Perioperative blood management strategies for patients undergoing total knee replacement: Where do we stand now?

Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty

Iron supplementation provides iron storage and facilitates effective production of hemoglobin. The purpose of this study was to investigate the effect of early postoperative intravenous (IV) iron supplementation in different types of total knee arthroplasty (TKA) surgery. We retrospectively analyzed 863 patients who underwent TKA between September 2017 and September 2021. The IV iron (I) and non-IV iron (NI) groups were compared. Hemoglobin responders, defined as patients who showed a change in hemoglobin level of ≥2 g/dL at 6 weeks of surgery compared to the baseline immediate postoperative hemoglobin level, were identified and they were compared with the nonresponders. After logistic regression analysis, the patients were classified according to the type of surgery (unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA). A subgroup analysis was performed according to the comorbidity as Charlson Comorbidity Index (CCI). The type of surgery and the rate of hemoglobin responders differed between the I and NI groups. The surgery type and iron supplementation significantly affected the hemoglobin responder in the logistic regression model. In each surgery type, hemoglobin drop in the I group was generally lower in the second and sixth weeks than that in the NI group. It was also effective in reducing hemoglobin drop on the first day of the second surgery in staged bilateral TKA. In addition, the number of hospital days was lower in the IV iron supplementation group who underwent a staged bilateral TKA. CCI did not affect hemoglobin responder, hemoglobin drop, and transfusion rate in both the I and NI groups. Postoperative IV iron supplementation affected the outcome of hemoglobin responders. In addition, it reduced early postoperative hemoglobin drop. However, iron supplementation did not affect the transfusion rate, complications, and clinical outcome, regardless of the type of surgery. LEVEL OF EVIDENCE:  Level III, case-control study.

Is prophylactic intraoperative transfusion needed in unilateral total knee arthroplasty? Comparison of hematologic data and postoperative transfusion rate between a prophylactic allogenic or autologous transfusion group with a no-transfusion group: A preliminary retrospective cohort study

OBJECTIVES

To determine whether prophylactic intra-operative allogenic or autologous transfusion could prevent postoperative anemia and additional transfusion comparing to the control group without receiving any prophylactic intervention in unilateral total knee arthroplasty.

MATERIALS AND METHODS

This study included 711 patients who underwent unilateral TKA. They were divided into four groups: allogeneic transfusion group (group AL), autologous transfusion group (group AT), tranexamic acid group (group TA), and control group (group C). The primary outcome was rate of postoperative allogeneic blood transfusions. Secondary outcomes were postoperative hemoglobin and hematocrit levels, postoperative bleeding amount.

RESULTS

Groups AT and AL did not exhibit a significant reduction in postoperative allogenic blood transfusion rate compared to group C (28/108 vs. 20/108, p = 0.21 and 37/159 vs. 34/159, p = 0.78 respectively). However, group TA demonstrated a significantly lower rate of postoperative allogenic blood transfusions than group C (22/125 vs. 3/125, p = 0.0001). Postoperative hemoglobin and hematocrit levels were statistically higher in group TA than in group C. However, those levels in group AT and AL did not differ significantly from those of group C.

CONCLUSION

Intra-operative prophylactic transfusions did not decrease postoperative anemia or additional postoperative transfusion compared to the control group in patients undergoing total knee arthroplasty. However, the group receiving tranexamic acid showed lower transfusion rate and higher levels of hemoglobin and hematocrit.

Effect of acute normovolemic hemodilution on anesthetic effect, plasma concentration, and recovery quality in elderly patients undergoing spinal surgery

OBJECTIVE

To explore the effect of acute normovolemic hemodilution (ANH) on the anesthetic effect, plasma concentration, and postoperative recovery quality in elderly patients undergoing spinal surgery.

METHODS

A total of 60 cases of elderly patients aged 65 to 75 years who underwent elective multilevel spinal surgery were assigned randomly into the ANH group (n = 30) and control group (n = 30). Hemodynamic and blood gas analysis indexes were observed and recorded before ANH (T1), after ANH (T2), immediately after postoperative autologous blood transfusion (T3), 10 min (T4), 20 min (T5), 30 min (T6), 40 min (T7), and 50 min (T8) after the transfusion, and at the end of the transfusion (i.e., 60 min; T9). At T3 ~ 9, bispectral index (BIS) and train-of-four (TOF) stimulation were recorded and the plasma propofol/cisatracurium concentration was determined. The extubation time and recovery quality were recorded.

RESULTS

The ANH group presented a lower MAP value and a higher SVV value at T2, and shorter extubation and orientation recovery time (P < 0.05) compared with the control group. BIS values at T8 and T9 were lower in the ANH group than those in the control group (P < 0.05). TOF values at T7 ~ 9 were lower in the ANH group than those in the control group (P < 0.05). There were no statistically significant differences in the postoperative plasma concentrations of propofol and cisatracurium between the groups (P > 0.05).

CONCLUSION

During orthopedic surgery, the plasma concentration of elderly patients is increased after autologous blood transfusion of ANH, and the depth of anesthesia and muscle relaxant effect are strengthened, thus leading to delayed recovery of respiratory function and extubation.

Effect of Preoperative Antianxiety Medications on Blood Pressure and Blood Loss in Total Knee Arthroplasty: A Case-Control Study

Background

The increasing number of canceled operations in patients undergoing total knee arthroplasty (TKA) due to high blood pressure readings has put a considerable burden on surgeons. In this study, we aim to assess the effect of giving antianxiety drugs preoperatively on maintaining blood pressure (BP) and blood loss for patients undergoing TKA surgery.

Methods

This retrospective case-control study included patients who underwent total knee arthroplasty and divided them into two main groups: those who had taken a 3 mg bromazepam oral tablet at the night preoperatively and the control group. The blood pressure of patients was then measured preoperatively (baseline), in the morning of surgery, in the operating room before anesthesia, and during the surgery. The percentage of measured BP was calculated by dividing the measured BP by the baseline, then multiplying by 100.

Results

301 patients were included in our study: 137 received bromazepam and 164 as a control group. The ratio of systolic BP (SBP) in the morning of surgery to the baseline (percentage of morning SBP) decreased significantly in the bromazepam group compared with the controls. The ratio of SBP, in the operating room before anesthesia (percentage of preanesthesia SBP) also decreased significantly in the bromazepam group. However, the percentage of SBP in the middle of surgery did not change significantly. In addition, there was a significant difference change from the baseline in diastolic BP and mean arterial BP between the two groups in the morning of surgery, inside the theatre, and in the middle of the operation. The bromazepam group also showed a significant decrease in blood loss.

Conclusion

Preoperative oral antianxiety drugs (bromazepam) helps in controlling hemodynamic changes associated with anxiety, including maintaining BP in well-controlled hypertensive and healthy patients undergoing TKA, and it plays a role in decreasing the total blood loss.

Does the accelerometer-based navigation system reduce blood loss and transfusion in one-stage sequential bilateral total knee arthroplasty? A randomized double-blind controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with significant blood loss and postoperative transfusion. The accelerometer-based navigation (ABN) system guides the bone cutting plane without breaching the intramedullary canal, which may reduce bleeding. This study aimed to investigate blood loss and transfusion compared between the ABN system and the conventional procedure in patients undergoing one-stage sequential bilateral TKA (SBTKA).

METHODS

A total of 66 patients scheduled for SBTKA were randomly allocated to either the ABN or conventional group. Postoperative hematocrit (Hct) level, drainage blood loss, transfusion rate, and amount of packed red cell transfusion were collected. Total red blood cell (RBC) loss was then calculated for the primary outcome.

RESULTS

The mean calculated total RBC loss in the ABN and conventional group was 669.7 and 630.0 mL, respectively (p = 0.572). There was no significant difference between groups for other evaluated outcome parameters, including postoperative Hct level, drainage blood loss, or packed red cell transfusion volume. All patients in the conventional group required postoperative blood transfusion while 96.8% of patients in the ABN group were transfused.

CONCLUSIONS

The total RBC loss and volume of packed red cells transfusion were not significant difference between interventions, which suggest no benefit of the ABN system in reducing blood loss and transfusion in patients undergoing SBTKA.

TRIAL REGISTRATION

The protocol of this study was registered in the Thai Clinical Trials Registry database no. TCTR20201126002 on 26/11/2020.

Primary Total Knee Replacement: A Recipe for Dry Dressing

OBJECTIVE

 To evaluate surgical outcomes using sets of techniques to achieve single dry dressing for two weeks post total knee replacement (TKR) at Dr. Sulaiman Al-Habib Hospital, Riyadh, Saudi Arabia.

MATERIAL AND METHODS

A prospective study comprised of 110 consecutive unilateral total knee replacements was conducted at the orthopedic department of Dr. Sulaiman Al-Habib Hospital, Suwaidi, Riyadh, KSA. Patients of both genders underwent knee replacement surgery due to primary knee osteoarthritis, Kellgren-Lawrence grades 3 and 4. Routine investigations and fitness evaluations of patients were carried out preoperatively. Preoperative minimal use of a tourniquet and release prior to arthrotomy closure; intravenous tranexamic acid, no drains; capsule infiltration with local anesthetics without adrenaline; tight closure with barbed sutures up to the skin in three layers; skin glue; Aquacel dressing; adductor canal block; and continuation of oral anticoagulant for four weeks.

RESULTS

A total of 110 cases were included, of which 81 (73.6%) were females and 29 (26.4%) were males. The mean age of the study population was 60.5+10.3 years (48 to 88 years). The mean BMI in our patients was 30.57+10.5 kg/m². Most patients were morbidly obese 13 (30.95%). The mean preoperative Hb% was 13.07+1.6 g/dl, while the mean postoperative Hb% was 12.58+1.9 mg/dl with a p-value of 0.28, which was non-significant statistically. Only two patients needed a change of Aquacel wound dressing for ooze. None of our patients developed deep venous thrombosis (DVT) or an infection.

CONCLUSION

A sequential use of sets of techniques is observed to be associated with improved outcomes in terms of blood loss, wound infection, mobility, and patient satisfaction, leading to the ultimate end point of dry Aquacel wound dressing.

Tourniquet application in primary total knee arthroplasty for osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Objective

The aim of this study was to identify the influence of a tourniquet on the blood loss, transfusion requirement, swelling, pain, knee function, range of motion (ROM), operation time, bone cement mantle thickness, and complications in patients operated with total knee arthroplasty (TKA).

Methods

Two authors independently retrieved PubMed, Embase, and CENTRAL to identify eligible randomized controlled trials (RCTs) evaluating the effectiveness of a tourniquet in TKA. Fixed- (I ²< 50%) or random-effects (I ²> 50%) models were selected to perform meta-analysis according to the value of I ². Mean difference (MD) and risk ratio were selected as the effect sizes for continuous and dichotomous variables, respectively.

Results

A total of 29 RCTs, involving 2,512 operations (1,258 procedures with a tourniquet and 1,254 procedures without a tourniquet), were included, and 18 outcomes were compared. Tourniquet application could significantly decrease intraoperative blood loss (MD = -138.72 ml, p < 0.001), shorten operation duration (MD = -1.77 min, p < 0.001), and increase cement mantle thickness (MD = 0.17 mm, p < 0.001). However, it was significantly associated with increased postoperative pain intensity, decreased full ROM/flexion ROM/extension ROM, poorer knee function, increased knee swelling, and increased length of hospital stay (LOS) at several follow-up points (p < 0.050). No significant difference was found for postoperative draining volume, total blood loss, transfusion rate, change of Hb level, and risks of deep venous thrombosis and all complications.

Conclusions

Tourniquet application could only decrease the intraoperative blood loss but has no effectiveness on the total blood loss and transfusion requirement. On the contrary, it has a reverse effect on the pain score, knee function, ROM, swelling, and LOS.

¿Es seguro el ácido tranexámico en la cirugía de reemplazo total de rodilla de pacientes con enfermedad coronaria?

Introducción: El ácido tranexámico reduce la pérdida sanguínea y los requerimientos de transfusiones luego de un reemplazo total de rodilla. Una de sus contraindicaciones relativas son los antecedentes de colocación de prótesis intravasculares coronarias, por un supuesto aumento de eventos tromboembólicos. Materiales y Métodos: Análisis retrospectivo de pacientes sometidos a un reemplazo total de rodilla primario y de revisión que recibieron ácido tranexámico y tenían antecedente de colocación de prótesis intravascular coronaria. Se los comparó con un grupo sin estas prótesis. Se analizó la presencia de cualquier cambio clínico o electrocardiográfico de oclusión coronaria aguda, eventos tromboembólicos, el requerimiento de transfusión sanguínea y el nivel de hemoglobina pre y posoperatorio. Resultados: 57 pacientes (59 cirugías, 56 reemplazos primarios y 3 revisiones) con colocación de prótesis intravascular coronaria, al menos, un año antes de la artroplastia. Un paciente tuvo síntomas de síndromecoronario agudo y cambios en el electrocardiograma. No hubo diferencias en la cantidad de eventos tromboembólicos. Solo un paciente del grupo de control recibió una transfusión de glóbulos rojos. El sangrado relativo fue menor en el grupo coronario independientemente del uso crónico de aspirina y clopidogrel antes de la cirugía (2,09 vs. 3,06 grupo de control; p = 0,01). En pacientes del alto riesgo, el ácido tranexámico no se asoció con más eventos tromboembólicos. Conclusiones: El ácido tranexámico impresionó ser seguro y efectivo en nuestro grupo de pacientes con prótesis intravasculares coronarias; sin embargo, se necesita un estudio prospectivo con más casos para confirmar estos resultados

Evaluation of Blood Loss in Conventional vs MAKOplasty Total Knee Arthroplasty

Background

Methods

Results

Conclusions

HTX-011 in Combination with Multimodal Analgesic Regimen Minimized Severe Pain and Opioid Use after Total Knee Arthroplasty in an Open-Label Study

Total knee arthroplasty (TKA) can be associated with significant postoperative pain despite multimodal analgesic (MMA) protocols, and most patients require the use of opioids postoperatively. HTX-011 is a dual-acting local anesthetic containing bupivacaine and low-dose meloxicam in an extended-release polymer. In a prior randomized controlled trial (RCT), HTX-011 reduced pain and opioid use through 72 hours after TKA compared with bupivacaine hydrochloride. This open-label study (NCT03974932) evaluated the efficacy and safety of HTX-011 combined with an MMA regimen in patients undergoing TKA under spinal anesthesia. All patients received intraoperative HTX-011 (400 mg bupivacaine/12 mg meloxicam) in combination with an MMA regimen consisting of preoperative acetaminophen, celecoxib, and pregabalin and postoperative acetaminophen and celecoxib until discharge. Opioid rescue was allowed upon patient request for additional pain control. Pain scores, opioid consumption, discharge readiness, and adverse events were recorded. Fifty-one patients were treated. Compared with the prior RCT, HTX-011 with this MMA regimen further lowered pain scores and reduced opioid use. Mean patient-reported pain scores remained in the mild range, and 82% of patients or more did not experience severe pain at any individual time point through 72 hours after surgery. Mean total opioid consumption was low over 72 hours: 24.8 morphine milligram equivalents (1-2 tablets of oxycodone 10 mg/day). Approximately 60% of patients were ready for discharge by 12 hours, and 39% were discharged without an opioid prescription and did not call back for pain management. The treatment regimen was well tolerated, and no added risk was observed with the addition of MMA. HTX-011 with an MMA regimen reduced postoperative pain and opioid use following TKA.

Hypotensive Anesthesia Combined with Tranexamic Acid Reduces Perioperative Blood Loss in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Cohort Study

OBJECTIVE

To assess the efficacy and safety of hypotensive anesthesia (HA) combined with tranexamic acid (TXA) for reducing perioperative blood loss in simultaneous bilateral total hip arthroplasty (SBTHA).

METHODS

In this retrospective cohort study, a total of 183 eligible patients (15 females and 168 males, 44.01 ± 9.29 years old) who underwent SBTHA from January 2015 to September 2020 at our medical center were enrolled for analysis. Fifty-nine patients received standard general anesthesia (Std-GA group), the other 85 and 39 patients received HA with an intraoperative mean arterial pressure between 70 and 80 mmHg (70-80 HA group) and below 70 mmHg (<70 HA group), respectively. TXA was administrated to all patients. Perioperative blood loss (total, dominant, and hidden), transfusion rate and volume, hemoglobin and hematocrit reduction, duration of operation and anesthesia, length of hospitalization, range of hip motion as well as postoperative complications were collected from hospital's electronic records and compared between groups.

RESULTS

All patients were followed for more than 3 months. Total blood loss in the two HA groups (1390.25 ± 595.67 ml and 1377.74 ± 423.46 ml, respectively) was significantly reduced compared with that in Std-GA group (1850.83 ± 800.73 ml, P < 0.001). Both dominant and hidden blood loss were dramatically decreased when HA was applied (both P < 0.001). Accordingly, the transfusion rate along with volume in 70-80 HA group (14.1%, 425.00 ± 128.81 ml) and <70 HA group (12.8%, 340.00 ± 134.16 ml) were reduced in comparison with those in Std-GA group (37.3%, 690.91 ± 370.21ml; P = 0.001 and P = 0.014, respectively). The maximal hemoglobin and hematocrit reduction in both HA groups were significantly less than those in Std-GA group (both P < 0.001). Of note, 70-80 and <70 HA groups exhibited comparable efficacy with no significant differences between them. Besides, significant difference in duration of surgery was found among groups (P = 0.044 and P < 0.001), while no differences in anesthesia time and postoperative range of hip motion were observed. Regarding complications, the incidence of both acute kidney injury and postoperative hypotension in <70 HA group was significantly higher than that in 70-80 HA and Std-GA groups (P = 0.014 and P < 0.001). Incidence of acute myocardial injury was similar among groups (P = 0.099) and no other severe complications or mortality were recorded.

CONCLUSION

The combination of HA with a mean arterial pressure (MAP) of 70-80 mmHg and TXA could significantly reduce blood loss and transfusion during SBTHA, in addition to shortening operation time and length of hospitalization, and with no increase in complications.

Safety and Blood Loss Associated With Tourniquets in Total Knee Arthroplasty

Objective

To measure total blood loss and safety of tourniquets, tourniquets during cementation, or no tourniquets during total knee arthroplasty (TKA).

Methods

This retrospective cohort study included 75 patients from King Khalid University Hospital in Riyadh, Saudi Arabia. Patients were equally divided into three groups: tourniquets, no-tourniquets, and tourniquets during cementation. Recorded data included: baseline characteristics (age, sex, weight, height, body mass index (BMI), anesthesia type, and comorbidities), blood loss parameters (total blood loss, preoperative and postoperative hematocrit (Hct) and hemoglobin (Hgb), and blood transfusion units), duration of surgery, hospital stay, and thromboembolic events during 3-months postoperatively. Statistical significance was reported by using a P-value < 0.05, and 95% confidence intervals.

Results

The tourniquet group had significantly lower mean total blood loss (544.67 mL ± 418.86; P = 0.001), higher mean postoperative hemoglobin values (115.44 g/dL ± 10.97; P = 0.004) and hematocrit (34.25 % ± 3.35; P = 0.005), and lower median intra-operative loss (100 cc, 10-300; P < 0.001), than the other groups. Tourniquets during cementation required significantly more mean surgery time (131.84 minutes ± 22.12; P = 0.003), and longer median hospital stay (8 days, 5-13) than the other groups.

Conclusion

Tourniquet use during TKA significantly decreased total and intraoperative blood loss, but it did not have any significant effect on the transfusion rate or the incidence of thromboembolic events.

Using of Intraoperative Cell Salvage and Tranexamic Acid as Protective Factor for Postoperative Anemia Appearance in Patients with Total Hip or Knee Arthroplasty

(1) Background: The purpose of this study was to investigate intraoperative pharmacological and nonpharmacological methods and techniques in reducing blood loss in patients following total hip or knee arthroplasty. (2) Methods: A retrospective cross-sectional study was conducted in patients undergoing TKA or THA surgery, electively performed at the General Hospital Valjevo, Valjevo, Serbia, in 2014 when the principles of patient blood management (PBM) were not applied at all or in part, and in 2019 when PBM principles were applied as standard. (3) Results: This study includes 197 patients, of whom 83.8% developed postoperative anemia (PA defined by haemoglobin < 12 g/dL in both sexes). Using multivariate logistic regression and ROC curve analysis, it was shown that the use of tranexamic acid (TXA) with intraoperative cell salvage (ICS) in patients without preoperative anemia reduced the incidence of PA (odds ratio = 0.081). (4) Conclusions: Preoperative diagnosis and treatment of anemia are necessary in orthopedic patients since the use of TXA with ICS strongly reduces PA in patients without preoperative anemia.

Tranexamic Acid Is Safe in Patients with a History of Coronary Artery Disease Undergoing Total Joint Arthroplasty

BACKGROUND

Tranexamic acid (TXA) is increasingly used to minimize blood loss during total joint arthroplasty (TJA). Although TXA has been shown to be highly effective in reducing operative blood loss, many surgeons believe that it places patients with coronary artery disease (CAD) or a history of coronary stents at an increased risk for myocardial infarction. The purpose of this study was to determine if TXA is safe to use in patients with a history of CAD or coronary stents.

METHODS

We performed a retrospective analysis at a single, tertiary academic medical center identifying consecutive total hip and knee arthroplasty cases over an 8-year period. From this cohort who received TXA intraoperatively, we identified patients with a history of CAD or coronary stents and determined the total myocardial infarction and venous thromboembolism (VTE) rates within a 90-day postoperative period. Chi-square analyses were used to identify differences in VTE rates between cohorts. A post hoc power analysis was also performed to determine whether our results were powered to detect a difference in VTE rates.

RESULTS

In the 26,808 identified at-risk patients, there were no postoperative myocardial infarctions. No significant differences were observed for VTE rates compared with the control cohort using either topical or intravenous TXA, with regard to CAD (0.29% compared with 0.76%; p = 0.09) or coronary stents (0% compared with 0.76%; p = 0.14). Moreover, there was no significant difference observed in VTE rates when administration was subcategorized into intravenous and topical methods with regard to CAD (0.13% compared with 0.72%; p = 0.12) or coronary stents (0% compared with 0%; p = 1.0).

CONCLUSIONS

In our series, topical and intravenous TXA were equally safe when used in patients with a history of CAD and coronary stents in comparison with the control cohort. With equal efficacy and risk of adverse events, we recommend intravenous TXA, which may enable easier institutional implementation.

LEVEL OF EVIDENCE

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

Multiple intravenous tranexamic acid doses in total knee arthroplasty in patients with rheumatoid arthritis: a randomized controlled study

Background

We aimed to determine the efficacy and safety of multiple doses of intravenous tranexamic acid (IV-TXA) on perioperative blood loss in patients with rheumatoid arthritis (RA) who had undergone primary unilateral total knee arthroplasty (TKA).

Methods

For this single-center, single-blind randomized controlled clinical trial, 10 male and 87 female participants with RA, aged 50–75 years, who underwent unilateral primary TKA were recruited. The patients received one dose of 1 g IV-TXA 10 min before skin incision, followed by articular injection of 1.5 g tranexamic acid after cavity suture during the surgery. The patients were randomly assigned (1:1) into two groups and received an additional single dose of IV-TXA (1 g) for 3 h (group A) or three doses of IV-TXA (1 g) for 3, 6, and 12 h (group B) postoperatively. Primary outcomes were total blood loss (TBL), hidden blood loss (HBL), and maximum hemoglobin (Hb) level decrease. Secondary outcomes were transfusion rate and D-dimer levels. All parameters were measured postoperatively during inpatient hospital stay.

Results

The mean TBL, HBL, and maximum Hb level decrease in group B (506.1 ± 227.0 mL, 471.6 ± 224.0 mL, and 17.5 ± 7.7 g/L, respectively) were significantly lower than those in group A (608.8 ± 244.8 mL, P = 0.035; 574.0 ± 242.3 mL, P = 0.033; and 23.42 ± 9.2 g/L, P = 0.001, respectively). No episode of transfusion occurred. The D-dimer level was lower in group B than in group A on postoperative day 1 (P <  0.001), and the incidence of thromboembolic events was similar between the groups (P > 0.05).

Conclusion

In patients with RA, three doses of postoperative IV-TXA further facilitated HBL and Hb level decrease without increasing the incidence of adverse events in a short period after TKA.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR1900025013).

Should We Use Intra-articular Tranexamic Acid Before or After Capsular Closure During Total Knee Replacement? A Study of 100 Knees

BACKGROUND

Intraarticular (IA) administration of tranexamic acid (TXA) is a proven way of reducing blood loss in total knee replacement (TKR). However, different methods of administration have been described in literature such as placement of an intra-articular swab soaked in TXA before capsular closure or injecting TXA intraarticularly after capsular closure. We decided to compare these two methods.

MATERIALS AND METHODS

One hundred consecutive patients planned for unilateral TKR between December 2018 and March 2019 were selected for the study and divided into 2 groups of 50 patients each. All patients received IV and oral TXA identically-15 mg/kg TXA IV preoperatively, 10 mg/kg IV TXA at 3 and 6 h postoperatively, and 1 g oral TXA for the next 2 days. Group A was given IA TXA via swab soaked with 1 g TXA in 100 ml normal saline (NS) before closure of arthtrotomy, while Group B was given 1 g of IA TXA via injection in the knee after capsular closure. Preoperative haemoglobin (Hb) and postoperative day 4 Hb values were measured. Blood loss was calculated and compared in both groups using Mann Whitney test.

RESULT

The mean blood loss was 652.23 ± 64.36 ml in Group A and 542.68 ± 266.23 ml in Group B. The difference in blood loss between both groups was found to be clinically significant with a p-value of 0.03236 (significant, p < 0.05).

CONCLUSION

Injecting TXA intraarticularly after capsular closure is more effective than using an intra-articular swab containing TXA.

LEVEL OF EVIDENCE

Level III Retrospective Comparative study.

Topical co-delivery of platelet rich fibrin and tranexamic acid does not decrease blood loss in primary total knee arthroplasty compared to the standard of care: a prospective, randomized, controlled trial

PURPOSE

The purpose of this study was to evaluate the efficacy of intra-operative co-administration of tranexamic acid (TA) and platelet rich fibrin (PRF) using a proprietary co-delivery system on the amount of blood loss, early functional outcomes and wound complications after primary total knee arthroplasty (TKA). The intervention was compared to the standard of care (combined intravenous & topical TA) in a prospective, randomized, blinded setting.

METHODS

80 patients undergoing primary cemented TKA without tourniquet were prospectively randomized into control (combined intravenous and topical TA) and PRF (intra-venous TA and co-delivery of topical PRF and TA) groups after informed consent. Total blood loss, drainage blood loss, knee range of motion, VAS pain scores, length of stay and wound complications were analysed. Data collection was performed in a double blind manner on days 1, 3 and 21.

RESULTS

There was no statistically significant difference in drainage blood loss (550 ml vs. 525 ml, p = 0.643), calculated total blood loss on day 1 (401 ml vs. 407 ml, p = 0.722), day 3 (467 ml vs 471 ml, p = 0.471) and day 21 (265 ml vs. 219 ml, p = 0.082) between the PRF and control groups respectively. The PRF group had a small but statistically significant increase in median knee extension in the early post-operative period, however this difference evened out at 3 weeks. No significant difference could be demonstrated between the PRF and control groups in length of stay, VAS pain scores, narcotic usage, wound complications and knee flexion at all time points.

CONCLUSIONS

The topical co-delivery of PRF and TA does not significantly decrease blood loss in primary TKA compared to the standard of care. Slightly better active knee extension in the first 3 postoperative days can be achieved, however this benefit is not clinically relevant.

LEVEL OF EVIDENCE

I, Therapeutic study.

Does intraoperative transfusion during total knee arthroplasty reduce the need for transfusion after surgery?: A preliminary retrospective cohort study

OBJECTIVES

After total knee arthroplasty (TKA), many patients experience anemia due to blood loss. To prevent postoperative anemia and allogeneic blood transfusion after TKA, we used prophylactic allogeneic or autologous blood transfusion intraoperatively. This study evaluated the effects of prophylactic transfusion during TKA.

MATERIALS AND METHODS

This retrospective cohort study included 579 patients receiving scheduled unilateral TKA. We allocated the patients into three groups, the prophylactic allogeneic transfusion (Group AL), prophylactic autologous transfusion (Group AT), and no prophylactic transfusion with intra-articular tranexamic acid administration (GroupC) groups. After propensity score matching, we compared the rate of postoperative allogeneic blood transfusions until three days after TKA, postoperative hemoglobin and hematocrit levels until four days after TKA, and the side effects in each groups.

RESULTS

The postoperative allogeneic blood transfusion rates were statistically higher in group AL and AT than in group C (18.2% and, 18.9% vs 2.3%, respectively; P<0.000). The postoperative hemoglobin and hematocrit levels were statistically lower in group Auto than in group C (P<0.0001), but the levels in group AL were not different from those of group C (P=0.493 vs. P=0.384 respectively). In addition, the side effects were statistically higher in group AL and AT than in group C.

CONCLUSION

Prophylactic intra-operative transfusions did not reduce the rates of allogeneic transfusions and produced more side effects and hypotension after surgery than intra-articular tranexamic acid administration with no prophylactic transfusion in patients undergoing TKAs.

The optimal regimen of oral tranexamic acid administration for primary total knee/hip replacement: a meta-analysis and narrative review of a randomized controlled trial

Background

Oral tranexamic acid (TXA) has been demonstrated to reduce the blood loss in primary total knee and hip arthroplasty, but the optimal regimen of oral TXA administration is still unknown. This study aimed to find the best number of administrations of oral TXA for primary total knee and hip arthroplasty.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies published before March 20, 2020. Studies clearly reporting a comparison of multiple administrations of oral TXA for total hip/knee replacement were included, and the total blood loss (TBL), intraoperative blood loss (IBL), decline in hemoglobin (DHB), deep vein thrombosis (DVT), intramuscular venous thrombosis (IVT), length of hospital stay (LOS), and transfusion rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed effects or random effects model.

Results

Nine studies involving 1678 patients were included in this meta-analysis (TXA 1363 (one administration, 201; two administrations, 496; three administrations, 215; four administrations, 336; five administrations, 115); placebo 315); the results show that compared with placebo groups, oral TXA could significantly reduce the TBL, IBL, DHB, LOS, and transfusion rate. In addition, the incidences of IVT and DVT were similar between the TXA and placebo groups. Moreover, two administrations of oral TXA significantly reduced the TBL and DHB compared with one administration, three administrations of oral TXA were better than two administrations, and four administrations of oral TXA were better than three administrations.

Conclusion

Our results suggested that oral TXA could significantly reduce the blood loss and the length of hospital stay but could not increase the incidence of DVT and IVT for total joint replacement patients; additionally, the effectiveness of oral TXA administration increased as the number of administrations increased.

Comparison of hemocoagulase atrox versus tranexamic acid used in primary total knee arthroplasty: A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) has been considered as an effective choice for end-stage osteoarthritis or rheumatic arthritis. Tranexamic acid (TXA) has been widely used to prevent excessive blood loss perioperatively. Similarly, hemocoagulase atrox can significantly diminish blood loss and transfusion requirements in surgeries, however, it was rarely used in TKA. The purpose of this study is to identify whether hemocoagulase atrox is equal to TXA in reducing blood loss and transfusion rates following TKA, and compare clinical outcomes and complications between the two groups.

METHODS

74 patients were randomized to receive TXA (1.5 g intra-articular combined with 1.5 g intravenous), or hemocoagulase atrox (1 U intra-articular combined with 1 U intravenous). The primary outcome was total blood loss. The secondary outcomes included reduction of hemoglobin concentration, clinical outcomes, blood coagulation values, thromboembolic complications, and transfusion rates.

RESULTS

The mean total blood loss was 431.7 mL in the TXA group compared with 644.6 mL in the hemocoagulase atrox group, with statistical significance (P < 0.05). There were significant differences in reduction of hemoglobin level (P < 0.05). The rate of deep vein thrombosis (DVT) in patients given TXA was higher than those given hemocoagulase atrox, however, there were no significant differences. No transfusions were required in either group, and no significant differences were found in the length of hospital stay and clinical outcomes.

CONCLUSIONS

Although the blood loss was significantly greater in the hemocoagulase atrox group, no transfusions were required and no significant differences were observed for any other outcomes measured. Meanwhile, the rate of DVT in the hemocoagulase atrox group tends to be lower than those in TXA group. We concluded that hemocoagulase atrox was not superior to TXA in reducing perioperative blood loss. Further studies are warranted to evaluate if hemocoagulase atrox use could improve perioperative blood loss in patients with high thrombotic risk undergoing TKA.

Does tourniquet use decrease blood loss following primary total knee arthroplasty in Jehovah's Witness patients?

OBJECTIVES

This study aims to investigate the use of multiple blood management strategies and the effect of tourniquet on the estimated blood loss (EBL) in Jehovah's Witness (JW) patients who underwent primary total knee arthroplasty (TKA).

PATIENTS AND METHODS

Twenty-two self-reported JW patients (9 males, 13 females; mean age 66.8±8.6 years; range, 51 to 83 years) who underwent primary TKA between January 2014 and January 2020 in our institution were retrospectively reviewed. A standard blood management protocol that consisted of hypotensive anesthesia, local and systemic administration of tranexamic acid (TXA) and intraoperative cell salvage was applied to all patients. Patients were divided into two groups: with (n=11) and without (n=11) tourniquet use. The EBL was calculated according to Meunier's formula. Hemoglobin (Hgb), hematocrit (Hct), and EBL on the first and third postoperative days were compared statistically.

RESULTS

There was no significant difference between groups regarding postoperative Hgb (p=0.801 and p=0.767), Hct (p=0.617 and p=0.895), Hgb decline (p=0.311 and p=0.822), and EBL (p=0.067 and p=0.284) at first and third postoperative days. None of the patients required blood transfusion. No wound complication or symptomatic deep vein thrombosis was seen during the hospital stay.

CONCLUSION

Combined use of hypotensive anesthesia, intravenous administration of TXA, intraoperative periarticular injection, and cell salvage seem to be sufficient in controlling the blood loss in JW patients during TKA. Additional tourniquet use may not further decrease the EBL.

Prospective randomized controlled study on improving sleep quality and impact of zolpidem after total hip arthroplasty

Background

Total hip arthroplasty (THA) is a proven surgical option for patients with end-stage osteoarthritis in terms of improved function and pain relief. A prospective study was conducted to examine and evaluate the effect and impact of zolpidem postoperatively on the sleep quality, pain alleviation, and quality of life of patients who underwent total hip arthroplasty.

Methods

A total of 160 patients was randomized 1:1 to receive either zolpidem or placebo 2 days preoperative to 5 days postoperatively. Pain scores using visual analog scale (VAS), sleep quality using Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale, quality of life using QoR-40, and Hip disability and Osteoarthritis Outcome Score were recorded. The total amount of opioid analgesics and antiemetics taken was recorded as well.

Results

Patients in the intervention group had higher VAS score and took less analgesic and antiemetic. Moreover, the study demonstrated that QoR-40 was higher and Hip disability and Osteoarthritis Outcome Score had relatively lower mean value (P < 0.05) in the treatment group. Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale were also lower in the treatment group (P < 0.05).

Conclusion

Patients taking zolpidem achieved greater improvement in the quality of life and reported better satisfaction. The study demonstrated zolpidem 10 mg can improve sleep quality effectively, relieve pain, increase early range of motion and muscle strength, reduce the perioperative anxiety and depression, and improve perioperative experience and satisfaction, thereby reducing the hospital stay and medical costs and promote the rapid recovery and quality of life.

Trial registration

The trial was registered on Chinese Clinical Trial Registry, ChiCTR-IOR-16007861.

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

BACKGROUND AND PURPOSE

Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

METHODS AND MATERIALS

We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital.

RESULTS

Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction.

CONCLUSION

The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

Topical Tranexamic Acid in Revision Total Knee Arthroplasty Reduces Transfusion Rates and May Be Associated With Earlier Recovery

BACKGROUND

The use of tranexamic acid (TXA) has been proved to be effective in reducing blood loss and transfusion requirements after primary total knee arthroplasty (TKA). However, the evidence for its use in revision surgery is scant. We assessed the safety and efficacy of topical TXA in revision TKA.

METHODS

We retrospectively compared 76 revision TKA patients who received topical TXA (3 g before tourniquet deflation) "study group" with a historic control group of 205 revision TKA patients in which TXA was not used. Each group was further stratified into subgroups according to the type of revision. All patients were followed for a minimum of 6 weeks. Blood loss, transfusion requirements, changes in hemoglobin-hematocrit levels, Knee Society Score, and complications were recorded.

RESULTS

The mean estimated blood loss, hemoglobin drop, and transfusion rate were significantly lower in the study group than in the control group (P = .008, P < .001, P < .001, respectively). Hidden blood loss was similar between the 2 groups (P = .12). Six weeks postoperatively, the improvement in the knee-specific Knee Society Score was significantly higher in the study group than in the control group (P < .001). No significant differences were found in thromboembolic complications between the 2 groups (P = .92). In the subgroup analysis, when both components (femur and tibia) were revised, the relative risk of transfusion was significantly lower with the use of TXA (relative risk 0.227, confidence interval 0.0593-0.860, P = .004).

CONCLUSION

Topical TXA in revision TKA is safe and effective in reducing blood loss and transfusions. This effect is enhanced when both components are revised. Additionally, the use of TXA may improve early outcomes.

Multiple intravenous tranexamic acid doses in total knee arthroplasty without tourniquet: a randomized controlled study

BACKGROUND

Tranexamic acid (TXA) is widely used in the orthopedic field and particularly in total knee arthroplasty (TKA). Its efficacy and safety in reducing the blood loss in TKA have been well-documented in the current literature. Little data regarding TKA without tourniquet and TXA exist. Our aim is to compare three different dosages of intravenous (IV) TXA in TKA without tourniquet.

MATERIALS AND METHODS

A total of 180 patients undergoing TKA for knee osteoarthritis were stratified in three equal groups. All surgeries were performed under spinal anesthesia, without tourniquet. Group A (60 patients) received 15 mg/kg of IV TXA given on induction, Group B (60 patients) received an additional dose of IV TXA (15 mg/kg) 3 h after incision and Group C (60 patients) received an additional (third) dose 3 h later (15 mg/kg). The measured outcomes were the change in hemoglobin (Hb) from pre-operatively to post-operatively, the amount of blood transfusion given (units), the functional and quality of life (QoL) and pain assessment based on their corresponding scoring system.

RESULTS

Calculated blood loss, Hb decrease and transfusion rate were significantly lower in Group C (p value < 0.05). Additionally, patients that had been included in the three-dosage group benefited much more in terms of faster rehabilitation, better QoL, decreased post-operative pain, with no increase in complications.

CONCLUSION

According to our results, three doses of IV TXA have effectively and safely reduced blood loss and the need of allogeneic blood transfusion in patients undergoing TKA without tourniquet, with additional patients-related benefits.

LEVEL OF EVIDENCE

II.

Revisiting old practices: More restricted indication of preoperative autologous blood donation in healthy bone marrow donors according to baseline hemoglobin levels

There is no consensus on the risk-benefit status of preoperative autologous blood donation (PAD) for healthy bone marrow donors and there is concern regarding its impact on the development of pre-surgical anemia. We evaluated the changes in hemoglobin levels related to PAD in 80 bone marrow donors of our institution between 2002 and 2016. Mean Hgb values were compared separately for donors who donated 1 or 2 units, at 3 time-points: before PAD collection, the morning before marrow harvest and soon after harvest. Mean baseline Hgb values did not differ significantly between the 2 groups. After PAD collection, there was a significant drop in Hgb levels for the whole cohort of donors but more pronounced for the group that donated 2 units [1 unit: 12.8(8.9-17.4) × 2 units: 11.55(11.2-12.1), p = 0.045]. However, after marrow harvest, Hgb levels were similar for the 2 groups; 61.2% of all donors required autologous transfusion and none required allogeneic transfusion. Furthermore, baseline Hgb <14.35 g/dL was identified as the sensitive cutoff to predict the need for transfusion after marrow harvest (sensitivity of 52% and specificity of 80.4%, p = 0.001). Thus, our analysis demonstrates the possibility of using hemoglobin thresholds as cutoff points for indication of PAD, tending to a more cost-effective approach. Despite significant declines in Hgb levels after PAD, none of the donors in our cohort required allogeneic transfusion, demonstrating the safety of this procedure. Thus, the indication of PAD remains an option for those who feel insecure despite higher baseline Hgb levels.

Finding the Optimal Regimen for Oral Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Previous studies have confirmed that, compared with intravenous and intra-articular formulations, oral tranexamic acid (TXA) provides equivalent reduction in blood loss, at a substantially reduced cost and greater ease of administration. However, the optimal oral dosage regimen to achieve maximum blood-loss reduction remains unclear. The aim of this study was to assess the efficacy of a regimen of multiple doses of oral TXA on blood loss in primary total hip arthroplasty.

METHODS

In this randomized controlled trial, 200 patients were randomized to 1 of 4 interventions. Group A received a single dose of 2.0 g of TXA orally at 2 hours preoperatively. In addition to this same preoperative dose, Group B received 1.0 g of TXA orally at 3 hours postoperatively, Group C received 1.0 g of TXA orally at 3 and 9 hours postoperatively, and Group D received 1.0 g of TXA orally at 3, 9, and 15 hours postoperatively. All patients received a 1.0-g topical dose of TXA. The primary outcome was total blood loss. Secondary outcomes included hemoglobin reduction, transfusion rate, thromboembolic complications, and adverse events.

RESULTS

The mean total blood loss (and standard deviation) was significantly less in Groups B, C, and D (792.2 ± 293.0, 630.8 ± 229.9, and 553.0 ± 186.1 mL, respectively) than in Group A (983.6 ± 286.7 mL) (p < 0.001). Moreover, Groups C and D had a lower mean reduction in hemoglobin than did Groups A and B. However, no differences were identified between Groups C and D for blood loss and hemoglobin reduction. Additionally, no differences were observed among the groups regarding thromboembolic complications and transfusions.

CONCLUSIONS

The multiple postoperative doses of oral TXA further reduced blood loss compared with a single preoperative bolus. The regimen of a preoperative dose and 3 postoperative doses of oral TXA produced maximum effective reduction of blood loss in total hip arthroplasty.

LEVEL OF EVIDENCE

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

Preoperative blood transfusion associated with increased length of stay and increased postoperative complications after revision total knee arthroplasty

Currently, the impact of preoperative transfusion on postoperative morbidity following revision total knee arthroplasty (TKA) is unknown. A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed and included patients who underwent revision TKAs. Postoperative complications were analyzed. A total of 6,849 patients were included. Patients who received a preoperative blood transfusion were found to have an increased risk of developing 3 of 17 adverse events. Although overall complication rates remain relatively low, orthopedic surgeons should counsel their patients on the implications of preoperative blood transfusions on post-operative outcomes.

Identifying the period of greatest blood loss after lower limb arthroplasty

Background

The use of tranexamic acid (TXA) in total hip replacement (THR) typically reduces blood loss by approximately 400 mL, and typical total blood loss is still approximately 1 L. A barrier to harnessing the full potential of TXA is disagreement on the optimum timing of administration. To address this, we aimed to identify the period of greatest blood loss.

Methods

We analyzed the perioperative data of 870 patients who had undergone THR, total knee replacement, or unicompartmental knee replacement just before the introduction of TXA to our unit. Total blood loss was calculated on postoperative day (POD) 1 and POD2 using an equation based on change in hematocrit.

Results

Average total blood loss at POD2 was 1505, 1322, and 611 mL for THR, total knee replacement, and unicompartmental knee replacement, respectively. Between 86% and 96% of this blood loss occurred in the period between skin closure and POD1. Intraoperative loss did not correlate with total loss at POD2. Blood transfusion was more likely if the patient was female (odds ratio [OR], 6.8) or if they had preoperative anemia (OR, 8.3) than if there was a high-volume blood loss (OR, 1.6).

Conclusions

Approximately 90% of blood loss occurs between skin closure and the first postoperative 24 hours. “Intraoperative blood loss” and “transfusion rate” are not reliable markers of total blood loss. The full potential of TXA could be harnessed by using it during the period of greatest blood loss, that is, during the first postoperative 24 hours.

Blood-conserving efficacy of multiple doses of oral tranexamic acid associated with an enhanced-recovery programme in primary total knee arthroplasty: a randomized controlled trial

Aims

The aim of this study was to identify the most effective regimen of multiple doses of oral tranexamic acid (TXA) in achieving maximum reduction of blood loss in total knee arthroplasty (TKA).

Patients and Methods

In this randomized controlled trial, 200 patients were randomized to receive a single dose of 2.0 g of TXA orally two hours preoperatively (group A), a single dose of TXA followed by 1.0 g orally three hours postoperatively (group B), a single dose of TXA followed by 1.0 g three and nine hours postoperatively (group C), or a single dose of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively (group D). All patients followed a routine enhanced-recovery protocol. The primary outcome measure was the total blood loss. Secondary outcome measures were hidden blood loss (HBL), reduction in the level of haemoglobin, the rate of transfusion and adverse events.

Results

Groups C (661.1 ml, sd 262.4) and D (597.7 ml, sd 219.6) had significantly lower mean total blood loss compared with groups A and B. The mean HBL was significantly lower in groups B (699.2 ml), C (533.1 ml) and D (469.9 ml) than in group A (p = 0.006, p < 0.001, and p < 0.001, respectively). Groups C (2.22 ml, sd 0.91) and D (2.04 ml, sd 0.95) had a lower reduction in the level of haemoglobin than groups A and B. However, there were no differences between groups C and D in relation to the three parameters.

Conclusion

The addition of two or three postoperative doses of TXA to one preoperative dose produced a significant reduction in blood loss. The two-dose postoperative regimen is the least necessary regimen for clinical efficacy in primary unilateral TKA. The three-dose regimen produced maximum reduction of blood loss. Cite this article: Bone Joint J 2018;100-B:1025–32.

Assessment of the effect of addition of 24 hours of oral tranexamic acid post-operatively to a single intraoperative intravenous dose of tranexamic acid on calculated blood loss following primary hip and knee arthroplasty (TRAC-24): a study protocol for a randomised controlled trial

BACKGROUND

While it is has been proven that tranexamic acid (TXA) reduces blood loss in primary total hip and knee arthroplasty (THA and TKA), there is little published evidence on the use of TXA beyond 3 h post-operatively. Most blood loss occurs after wound closure and the primary aim of this study is to determine if the use of oral TXA post-operatively for up to 24 h will reduce calculated blood loss at 48 h beyond an intra-operative intravenous bolus alone following primary THA and TKA. To date, most TXA studies have excluded patients with a history of thromboembolic disease.

METHODS/DESIGN

This is a phase IV, single-centred, open-label, parallel-group, randomised controlled trial. Participants are randomised to one of three groups: group 1, an intravenous (IV) bolus of TXA peri-operatively plus oral TXA post-operatively for 24 h; group 2, an IV bolus of TXA peri-operatively or group 3, standard care (no TXA). Eligible participants, including those with a history of thromboembolic disease, are allocated to these groups with a 2:2:1 allocation ratio. The primary outcome is the indirectly calculated blood loss 48 h after surgery. Researchers and patients are not blinded to the treatment; however, staff processing blood samples are. Originally 1166 participants were required to complete this study, 583 THA and 583 TKA. However, following an interim analysis after 100 THA and 100 TKA participants had been recruited to the study, the data monitoring ethics committee recommended stopping group 3 (standard care).

DISCUSSION

TRAC-24 will help to determine whether an extended TXA dosing regimen can further reduce blood loss following primary THA and TKA. By including patients with a history of thromboembolic disease, this study will add to our understanding of the safety profile of TXA in this clinical situation.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN58790500 . Registered on 3 June 2016, EudraCT: 2015-002661-36.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013

BACKGROUND

Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013.

METHODS

A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges.

RESULTS

There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size.

CONCLUSION

Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

Comparing the efficacy of intravenous or intra-articular tranexamic acid in reducing blood loss in simultaneous bilateral knee replacement surgery without the use of tourniquet

PURPOSE

To compare the effect of intravenous or intra-articular route of administration of tranexamic acid in reducing the blood loss in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquets.

METHODS

Prospective cohort study of 30 consecutive patients grouped into two groups; Group 1: intravenous group and group 2: intra-articular group. Two outcome measures were studied; mean drop in post-operative haemoglobin and need for blood transfusion in both groups.

RESULTS

No significant difference in mean drop of haemoglobin and need for blood transfusion in both groups.

CONCLUSION

Route of administration of tranexamic acid does not influence on the mean drop of haemoglobin and need for blood transfusion in simultaneous bilateral total knee replacement surgeries performed without the use of tourniquet.

Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature

Background

Life expectancy lengthening and aging of population resulted in dramatically increase of patients with osteoarthritis. Total knee arthroplasty is widely used as the gold standard in order to relieve pain, correct deformity and restore function. A contemporary and controversial topic, is that of minimally invasive surgery for TKA. The minimally invasive approaches are based on the concept that they don't violate the extensor mechanism, resulting in earlier functional recovery, shorter hospital stay and enhanced patients' overall satisfaction. The most commonly used MIS approaches in TKA are the subvastus, midvastus and the quadriceps sparing. There is a debate regarding the efficacy and safety of these methods.

Objective

In this article we will review the current literature (randomized controlled trials and systematic reviews/meta-analyses) on MIS compared to traditional approach and analyse their clinical safety, efficacy and long-term results.

Design

Comparison of well-designed studies have tried to demonstrate the advantages/disadvantages, the clinical results and the complications of the MIS approaches compared to the MPP approach.

Results

MIS approaches seem to provide advantages in the immediate post-operative period accompanied by increased reports of complications. Consequently, further investigation based on large well-designed studies with long-term results are warranted to further clarify MIS effectiveness/safety.

Comparison of oral versus intra-articular tranexamic acid in enhanced-recovery primary total knee arthroplasty without tourniquet application: a randomized controlled trial

Background

Although randomized controlled trials have confirmed oral tranexamic acid (TXA) can provide similar blood-sparing efficacy compared with intravenous (IV) TXA in total knee arthroplasty (TKA), some concerns do remain about thromboembolic events after such systemic administration. Many studies have confirmed that intra-articular (IA) application of TXA can show similar blood-saving efficacy with minimal levels of systemic absorption compared with IV TXA. However, it remains unclear whether the efficacy and safety of oral TXA administration is equal to or less than that of IA administration in TKA without the use of a tourniquet and drain. Thus, this study was to verify non-inferior efficacy and safety of oral TXA compared with IA TXA in primary TKA.

Methods

A double-blind, randomized, controlled trial was performed to compare three oral doses of TXA (2 g of TXA 2 h before incision, and 1 g of TXA 6 and 12 h after surgery, respectively) with IA TXA (3 g of TXA in 100 mL of saline solution). One hundred forty-seven patients scheduled for TKA were randomized to one of the two interventions. The primary outcome was total blood loss. The secondary outcomes included reduction of hemoglobin concentration, clinical outcomes, blood coagulation values, thromboembolic complications, and transfusion rates.

Results

The mean total blood loss was 788.8 mL in the oral TXA group compared with 872.4 mL in the IA TXA group, with no statistical significance (p > 0.05). There were no significant differences in reduction of hemoglobin level, blood coagulation level, and clinical outcomes. The transfusion rates were 4% in oral group and 5% IA group, respectively. Also, no significant differences were identified in thromboembolic complications.

Conclusion

Oral TXA according to the described protocol demonstrated non-inferiority for primary TKA, with no safety concerns and a greatly reduced cost, compared with the IA TXA. This randomized controlled trial supports the oral administration of TXA in TKA.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-17010968) dated 23rd March 2017.

Towards a systematic approach for (de)implementation of patient blood management strategies

Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.