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Xie W, Donat A, Jiang S, Baranowsky A, Keller J. The emerging role of tranexamic acid and its principal target, plasminogen, in skeletal health. Acta Pharm Sin B 2024; 14:2869-2884. [PMID: 39027253 PMCID: PMC11252461 DOI: 10.1016/j.apsb.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 07/20/2024] Open
Abstract
The worldwide burden of skeletal diseases such as osteoporosis, degenerative joint disease and impaired fracture healing is steadily increasing. Tranexamic acid (TXA), a plasminogen inhibitor and anti-fibrinolytic agent, is used to reduce bleeding with high effectiveness and safety in major surgical procedures. With its widespread clinical application, the effects of TXA beyond anti-fibrinolysis have been noticed and prompted renewed interest in its use. Some clinical trials have characterized the effects of TXA on reducing postoperative infection rates and regulating immune responses in patients undergoing surgery. Also, several animal studies suggest potential therapeutic effects of TXA on skeletal diseases such as osteoporosis and fracture healing. Although a direct effect of TXA on the differentiation and function of bone cells in vitro was shown, few mechanisms of action have been reported. Here, we summarize recent findings of the effects of TXA on skeletal diseases and discuss the underlying plasminogen-dependent and -independent mechanisms related to bone metabolism and the immune response. We furthermore discuss potential novel indications for TXA application as a treatment strategy for skeletal diseases.
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Affiliation(s)
- Weixin Xie
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Antonia Donat
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Shan Jiang
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Anke Baranowsky
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Johannes Keller
- Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg 20246, Germany
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Benjumea A, Díaz-Navarro M, Gago-Campos ÁS, Visedo A, Hafian R, Cercenado E, Sánchez-Somolinos M, Muñoz P, Vaquero J, Chana F, Guembe M. Validation of the antibacterial effect of topically applied tranexamic acid using in vitro and in vivo models. Front Microbiol 2024; 15:1367884. [PMID: 38808275 PMCID: PMC11130467 DOI: 10.3389/fmicb.2024.1367884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024] Open
Abstract
Background Several studies have shown that tranexamic acid (TXA), an antifibrinolytic, reduces postoperative infection rates. Recent in vitro research showed that TXA alone and in combination with vancomycin and gentamicin had a synergistic effect against some staphylococcal strains. In the present study, this synergistic effect was validated in samples from patients with staphylococcal periprosthetic infection (PPI) and in an in vivo model. Methods We tested 19 clinical strains (5 Staphylococcus aureus and 14 coagulase-negative staphylococci [CoNS]) against 10 mg/ml TXA alone and in combination with serial dilutions of vancomycin and gentamicin. The standardized microtiter plate method was used. The minimal inhibitory concentration (MIC) were calculated using standard visualization of well turbidity. We also used an S. aureus (ATCC29213) murine subcranial PPI model to compare the synergistic effect of TXA and gentamicin with that of TXA or gentamicin alone after 4 days of monitoring. The mice were euthanized, and disks were removed for analysis of cfu/ml counts and cell viability rate. Biofilm structure of both in vitro and in vivo samples was also analyzed using scanning electron microscopy (SEM). Results When TXA was combined with vancomycin or gentamicin, the MIC decreased in 30% of the strains studied. According to species, the MIC50 for vancomycin and gentamicin alone and in combination with TXA against S. aureus strains was the same. This was also the case for CoNS with vancomycin and its corresponding combination, whereas with gentamicin and TXA, a reduction in MIC50 was observed (2 dilutions). In addition, in the in vivo model, the mean (SD) log cfu/ml and cell viability rate obtained from the implant was lower in the group of mice treated with TXA and gentamicin than in those treated only with TXA or gentamicin. SEM images also corroborated our findings in strains in which the MIC was reduced, as well as the in the mice implants, with the area occupied by biofilm being greater in samples treated only with gentamicin or TXA than in those treated with TXA+gentamicin. Conclusion We confirm that combining TXA with vancomycin or gentamicin exerts a synergistic effect. However, this only occurs in selected strains.
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Affiliation(s)
- Antonio Benjumea
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Díaz-Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Andrés Visedo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rama Hafian
- Department of Biomedicine and Biotechnology, Universidad de Alcalá de Henares, Alcala de Henares, Spain
| | - Emilia Cercenado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Mar Sánchez-Somolinos
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Vaquero
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Chana
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Poston JN, Brown SP, Ilich A, Ginsburg AS, Herren H, El Kassar N, Jensen CE, Triulzi DJ, Key NS, May S, Gernsheimer TB. Fewer severe infections with tranexamic acid in patients with hematologic malignancies. Res Pract Thromb Haemost 2024; 8:102358. [PMID: 38666065 PMCID: PMC11043644 DOI: 10.1016/j.rpth.2024.102358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding in a multitude of clinical settings from postpartum hemorrhage to trauma. TXA may have clinical effects unrelated to bleeding; plasminogen, the target of TXA, alters immune responses, and TXA appears to decrease the risk of infection in patients undergoing cardiac surgery, as well as joint arthroplasty. Objectives To address whether TXA alters rates of infection and inflammatory outcomes in patients with hematologic malignancies. Methods We performed a post hoc analysis of outcomes of patients randomized to receive either TXA or placebo in the double-blinded, multicenter American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (Clinicaltrials.gov identifier: NCT02578901). Results TXA did not change the overall rate of infections, but the rate of severe infections (Common Toxicology Criteria for Adverse Events grade 3+) was lower in patients who received TXA compared with the placebo group. Patients who experienced grade 3+ infections had higher rates of World Health Organization grade 2+ bleeding and red blood cell transfusion requirements than patients who did not experience a grade 3+ infection, irrespective of treatment group. TXA did not impact other inflammatory outcomes such as mucositis, rash, or graft vs host disease. Conclusion Patients with hematologic malignancies who received TXA had less severe infections than those who received placebo with no difference in overall rate of infection or other inflammatory outcomes. Further investigation is needed on the impact of TXA on infections in this population.
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Affiliation(s)
- Jacqueline N. Poston
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Anton Ilich
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Sarah Ginsburg
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Christopher E. Jensen
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Darrell J. Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nigel S. Key
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Terry B. Gernsheimer
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Imanishi K, Kobayashi N, Kamono E, Yukizawa Y, Takagawa S, Choe H, Kumagai K, Inaba Y. Tranexamic acid administration for the prevention of periprosthetic joint infection and surgical site infection: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:6883-6899. [PMID: 37355487 DOI: 10.1007/s00402-023-04914-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/21/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has been widely utilized to reduce blood loss and allogeneic transfusions in patients who undergo lower limb arthroplasty. In recent years, there have been several articles reporting the incidence of periprosthetic joint infection (PJI) as a primary outcome of TXA administration, but no meta-analysis has been conducted to date. The present systematic review and meta-analysis evaluated the efficacy of TXA administration in preventing PJI and surgical site infection (SSI). MATERIALS AND METHODS Pubmed, CINAHL, and the Cochrane Library bibliographic databases were searched for studies published by May 24, 2022, that evaluated the effects of TXA on PJI and SSI. Two researchers screened the identified studies based on the PRISMA flow diagram. The quality of each randomized clinical trial was assessed using Version 2 of the Cochrane risk-of-bias tool for randomized trials (ROB2.0), and the quality of cohort and case-control studies was assessed by risk of bias for nonrandomized studies (ROBANS-I). RESULTS Of the 2259 articles identified from the database search, 31 were screened and selected. Treatment with TXA significantly reduced the incidence of overall infection, including PJI, SSI, and other infections (OR 0.55; 95% CI 0.49-0.62) (P < 0.00001), and that of PJI alone (OR 0.53; 95% CI 0.47-0.59) (P < 0.00001). TXA reduced the incidence of overall infection in patients who underwent total hip arthroplasty (THA; OR 0.51; 95% CI: 0.35-0.75) (P = 0.0005) and total knee arthroplasty (TKA; OR 0.55; 95% CI: 0.43-0.71) (P < 0.00001). Intravenous administration of TXA reduced the incidence of overall infection (OR 0.59; 95% CI 0.47-0.75) (P < 0.0001), whereas topical administration did not. CONCLUSIONS Intravenous administration of TXA reduces the incidence of overall infection in patients undergoing both THA and TKA. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Keiji Imanishi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan.
| | - Emi Kamono
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Yohei Yukizawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Shu Takagawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Ken Kumagai
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
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Alasaad H, Ibrahim J. Primary total knee arthroplasty in patients with a significant bone defect in the medial tibial plateau: Case series and literature review. Int J Surg Case Rep 2023; 110:108779. [PMID: 37666156 PMCID: PMC10510074 DOI: 10.1016/j.ijscr.2023.108779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Total knee arthroplasty (TKA) can significantly enhance a patient's quality of life and knee function. As a result, it has become a popular procedure among orthopedic surgeons. However, there are some challenging cases that surgeons may encounter, such as treating bony defects in the tibial plateau in patients with advanced degeneration. If not managed properly, these cases can have serious consequences. CASE PRESENTATION 4 patients with severe knee joint degeneration and bone loss in the medial tibial plateau were included in the series. The patients underwent TKA using the cement and screws technique to compensate for the defect in the medial tibial plateau. After (12-24 months) follow-up, all patients showed a clear clinical and functional improvement. CLINICAL DISCUSSION Several ways exist to address bone loss in the tibial plateau in primary total knee joint arthroplasty. Among them, metal prostheses are frequently used. In certain situations, we may need to use more affordable techniques to ensure success for patients facing financial difficulties. This is particularly common in our country, and we may utilize methods such as the cement and screws technique. This study showed a clear improvement in the patient's clinical and functional outcomes according to The Western Ontario and McMaster Universities Arthritis Index (WOMAC) at the end of the follow-up period. CONCLUSION The cement and screw technique might be a good solution for moderate bone loss in the tibial plateau. It might be a safe and simple method for patients, and it's also a viable option for those who can't afford pricier alternatives like metal augmentation or structural allografts.
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Rodriguez-Merchan EC, Delgado-Martinez AD. Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty. J Clin Med 2022; 11:6128. [PMID: 36294449 PMCID: PMC9605414 DOI: 10.3390/jcm11206128] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 08/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a major adverse event of primary total knee arthroplasty (TKA) from the patient's perspective, and it is also costly for health care systems. In 2010, the reported incidence of PJI in the first 2 years after TKA was 1.55%, with an incidence of 0.46% between the second and tenth year. In 2022, it has been published that 1.41% of individuals require revision TKA for PJI. The following risk factors have been related to an increased risk of PJI: male sex, younger age, type II diabetes, obesity class II, hypertension, hypoalbuminemia, preoperative nutritional status as indicated by prognostic nutritional index (PNI) and body mass index, rheumatoid arthritis, post-traumatic osteoarthritis, intra-articular injections prior to TKA, previous multi-ligament knee surgery, previous steroid therapy, current tobacco use, procedure type (bilateral), length of stay over 35 days, patellar resurfacing, prolonged operative time, use of blood transfusions, higher glucose variability in the postoperative phase, and discharge to convalescent care. Other reported independent risk factors for PJI (in diminishing order of importance) are congestive heart failure, chronic pulmonary illness, preoperative anemia, depression, renal illness, pulmonary circulation disorders, psychoses, metastatic tumor, peripheral vascular illness, and valvular illness. Preoperative intravenous tranexamic acid has been reported to diminish the risk of delayed PJI. Knowing the risk factors for PJI after TKA, especially those that are avoidable or controllable, is critical to minimizing (ideally preventing) this complication. These risk factors are outlined in this article.
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Affiliation(s)
- Emerito Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research—IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain
| | - Alberto D. Delgado-Martinez
- Department of Orthopedic Surgery, Hospital Universitario de Jaen, 23007 Jaen, Spain
- Department of Surgery, University of Jaen, 23071 Jaen, Spain
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Akdoğan M, Öztürk A, Faruk Çatma M, Akdoğan BM, Gülsoy A, Atilla HA. Use of tranexamic acid may reduce the need for routine tourniquet use in total knee arthroplasty. Jt Dis Relat Surg 2022; 33:547-552. [PMID: 36345182 PMCID: PMC9647687 DOI: 10.52312/jdrs.2022.737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/01/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the effects of tranexamic acid (TXA) administration on bleeding control and to compare its utilization with and without simultaneous use of conventional pneumatic tourniquets during total knee arthroplasty (TKA). PATIENTS AND METHODS Between January 2017 and December 2017, a total of 204 patients (23 males, 181 females; mean age: 66±6.9 years; range, 45 to 86 years) who underwent TKA for Stage 4 gonarthrosis were retrospectively analyzed. The patients were divided into two groups as those with (n=110) and without (n=94) pneumatic tourniquet use. Tranexamic acid (1 g) was administered intravenously to all patients in both study groups. Intra- and postoperative blood loss were calculated, and postoperative pain was evaluated by a Visual Analog Scale. Demographic and clinical data were compared between the study groups. RESULTS The amount of total blood loss and postoperative blood loss were significantly higher in the tourniquet group than that in the no-tourniquet group (589.4±69.5 mL vs. 490.8±55.2 mL and 326±56 mL vs. 164±35.5 mL, respectively; p<0.001 for both). Intraoperative blood loss was significantly higher in the no-tourniquet group (326.9±42.9 mL vs. 263.5±53.8 mL, respectively; p<0.001). The pain score at 24 h was significantly higher in the tourniquet group (p<0.001). CONCLUSION Total blood loss and postoperative pain were significantly higher among patients in whom a tourniquet was used during TKA. Therefore, the routine use of tourniquets with TXA should be reconsidered.
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Affiliation(s)
- Mutlu Akdoğan
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
| | - Alper Öztürk
- Department of Orthopedics and Traumatology, Ankara Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Faruk Çatma
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
| | - Burak Menderes Akdoğan
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
| | - Atakan Gülsoy
- Department of Orthopedics and Traumatology, Anamur Devlet Hastanesi, Mersin, Türkiye
| | - Halis Atıl Atilla
- Department of Orthopedics and Traumatology, Dışkapı Training and Research Hospital, Ankara, Türkiye
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Benjumea A, Díaz-Navarro M, Hafian R, Cercenado E, Sánchez-Somolinos M, Vaquero J, Chana F, Muñoz P, Guembe M. Tranexamic Acid in Combination With Vancomycin or Gentamicin Has a Synergistic Effect Against Staphylococci. Front Microbiol 2022; 13:935646. [PMID: 35847081 PMCID: PMC9280180 DOI: 10.3389/fmicb.2022.935646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent applied in orthopedic surgery and has been proven to reduce post-surgery infection rates. We previously showed that TXA also had an additional direct antimicrobial effect against planktonic bacteria. Therefore, we aimed to evaluate whether it has a synergistic effect if in combination with antibiotics. Materials and Methods Three ATCC and seven clinical strains of staphylococci were tested against serial dilutions of vancomycin and gentamicin alone and in combination with TXA at 10 and 50 mg/ml. The standardized microtiter plate method was used. Minimal inhibitory concentrations (MICs) were calculated by standard visualization of well turbidity (the lowest concentration at which complete absence of well bacterial growth was observed by the researcher) and using the automated method (the lowest concentration at which ≥80% reduction in well bacterial growth was measured using a spectrophotometer). Results Tranexamic acid-10 mg/ml reduced the MIC of vancomycin and gentamicin with both the standard method (V: 1-fold dilution, G: 4-fold dilutions) and the automated turbidity method (vancomycin: 8-fold dilutions, gentamicin: 8-fold dilutions). TXA-50 mg/ml reduced the MIC of gentamicin with both the standard turbidity method (6-fold dilutions) and the automated turbidity method (1-fold dilutions). In contrast, for vancomycin, the MIC remained the same using the standard method, and only a 1-fold dilution was reduced using the automated method. Conclusion Ours was a proof-of-concept study in which we suggest that TXA may have a synergistic effect when combined with both vancomycin and gentamicin, especially at 10 mg/ml, which is the concentration generally used in clinical practice.
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Affiliation(s)
- Antonio Benjumea
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Díaz-Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rama Hafian
- School of Biology, Universidad Complutense de Madrid, Madrid, Spain
| | - Emilia Cercenado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Mar Sánchez-Somolinos
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Vaquero
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Chana
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Effect of Tranexamic Acid against Staphylococcus spp. and Cutibacterium acnes Associated with Peri-Implant Infection: Results from an In Vitro Study. Microbiol Spectr 2022; 10:e0161221. [PMID: 35171021 PMCID: PMC8849059 DOI: 10.1128/spectrum.01612-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Tranexamic acid (TXA) is extensively used in orthopedic surgery and traumatology as an antifibrinolytic agent to control intra- and postoperative bleeding and, therefore, indirectly, to reduce postsurgery infection rates. The hypothesis of an additional antibiotic effect against microorganisms associated with periprosthetic joint infection needs to be further evaluated. We aimed to assess whether TXA could reduce bacterial growth using an in vitro model. ATCC and clinical strains of staphylococci and Cutibacterium acnes were tested against TXA in both planktonic and sessile forms. We recorded the percent reduction in the following variables: log CFU/mL by microbiological culture, percentage of live cells by confocal laser scanning microscopy, and, additionally in sessile cells, metabolic activity by the 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide salt (XTT) assay. Variables were compared between groups using the Kruskal-Wallis test, and the results were reported as median (interquartile range [IQR]). Statistical significance was set at a P value of <0.05. Clinical significance was defined as a reduction of ≥25%. TXA at 50 mg/mL led to a slight reduction in CFU counts (4.5%). However, it was at 10 mg/mL that the reduction reached 27.2% and 33.0% for log CFU/mL counts and percentage of live cells, respectively. TXA was not efficacious for reducing preformed 24-h mature staphylococci and 48-h mature C. acnes biofilms, regardless of its concentration. TXA did not exert an antimicrobial effect against bacterial biofilms. However, when bacteria were in the planktonic form, it led to a clinically and statistically significant reduction in bacterial growth at 10 mg/mL. IMPORTANCE The possible use of TXA as an antibiotic agent in addition to its antifibrinolytic effect may play an important role in the prevention of prosthetic joint infection.
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Are outpatient total hip and knee arthroplasties safe? Jt Dis Relat Surg 2021; 32:1-2. [PMID: 33463410 PMCID: PMC8073460 DOI: 10.5606/ehc.2020.57898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 11/21/2022] Open
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Bone cement with screw augmentation technique for the management of moderate tibial bone defects in primary knee arthroplasty patients with high body mass index. Jt Dis Relat Surg 2021; 32:28-34. [PMID: 33463415 PMCID: PMC8073457 DOI: 10.5606/ehc.2021.76491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/10/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives
This study aims to investigate whether variables such as body mass index (BMI), size of the cement with screw augmentation area (CSA), distance between the base of tibial plate and the deepest point of the defect area (DPDA) may cause any mechanical problems leading to deterioration in tibiofemoral alignment or impact clinical outcomes when the surgeon utilizes bone cement with screw augmentation (BCSA) technique in the treatment of moderate non-contained tibial bone defects in total knee arthroplasty (TKA). Patients and methods
This cross-sectional study, conducted between March 2018 and March 2019, included 37 knees of 28 patients (4 males, 24 females; mean age 71.3±8.9; range, 55 to 86 years) with moderate tibial bone defects requiring treatment with BCSA during primary TKA. Patients with BMI >30 were scored with Hospital for Special Surgery (HSS) score for clinical outcomes; besides, CSA, DPDA, and tibiofemoral alignment were calculated on plain X-rays. Results
Mean BMI was 34.1±5.7 (range, 24.9 to 45.9). Patients had a mean follow-up period of 44±13.9 (range, 28 to 75) months. Mean postoperative CSA was 98.2±35.3 (range, 42 to 180) mm2 and DPDA was 7.4±2.6 (range, 3.5 to 12.9) mm. Mean HSS score at last follow-up was 88.0±7.5 (range, 71 to 97). Conclusion
Bone cement with screw augmentation technique was associated with satisfactory clinical outcomes and tibiofemoral alignment was not significantly deviated in patients with high BMI. We determined that neither the depth of DPDA nor the size of CSA had any correlation with clinical outcomes.
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Intravenous tranexamic acid is associated with safe reduced blood loss and transfusion rate in one-stage exchange for infected hip arthroplasty. Jt Dis Relat Surg 2021; 32:17-21. [PMID: 33463413 PMCID: PMC8073466 DOI: 10.5606/ehc.2021.77652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/23/2020] [Indexed: 12/05/2022] Open
Abstract
Objectives
This study aims to investigate if the use of intravenous (IV) tranexamic acid (TXA) during one-stage exchange for periprosthetic joint infection (PJI) of the hip that necessitates an extensive debridement is associated with decreased blood loss, if the rate of blood transfusion that may lead to side effects can be lowered with IV TXA, and if there is any difference regarding the occurrence of postoperative venous thromboembolism (VTE). Patients and methods
We retrospectively reviewed patients who underwent one-stage exchange for PJI of the hip with perioperative IV administration of TXA (n=163; 90 males, 73 females; mean age 68±10.3; range, 25 to 90 years) between January 2015 and December 2016 and compared them to another group (n=190; 106 males, 84 females; mean age 71±10.1; range, 39 to 92 years) who underwent one-stage exchange for PJI of the hip without perioperative IV administration of TXA between January 2006 and December 2012. Blood loss, transfusion rates, amount of transfused blood, and occurrence of VTE complications were observed. Results
Mean blood loss of the TXA group was significantly lower than that of the non-TXA group (2.4 L and 4.5 L, respectively; p<0.001). Patients in non-TXA group experienced significantly higher rate of blood transfusion (71.1% and 58.3%, respectively; p=0.014) and higher quantity of transfused packed red blood cells (3.2 and 1.9 units, respectively; p<0.001). There was one patient with VTE complication in each group. Conclusion
Even in the presence of infection, usage of IV TXA during one-stage exchange for PJI of the hip is associated with significantly lower blood loss and transfusion rates showing no higher risk of VTE events.
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Histopathological and immunohistochemical investigation of the local and systemic effects of tranexamic acid on the healing of the Achilles tendon in rats. Jt Dis Relat Surg 2021; 32:152-161. [PMID: 33463431 PMCID: PMC8073426 DOI: 10.5606/ehc.2021.76301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This study aims to compare the effects of systemic and local applications of tranexamic acid (TXA) on tendon healing using a rat Achilles tendon injury model. PATIENTS AND METHODS Thirty-six adult male albino Wistar rats (aging 3-4 months; weighing 350 to 400 g) were used in this study conducted between December 2019 and January 2020. The Achilles tendon was performed bilateral tenotomy and surgically repaired. Postoperatively, 1 mL of TXA was administered to each leg locally in the local group, whereas 2 mL of TXA was intraperitoneally administered in the systemic group. The control group was left untreated. Half of the rats were sacrificed on Day 15 and the other half on Day 30. Tendon healing was evaluated with the Bonar and the Movin scoring systems and immunohistochemical methods. RESULTS The systemic group had the highest Bonar and Movin scores on Day 15. All groups exhibited tendon healing on Day 30, with no significant differences among the groups. The tenocyte morphology was found to be more impaired in both TXA groups on Day 30 (p=0.013). Ground substance scores were lower in the systemic group on Day 30 (p=0.028). The fiber structure and arrangement scores were higher in the systemic group on Day 15 (p=0.007 and p=0.032). Immunohistochemical analyses showed that galectin-3 values exhibited a significant difference in all groups on Day 30 (p=0.020). In all groups, it was determined that type I collagen values showed an increasing trend on Day 30, compared to the values on Day 15, whereas type III collagen values showed a decreasing trend. CONCLUSION Our results demonstrated that local and systemic use of TXA does not impair tendon healing. Although advanced studies are needed, our study suggests that TXA application reduces the development of fibrosis.
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To sacrifice or replace the posterior cruciate ligament in primary total knee arthroplasty? Jt Dis Relat Surg 2020; 31:656-657. [PMID: 32962607 PMCID: PMC7607929 DOI: 10.5606/ehc.2020.57897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Çimen O, Azboy N, Çatal B, Azboy İ. Assessment of periprosthetic joint infection prevention methods amongst Turkish orthopedic surgeons in total joint replacement: A survey. Jt Dis Relat Surg 2020; 31:230-237. [PMID: 32584719 PMCID: PMC7489147 DOI: 10.5606/ehc.2020.71425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This study aims to assess the methods employed by Turkish orthopedic surgeons to prevent periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). PATIENTS AND METHODS The data obtained for this study, conducted between January 2019 and February 2019, were gathered by sending out an online survey to Turkish Society of Orthopedics and Traumatology members (n=2,267). A total of 354 orthopedic surgeons responded and completed survey. The survey had 23 questions which include the experience, academic position, hospital where the physician works, monthly arthroplasty numbers, and infection prevention methods employed before, during, and after surgery. RESULTS The period for antibiotics prophylaxis showed variability, with about 63% of surgeons using prophylaxis longer than 24 hours. In terms of academic position, 52.4% of professors and 52.8% of associate professors used prophylaxis for the first 24 hours whereas this rate was 31.3% in operators (p=0.01). Of surgeons, 50.7% who perform more than 10 arthroplasties per month and 33.6% of surgeons who perform less than 11 arthroplasties per month used 24-hour antibiotic prophylaxis (p=0.006). Blood glucose level assessment prior to surgery was performed by the majority of surgeons (94%). A total of 118 orthopedic surgeons (33.3%) performed methicillin- resistant Staphylococcus aureus (MRSA) decolonization with 54.7% of associate professors, 59.5% of professors, and 24.7% of operators (p=0.001). Only 60 surgeons (16.9%) checked vitamin D levels. CONCLUSION Our study results demonstrated that the majority of orthopedic surgeons in Turkey do not follow the antibiotic prophylaxis recommendations and they use antibiotic prophylaxis for longer periods. Professors and associate professors, and surgeons with higher monthly arthroplasty numbers than surgeons with lower monthly arthroplasty numbers follow the recommended periods more than their counterparts. Most surgeons assess blood glucose levels whereas a small number of surgeons perform MRSA decolonization and check vitamin D levels.
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Affiliation(s)
- Oğuzhan Çimen
- Koşuyolu İstanbul Medipol Hastanesi Ortopedi ve Travmatoloji Bölümü, 34718 Kadıköy, İstanbul, Türkiye.
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Levent A, Köse Ö, Linke P, Gehrke T, Çıtak M. Does tourniquet use decrease blood loss following primary total knee arthroplasty in Jehovah's Witness patients? Jt Dis Relat Surg 2020; 31:419-425. [PMID: 32962570 PMCID: PMC7607954 DOI: 10.5606/ehc.2020.76244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ali Levent
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767 Hamburg, Germany.
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