid for alleviating postoperative inflammation and joint fibrosis in an experimental model of knee arthroplasty. J Orthop Surg Res 2021; 16:726. [PMID: 34930351 PMCID: PMC8686251 DOI: 10.1186/s13018-021-02871-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dysregulated inflammatory responses are implicated in the pathogenesis of joint stiffness and arthrofibrosis following total knee arthroplasty (TKA). The purpose of this study was to compare the effects of intra-articular (IA) administration of tranexamic acid (TXA), an anti-fibrinolytic commonly used in TKA, and ALM chondroprotective solution on postoperative inflammation and joint tissue healing in a rat model of knee implant surgery. METHODS Male Sprague-Dawley rats (n = 24) were randomly divided into TXA or ALM treatment groups. The right knee of each rat was implanted with titanium (femur) and polyethylene (tibia) implants. An IA bolus (0.1 ml) of TXA or ALM was administered after implantation and capsule closure, and before skin closure. Postoperative coagulopathy, haematology and systemic inflammatory changes were assessed. Inflammatory and fibrotic markers were assessed in joint tissue, 28 days after surgery. RESULTS Haemostasis was comparable in animals treated with TXA or ALM after knee implant surgery. In contrast to ALM-treated animals, systemic inflammatory markers remained elevated at day 5 (IL-6, IL-12, IL-10, platelet count) and day 28 (IL-1β, IL-10) following surgery in TXA-treated animals. At day 28 following surgery, the extension range of motion of operated knees was 1.7-fold higher for ALM-treated animals compared to the TXA group. Key inflammatory mediators (NF-κB, IL-12, IL-2), immune cell infiltration (CD68+ cells) and markers of fibrosis (α-SMA, TGF-β) were also lower in capsular tissue of ALM-treated knees at day 28. CONCLUSION Data suggest that IA administration of ALM is superior to TXA for reducing postoperative systemic and joint inflammation and promoting restoration of healthy joint tissue architecture in a rat model of TKA. Further studies are warranted to assess the clinical translational potential of ALM IA solution to improve patient outcomes following arthroplasty.
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Affiliation(s)
- Jodie L Morris
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Peter McEwen
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Erik Biros
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Constantin Dlaska
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Kaushik Hazratwala
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Geoffrey P Dobson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
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Amin MS, Habib MK, Rehman AU. Comparison of blood loss between intra-articular and intra-venous administration of tranexamic acid in primary total knee arthroplasty. SICOT J 2020; 6:20. [PMID: 32553103 PMCID: PMC7301632 DOI: 10.1051/sicotj/2020017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/27/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To compare the blood loss between intra-articular and intra-venous administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty. DESIGN OF STUDY It was a randomized controlled trial. Study duration and settings: This study was carried out at the Orthopedic Departments of Combined Military Hospital Lahore and Rawalpindi from Jan 2016 to March 2018. METHODOLOGY Patients of both the genders were involved this study who had age in the rage of 40-80 years undergoing primary unilateral total knee arthroplasty for degenerative conditions like osteoarthritis and rheumatoid arthritis. These patients were randomly divided into two treatment groups. Patients in IA group received intra-articular tranexamic acid while those in IV group received intravenous tranexamic acid. From all the patients, a written signed consent was taken. FINDINGS Females were predominant with male-to-female ratio of 1:3.7. The mean age of the patients was 67.3 ± 8.2 years while the mean BMI was 30.9 ± 2.9 Kg/m2. Majority (n = 191, 95.5%) of the patients had osteoarthritis while remaining 9 (4.5%) patients had rheumatoid arthritis. There was no statistically significant difference between intra-articular and intra-venous administration of tranexamic acid in terms of mean post-operative hemoglobin (9.93 ± 1.14 vs. 9.87 ± 1.26 g/dL; p-value = 0.724), mean post-operative hematocrit (34.8 ± 1.66 vs. 34.73 ± 1.27%; p-value = 0.594), and mean fall in hemoglobin (2.27 ± 0.34 vs. 2.25 ± 0.30 g/dL; p-value = 0.587) and hematocrit (2.34 ± 0.94 vs. 2.46 ± 0.28%; p-value = 0.216). CONCLUSION Intra-articular administration of tranexamic acid was found to be as effective and safe as intra-venous administration in reducing blood loss in primary total knee arthroplasty. Due to convenience, the use of intra-articular administration of tranexamic acid after primary TKA may be considered in future practice.
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Affiliation(s)
- Muhammad Suhail Amin
- Professor Orthopedic, CMH Hospital Rawalpindi and CMH Lahore Orthopedic ward, CMH Hospital Rawalpindi, Pakistan
| | - Muhammad Khurram Habib
- Assistant Professor Orthopedics, DHQ Hospital Faisalabad, Clinical Fellow, CMH Lahore, DHQ Hospital Faisalabad Orthopedics ward, Pakistan
| | - Aziz Ur Rehman
- Clinical fellow CMH Hospital Rawalpindi and CMH Lahore, Pakistan
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Pathan S, Cruz JE, Curtin P. Comparison of the Effects of Intravenous and Oral Tranexamic Acid on Perioperative Hemoglobin Levels During Total Knee Arthroplasty. Ann Pharmacother 2019; 54:138-143. [PMID: 31507212 DOI: 10.1177/1060028019876077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce perioperative blood loss in patients undergoing total knee arthroplasty (TKA), but there are limited data regarding the efficacy of intravenous (IV) in comparison to oral (PO) TXA. Objective: The purpose of this research was to compare the effects of IV and PO TXA on perioperative hemoglobin (Hgb) levels in patients who have undergone TKA. Methods: In this single-center, retrospective chart review, patients at least 18 years of age who received IV or PO TXA following medical center protocol from 1 of 3 orthopedic surgeons were included. The primary outcome was the change in Hgb within 24 hours following TKA. Secondary outcomes included comparisons of postsurgical complications and hospital length of stay. Results: The IV TXA group contained 62 participants, and the PO TXA group contained 61 participants. Patients receiving PO therapy had a larger decrease in Hgb compared with the IV TXA group (-2.382 vs -1.908, P = 0.02), but there were no statistically significant differences in mean length of stay (3.13 vs 2.95, P = 0.27), venous thromboembolism (VTE) occurrence (0 vs 0, P = 1), or requirement for transfusions (6 vs 5, P = 0.76). Conclusions and Relevance: IV and PO TXA may not be equivalent in outcomes for patients undergoing TKA. This study found a statistically significant decrease in the mean change of Hgb in patients receiving PO TXA compared with IV TXA. However, the rate of transfusions, mean length of stay, and rate of VTE were similar between groups.
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Grant AL, Letson HL, Morris JL, McEwen P, Hazratwala K, Wilkinson M, Dobson GP. Tranexamic acid is associated with selective increase in inflammatory markers following total knee arthroplasty (TKA): a pilot study. J Orthop Surg Res 2018; 13:149. [PMID: 29914535 PMCID: PMC6006687 DOI: 10.1186/s13018-018-0855-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/05/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce excessive bleeding and transfusion requirements. Our aim was to examine if TXA was required in all osteoarthritis patients undergoing TKA surgery, and its possible effects on systemic inflammation and coagulation properties. METHODS Twenty-three patients (Oxford Score 22-29) were recruited consecutively; 12 patients received TXA before (IV, 1.2 g/90 kg) and immediately after surgery (intra-articular, 1.4 g/90 kg). Inflammatory mediators and ROTEM parameters were measured in blood at baseline, after the first bone-cut, immediately after surgery, and postoperative days 1 and 2. RESULTS After the bone cut and surgery, TXA significantly increased MCP-1, TNF-α, IL-1β and IL-6 levels compared to non-TXA patients, which was further amplified postoperatively. During surgery, TXA significantly prolonged EXTEM clot times, indicating a thrombin-slowing effect, despite little or no change in clot amplitude or fibrinogen. TXA was associated with three- to fivefold increases in FIBTEM maximum lysis (ML), a finding counter to TXA's antifibrinolytic effect. Maximum lysis for extrinsic and intrinsic pathways was < 8%, indicating little or no hyperfibrinolysis. No significant differences were found in postoperative hemoglobin between the two groups. CONCLUSIONS TXA was associated with increased systemic inflammation during surgery compared to non-TXA patients, with further amplification on postoperative days 1 and 2. On the basis of little or no change in viscoelastic clot strength, fibrinogen or clot lysis, there appeared to be no clinical justification for TXA in our group of patients. Larger prospective, randomized trials are required to investigate a possible proinflammatory effect in TKA patients.
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Affiliation(s)
- Andrea L Grant
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Jodie L Morris
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Peter McEwen
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Kaushik Hazratwala
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Matthew Wilkinson
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia.
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Alajmi T, Saeed H, Alfaryan K, Alakeel A, Alfaryan T. Efficacy of tranexamic acid in reducing blood loss and blood transfusion in idiopathic scoliosis: a systematic review and meta-analysis. JOURNAL OF SPINE SURGERY 2017; 3:531-540. [PMID: 29354728 DOI: 10.21037/jss.2017.08.17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tranexamic acid is a synthetic lysine-analogue antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin, it is a well-documented blood sparing agent. However, its routine use in idiopathic scoliosis surgery is poorly documented. The objective of this meta-analysis was to determine TXA's efficacy in reducing blood loss and blood transfusion in idiopathic scoliosis surgery. Methods Five databases (Medline, PubMed, Web of Science, Embase and The Cochrane Central Register of Controlled Trials) were searched to identify the relevant randomized controlled trials (RCTs), prospective cohort control (PCC), and retrospective controlled trails regarding the TXA efficacy in idiopathic scoliosis surgery. Mean differences (MDs) of blood loss and blood transfusions in TXA-treated group compared to control and/or placebo group were extracted and combined using random-effect meta-analysis model. Results A total of seven studies comprising 426 patients were included in the meta-analysis according to the pre-defined selection criteria. TXA-treated group had an overall significantly (P<0.005) less volume of blood loss [ES (MD) =727.71 mL; CI, 281.86-1,173.56 mL]. Six studies comprising 346 patients TXA-treated group had an overall significantly {P<0.001 less transfusion volume [ES (MD) =268.30 mL; CI, 105.19-431.44 mL]}. Conclusions Patients treated with TXA had a significantly lower blood loss and lower rates of allogeneic blood transfusion than the control group. Further investigation is required regarding the safety of TXA before it can be generalized in the use of idiopathic scoliosis surgery.
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Affiliation(s)
- Turki Alajmi
- Al-Imam Mohammed Ibn Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Halah Saeed
- Al-Imam Mohammed Ibn Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Khalid Alfaryan
- Al-Imam Mohammed Ibn Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Ahmed Alakeel
- Al-Imam Mohammed Ibn Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Thamer Alfaryan
- Al-Imam Mohammed Ibn Saud University, College of Medicine, Riyadh, Saudi Arabia
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A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement. Arthroplast Today 2017; 4:85-88. [PMID: 29560401 PMCID: PMC5859204 DOI: 10.1016/j.artd.2017.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023] Open
Abstract
Background Studies on the use of tranexamic acid (TXA) to improve clinical outcomes after joint arthroplasty have reported contrasting results between intravenous (IV) TXA alone and combined IV and intraarticular (IA) administration. We compared the effectiveness of the 2 methods in providing higher postoperative hemoglobin (Hb) levels in patients undergoing primary total knee arthroplasty (TKA). Methods A total of 100 TKA patients were randomly assigned to receive either IV TXA alone (group 1) or combined IV and topical IA TXA (group 2). Hb and hematocrit levels were measured before and after surgery. The amount of drained blood and transfused blood for the 2 groups was compared. Results The Hb level was significantly higher at postoperative day 4, together with a positive, albeit not significant, trend toward less postoperative blood loss in the group that received combined IV and IA TXA. No postoperative infections or deep venous thrombosis events occurred. Conclusions This study reinforces evidence that, as compared to IV TXA alone, combined IV and IA administration of TXA has a synergic effect, leading to higher postoperative Hb levels without influencing drug safety in TKA patients.
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Gausden EB, Garner MR, Warner SJ, Levack A, Nellestein AM, Tedore T, Flores E, Lorich DG. Tranexamic acid in hip fracture patients: a protocol for a randomised, placebo controlled trial on the efficacy of tranexamic acid in reducing blood loss in hip fracture patients. BMJ Open 2016; 6:e010676. [PMID: 27329438 PMCID: PMC4916621 DOI: 10.1136/bmjopen-2015-010676] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION There is a high incidence of blood transfusion following hip fractures in elderly patients. Tranexamic acid (TXA) has proven efficacy in decreasing blood loss in general trauma patients as well as patients undergoing elective orthopaedic surgery. A randomised controlled trial will measure the effect of TXA in a population of patients undergoing hip fracture surgery. METHODS This is a double-blinded, randomised placebo-controlled trial. Patients admitted through the emergency room that are diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrolment and randomised to either treatment with 1 g of intravenous TXA or intravenous saline at the time of skin incision. Patients undergoing percutaneous intervention for non-displaced or minimally displaced femoral neck fractures will not be eligible for enrolment. Postoperative transfusion rates will be recorded and blood loss will be calculated from serial haematocrits. ETHICS AND DISSEMINATION This protocol was approved by the Institutional Review Board (IRB) and is registered with clinicaltrials.gov. The findings of the trial will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT01940536.
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Affiliation(s)
| | - Matthew R Garner
- Department of Orthopaedics, Harborview Medical Center, Seattle, Washington, USA
| | - Stephen J Warner
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Ashley Levack
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Andrew M Nellestein
- Department of Orthopaedic Trauma, New York Presbyterian Hospital, New York, New York, USA
| | - Tiffany Tedore
- Department of Anesthesiology, New York Presbyterian Hospital, New York, New York, USA
| | - Eva Flores
- Department of Internal Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Dean G Lorich
- Department of Orthopaedic Trauma, New York Presbyterian Hospital, New York, New York, USA
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Gómez-Barrena E, Ortega-Andreu M. Widespread of total knee arthroplasty perioperative blood management techniques based on tranexamic acid: barriers and opportunities. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:299. [PMID: 26697459 DOI: 10.3978/j.issn.2305-5839.2015.10.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Enrique Gómez-Barrena
- Hospital Universitario "La Paz", Hospital de Traumatología y Hospital de Cantoblanco, Universidad Autónoma de Madrid, Madrid, Spain
| | - Miguel Ortega-Andreu
- Hospital Universitario "La Paz", Hospital de Traumatología y Hospital de Cantoblanco, Universidad Autónoma de Madrid, Madrid, Spain
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Ng BKW, Chau WW, Hung ALH, Hui AC, Lam TP, Cheng JCY. Use of Tranexamic Acid (TXA) on reducing blood loss during scoliosis surgery in Chinese adolescents. SCOLIOSIS 2015; 10:28. [PMID: 26442124 PMCID: PMC4593193 DOI: 10.1186/s13013-015-0052-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 09/13/2015] [Indexed: 01/22/2023]
Abstract
Background Many reports had been received on the application of antifibrinolytic medications on spinal corrective surgery and the surgical outcome evaluations of its efficacy on reducing blood loss. This study aimed to assess the efficacy of tranexamic acid (TXA) in reducing operative blood loss during posterior spinal fusion for the treatment of severe adolescent idiopathic scoliosis (AIS). Methods A retrospective cohort study was carried out on 90 (TXA = 55, Control = 35) AIS girls undergoing posterior spinal surgery. Patients in TXA group used TXA as an antifibrinolytic agent to reduce blood loss, while control group did not. Blood loss, haemoglobin change and amount of blood transfused was estimated from intraoperative measurement by anaesthesiologists. Demographics were compared using Student’s T-test or Chi-square test where appropriate. Linear regression modelling was carried out between the use of TXA and total blood loss with controlling of confounding factors. Results Mean age and mean maximum major curve were 15.2 and 73°, and 15.3 and 63° in TXA and control groups respectively. TXA group showed significantly less intra-operative blood loss than the control group from intraoperative measurement (1.8 L vs. 3.9 L, p < 0.01) and volume of cell saver blood transfused back to patients (0.6 L vs. 1.7 L, p < 0.01). TXA group also showed significantly shorter total time taken for surgery (437 min vs. 502 min, p < 0.01), and total blood loss per surgical segment level (0.1 L vs. 0.3 L, p < 0.01). Regression models showed that the use of TXA decreased total blood loss by 794.3 ml after adjusting for maximum major curve, age, number of segments fused, bone graft, clotting capability, and infusion of coagulation factors. Conclusions Patients undergoing posterior spinal corrective surgery with the use of TXA showed much reduced total blood loss, reduced use of transfused blood, much less cell saver blood transfused back to the patient. The total blood loss was decreased by after using TXA after controlling for maximum major curve, age, surgical parameters, clotting capability, and infusion of coagulation factors.
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Affiliation(s)
- Bobby K W Ng
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong ; Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T. Hong Kong
| | - W W Chau
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Alec L H Hung
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anna Cn Hui
- Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong
| | - Tze Ping Lam
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jack C Y Cheng
- Department of Orthopaedics & Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong
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