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Samborski SA, Morris SC, Leary S, Geiger K, Hlas A, Westermann R, Banffy M. Single Dose IV Tranexamic Acid is Safe for use in Hip Arthroscopy. Arthroscopy 2024:S0749-8063(24)00300-1. [PMID: 38703922 DOI: 10.1016/j.arthro.2024.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 03/25/2024] [Accepted: 03/30/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE The primary purpose of this study was to determine if TXA is safe to administer preoperatively for patients undergoing hip arthroscopy by comparing the rate of VTE and complications between patients who did and did not receive TXA pre-operatively. METHODS This is a multicenter consecutive cohort series of patients that underwent arthroscopic hip surgery from 2014-2021. The two cohorts were patients who did and did not receive TXA preoperatively (single dose of 1-2g) after a practice change. Data was collected via chart review. Surgical outcomes included: days until follow up, Visual Analog Scale (VAS) pain scores at first follow-up, total operating room time, number of arthroscopic fluid bags (3 liters/bag), complications and revision operations up to 1 year after surgery. A Mann-Whitney U test was performed for continuous variables and chi square test for categorical variables. RESULTS A total of 862 patients were identified: 449 (52%) did receive TXA and 413 (48%) did not. Patient demographics including age, sex, height, weight, BMI, smoking status, procedures performed, number of anchors used (no TXA: 3.5 anchors; TXA 3.7 anchors), and traction time (no TXA: 38 minutes; TXA: 40 minutes) did not significantly differ between groups. Significantly more patients had a prior hip arthroscopy in the group that received TXA (primary n=404; prior hip arthroscopy n=45) compared to the group that did not receive TXA (primary n=388; prior hip arthroscopy n=25) (p=0.03). VAS pain scores at the first follow up visit (no TXA: 2.61; TXA: 2.62 TXA) (p=0.62) and need for subsequent revision surgery were not significantly different (n=24 no TXA and n=18 TXA) (p=0.68). TXA use was associated with less arthroscopic fluid utilization (no TXA: 5.9 bags of 3L fluid; TXA: 5.3 bags of 3L fluid) (p<0.01) and less total operating room (OR) time (no TXA: 99.5 minutes; TXA: 90.0 minutes) (p<0.01). There was a higher overall complication rate in the no TXA group (n=27) compared to the TXA group (n=10) (p=0.01). However, if lateral femoral cutaneous nerve neuropraxia was excluded, then no difference in complication rate was observed (p=0.24). CONCLUSIONS There was no difference in the incidence of VTE complications between patients that did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the two groups when LFCN neuritis was excluded. No difference in early pain control or revision surgery rates were observed between groups. While there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. In conclusion, preoperative administration of TXA is a safe adjunct medication for patients undergoing arthroscopic hip surgery.
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Wang M, Li Y, Lin S, Ong MTY, Yung PSH, Li G. In Vivo Effect of Single Intra-Articular Injection of Tranexamic Acid on Articular Cartilage and Meniscus: Study in a Rat Model. J Bone Joint Surg Am 2024; 106:232-240. [PMID: 38015926 DOI: 10.2106/jbjs.23.00294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) has been increasingly used in arthroscopic surgery to prevent hemarthrosis. Despite its effectiveness, safety concerns have been raised regarding its potential cytotoxicity to articular cartilage and meniscus following intra-articular injection. METHODS To evaluate the impact of TXA on cartilage and meniscus, a rat model of knee instability was utilized wherein anterior cruciate ligament (ACL) transection surgery was followed by a single intra-articular injection of TXA at varying concentrations (0, 20, 50, 100, and 150 mg/mL) in saline solution. Cell viability assessment of the cartilage and meniscus (n = 6 per group) was conducted at 24 hours, and gross observation and histological analysis of the medial tibial plateau and medial meniscus were conducted at 2, 4, and 8 weeks (n = 6 per group and time point). RESULTS The chondrocyte viability was significantly decreased in the 50, 100, and 150 mg/mL TXA groups compared with the specimens injected with saline solution only (saline group) (p = 0.001, p < 0.001, p < 0.001, respectively), as was meniscal cell viability (p = 0.042, p < 0.001, p < 0.001, respectively). At week 8, the saline and 20 and 50 mg/mL groups showed relatively normal appearances, whereas the 100 and 150 mg/mL groups exhibited increased and varying severity of cartilage and meniscal degeneration. In the 150 mg/mL group, the mean Osteoarthritis Research Society International score was significantly higher than that in the saline and 20 mg/mL groups (p = 0.010 and p = 0.007). Additionally, the mean meniscus score in the 150 mg/mL group was significantly higher than that in the saline, 20 mg/mL, and 50 mg/mL groups (p = 0.020, p = 0.021, p = 0.031, respectively). CONCLUSIONS Our findings indicate that concentrations of TXA at or above 100 mg/mL can lead to decreased cell viability in both cartilage and meniscus, resulting in significant cartilage degeneration in rats with ACL transection. Furthermore, the use of 150 mg/mL of TXA led to significant meniscal degeneration. CLINICAL RELEVANCE It is prudent to avoid using concentrations of TXA at or above 100 mg/mL for intra-articular injection, as such concentrations may result in adverse effects on the cartilage and meniscus.
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Affiliation(s)
- Ming Wang
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Yucong Li
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Sien Lin
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Michael T Y Ong
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Patrick S H Yung
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Gang Li
- Stem Cells and Regenerative Medicine Laboratory, Prince of Wales Hospital, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
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Çağlar C, Akçaalan S, Akçaalan Y, Akcan G, Tufan AC, Akkaya M, Doğan M. Tranexamic acid administered intraarticularly to the knee is safer for the articular cartilage and anterior cruciate ligament compared to intravenous administration: Histological analysis of an experimental rat model. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:1045-1051. [PMID: 37566306 DOI: 10.1007/s00210-023-02666-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/08/2023] [Indexed: 08/12/2023]
Abstract
In this study, the effects of tranexamic acid (TXA) on the knee's articular cartilage, anterior cruciate ligament (ACL), and joint capsule were assessed histologically. There were 15 rats in each of the 3 groups, totaling 45 rats. Intraarticular (IA) saline injections were applied for the first group, IA TXA injections for the second group, and intravenous (IV) TXA injections for the third group. Using samples taken from the knee joint 3 weeks later, the medial/lateral femoral condyle and medial/lateral tibial plateau articular cartilages were evaluated with Osteoarthritis Research Society International (OARSI) scoring, while ACL diameter and joint capsule thickness were analyzed histologically. In comparisons of OARSI scores for the medial/lateral femoral condyle and medial/lateral tibial plateau cartilage regions, the scores obtained for the IV TXA group were significantly higher than those of the IA saline group (P < 0.001, P = 0.001, P = 0.003, P = 0.011). In comparisons of medial/lateral femoral condyle and medial/lateral tibial plateau OARSI scores, the scores obtained for the IV TXA group were again significantly higher than those of the IA TXA group (P < 0.001, P < 0.001, P < 0.001, P = 0.002). When ACL diameters were compared, a significant decrease was observed in the ACL diameters of the IV TXA group compared to the IA saline and IA TXA groups (P < 0.001, P = 0.039). Histologically, IV TXA damages the articular cartilage and ACL more than IA TXA. IA administration of TXA is more protective when the articular cartilage and ACL are preserved.
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Affiliation(s)
- Ceyhun Çağlar
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06800, Ankara, Turkey.
| | - Serhat Akçaalan
- Department of Orthopedics and Traumatology, Ankara City Hospital, 06800, Ankara, Turkey
| | - Yasemin Akçaalan
- Department of Anesthesiology and Reanimation, Ankara City Hospital, 06800, Ankara, Turkey
| | - Gülben Akcan
- Department of Histology and Embryology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Ahmet Cevik Tufan
- Department of Histology and Embryology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Mustafa Akkaya
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
| | - Metin Doğan
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University, 06800, Ankara, Turkey
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Wang J, Liang S, Ma T, Chen S, Hu Y, Wang L. Tranexamic Acid Causes Chondral Injury Through Chondrocytes Apoptosis Induced by Activating Endoplasmic Reticulum Stress. Arthroscopy 2023; 39:2529-2546.e1. [PMID: 37683831 DOI: 10.1016/j.arthro.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE To investigate whether tranexamic acid (TXA) is cytotoxic in chondrocyte and cartilage tissues, as well as explore the mechanisms behind the possible toxicity in detail. METHODS We detected the cell viability of chondrocytes in vitro and the change of morphology and specific in vivo contents of cartilage after TXA treatment. Furthermore, we detected apoptosis in cartilage. We used apoptosis-specific staining, reactive oxygen species detection, mitochondrial membrane potential detection, flow cytometry, and western blot for apoptosis detection. Finally, we detected the activation of endoplasmic reticulum stress (ERS) in TXA-treated chondrocytes to clarify the mechanism behind chondrocyte apoptosis. RESULTS TXA presented an increasing toxic effect with increasing concentrations, especially in the 100 mg/mL group. In addition, we found that 50 mg/mL and 100 mg/mL TXA significantly increased apoptosis in cartilage and subchondral bone. TXA could induce chondrocyte apoptosis in cell and protein levels with reactive oxygen species generation and mitochondrial membrane depolarization. An apoptosis inhibitor could inhibit the induced apoptosis. Next, TXA induced calcium overload in chondrocytes and increased ERS-specific protein expression, whereas ERS inhibitor blocked ERS activation and further inhibited chondrocyte apoptosis. CONCLUSIONS We concluded that TXA had a toxic effect on chondrocytes by inducing apoptosis through ERS activation, especially in 50 mg/mL and 100 mg/mL groups. We recommend TXA concentrations of less than 50 mg/mL in joint surgeries. CLINICAL RELEVANCE It is still unclear whether TXA has a toxic effect on cartilage when topically used in joint surgeries. The concentration also varies. This study provides additional evidence that TXA at high concentrations will cause cartilage damage, which will help to provide a new understanding of the clinical administration of TXA.
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Affiliation(s)
- Jiahao Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China
| | - Shuailong Liang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China
| | - Tianliang Ma
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China
| | - Sijie Chen
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yihe Hu
- Department of Orthopedics, First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China.
| | - Long Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratary of Aging Biology, Xiangya Hospital, Central South University, Changsha, China.
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Han C, Liu M, Lian X, Sun T, Yan S, Bai X, Gan D, Leng B, Qiu Y, Ren Y. Tranexamic acid use in arthroscopic rotator cuff repair is an effective and safe adjunct to improve visualization: a systematic review and meta-analysis. J Shoulder Elbow Surg 2023; 32:2389-2399. [PMID: 37468032 DOI: 10.1016/j.jse.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE Although tranexamic acid (TXA) is being increasingly used in orthopedic arthroplasty and lower-extremity arthroscopic procedures, its use in arthroscopic rotator cuff repair (ARCR) is less widely reported. The aim of this study was to evaluate the clinical effectiveness and safety of TXA administration in ARCR. METHODS A systematic review and meta-analysis of randomized controlled trials was performed to compare clinical outcomes in patients who underwent ARCR with or without TXA. Literature was retrieved using the Cochrane Library, MEDLINE, PubMed, and Embase electronic databases. The primary outcome of this study was visual clarity. Secondary outcomes contained total operative time, postoperative pain score, amount of blood loss, shoulder swelling (change in shoulder circumference), volume of irrigation fluid, number of adjustments of the pump pressure for irrigation, and adverse cardiovascular events. RESULTS Seven studies (3 and 4 with level I and II evidence, respectively), which included 272 and 265 patients who underwent arthroscopy with and without TXA, respectively, met the eligibility criteria. Pooled analysis showed significant improvements in visual clarity (mean difference, 9.10%; 95% CI, 4.05-14.15; P = .0004) and total operative time (mean difference, -11.24 minute; 95% CI, -19.90 to -2.57) associated with perioperative TXA application. None of the trials reported adverse events and complications associated with TXA. CONCLUSION The best available evidence indicates that TXA administration could significantly improve arthroscopic visual clarity and effectively save operative time in ARCR without increasing the incidence of adverse events. Furthermore, the optimal dose, route, and timing of TXA application in ARCR surgery remains to be validated by future high-level evidence studies.
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Affiliation(s)
- Changxu Han
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Ming Liu
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xin Lian
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Tao Sun
- Emergency Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Shengjuan Yan
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xianming Bai
- Spine Surgery Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Dige Gan
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Bing Leng
- Graduate School, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Yi Qiu
- Anesthesia Surgical Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
| | - Yizhong Ren
- Sports Medicine Center, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China.
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Takahashi R, Kajita Y, Iwahori Y, Harada Y. Tranexamic acid has no effect on postoperative pain control after arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial. Asia Pac J Sports Med Arthrosc Rehabil Technol 2023; 33:32-35. [PMID: 37693817 PMCID: PMC10491640 DOI: 10.1016/j.asmart.2023.08.003] [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: 07/07/2022] [Revised: 04/11/2023] [Accepted: 08/05/2023] [Indexed: 09/12/2023] Open
Abstract
Background The purpose of this study was to compare the efficacies of tranexamic acid (TXA) versus placebo after arthroscopic rotator cuff repair (ARCR). Methods This prospective, double-blind, and randomized study was conducted in 70 patients who underwent ARCR from 2021 to 2022 at our hospital. Thirty-four shoulders were randomly assigned to the TXA group, and 36 to the control group; TXA (10 mL) and normal saline (10 mL) were administered locally after surgery and in the control group, respectively. We evaluated visual analog scale pain scores at rest, during activity, and at night and the circumference and diameter of the shoulder joint in both groups preoperatively and at 1, 2, and 3 days, and 1 week after the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. Results There was no significant difference in the visual analog scale scores at rest, during activity, and at night between the groups (p > 0.05). The circumference and diameter of the shoulder joint were not also significantly different between both groups (p > 0.05). Conclusion Local TXA administration in patients who undergo ARCR does not significantly impact postoperative pain levels and the circumference and diameter of the shoulder joint.
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Affiliation(s)
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Japan
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Li J, You M, Yao L, Fu W, Li Q, Chen G, Tang X, Li J, Xiong Y. Topical administration of tranexamic acid reduces postoperative blood loss and inflammatory response in knee arthroscopic arthrolysis: a retrospective comparative study. BMC Musculoskelet Disord 2023; 24:269. [PMID: 37020204 PMCID: PMC10074680 DOI: 10.1186/s12891-023-06349-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Knee arthroscopic arthrolysis serves as an effective treatment for knee arthrofibrosis. However, hemarthrosis is the most common complication in arthroscopic surgery, which has potential adverse effects on postoperative rehabilitation. The purpose of this study was to evaluate the effects of topical tranexamic acid (TXA) in knee arthroscopic arthrolysis. METHODS A total of 87 patients with knee arthrofibrosis who underwent arthroscopic arthrolysis from September 2019 to June 2021 were eligible for this retrospective review. Patients in the TXA group (n = 47) received topical administration of TXA (50 mL, 10 mg/mL) at the end of the surgery, and patients in the control group (n = 40) received no TXA. The postoperative drainage volumes, hematologic levels, inflammatory marker levels, knee range of motion (ROM), visual analog scale (VAS) pain scores, Lysholm knee scores and complications were compared between the two groups. The curative effect of each group was calculated according to Judet's criteria. RESULTS The mean drainage volumes on postoperative day (POD) 1 and POD 2, and total drainage volume were significantly lower in the TXA group than in the control group (P < 0.001 for all). The TXA group had significantly lower postoperative CRP and IL-6 levels on POD 1 and POD 2, and at postoperative week (POW) 1 and POW 2 than the control group. The VAS pain scores in the TXA group were significantly lower on POD 1 and POD 2, and at POW 1 and POW 2 than those in the control group (P < 0.001 for all). Patients in the TXA group showed better postoperative ROM and Lysholm knee scores at POW 1 and POW 2. No patient had any complications such as deep venous thrombosis (DVT) or infection. The excellent and good rates of knee arthroscopic arthrolysis were comparable between the two groups at the sixth postoperative month (P = 0.536). CONCLUSIONS Topical administration of TXA in knee arthroscopic arthrolysis can reduce postoperative blood loss and inflammatory response, alleviate early postoperative pain, increase early postoperative knee ROM, and improve early postoperative knee function without increased risks.
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Affiliation(s)
- Junqiao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Mingke You
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lei Yao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Weili Fu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qi Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Gang Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jian Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yan Xiong
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Mousavi H, Akbari-Aghdam H, Entezari R. The effect of tranexamic acid injection during anterior cruciate ligament reconstruction surgery on postoperative bleeding, pain and swelling. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:639-644. [PMID: 35779145 DOI: 10.1007/s00590-022-03318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anterior Cruciate Ligament (ACL) reconstruction is a common surgery in orthopedics. Strategies that could reduce the bleeding during the surgery could be helpful. Here, we aimed to assess the effects of tranexamic acid injection in ACL reconstruction on patient's functions. METHODS This is a clinical trial performed in 2019-2020 in XX on 61 patients with teared ACL who were candidates of surgical reconstruction. Patients were divided into two groups receiving 15 mg/kg of intravenous tranexamic acid and normal saline. Data regarding the following items were collected: amounts of drain discharge, the severity of the swelling, the pain severity in 1, 7 and 14 days after the surgeries and restrictions in joint range of motion (ROM) in 30 and 60 days after the surgeries. RESULTS We observed significantly lower swelling severities in patients who received tranexamic acid in different measuring times (P = 0.029). These cases also had significantly lower pain severity after 30 days post-operation (P = 0.041). We also observed that patients in the tranexamic acid group had significantly lower ROM restriction than controls (P < 0.001). The total knee scores were similar in both groups (P > 0.05). CONCLUSION Administration of intravenous tranexamic acid significantly improved swelling, pain and lower ROM restriction in patients undergoing ACL reconstruction.
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Affiliation(s)
- Hamid Mousavi
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Hezar Jarib St., Isfahan, Isfahan Province, Iran
| | - Hossein Akbari-Aghdam
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Hezar Jarib St., Isfahan, Isfahan Province, Iran
| | - Reza Entezari
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Hezar Jarib St., Isfahan, Isfahan Province, Iran.
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Iseki T, Iseki T, Kanto R, Onishi S, Yoshiya S, Tachibana T, Nakayama H. Efficacy of intravenous tranexamic acid administration in medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO) for varus knee osteoarthritis: a randomized control trial. J Orthop Surg Res 2023; 18:178. [PMID: 36890541 PMCID: PMC9996975 DOI: 10.1186/s13018-023-03666-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/01/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND This randomized controlled study was undertaken to investigate the efficacy of intravenous tranexamic acid (TXA) administration in reducing perioperative blood loss in patients undergoing medial opening-wedge distal tibial tuberosity osteotomy (MOWDTO). It was hypothesized that TXA would reduce perioperative blood loss in MOWDTO. METHODS A total of 61 knees in 59 patients who underwent MOWDTO during the study period were randomly assigned to either of the groups with intravenous TXA administration (TXA group) or without TXA administration (control group). In the TXA group, patients received 1000 mg of TXA intravenously before skin incision and 6 h after the first dose. The primary outcomes was the volume of perioperative total blood loss which calculated using the blood volume and hemoglobin (Hb) drop. The Hb drop was calculated as the difference between preoperative Hb and postoperative Hb at days 1, 3, and 7. RESULTS The perioperative total blood loss was significantly lower in the TXA group (543 ± 219 ml vs. 880 ± 268 ml, P < 0.001). The Hb drop was significantly lower at postoperative days 1, 3 and 7 in the TXA group than in the control group (day 1: 1.28 ± 0.68 g/dl vs. 1.91 ± 0.69 g/dl, P = 0.001; day 3: 1.54 ± 0.66 g/dl vs. 2.69 ± 1.00 g/dl, P < 0.001; day 7: 1.74 ± 0.66 g/dl vs. 2.83 ± 0.91 g/dl, P < 0.001). CONCLUSION Intravenous TXA administration in MOWDTO could reduce the perioperative blood loss. Trial registration The study was approved by the institutional review board. (Registered on 26/02/2019 Registration Number 3136). Level of Evidence Level I, randomized controlled trial.
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Affiliation(s)
- Takuya Iseki
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan.
| | - Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Ryo Kanto
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Shintaro Onishi
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, 1-4 Ohama-Cho, Nishinomiya City, Hyogo, 662-0957, Japan
| | - Shinichi Yoshiya
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, 1-4 Ohama-Cho, Nishinomiya City, Hyogo, 662-0957, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
| | - Hiroshi Nakayama
- Department of Orthopaedic Surgery, Hyogo Medical University, 1-1 Mukogawa-Cho, Nishinomiya City, Hyogo, 663-8501, Japan
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Takahashi R, Kajita Y, Iwahori Y, Harada Y. Tranexamic acid administration for arthroscopic rotator cuff repair: A prospective, double-blind, randomized controlled trial. J Orthop Sci 2023; 28:328-332. [PMID: 34949506 DOI: 10.1016/j.jos.2021.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to compare the efficacy of tranexamic acid versus placebo after arthroscopic rotator cuff repair. METHODS This prospective, double-blind, and randomized study involved 66 patients who consecutively underwent arthroscopic rotator cuff repair from 2020 to 2021 at our hospital. Thirty-three shoulders each were randomly assigned to the tranexamic acid and control groups. In the former group, 1000 mg of tranexamic acid (20 mL) was administered intravenously 10 min before surgery and the same volume of normal saline (20 mL) was administered intravenously in the control group. We evaluated visual clarity; visual analog scale pain scores at rest, during activity, and at night; the circumference and diameter of the shoulder joint in the groups before and after the surgery at 1, 2, and 3 days, and 1 week; estimated perioperative blood loss; and operative time. Visual clarity was rated using a numeric rating scale from grade 1 (poor) to grade 3 (clear) every 15 min throughout the surgery. We compared and analyzed the results between the groups. Statistical significance was set at a p-value of <0.05. RESULTS Visual clarity was found to be significantly better in the tranexamic acid group, with a greater percentage of grade 3 visual clarity (75.6 ± 11.2% vs 68.1 ± 13.4%, p = 0.045). The visual analog scale scores at rest and at night in the control group were significantly lower than those in the tranexamic acid group for 1 week postoperatively (13.8 ± 14.8 vs 5 ± 9.3, p = 0.008, 36.1 ± 23.3 vs 19.3 ± 24, p = 0.012). The circumference and diameter of the shoulder joint, estimated perioperative blood loss, and operative time were not significantly different between the two groups. CONCLUSION Intravenous administration of tranexamic acid is an alternative way to improve visual clarity in arthroscopic rotator cuff repair; however, there are no other significant differences compared to the administration of placebo.
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Affiliation(s)
- Ryosuke Takahashi
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan.
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Ichinomiya Nishi Hospital, Japan; Department of Orthopaedic Surgery, Aichi Medical University, Japan.
| | - Yusuke Iwahori
- Department of Orthopaedic Surgery, Asahi Hospital, Japan.
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Japan.
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Zhu R, Jiang H, Xu W, Shen L, Jin G. Impact of intra-articular injection with tranexamic acid on total blood loss and postoperative pain after arthroscopic rotator cuff repair surgery. Front Surg 2023; 10:1052039. [PMID: 36911608 PMCID: PMC9995381 DOI: 10.3389/fsurg.2023.1052039] [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: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives To evaluate the impact of intra-articular injection with tranexamic acid (TXA) on total blood loss (TBL) and postoperative pain after arthroscopic rotator cuff repair (ARCR). Methods This study retrospectively included patients with full-thickness rotator cuff tears who underwent shoulder ARCR surgery in Taizhou hospital, China, between January 2018 and December 2020. Patients received 10 ml (100 mg/ml) of intra-articular TXA injection (TXA group) or 10 ml of normal saline (non-TXA group) after the incision was sutured. The primary variable was the type of drug injected into the shoulder joint at the end of the operation. The primary outcome were perioperative TBL and postoperative pain [measured by visual analog scale (VAS)]. The secondary outcomes were differences in red blood cell count, hemoglobin count, hematocrit, platelet count. Results A total of 162 patients were included, 83 patients in TXA group and 79 patients in non-TXA group. Notably, patients in TXA group were more likely to have lower TBL volume [261.21 (175.13-506.67) ml vs. 382.41 (236.11-593.31), P = 0.025], and postoperative VAS score ≤ 2 within 24 h (P = 0.031) compared with those in non-TXA group. In addition, the median hemoglobin count difference was significantly lower in TXA group than that of in non-TXA group (P = 0.045), while, the differences in median counts of red blood cell, hematocrit, and platelet between the two groups were comparable (all P > 0.05). Conclusion Intra-articular injection of TXA might reduce the TBL and degree of postoperative pain within 24 h after shoulder arthroscopy.
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Affiliation(s)
- Rangteng Zhu
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Hantao Jiang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Wei Xu
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Liping Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Gang Jin
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
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Johns WL, Walley KC, Jackson B, Gonzalez TA. Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis. Foot Ankle Spec 2022; 15:377-383. [PMID: 33401927 DOI: 10.1177/1938640020983639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Benjamin Jackson
- School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina
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Bolam SM, O’Regan-Brown A, Konar S, Callon KE, Coleman B, Dalbeth N, Monk AP, Musson DS, Cornish J, Munro JT. Cytotoxicity of tranexamic acid to tendon and bone in vitro: Is there a safe dosage? J Orthop Surg Res 2022; 17:273. [PMID: 35570313 PMCID: PMC9107642 DOI: 10.1186/s13018-022-03167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Tranexamic acid (TXA) has been shown to be effective at reducing peri-operative blood loss and haemarthrosis in arthroplasty and arthroscopic soft tissue reconstructions. Intra-articular application, as an injection or peri-articular wash, is becoming increasingly common. Recent studies have shown TXA has the potential to be cytotoxic to cartilage, but its effects on human tendon and bone remain poorly understood. The aim of this study was to investigate whether TXA has any detrimental effects on tendon-derived cells and osteoblast-like cells and determine whether there is a safe dosage for clinical application.
Materials and methods
Primary tendon-derived cells and osteoblast-like cells were harvested from hamstring tendons and trabecular bone explants, respectively, and analysed in vitro with a range of TXA concentrations (0 to 100 mg/ml) at time points: 3 and 24 h. The in vitro toxic effect of TXA was investigated using viability assays (alamarBlue), functional assays (collagen deposition), fluorescent microscopy and live/apoptosis/necrosis staining for cell death mechanisms in 2D monolayer and 3D collagen gel cell culture.
Results
There was a significant (P < 0.05) decrease in tendon-derived cell and osteoblast-like cell numbers following treatment with TXA ≥ 50 mg/ml after 3 h and ≥ 20 mg/ml after 24 h. In tendon-derived cells, increasing concentrations > 35 mg/ml resulted in significantly (P < 0.05) reduced collagen deposition. Fluorescence imaging confirmed atypical cellular morphologies with increasing TXA concentrations and reduced cell numbers. The mechanism of cell death was demonstrated to be occurring through apoptosis.
Conclusions
Topical TXA treatment demonstrated dose- and time-dependent cytotoxicity to tendon-derived cells and osteoblast-like cells with concentrations 20 mg/ml and above in isolated 2D and 3D in vitro culture. On the basis of these findings, concentrations of less than 20 mg/ml are expected to be safe. Orthopaedic surgeons should show caution when considering topical TXA treatments, particularly in soft tissue and un-cemented arthroplasty procedures.
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Goldstein K, Jones C, Kay J, Shin J, de Sa D. Tranexamic Acid Administration in Arthroscopic Surgery Is a Safe Adjunct to Decrease Postoperative Pain and Swelling: A Systematic Review and Meta-analysis. Arthroscopy 2022; 38:1366-1377.e9. [PMID: 34655767 DOI: 10.1016/j.arthro.2021.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 10/03/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model. RESULTS There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: -1.65, 95% confidence interval [CI] -3.41 to 0.10, P = .06, I2 = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I2 = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: -61.14 mL, 95% CI -104.43 to -17.85, I2 = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: -0.76, 95% CI -0.97 to -0.54, I2 = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI -3.43 to 4.50, I2 = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups. CONCLUSIONS This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kyle Goldstein
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Conor Jones
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario
| | - Jason Shin
- Department of Orthopaedic Surgery. University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario.
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The utilization of tranexamic acid in orthopaedic procedures and gap in research for its benefits conferred in hip arthroscopy. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alkhatib N, AlNouri M, Abdullah ASA, Ahmad Alzobi OZ, Alkaramany E, Sasaki E, Ishibashi Y. Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Arthroscopy 2022; 38:506-518.e6. [PMID: 34358640 DOI: 10.1016/j.arthro.2021.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review all available randomized controlled trials (RCTs) in the literature that examine outcomes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effectiveness. METHODS PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes. RESULTS A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded "low" in 4 RCTs, "some concerns" in 2 RCTs, and "high" in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I2 = 96%, P = .14) and 12 weeks (MD -0.03, I2 = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I2 = 56%, P < .00001) and weeks 3-6 (MD -0.38, I2 = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I2 = 74%, P = .002) and weeks 4-6 (MD 6.17, I2 = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I2 = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I2 = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5. CONCLUSIONS Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early improvements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak. LEVEL OF EVIDENCE Level II, systematic review of therapeutic Level I-II studies.
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Affiliation(s)
- Nedal Alkhatib
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mason AlNouri
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hirosaki University, Hirosaki, Aomori, Japan.
| | - Abdullah Saad A Abdullah
- Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Eslam Alkaramany
- Orthopaedic Surgery Department, Hamad Medical Corporation, Doha, Qatar
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hirosaki University, Hirosaki, Aomori, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hirosaki University, Hirosaki, Aomori, Japan
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Na Y, Jia Y, Shi Y, Liu W, Han C, Hua Y. Administration of Tranexamic Acid to Reduce Intra-articular Hemarthrosis in ACL Reconstruction: A Systematic Review. Orthop J Sports Med 2022; 10:23259671211061726. [PMID: 35111862 PMCID: PMC8801653 DOI: 10.1177/23259671211061726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Although tranexamic acid (TXA) has been shown to reduce bleeding in joint replacement procedures, its effectiveness for anterior cruciate ligament reconstruction (ACLR) has not been widely reported. Purpose: To evaluate the effectiveness of TXA to reduce postoperative hemarthrosis and improve clinical outcomes after ACLR. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review of the literature following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was performed; literature retrieval was carried out using the MEDLINE, Embase, and Cochrane Library electronic databases. The inclusion criteria were comparative studies in English that reported the administration of intravenous or intra-articular TXA versus other modalities or placebo in patients undergoing ACLR. Results: Six studies comprising 418 patients who were treated with TXA were included. Heterogeneity among studies did not allow for the pooling of data. Five studies showed decreased drainage volume in the first 24 or 48 hours postoperatively as compared with control (ACLR with no TXA). Four studies showed lower hemarthrosis grades and visual analog scale scores in TXA versus control in the early postoperative period, although this difference was not evident at 4 weeks postoperatively. No studies showed differences in infection, deep venous thrombosis, or adverse events between the TXA and control groups. Conclusion: The current best available evidence suggests that TXA administration at the time of ACLR results in decreased intra-articular bleeding (measured using a drainage system), hemarthrosis grade, and pain when compared with control.
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Affiliation(s)
- Yuyan Na
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yanbo Jia
- Department of Arthroscopy and Sports Medicine, the Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Yuting Shi
- Cardiac Function Department, Cadre Health Care Center, Inner Mongolia Autonomous Region People’s Hospital, Hohhot, Inner Mongolia Autonomous Region, China
| | - Wanlin Liu
- Department of Pediatric Orthopedics, the Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Changxu Han
- Department of Arthroscopy and Sports Medicine, the Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Johns WL, Walley KC, Hammoud S, Gonzalez TA, Ciccotti MG, Patel NK. Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:4030-4041. [PMID: 33630652 DOI: 10.1177/0363546521988943] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study. PURPOSE To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures. STUDY DESIGN Meta-analysis. METHODS A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis. RESULTS Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, -95.51 to -27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (-1.96 points; 95% CI, -2.19 to -1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups. CONCLUSION The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Sommer Hammoud
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tyler A Gonzalez
- School of Medicine, University of South Carolina, Columbia, South Carolina, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Medical College of Virginia at Virginia Commonwealth University, Richmond, Virginia, USA
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Haratian A, Shelby T, Hasan LK, Bolia IK, Weber AE, Petrigliano FA. Utilization of Tranexamic Acid in Surgical Orthopaedic Practice: Indications and Current Considerations. Orthop Res Rev 2021; 13:187-199. [PMID: 34703327 PMCID: PMC8541761 DOI: 10.2147/orr.s321881] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023] Open
Abstract
Tranexamic acid (TXA) is a lysine analog that exhibits an anti-fibrinolytic effect by directly preventing the activation of plasminogen as well as inhibiting activated plasmin from degrading fibrin clots, thereby promoting hemostasis and reducing the duration and quantity of blood loss. The aims of this study were to summarize the indications, routes of administration, safety, and clinical outcomes of TXA use throughout the different subspecialities in orthopedic surgery. Given that orthopedic procedures such as TKA, THA, fracture fixation, and various spine surgeries involve significant intraoperative blood loss, TXA is indicated in providing effective perioperative hemostasis. Additionally, use of TXA in orthopedic trauma has been indicated as a measure to reduce blood loss especially in a group with potential for hemodynamic compromise. TXA has been implicated in reducing the risk of blood transfusions in orthopedic trauma, joint surgery, and spine surgery, although this effect is not seen as prominently in sports medicine procedures. There remains disagreement in literature as to whether TXA via any route of administration can improve other clinically significant outcomes such as hospital length of stay and total operative time. Procedures that rely extensively on clarity on visualization of the surgical field such as knee and shoulder arthroscopies can greatly benefit from the use of TXA, thereby leading to less intraoperative bleeding, with better visual clarity of the surgical field. While most studies agree thrombosis due to TXA is unlikely, new research in cells and animal models are evaluating whether TXA can negatively impact other aspects of musculoskeletal physiology, however with conflicting results thus far. As of now, TXA remains a safe and effective means of promoting hemostasis and reducing intraoperative blood loss in orthopedic surgery.
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Affiliation(s)
- Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Tara Shelby
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Tan TK, Ng KT, Lim HJ, Radic R. Effect of tranexamic acid in arthroscopic anterior cruciate ligament repair: A systematic review and meta-analysis of randomised clinical trials. J Orthop Surg (Hong Kong) 2021; 29:23094990211017352. [PMID: 34027721 DOI: 10.1177/23094990211017352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Perioperative blood loss remains a major challenge to surgeons in anterior cruciate ligament reconstruction (ACLR) surgery, despite of the introduction of minimally invasive approach. Tranexamic acid (TXA) is believed to reduce blood loss, which may minimise the complication of postoperative haemarthrosis with insufficient evidence on its effectiveness in ACLR. The primary aim of this study was to examine the effect of TXA on postoperative blood loss and other secondary outcomes in patients undergoing arthroscopic ACLR surgery. METHOD PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All randomised clinical trials (RCTs) comparing TXA (intravenous or intra-articular) versus placebo in the arthroscopic ACLR surgery were included. Case series, case report and editorials were excluded. RESULTS Five RCTs comprising of a total of 580 patients (291 in TXA group, 289 in control group) were included for qualitative and quantitative meta-analysis. In comparison to placebo, TXA group was significantly associated with lower postoperative blood loss (mean difference (MD): -81.93 ml; 95% CI -141.80 to -22.05) and lower incidence of needing knee aspiration (odd ratio (OR): 0.19; 95% CI 0.08 to 0.44). Patients who randomised to TXA were also reported to have better range of movement (MD: 2.86; 95% CI 0.54 to 5.18), lower VAS Pain Score (MD: -1.39; 95% CI -2.54 to -0.25) and higher Lysholm Score (MD: 7.38; 95% CI 2.75 to 12.01). CONCLUSION In this meta-analysis, TXA reduced postoperative blood loss with lesser incidence of needing knee aspiration along with better range of knee movement and Lysholm score in patients undergoing arthroscopic ACLR surgery.
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Affiliation(s)
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia
| | - Hui Jane Lim
- 155310Altnagelvin Area Hospital, Londonderry, UK
| | - Ross Radic
- Perth Orthopaedics and Sports Medicine Research Institute, West Perth, WA, Australia
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Bolia IK, Haratian A, Bell JA, Hasan LK, Saboori N, Palmer R, Petrigliano FA, Weber AE. Managing Perioperative Pain After Anterior Cruciate Ligament (ACL) Reconstruction: Perspectives from a Sports Medicine Surgeon. Open Access J Sports Med 2021; 12:129-138. [PMID: 34512045 PMCID: PMC8426642 DOI: 10.2147/oajsm.s266227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.
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Affiliation(s)
- Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Jennifer A Bell
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Nima Saboori
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ryan Palmer
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Alaia MJ, Fried JW, Bloom DA, Hurley ET, Popovic J, Baron SL, Campbell KA, Strauss EJ, Jazrawi LM. Author Reply to "Regarding 'Tranexamic Acid Has No Effect on Postoperative Hemarthrosis or Pain Control After Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft: A Double-Blind, Randomized, Controlled Trial'". Arthroscopy 2021; 37:2020-2022. [PMID: 34225992 DOI: 10.1016/j.arthro.2021.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Michael J Alaia
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Jordan W Fried
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - David A Bloom
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eoghan T Hurley
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Jovan Popovic
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Samuel L Baron
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kirk A Campbell
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Laith M Jazrawi
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
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Chiang ER, Chen KH, Ma HL. Editorial Commentary: Tranexamic Acid Is Beneficial in the Very Early Postoperative Period in Anterior Cruciate Ligament Reconstruction Patients. Arthroscopy 2021; 37:1890-1891. [PMID: 34090572 DOI: 10.1016/j.arthro.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
Tranexamic acid (TXA) has been administrated in many orthopaedic surgical procedures to decrease perioperative and postsurgical bleeding. Relatively scant literature exists regarding the effect of TXA in patients after anterior cruciate ligament reconstruction. Currently, most evidence shows that within about 1 month after anterior cruciate ligament reconstruction, TXA can effectively reduce postoperative joint swelling and pain, as well as the aspiration rate. However, there are still controversies regarding the optimal dosage, timing, and route of administration of TXA in these patients. In addition, the potential chondrotoxic effect of TXA needs to be further clarified with longer clinical follow-up.
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Fried JW, Bloom DA, Hurley ET, Baron SL, Popovic J, Campbell KA, Strauss EJ, Jazrawi LM, Alaia MJ. Tranexamic Acid Has No Effect on Postoperative Hemarthrosis or Pain Control After Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft: A Double-Blind, Randomized, Controlled Trial. Arthroscopy 2021; 37:1883-1889. [PMID: 33529783 DOI: 10.1016/j.arthro.2021.01.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this double-blind, randomized, controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone-patellar tendon-bone (BPTB) anterior cruciate ligament reconstruction (ACLR) regarding postoperative hemarthrosis, pain, opioid consumption, and quadriceps atrophy and activation. METHODS A controlled, randomized, double-blind trial was conducted in 110 patients who underwent ACLR with BPTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-g boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated and the volume of blood (in milliliters) was recorded. Additionally, we recorded perioperative blood loss (in milliliters); visual analog scale scores on postoperative days 1, 4, and 7 and at postoperative weeks 1, 6, and 12; postoperative opioid consumption on postoperative days 1, 4, and 7; range of motion (ROM) and ability to perform a straight leg raise at postoperative weeks 1, 6, and 12; and preoperative and postoperative thigh circumference ratio. RESULTS There was no significant difference in perioperative blood loss between the TXA and control groups (32.5 mL vs 35.6 mL, P = .47). In the TXA group, 23 knees were aspirated; in the control group, 26 knees were aspirated (P = .56). No significant difference in postoperative hemarthrosis volume was seen in patients who received IV TXA versus those who did not (26.7 mL vs 37.3 mL, P = .12). There was no significant difference in visual analog scale scores between the 2 groups (P = .15); in addition, there was no difference in postoperative opioid consumption (P = .33). No significant difference in ROM, ability to perform a straight leg raise, or postoperative thigh circumference ratio was observed (P > .05 for all). CONCLUSIONS IV TXA in patients who undergo ACLR with BPTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early postoperative recovery regarding ROM or quadriceps reactivation. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Jordan W Fried
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - David A Bloom
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eoghan T Hurley
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Samuel L Baron
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Jovan Popovic
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kirk A Campbell
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Laith M Jazrawi
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Michael J Alaia
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A..
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Bolam SM, O'Regan-Brown A, Paul Monk A, Musson DS, Cornish J, Munro JT. Toxicity of tranexamic acid (TXA) to intra-articular tissue in orthopaedic surgery: a scoping review. Knee Surg Sports Traumatol Arthrosc 2021; 29:1862-1871. [PMID: 32860523 DOI: 10.1007/s00167-020-06219-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/06/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Intra-articular administration of tranexamic acid (TXA) in orthopaedic arthroplasty and arthroscopic procedures has become increasingly common over the past decade. However, several recent reports have shown that TXA has the potential to be cytotoxic to cartilage, tendon and synovium. Our aim was to review the literature for evidence of toxic effects from TXA exposure to intra-articular tissue. METHODS A scoping review methodology was used to search for studies assessing the toxic effects of TXA exposure to intra-articular tissues. MEDLINE, EMBASE, SCOPUS and The Cochrane Library were searched. Relevant information was extracted and synthesis of the retrieved data followed a basic content analytical approach. RESULTS A total of 15 laboratory studies were retrieved. No clinical studies reporting a toxic effect of TXA on intra-articular tissue were identified in our search. Studies were analysed according to species of origin, tissue of origin and study setting (in vitro, ex vivo, or in vivo). There was increasing cytotoxicity to chondrocytes, tenocytes, synoviocytes and periosteum-derived cells with TXA concentrations beyond 20 mg/ml. Monolayer cell cultures appear more susceptible to TXA exposure, than three-dimensional and explant culture models. In vivo studies have not demonstrated a major toxic effect. CONCLUSIONS Current evidence suggests a dose-dependent toxic effect on cartilage, tendon, and synovial tissue. Concentrations of 20 mg/ml or less are expected to be safe. There is a significant body of evidence to suggest the need for caution with intraarticular administration of TXA. There is a need for further human clinical trials in order to clarify the long-term safety of TXA topical application.
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Affiliation(s)
- Scott M Bolam
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand.
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton, New Zealand.
| | - Arama O'Regan-Brown
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
| | - A Paul Monk
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton, New Zealand
- Auckland Bioengineering Institute, University of Auckland, 70 Symonds St, Grafton, 1010, New Zealand
| | - David S Musson
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
| | - Jillian Cornish
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
| | - Jacob T Munro
- Faculty of Medical and Health Sciences, University of Auckland, Building 502 201, 85 Park Road, Grafton, 1023, New Zealand
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton, New Zealand
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Davey MS, Hurley ET, Anil U, Moses A, Thompson K, Alaia M, Strauss EJ, Campbell KA. Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis. Arthroscopy 2021; 37:1290-1300.e6. [PMID: 33515736 DOI: 10.1016/j.arthro.2021.01.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable. RESULTS Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. CONCLUSIONS Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of RCTs.
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Affiliation(s)
- Martin S Davey
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eoghan T Hurley
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Utkarsh Anil
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Akini Moses
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kamali Thompson
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Michael Alaia
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kirk A Campbell
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
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Belk JW, McCarty EC, Houck DA, Dragoo JL, Savoie FH, Thon SG. Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies. Arthroscopy 2021; 37:1323-1333. [PMID: 33278534 DOI: 10.1016/j.arthro.2020.11.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder. METHODS A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores). RESULTS Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05). CONCLUSION Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients. LEVEL OF EVIDENCE II, systematic review of level I and II studies.
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Affiliation(s)
- John W Belk
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A..
| | - Eric C McCarty
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Darby A Houck
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Jason L Dragoo
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Felix H Savoie
- Department of Orthopaedics, Tulane University, New Orleans, Louisiana, U.S.A
| | - Stephen G Thon
- Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
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Alaia MJ, Gipsman AM. Editorial Commentary: The Benefits of Tranexamic Acid May Outweigh Risks in Arthroscopy and Sports Medicine. Arthroscopy 2021; 37:1334-1336. [PMID: 33812531 DOI: 10.1016/j.arthro.2021.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/08/2021] [Accepted: 01/14/2021] [Indexed: 02/02/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic that lowers the risk of hemarthrosis-related surgical complications and has been extensively studied in orthopaedic trauma surgery, primary and revision total joint replacement, open shoulder reconstruction, and spine surgery. Its use, however, has been minimally studied in orthopaedic sport medicine, and, in particular, arthroscopic surgery. Despite being an inexpensive medication with a minimal side effect profile, there has been a paucity of Level I and II studies to support or refute its use in some of the most common procedures performed in orthopaedic surgery. TXA may be of small benefit in routine partial meniscectomy or routine, outpatient, anterior cruciate ligament reconstruction. However, although there are potential risks and side effects of TXA, the risk is very low, the cost is very low, and even a small benefit may justify its use.
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Ma R, Wu M, Li Y, Wang J, Wang W, Yang P, Wang K. The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction for reducing postoperative hemarthrosis: a prospective randomized study. BMC Musculoskelet Disord 2021; 22:114. [PMID: 33499848 PMCID: PMC7836152 DOI: 10.1186/s12891-021-03990-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/19/2021] [Indexed: 12/15/2022] Open
Abstract
Background Hemarthrosis after anterior cruciate ligament (ACL) reconstruction can create many adverse joint effects. Tranexamic acid (TXA) can be used to minimize hemarthrosis and associated pain after ACL reconstruction. We aimed to compare the efficacies of intravenous (IV) administration and intra-articular (IA) injection of TXA during ACL reconstruction for reducing postoperative hemarthrosis. Methods A total of 120 patients who underwent arthroscopic ACL reconstruction were included in this prospective and randomized study. All patients were randomized into three groups: IV group, IA group and placebo group. Patients in the IV group received intravenously administered TXA (15 mg/kg in 100 mL of saline solution) 10 min before tourniquet release; patients in the IA group received intra-articular TXA (15 mg/kg in 100 mL of saline solution) injected via the drainage tube; and patients in the placebo group received an equivalent volume of normal saline administered into the knee joint cavity and intravenously. Drainage tubes were removed 24 h after surgery, and all enrolled patients experienced a 4-week follow-up period. The drain output volume, visual analogue scale (VAS) score, patellar circumference, hemarthrosis grade and Lysholm score of all patients were recorded. Results Both the IV group and the IA group had significantly lower drain output volumes at day 1, lower VAS scores at weeks 1 and 2, smaller patellar circumferences at weeks 1 and 2, and lower hemarthrosis grades at weeks 1 and 2 than the placebo group (p < 0.05). There were no significant differences in drain output volume, VAS score, patellar circumference or hemarthrosis grade between the IV group and the IA group at any time point (p > 0.05). No obvious differences in Lysholm score were observed between any pair of groups at week 4 (p > 0.05)). Neither infection nor deep vein thrombosis occurred in any group. Conclusions Both intravenous administration and intra-articular injection can reduce intra-articular hemarthrosis, joint pain and swelling during ACL reconstruction. No significant difference in the efficacies of reducing hemarthrosis, joint pain and swelling was found between intravenous administration and intra-articular injection. Trial registration The study was registered by the Chinese Clinical Trial Registry (The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction; ChiCTR-INR-17012217; August 1, 2017).
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Affiliation(s)
- Rui Ma
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Mengjun Wu
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Yongwei Li
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Jialin Wang
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Wei Wang
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Pei Yang
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Kunzheng Wang
- Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China.
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Complications of Tranexamic Acid in Orthopedic Lower Limb Surgery: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6961540. [PMID: 33532495 PMCID: PMC7834786 DOI: 10.1155/2021/6961540] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
Objective Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. Design A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. Results A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. Conclusions There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures.
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Comparison of the efficacy of irrigation with epinephrine or tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A double-blind, randomized-controlled study. Jt Dis Relat Surg 2021; 32:115-121. [PMID: 33463426 PMCID: PMC8073435 DOI: 10.5606/ehc.2021.78393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/18/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES This study aims to investigate whether there was a difference between epinephrine (EPN) and tranexamic acid (TXA) in providing visual clarity during arthroscopic rotator cuff tear repair. PATIENTS AND METHODS This double-blind, prospective, randomized-controlled clinical study included a total of 90 patients (42 males, 48 females; mean age: 55.6±8.3 years; range, 18 to 69 years) in whom either EPN (EPN group, n=47) or TXA-diluted irrigation solutions (TXA group, n=43) were used during rotator cuff tear arthroscopy between December 2017 and November 2019. Arthroscopy was performed using irrigation fluid containing 0.33 mg of EPN per 1 L of saline in the EPN group and 0.42 mg of TXA per 1 L of saline in the TXA group. All procedures were performed by two specialized shoulder surgeons. Visual clarity (primary endpoint) was rated by the operating surgeon using the Visual Analog Scale (VAS) in the immediate postoperative period. Secondary endpoints included total operating time (TOT), potential thrombotic or thromboembolic side effects, mean arterial pressure (MAP), and total amount of irrigation fluid used. RESULTS There was no significant difference in the surgeon rated- VAS scores between the groups. The mean VAS score was 7.6±1.62 (range, 4 to 10) in the EPN group and 7.1±1.74 (range, 3 to 10) in the TXA group (p=0.59). No cardiac, thrombotic, or thromboembolic complications were observed in any of the groups. CONCLUSION Adding TXA to the irrigation fluid during the arthroscopic rotator cuff repair may provide similar visual quality to the EPN, as measured by VAS.
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Rodriguez-Merchan EC. Does Intravenous or Intraarticular Tranexamic Acid (TXA) Reduce Joint Bleeding Following Arthroscopic Anterior Cruciate Ligament (ACL) Reconstruction and Arthroscopic Meniscectomy? Can Intraarticular Use be Harmful to Chondrocytes? THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:557-559. [PMID: 33088855 DOI: 10.22038/abjs.2020.50710.2513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lee JW, Kim SG, Kim SH, Cho HW, Bae JH. Intra-articular Administration of Tranexamic Acid Has No Effect in Reducing Intra-articular Hemarthrosis and Postoperative Pain After Primary ACL Reconstruction Using a Quadruple Hamstring Graft: A Randomized Controlled Trial. Orthop J Sports Med 2020; 8:2325967120933135. [PMID: 32743011 PMCID: PMC7376302 DOI: 10.1177/2325967120933135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/01/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Insufficient data are available to support the routine use of tranexamic acid
(TXA) in anterior cruciate ligament (ACL) surgeries with respect to
administration method and frequency, exposure duration, dose, and adverse
effects. Purpose: To investigate whether intra-articular (IA) administration of TXA could
reduce hemarthrosis and postoperative pain in patients after ACL
reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 47 patients were included in this study, which was performed
between July 2017 and May 2019. Single-bundle reconstructions using
autologous hamstring tendon grafts were performed in all patients. The
patients were randomized into 2 groups: the TXA group (received the index
procedure with 100-mL IA injection of TXA [30 mg/mL]) and a control group
(did not receive IA injection of TXA). No patients received a drain. Blood
loss was calculated on the basis of hemoglobin balance at postoperative day
(PD) 2. The visual analog scale (VAS) for pain score was assessed at PD 3.
The midpatellar circumference was measured at PD 2 and PD 5. Knee range of
motion (ROM) was evaluated 6 weeks after surgery. Results: The mean ± SD blood loss was 467 ± 242 mL in the TXA group and 558 ± 236 mL
in the control group. No significant differences were found for blood loss
(P = .20), VAS pain scores (P = .28),
ROM at postoperative week 6 (P = .61), or patellar
circumference at PD 2 (P = .75) and PD 5
(P = .84). Conclusion: This study showed that IA administration of 3.0 g of TXA had no effect in
reducing blood loss and postoperative pain after primary anatomic
single-bundle ACL reconstruction using quadruple hamstring autografts. Registration: NCT04042688 (ClinicalTrials.gov
identifier).
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Affiliation(s)
- Ja-Woon Lee
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Su-Hyun Kim
- Department of Orthopedic Surgery, Naval Maritime Medical Center, Jinju, Republic of Korea
| | - Hyun-Woo Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Bae
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Levy BJ, Sperling K, Davila J, Levy IM. A Novel Case of Recurrent Hemarthrosis Following Knee Arthroscopy in a Patient with Undiagnosed Hemophilia. Arthrosc Sports Med Rehabil 2020; 2:e289-e294. [PMID: 32548594 PMCID: PMC7283926 DOI: 10.1016/j.asmr.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Benjamin J Levy
- University of Connecticut, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut
| | - Karen Sperling
- Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Jennifer Davila
- Department of Pediatrics, Division of Hematology, Albert Einstein College of Medicine, Bronx, New York
| | - I Martin Levy
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Hurley ET, Lim Fat D, Pauzenberger L, Mullett H. Tranexamic acid for the Latarjet procedure: a randomized controlled trial. J Shoulder Elbow Surg 2020; 29:882-885. [PMID: 32305106 DOI: 10.1016/j.jse.2020.01.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 12/26/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce perioperative bleeding and the need for transfusion. The purpose of the study was to assess whether TXA could reduce the incidence of postoperative swelling and hematoma formation and pain and opioid use in the early postoperative period following the Latarjet procedure. METHODS A randomized controlled trial was conducted in 100 patients undergoing open Latarjet surgery for anterior shoulder instability by a single surgeon. Patients were randomized to receive either 1 g TXA or a placebo intravenously preoperatively. Outcomes measured during the perioperative period were (1) intraoperative blood loss, (2) postoperative blood loss (via drain output), (3) postoperative swelling/hematoma formation, (4) visual analog scale (VAS) score, and (5) postoperative opioid use (in morphine milligram equivalents). RESULTS There was no significant difference in intraoperative blood loss (60.9 vs. 68.9 mL, P = .18). However, there was significantly lower postoperative blood loss with TXA (29.6 vs. 64.9 mL, P < .01). There was a significantly lower rate of painful postoperative swelling (4% vs. 32%, P < .01). Additionally, we found a significantly lower VAS score for pain (1.7 vs. 3.0, P < .01) and significantly less postoperative opioid use (9.4 vs. 22 mg, P < .01) in the TXA group. Postoperative swelling was shown to correlate with increased pain and opioid use (P < .01). CONCLUSION Our study found that TXA significantly reduced postoperative blood loss, painful postoperative swelling, and hematoma formation and subsequently reduced postoperative pain and opioid use following the Latarjet procedure.
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Affiliation(s)
- Eoghan T Hurley
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Department of Trauma & Orthopaedic Surgery, Dublin, Ireland; National University of Ireland Galway, Galway, Ireland.
| | | | | | - Hannan Mullett
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Department of Trauma & Orthopaedic Surgery, Dublin, Ireland
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Liu YF, Hong CK, Hsu KL, Kuan FC, Chen Y, Yeh ML, Su WR. Intravenous Administration of Tranexamic Acid Significantly Improved Clarity of the Visual Field in Arthroscopic Shoulder Surgery. A Prospective, Double-Blind, and Randomized Controlled Trial. Arthroscopy 2020; 36:640-647. [PMID: 31870749 DOI: 10.1016/j.arthro.2019.10.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/31/2019] [Accepted: 10/16/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine whether intravenous administration of tranexamic acid (TXA) before shoulder arthroscopic rotator cuff repair surgery can improve arthroscopy visual clarity. METHODS This was a prospective, double-blind, randomized, and placebo-controlled study. From May 2016 to April 2018, patients requiring arthroscopic rotator cuff repair were enrolled and randomly assigned to either the TXA group. receiving 1000 mg of TXA intravenously 10 minutes before surgery. or the placebo group. receiving the same volume of plain saline. Patients with pre-existing liver/renal disease, coagulopathy, or concurrent use of anticoagulation medications were excluded. Visual clarity was rated using a Numeric Rating Scale from grade 1 (poor) to grade 3 (clear) every 15 minutes throughout the surgery. Secondary outcomes included estimated perioperative blood loss, operative time, degree of shoulder swelling, postoperative subjective pain score, inpatient duration, and associated comorbidities were recorded. Both parametric and nonparametric methods were used for the statistical analysis. RESULTS In total, 72 patients were enrolled, 37 in the TXA group and 35 in the placebo group. The demographic data were similar between the 2 groups. Visual clarity was found to be significantly better in the TXA group, with a greater percentage of grade 3 vision clarity (53.7 ± 18.9 % vs 40.5 ± 22.1%, P = .036). The average visual score in the TXA group (2.5 ± 0.2) also was better than that of the control group (2.3 ± 0.3) (P = .048). The postoperative subjective pain score was significantly lower in the TXA group (3.0 ± 1.5) than in the control group (4.3 ± 2.0) (P = .009). In addition, postoperative analgesic usage was significant lower in the TXA groups (9.6 ± 9.7 morphine milligram equivalent) than in the control group (14.7 ± 13.4 morphine milligram equivalent) (P = .037). Other parameters, such as operative time, estimated perioperative blood loss, degree of shoulder swelling, and duration of inpatient stay were similar between the 2 groups. None of the patients developed complications after surgery. CONCLUSIONS Intravenous administration of TXA is an alternative way to improve visual clarity in arthroscopic shoulder surgery. It also reduces subjective pain and analgesic consumption in the early postoperative period without significant side effects. LEVEL OF EVIDENCE Therapeutic studies level II.
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Affiliation(s)
- Yuan-Fu Liu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Yueh Chen
- Department of Orthopaedic Surgery, Sin Lau Christian Hospital, Tainan, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Tranexamic acid is effective in decreasing postoperative intraarticular bleeding in arthroscopic knee surgery. Blood Coagul Fibrinolysis 2020; 31:175-178. [PMID: 31990755 DOI: 10.1097/mbc.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Arthroscopic knee surgery to perform partial meniscectomy and anterior cruciate ligament (ACL) reconstruction is frequent and effective, although a possible complication is postoperative hemarthrosis. When intraarticular bleeding occurs, in addition to the associated pain, the patient usually requires joint aspiration (arthrocentesis) to avoid loss of range of motion (ROM). Sometimes this complication ends up associated with a poor result of surgery due to a loss of ROM. The aim of this narrative review of the literature is to attempt to clarify whether tranexamic acid (TXA) should be utilized in arthroscopic ACL reconstruction and arthroscopic meniscectomy and by what route (intraarticular or intravenous). A number of studies seem to favor the use of intravenous TXA in patients undergoing ACL reconstruction and arthroscopic synovectomy to diminish articular postoperative bleeding and its consequences (pain, swelling, loss of ROM, and the need for arthrocentesis). Regarding the use of intraarticular TXA, one in-vitro study has indicated that TXA in high concentrations is cytotoxic to chondrocytes. Common sense leads me to conclude that until better designed studies can confirm that intraarticular TXA is not cytotoxic to chondrocytes, its use should not be advised. Currently, for patients undergoing arthroscopic ACL reconstruction and arthroscopic meniscectomy, it seems safer to use intravenous TXA.
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Regarding "Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study". Arthroscopy 2019; 35:2974-2975. [PMID: 31699245 DOI: 10.1016/j.arthro.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/10/2019] [Indexed: 02/02/2023]
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Siegel MG. The Dangers and Concerns of Intra-articular Tranexamic Acid. Arthroscopy 2019; 35:2973-2974. [PMID: 31699244 DOI: 10.1016/j.arthro.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/10/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Mark G Siegel
- Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, Ohio, U.S.A
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Author Reply to "The Dangers and Concerns of Intra-articular Tranexamic Acid" and "Regarding 'Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study'". Arthroscopy 2019; 35:2975-2976. [PMID: 31699246 DOI: 10.1016/j.arthro.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 02/02/2023]
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Karaaslan F. Editorial Commentary: Tranexamic Acid: Okay, It Reduces the Bleeding, but Are We Sure Topical Use Is Not Harmful to the Cartilage? Arthroscopy 2019; 35:2133-2135. [PMID: 31272632 DOI: 10.1016/j.arthro.2019.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/12/2019] [Indexed: 02/02/2023]
Abstract
Numerous studies have estimated the role of hemarthrosis and intra-articular drains in anterior cruciate ligament (ACL) reconstructive procedures. Long-standing hemarthrosis and related pain can disrupt rehabilitation and lead to arthrofibrosis. A significant number of orthopaedic surgeons use intra-articular suction drains following arthroscopic ACL reconstruction. Hemarthrosis and pain have undesirable effects on the functional outcomes of ACL reconstruction in the early postoperative period.
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