The use of tranexamic acid to reduce blood loss during total knee arthroplasty

Does the clamping method in local and systemic TXA applications in total knee arthroplasty change the game?: A retrospective comparative cohort study

Many different methods and drain clamping periods have been described in systemic and local tranexamic acid (TXA) applications, and the superiority of the methods to each other has not been clearly demonstrated. The method of local infusion in combined TXA applications may not alter the Hb drop or total or hidden blood loss. We aim to compare two different combined TXA application methods. We retrospectively analyzed 182 patients who underwent total knee arthroplasty between 2018 and 2021. Patients over 40 years of age who underwent TKA for degenerative knee arthritis were included in the study. Unicondylar, revision, or bilateral arthroplasties and patients with the cardiovascular or cerebrovascular disease were excluded from the study. All patients in the study received 1 g TXA intravenously half an hour before the incision. For the first group, 1 g TXA was given intra-articularly at the drain site after closure, and the clamp was kept closed for 1 hour. In the second group, the drain was clamped for an additional 6 hours, and a 1 g intravenous dose was administered at the 5th hour postoperatively. No local applications were used in the control group. Total, hidden, and visible blood loss (total blood loss, hidden blood loss, visible blood loss), postoperative decreases in hemoglobin and hematocrit level (ΔHgb, ΔHtc), blood transfusion rates, and hospital stay durations were evaluated. There were 72 patients in the first group, 52 in the second, and 58 in control. A total of 37 patients received one or more blood transfusions postoperatively, and there was no statistical difference in the need for blood transfusions between the groups (P = .255). Although a statistically significant difference (P = .001) in total blood loss, hidden blood loss, visible blood loss and ΔHgb values was observed between the groups, the difference between the first and second groups was insignificant (P = .512). The duration of hospital stay was observed to be less in the first and second groups (P = .024). Local and systemic TXA applications were observed to be more effective than only systemic applications in reducing blood loss after total knee arthroplasty, regardless of the local method.

Combined use of intravenous and topical tranexamic acid efficiently reduces blood loss in patients aged over 60 operated with a 2-level lumbar fusion

PURPOSE

The current study was conducted to assess the efficacy and safety of the intravenous (IV) administration combined with topical administration of tranexamic acid (TXA)in patients (aged over 60) scheduled for a 2-level lumbar fusion surgery.

METHODS

Two hundred eighty patients scheduled for a 2-level lumbar fusion surgery were randomized into four groups, including an IV group, a local group, a combined group, and a control group. Patients in the combined group, in the IV group, in the topical group, and in the control group were administrated with 15 mg/kg of IV-TXA + 2 g TXA in local, 15 mg/kg IV-TXA, 2 g TXA in local, and 100 ml IV, respectively. The results of total blood loss (TBL), maximum hemoglobin drop, the transfusion rate, and the number of allogeneic blood units were compared. Deep venous thrombosis (DVT) and pulmonary embolism (PE) events were monitored and recorded.

RESULTS

The TBL was 635.49 ± 143.60, 892.62 ± 166.85, 901.11 ± 186.25, and 1225.11 ± 186.25 mL for the combined group, the IV group, the topical group, and the control group, respectively (p = 0.015, p = 0.001, respectively). The average maximum hemoglobin drop in the four above groups was 2.18 ± 0.24, 2.80 ± 0.37, 2.40 ± 0.64, and 3.40 ± 1.32 g/dL, respectively. No PE event was reported during the follow-up. Although asymptomatic DVT events were reported by 1, 2, and 2 patients in the combined group, topical group, and control group, respectively, there is no intergroup difference.

CONCLUSIONS

The combined use of TXA effectively reduced the total blood loss and blood transfusion rate in patients aged over 60 scheduled for a 2-level lumbar fusion, without increasing the incidence of DVT and PE formation.

Intravenous Tranexamic Acid Safely and Effectively Reduces Transfusion Rates in Revision Total Knee Arthroplasties

BACKGROUND

The efficacy and safety of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) have been well established. However, there have been limited data for revision TKAs. The primary aim was to assess the impact of intravenous TXA on transfusion rates and symptomatic venous thromboembolic events (VTEs) in a large revision TKA cohort with or without intravenous TXA utilization.

METHODS

A retrospective review of revision TKAs performed from 2005 to 2014 was performed, identifying 2,951 procedures (2,219 patients), in which TXA was utilized in 1,144 procedures (39%). The mean age was 65 years with 52% female patients in the TXA revision group and 67 years with 52% female patients in the non-TXA revision group. Transfusion rates and symptomatic VTEs were the primary outcomes assessed. Comparisons were performed between cohorts, utilizing a unique propensity model to mitigate bias, on the basis of TXA use and subsequently for aseptic or septic revision etiology.

RESULTS

Significant reductions in transfusion rates with use of TXA were identified in revision TKAs overall (13% compared with 39%; p < 0.001 [adjusted relative risk, 1.7]), including revisions for both aseptic etiology (6% with TXA compared with 28% without TXA; p < 0.001) and septic etiology (31% with TXA compared with 54% without TXA; p < 0.001). The risk of a postoperative symptomatic VTE was not significantly different (adjusted p = 0.63) with use of TXA at 11 events (1.0%) compared with 24 events (1.3%) in the non-TXA group).

CONCLUSIONS

Intravenous TXA significantly reduced transfusion rates in revision TKAs by approximately twofold, including cohorts revised for aseptic and septic etiologies. There was a very low rate of VTEs (1.2%) with no significant difference in the number of VTEs between groups after adjusting risk utilizing propensity modeling.

LEVEL OF EVIDENCE

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

Tranexamic Acid Administration Is Not Associated With an Increase in Complications in High-Risk Patients Undergoing Primary Total Knee or Total Hip Arthroplasty: A Retrospective Case-Control Study of 38,220 Patients

BACKGROUND

Tranexamic acid (TXA) administration to reduce postoperative blood loss and transfusion is a well-established practice for total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, clinical concerns remain about the safety of TXA in patients with a history of a prothrombotic condition. We sought to determine the risk of complications between high-risk and low-risk TKA and THA patients receiving TXA.

METHODS

We retrospectively reviewed 38,220 patients (8877 high-risk cases) who underwent primary TKA and THA between 2011 and 2017 at our institution. Intravenous TXA was administered in 20,501 (54%) of cases. The rates of thrombotic complications (deep vein thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], and cerebrovascular accident [CVA]) as well as mortality and readmission were assessed at 90 days postoperatively. Additionally, we evaluated 90-day postoperative occurrence of DVT and PE separate from occurrence of MI and CVA. Patients were categorized as high risk if they had a past medical history of a prothrombotic condition prior to surgery.

RESULTS

There was no significant difference in the odds of these adverse outcomes between high-risk patients who received TXA and high-risk patients who did not receive TXA (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85-1.18). There were also no differences when evaluating the odds of 90-day postoperative DVT and PE (OR 0.84, 95% CI 0.59-1.19) nor MI and CVA (OR 0.91, 95% CI 0.56-1.49) for high-risk patients receiving TXA vs high-risk patients who did not receive TXA.

CONCLUSION

TXA administration to high-risk TKA and THA patients is not associated with a statistically significant difference in adverse outcomes. We present incremental evidence in support of TXA administration for high-risk patients undergoing primary arthroplasties.

Combined use of intravenous and topical tranexamic acid in patients aged over 70 years old undergoing total hip arthroplasty

Purpose

The present study was designed to evaluate the efficacy and safety of combined use of intravenous (IV) TXA administration and topical intraarticular tranexamic acid (TXA) strategy in patients aged over 70 undergoing total hip arthroplasty (THA).

Methods

One hundred eighty patients were randomized into three groups, including an IV group, a local group, and a combined group. Patients were administrated with 15 mg/kg of IV-TXA in the IV group, 2 g TXA in the topical group, or 15 mg/kg IV-TXA combined with 2 g TXA in the combined group. Total blood loss (TBL), maximum hemoglobin drop, the transfusion rate and the number of allogeneic blood units, and the incidence of deep venous thrombosis (DVT), and pulmonary embolism (PE) were recorded and analyzed.

Results

TBL was 757.75 ± 188.95 mL in the combined group, which was significantly lower than in the IV group (892.75 ± 218.47) or the topical group (1015.75 ± 288.71) (p = 0.015, p = 0.001 respectively). The mean values of maximum hemoglobin drop in the combined, IV, and topical groups were 2.67 ± 0.42, 3.28 ± 0.52, and 3.75 ± 0.62 g/dL, respectively, with a significant intergroup difference (p < 0.001 for all). PE was not detected within 1 month after the surgery. Asymptomatic DVT was reported in 1 patient of the IV group, and in 2 patients from the combined group, while the difference was not statistically significant.

Conclusions

Compared to intravenous or topical use of TXA, the combined therapy effectively decreased total blood loss and reduced the transfusion rate, simultaneously possessed the same degree of safety in primary THA patients aged over 70.

Does Prophylactic Administration of TXA Reduce Mean Operative Time and Postoperative Blood Loss in Posterior Approach Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease?

STUDY DESIGN

This is a level III retrospective cohort study.

OBJECTIVE

To investigate association between prophylactic tranexamic acid (TXA) administration before 1 and 2-level posterior lumbar interbody fusion operations and perioperative blood loss (including intraoperative blood loss and postoperative drain output), mean operative time, postoperative transfusion, and postoperative venous thromboembolic events.

SUMMARY OF BACKGROUND DATA

TXA is a systemic antifibrinolytic that competitively inhibits lysine binding sites on plasminogen, reversibly blocking its binding to fibrin and impeding fibrinolysis and clot degradation. TXA's role in routine spinal surgery remains poorly described. Most spinal literature on perioperative TXA administration has considered operations performed for major adult and pediatric spinal deformity.

METHODS

Two groups, a study group composed of 75 patients who underwent 1 and 2-level posterior lumbar interbody fusion operations for degenerative indications who received TXA before the start of the procedure, and a control group composed of 75 patients who underwent similar surgeries for the same indications and did not receive TXA preoperatively, were retrospectively enrolled. Demographic, laboratory, and surgical data were collected and analyzed.

RESULTS

No statistically significant differences were found between groups with respect to surgery type, home anticoagulation, postoperative anticoagulation, preoperative hemoglobin and hematocrit, estimated intraoperative blood loss, postoperative day 2 drain output, postoperative day 3 drain output, rate of postoperative transfusion, and rate of postoperative thromboembolic events. Statistically significant reductions were noted in the TXA group with regards to postoperative day 1 drain output (P<0.0041), total postoperative drain output (P=0.027), and mean surgical time (P<0.0001).

CONCLUSIONS

In the present study, perioperative TXA administration was associated with reduced postoperative drain output and surgical time. Further higher-level studies are required to investigate the safety and utility of TXA's routine use in 1 and 2-level posterior lumbar fusion operations performed for degenerative indications.

Blood loss and perioperative transfusions related to surgery for spinal tumors. Relevance of tranexamic acid

INTRODUCTION

Tranexamic acid (TXA) has been shown to reduce bleeding. Patients with spinal tumors are fragile and acute anemia may be harmful. Tumor excision surgery is reputed to be hemorrhagic and treatment may increase thromboembolic complications. The aim of this study was to compare blood loss with or without perioperative TXA injection. The transfusion-related and postoperative complications were documents.

METHOD

This retrospective analysis of prospectively collected data involved 83 patients with spinal tumors who underwent decompressive surgery associated with bone fixation. Tranexamic acid was used arbitrarily in 36 of them, while the other 47 did not receive TXA. The overall, intraoperative and postoperative blood loss was recorded. Blood loss was reported relative to the number of fixed levels and the number of levels decompressed by laminectomy. Transfusions were quantified in number of red blood cell packets and erythrocyte volume. Postoperative complications were documented.

RESULTS

Epidemiological and morphological data were similar between groups. There were no significant differences between the two groups in the overall, intraoperative, and postoperative blood loss. A significant reduction in postoperative bleeding was found in the TXA group when the volume was related to the number of decompressed levels. A significant reduction (P<0.05) in the volume of transfused blood was identified in the treated group. No predictor of blood loss was identified, and no additional complications occurred.

CONCLUSION

The efficacy of TXA appears to be moderate during spinal tumor surgery since it does not lead to a reduction in perioperative bleeding. However, a significant reduction in transfusion volume was found without an increase in complications.

Comparative Efficacy of Intravenous With Intra-articular Versus Intravenous Only Administration of Tranexamic Acid to Reduce Blood Loss in Knee Arthroplasty

The objective of this study was to ascertain whether combined intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) is beneficial for reducing blood loss and the prevalence of deep venous thrombosis (DVT) in primary simultaneous bilateral total knee arthroplasty compared with IV only administration of TXA. One hundred fifty-four patients received a combined IV and IA injection of TXA in 1 knee and an IV only injection of TXA in the other. Transfusion rates and volumes and the amount of blood loss were recorded at 8 hours, 24 hours, and 48 hours. In addition, the authors ascertained whether the prevalence of DVT was higher in the patients with combined IV and IA administration of TXA than in the patients with IV only administration of TXA. Overall total blood loss was not significantly different (299.6 mL vs 280.1 mL, P=.22) between the 2 groups. The prevalence of DVT was 11% (17 knees) in the combined IV and IA group and 14% (22 knees) in the IV only group. This difference was not significant (P=.25). Combined IV and IA administration of TXA in bilateral total knee arthroplasty has no additional benefit in reducing total blood loss when compared with IV only administration. The prevalence of DVT was low and not significantly different between the 2 groups. Furthermore, no pulmonary embolism was found in either group. [Orthopedics. 2018; 41(6):e827-e830.].

Does tranexamic acid increase the risk of thromboembolism after bilateral simultaneous total knee arthroplasties in Asian Population?

PURPOSE

To ascertain whether tranexamic acid reduces the blood loss and transfusion rate and volumes; increase the prevalence of deep vein thrombosis (DVT); and investigate factors associated with DVT in patients undergoing primary bilateral total knee arthroplasties (TKAs) without use of chemical thromboprophylaxis.

METHODS

There were 874 patients (1748 knees) in the control group who did not receive tranexamic acid and 871 patients (1742 knees) in the study group who received tranexamic acid. Mechanical compression device was applied without any chemical thromboprophylaxis. Transfusion rates and volumes were recorded. DVT was diagnosed using both sonogram and venogram at 7 or 8 day post-operatively.

RESULTS

Intra- and post-operative blood loss and transfusion volumes were significantly lower in the tranexamic acid group. The prevalence of DVT was 14% (245 of 1748 knees) in the control group and 18% (314 of 1742 knees) in the tranexamic acid group. Pre- and post-operative perfusion lung scans revealed no evidence of PE in any patients in either group. Coagulation or thrombophilic data or molecular genetic testing was not significantly different between the two groups.

CONCLUSION

The use of tranexamic acid reduces the volume of blood transfusion and does not increase the prevalence of DVT or PE in the patients who did not receive routine chemical thromboprophylaxis after primary bilateral simultaneous sequential TKAs in Asian patients.

A comparative analysis of the role of Tranexamic acid as an independent variable in reducing intraoperative blood loss in patients undergoing conventional total knee arthroplasty versus computer-assisted total knee arthroplasty

BACKGROUND

Blood loss in total knee arthroplasty (TKA) is an area of significant concern as it has an effect on patient morbidity and hospital stay. Among many different modalities to reduce blood loss, the use of Tranexamic acid has become a standard procedure nowadays. The aim of our study was to determine if Tranexamic acid alone decreases blood loss as an independent variable irrespective of other blood loss preserving measures.

METHOD

This prospective non-randomized study included patients undergoing unilateral TKA by conventional method (Group 1) and computer-assisted TKA (Group 2). All the patients in both groups received Tranexamic acid in a dose of 10 mg/kg body weight prior to inflation of tourniquet. Blood loss in both the groups was calculated using Nadler's formula, and haemoglobin (Hb) level was calculated on day one and day three after surgery.

RESULTS

The mean drop of Hb in Group 1 was 1.608 and 1.56 g/dl in Group 2 which was statistically significant (p < 0.001); however, none of the patients in either of the groups actually required any blood transfusion postoperatively. Although there was a significant drop in haemoglobin and haematocrit in both the groups, on comparison, there was no significant difference in blood loss and fall in Hb levels between the groups (p > 0.001).

CONCLUSION

Tranexamic acid decreases blood loss in patients undergoing TKA independent of all the other blood conserving procedures.

Does intravenous tranexamic acid reduce blood loss during surgically assisted rapid palatal expansion?

Purpose:

The purpose of this study was to evaluate the efficacy of tranexamic acid (TXA) in reducing blood loss during surgically assisted rapid palatal expansion (SARPE) procedure.

Subjects and Methods:

A total of 34 patients (12 male, 22 female) who had been treated surgically under general anesthesia with SARPE including pterygoid disjunction for transverse maxillary deficiency (TMD) were included in this study. The study group (n=17) received intravenous (IV) TXA 10 mg/kg as a preoperative bolus; the control group (n=17) received normal saline solution. Preoperative and postoperative haemoglobin and haematocrit values, intraoperative blood loss, and any blood product transfusion were recorded.

Results:

Blood loss during SARPE was statistically significantly less in the study group than the control group (p=0.0001).

Conclusion:

Preoperative IV administration of TXA can effectively control blood loss during when SARPE with pterygoid disjunction is performed.

The effect of different dosage regimens of tranexamic acid on blood loss in bimaxillary osteotomy: a randomized, double-blind, placebo-controlled study

The purpose of this study was to compare the effects of three dosage regimens of intravenous tranexamic acid and normal saline placebo on blood loss and the requirement for transfusion during bimaxillary osteotomy. A prospective, randomized, double-blind, placebo-controlled study was performed. Eighty patients scheduled for elective bimaxillary osteotomy were divided into four groups: a placebo group and three groups receiving a single dose of tranexamic acid 10, 15, or 20mg/kg body weight after the induction of anaesthesia. Demographic data, the anaesthetic time, the operative time, and the experience of the surgical team were similar in the four groups. Patients receiving placebo had increased blood loss compared to those receiving tranexamic acid. No significant difference in blood loss was found among those who received 10, 15, or 20mg/kg body weight of tranexamic acid. There was no significant difference in transfusion requirement, amount of 24-h postoperative vacuum drainage, length of hospital stay, or complications among the four groups. Prophylactic tranexamic acid decreased bleeding during bimaxillary osteotomy. Of the three dosages of tranexamic acid studied, the most efficacious and cost-effective dose to reduce bleeding was 10mg/kg body weight.

Perioperative Management of Blood Loss in Spine Surgery

Spine procedures are associated with high rates of blood loss which can result in a greater need for transfusions. Repeated exposure to blood products is associated with risks and adverse reactions such as transfusion-related acute lung injury, fluid shifting, and infections. With the higher number of spine procedures and the increasing open surgery times associated with difficult procedures, excessive blood loss has become more prevalent. Perioperative methods have been established to combat the excessive blood loss and decrease the need for blood products. Preoperatively, anemia and coagulopathy screening is standard at least 4 weeks before elective procedures. Erythropoietin, iron loading or transfusions are used to decrease preoperative anemia, a predisposing factor for blood loss. Autologous predonation of blood has been shown to be ineffective and decreases preoperative hemoglobin levels. Intraoperatively, antifibrinolytics such as tranexamic acid and aminocaproic acid are used to decrease blood loss. In addition, fibrinogen concentrates, thromboelastometry, acute normovolemic hemodilution, controlled hypotension, and temperature regulation are some of the techniques used to decrease blood loss and the need for transfusions. Postoperatively, fibrin sealants, shed blood salvage, and erythropoietin or intravenous iron are used in management of blood loss, especially in instances when the patient refuses blood products.

Effect of Tranexamic Acid on Blood Loss and Blood Transfusion Reduction after Total Knee Arthroplasty

Purpose

Total knee arthroplasty (TKA) accompanies the risk of bleeding and need for transfusion. There are several methods to reduce postoperative blood loss and blood transfusion. One such method is using tranexamic acid during TKA. The purpose of this study was to confirm whether tranexamic acid reduces postoperative blood loss and blood transfusion after TKA.

Materials and Methods

A total of 100 TKA patients were included in the study. The tranexamic acid group consisted of 50 patients who received an intravenous injection of tranexamic acid. The control included 50 patients who received a placebo injection. The amounts of drainage, postoperative hemoglobin, and transfusion were compared between the groups.

Results

The mean amount of drainage was lower in the tranexamic acid group (580.6±355.0 mL) than the control group (886.0±375.5 mL). There was a reduction in the transfusion rate in the tranexamic acid group (48%) compared with the control group (64%). The hemoglobin level was higher in the tranexamic acid group than in the control group at 24 hours postoperatively. The mean units of transfusion were smaller in the tranexamic acid group (0.76 units) than in the control group (1.28 units).

Conclusions

Our data suggest that intravenous injection of tranexamic acid decreases the total blood loss and transfusion after TKA.

Impact of Tranexamic Acid in Total Knee and Total Hip Replacement

OBJECTIVE

To evaluate the net clinical benefit of tranexamic acid use in patients undergoing total knee or total hip replacement.

METHODS

This is a retrospective study of patients undergoing total knee or total hip replacement. The primary outcome was the net clinical benefit of tranexamic acid use. Secondary outcomes included length of stay, incidence of venous thromboembolism, change in hemoglobin, and number of units of blood transfused.

RESULTS

Four hundred and six patients were screened for inclusion and 327 patients met inclusion criteria; 174 patients received tranexamic acid versus 153 patients who received usual care. Tranexamic acid demonstrated a positive net clinical benefit versus usual care (40.8% vs 13.7%, P < .01) but did not affect length of stay (3.39 vs 3.37 days, respectively, P = .76). Venous thromboembolism was comparable between groups (2.3% vs 0.7%, P = .38). Average change in hemoglobin and need for transfusion were lower in the treatment group versus the usual care group, respectively (3.46 vs 4.26 mg/dL, P < .01).

CONCLUSION

Tranexamic acid demonstrated a significant benefit in decreasing change in hemoglobin as well as the need for blood transfusion with no increase in the risk of venous thromboembolism in patients undergoing total knee or total hip replacement.

Use of tranexamic acid in primary total knee replacement: effects on perioperative blood loss

BACKGROUND AND OBJECTIVES

The use of tranexamic acid in primary total knee replacement surgeries has been the subject of constant study. The strategies to reduce bleeding are aimed at reducing the need for blood transfusion due to the risks involved. In this study we evaluated the use of tranexamic acid in reducing bleeding, need for blood transfusion, and prevalence of postoperative deep vein thrombosis in primary total knee replacement.

METHOD

62 patients undergoing primary total knee replacement were enrolled in the study, from June 2012 to May 2013, and randomized to receive a single dose of 2.5g of intravenous tranexamic acid (Group TA) or saline (Group GP), 5min before opening the pneumatic tourniquet, respectively. Hemoglobin, hematocrit, and blood loss were recorded 24h after surgery. Deep vein thrombosis was investigated during patient's hospitalization and 15 and 30 days after surgery in review visits.

RESULTS

There was no demographic difference between groups. Group TA had 13.89% decreased hematocrit (p=0.925) compared to placebo. Group TA had a decrease of 12.28% (p=0.898) in hemoglobin compared to Group GP. Group TA had a mean decrease of 187.35mL in blood loss (25.32%) compared to group GP (p=0.027). The number of blood transfusions was higher in Group GP (p=0.078). Thromboembolic events were not seen in this study.

CONCLUSION

Tranexamic acid reduced postoperative bleeding without promoting thromboembolic events.

Does tranexamic acid reduce blood loss during head and neck cancer surgery?

Background and Aims:

Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery.

Methods:

After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications.

Results:

Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600–1000] ml vs. P - 780 [150–2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120–250] ml vs. TA - 250 [50–1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar.

Conclusion:

In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.

Combined Administration of Systemic and Topical Tranexamic Acid for Total Knee Arthroplasty: Can It Be a Better Regimen and Yet Safe? A Randomized Controlled Trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with substantial blood loss in postoperative period. Tranexamic acid (TXA) is potent antifibrinolytic agent, routinely administered by intravenous (IV) and topical route, which can possibly interrupt cascade of events due to hemostatic irregularities close to source of bleeding. However, scientific evidence of combined administration of TXA in TKA is still meagre. The present study aimed to compare efficacy of combined IV and topical TXA with IV use alone in terms of blood loss, transfusion rate, and incidence of deep vein thrombosis and thromboembolism.

PATIENTS AND METHODS

119 patients undergoing unilateral TKA were randomized into IV alone and combined group. Patients assigned to IV group were given IV TXA as a preoperative and postoperative dose given 3 and 6 hours after surgery, whereas in combined group, topical TXA solution was applied intraarticularly about 5 minutes before closure of arthrotomy in addition to IV doses.

RESULTS

Combined use of IV and topical TXA provided better results than IV use alone with mean calculated total blood loss (590.69±191.1 vs 385.68±182.5, P<.001), blood transfusion rate (6.6% vs 1.6%, P = .364), hemoglobin drop (1.82±0.6 vs 1.14±0.5, P<.001). No case of DVT or TE was noted among the 2 study groups.

CONCLUSION

Combined use of IV and intraarticular TXA provided significantly better results compared with IV use alone with respect to all variables related to postoperative blood loss in TKA. Moreover, TXA use is safe in terms of incidence of symptomatic DVT and TE.

Tranexamic Acid Benefits Total Joint Arthroplasty Patients Regardless of Preoperative Hemoglobin Value

While tranexamic acid (TXA) reduces transfusion in total joint arthroplasty (TJA), it remains unclear whether there is a preoperative hemoglobin (Hgb) threshold above which it is no longer beneficial. 2100 primary TJA patients were retrospectively categorized by preoperative Hgb; 1161 (55%) received TXA. Transfusion rates decreased with TXA in all groups; with Hgb>15 the transfusion rate was 0.5% with TXA and 4.5% without (P=0.0086); with Hgb>11 the transfusion rate was 4.7% with TXA and 18.7% without (P<0.0001). Patients receiving TXA had a shorter LOS by 0.51 days (P<0.0001). Patients receiving a postoperative transfusion had a longer LOS by 0.69 days (P<0.0001). TXA should be considered in all TJA patients independent of preoperative Hgb level.

Tranexamic acid reduces blood loss and need of blood transfusion in total knee arthroplasty: A prospective, randomized, double-blind study in Indian population

Introduction:

For quite a few years, tranexamic acid (TEA) has been used during total knee arthroplasty (TKA) to reduce blood loss. However, no consensus exits regarding its timing and doses.

Materials and Methods:

We conducted a prospective, randomized double-blinded study of 56 patients in the Indian population undergoing TKA from 2011 to 2012. A dose of 10 mg/kg body weight of TEA (three doses) was given in one group and normal saline was administered in the other.

Results:

The mean blood loss in the TEA unilateral group was 295 mL ± 218 mL and in the placebo group was 482 mL ± 186 mL (P < 0.005). In the bilateral TEA group, the mean blood loss was 596 mL ± 235 mL and in the placebo group was 1349 mL ± 41 mL (P < 0.005).

Conclusion:

The number of patients requiring blood transfusion reduced substantially. There was no increase in the risk of deep vein thrombosis (DVT) and pulmonary embolism. TEA reduces intraoperative and postoperative blood loss and thus reduces the need of allogenic blood transfusion.

Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty

TKA and THA are associated with blood transfusion and risk for postoperative venothromboembolism (VTE). Reports show that tranexamic acid (TA) may be safe to use in high-risk orthopedic patients, but further data are needed to substantiate its use. All patients who underwent primary or revision TKA or THA in a five year period were retrospectively identified. In 13,262 elective TKA or THA procedures, neither the odds of VTE (OR=0.98; 95% CI 0.67-1.45; P=0.939) or adjusted odds of death (OR=0.26; 95% CI 0.04-1.80; P=0.171) were significant with TA administration. The major findings of this large, single center, retrospective cohort study show the odds of postoperative VTE and 30-day mortality were unchanged with TA administration.

Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty

The ideal method of providing tranexamic acid (TXA) for decreasing hemoglobin drop after TKA is still controversial. In this clinical trial, 200 patients were randomly allocated to four groups. In group 1,500 mg TXA was administered intravenously. In group 2, the joint irrigated with 3 g of TXA in 100 cc of saline. In group 3, 1.5 g of TXA was injected through the drain. Group 4 did not take TXA. Albeit all methods had a statistical effect on hemoglobin drop, drainage and number of transfused units when compared to controls, but intravenous injection of TXA seems to be much more effective in terms of reducing hemoglobin drop and transfused units; and what's more TXA injection by drain is more effective regarding to reducing postoperative drainage.

A questionnaire-based survey investigating the current use of tranexamic acid in traumatic haemorrhage and elective hip and knee arthroplasty

OBJECTIVES

To record the current use of tranexamic acid during traumatic haemorrhage and elective arthroplasty of the hip and knee.

DESIGN

A questionnaire-based postal survey.

SETTING

The questionnaire was sent to the 'anaesthetic lead' at all acute trusts in England, excluding centres for children, women's health, cancer and cardiac care.

PARTICIPANTS

Ninety-nine (66%) centres replied to the questionnaire.

MAIN OUTCOME MEASURES

Is tranexamic acid used as part of routine standardized treatment for traumatic haemorrhage and for elective hip and knee arthroplasty, and if so what dosage regime was administered?

RESULTS

Few trusts (31%) use tranexamic acid during traumatic haemorrhage, with various dosages used. Its use in hip and knee arthroplasty was also low (38%) with a diverse range of doses prescribed.

CONCLUSIONS

Despite many trials showing its efficacy and low risk of side effect, it is clear that its use is not part of standard practice in most centres. Further studies could clarify these concerns and provide a definitive dosing schedule improving patient care and saving lives.

Preliminary results suggest tranexamic acid is safe and effective in arthroplasty patients with severe comorbidities

BACKGROUND

Tranexamic acid (TXA) reduces blood loss and transfusion after total joint arthroplasty (TJA) but concerns remain that patients with severe medical comorbidities might be at increased risk for thromboembolic complications.

QUESTIONS/PURPOSES

Among patients undergoing primary TJA with severe systemic medical disease, (1) was TXA associated with increased symptomatic thromboembolic events; (2) was TXA associated with decreased blood transfusion rates; and (3) were there differences in symptomatic thromboembolism or transfusions in the subset of patients with a history of, or risk factors for; thromboembolic disease?

METHODS

We performed a retrospective review of 1131 primary TJAs in 1002 patients with American Society of Anesthesiologists score III or IV. Of these, 402 had at least one of seven risk factors for thromboembolic events and were designated as high risk; 240 of those patients received TXA. Outcome measures included 30-day postoperative symptomatic thromboembolic events and postoperative transfusion.

RESULTS

There were no differences in symptomatic thromboembolic events within 30 days of surgery between patients who received TXA and those who did not (2.5% versus 2.6%, p = 0.97). Fewer patients treated with TXA received transfusions (11% with versus 41% without; p < 0.0001). In high-risk patients, TXA was not associated with an increase in symptomatic thromboembolic events (6.7% with versus 4.3% without; p = 0.27) and was associated with a decrease in transfusion rates (17% with versus 48% without; p = 0.001).

CONCLUSIONS

Although TXA seemed safe and effective in this database review of patients with severe medical comorbidities, a larger prospective trial is warranted to confirm these results.

Effect of fibrin sealant on blood loss following total knee arthroplasty: a systematic review and meta-analysis

OBJECTIVE

A systematic review of randomized controlled trials was conducted to examine the efficacy of fibrin sealants for the reduction of postoperative blood loss and allogeneic red blood cell transfusion in total knee arthroplasty (TKA).

METHODS

Studies published through May 2013 were identified from PubMed, Embase, the Cochrane library, ScienceDirect, and other databases. Two independent reviewers assessed the quality of methodology using the Grade of Recommendations Assessment, Development and Evaluation approach and extracted data from literature. The mean difference (MD) of blood loss, hemoglobin loss, and risk ratios (RR) of transfusion rate and adverse events in the fibrin-treated and placebo groups were pooled throughout the study. The relevant data were analyzed using Stata 11.0 software.

RESULTS

Eight studies were included in the review, with a total sample size of 558 patients. The drainage blood loss [MD = -354.02 mL, 95% confidence interval (CI) (-500.87 to -207.18); P < 0.05], reduction in calculated total blood loss [MD = -402.12, 95% CI (-599.16 to -205.08); P < 0.05], hemoglobin loss [MD = -0.86 g/dL, 95% CI (-1.10 g/dL to -0.61 g/dL); P < 0.05], and transfusion rate [RR = 0.62, 95% CI (0.45-0.86); P < 0.05] were all significantly reduced following treatment with fibrin sealants. There were no significant differences in the incidence of adverse events [RR = 0.69, 95% CI (0.32-1.59); P > 0.05] among the study groups.

CONCLUSIONS

The results of the present meta-analysis suggest that fibrin sealants for patients undergoing TKA may reduce blood loss and maintain higher hemoglobin levels, particularly when fibrin sealants are used at higher dosage. Furthermore, fibrin sealants do not increase the risk of postoperative deep vein thrombosis, superficial infection, pulmonary embolism, and hematoma. Further evaluation is required to confirm our findings before fibrin sealants can be used in patients undergoing TKA.

LEVEL OF EVIDENCE

II.

Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty: a prospective randomized controlled trial

PURPOSE

The objective of this prospective randomized controlled trial was to assess the efficacy and safety of simultaneous application of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty (TKA).

METHODS

Seventy-two primary osteoarthritis patients undergoing unilateral TKA using fondaparinux as a basic thromboprophylaxis were randomized to receive either placebo (36 patients) or tranexamic acid (36 patients). Prophylaxis against venous thromboembolism in all patients was administered with subcutaneous doses of 2.5 mg fondaparinux for 5 days post-operatively. Post-operative retransfusion volume, allogenic transfusion volumes and drain amount were recorded for each patient. Level of haemoglobin, prothrombin time, activated partial thromboplastin time and D-dimer were also assessed. Doppler ultrasonography was performed preoperatively and 7 days after surgery.

RESULTS

The rate of transfusion was lower in the tranexamic acid group than in the placebo group (p = 0.007). The drained blood volume during the initial 24 h and until drain removal was smaller in the tranexamic acid group than in the placebo group (p < 0.001). However, the haematologic laboratory results did not show any significant differences between the two groups. The prevalence of deep-vein thrombosis (DVT) was 4 (11.1 %) in the placebo group and 3 (8.3 %) in the tranexamic acid group (p = n.s.). There was no proximal DVT and no symptomatic pulmonary embolism in either group.

CONCLUSION

The use of tranexamic acid could reduce acute blood loss significantly without any adverse effect resulted from drug interaction with concomitant use of indirect factor Xa inhibitor following TKA. Therefore, simple combination of these drugs can be recommended to reduce post-operative blood loss as well as to reduce DVT following TKA.

Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty

BACKGROUND

The use of antifibrinolytic medications in hip and knee arthroplasty reduces intraoperative blood loss and decreases transfusion rates postoperatively. Tranexamic acid (TXA) specifically has not been associated with increased thromboembolic (TE) complications, but concerns remain about the risk of symptomatic TE events, particularly when less aggressive chemical prophylaxis methods such as aspirin alone are chosen.

QUESTIONS/PURPOSES

We determined whether the rate of symptomatic TE events differed among patients given intraoperative TXA when three different postoperative prophylactic regimens were used after primary THA and TKA.

METHODS

We retrospectively reviewed 2046 patients who underwent primary THA or TKA and received TXA from 2007 to 2009. The three chemical regimens included aspirin alone, warfarin (target international normalized ratio, 1.8-2.2), and dalteparin. Primary outcome measures were venous TE events, including symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE), and arterioocclusive events, including myocardial infarction and cerebrovascular accident. Patients judged to be at high risk for TE due to recent cardiac stent placement or strong personal/family history of TE disease were excluded.

RESULTS

For aspirin, warfarin, and dalteparin, the rates of symptomatic DVT (0.35%, 0.15%, and 0.52%, respectively) and nonfatal PE were similar (0.17%, 0.43%, and 0.26%, respectively). There were no fatal PE. Among the three groups, we found no difference in the rates of symptomatic DVT or PE with or without stratification by ASA score.

CONCLUSIONS

A low complication rate was seen when using TXA as a blood conservation modality during primary THA and TKA with less aggressive thromboprophylactic regimens such as aspirin alone and dose-adjusted warfarin.

Reducing blood loss in primary knee arthroplasty: a prospective randomised controlled trial of tranexamic acid and fibrin spray

A prospective, randomised controlled trial compared the effects of two medications intended to reduce blood loss from total knee arthroplasty. Patients were randomised to one of the following three treatment groups: 10mg/kg tranexamic acid at given at induction of anaesthesia, 10 ml of fibrin spray administered topically during surgery, or to a control group receiving neither treatment. Sixty six patients underwent elective cemented total knee arthroplasty; computer navigation was used in all cases. There was no significant difference in blood loss between the tranexamic acid and fibrin spray groups (p=0.181). There was no significant difference in blood loss between the tranexamic acid and fibrin spray groups(p=0.181). The fibrin spray led to a significant reduction in blood loss compared to control (p=0.007). The effect of tranexamic acid did not reach significance (p=0.173). We conclude that fibrin spray was effective in reducing blood loss but that with a study of this power, we were unable to detect an effect of tranexamic acid in cemented navigated total knee replacement at the dose used.

Temporary clamping of drain combined with tranexamic acid reduce blood loss after total knee arthroplasty: a prospective randomized controlled trial

Background

Total knee arthroplasty (TKA) is associated with a significant blood loss. Several methods have been reported to reduce postoperative blood loss and avoid homologous blood transfusions. In this study, we investigated the efficacy of temporary clamping of the drain either or not in combination with tranexamic acid administration for controlling blood loss after TKA.

Methods

The prospective, randomized, and double-blinded study was conducted in our institute. Total of 240 patients, who diagnosed primary osteoarthritis and scheduled to undergo a primary TKA,,were randomized into one of the four groups: Group A or control group, the drain was not clamped and the patient received a placebo; Group B, the drain was not clamped and the patient received tranexamic acid; Group C, the drain was clamped and the patient received a placebo; and Group D, the drain was clamped and the patient received tranexamic acid. The volume of drained blood at 48 hours postoperatively, the decreasing of hemoglobin (Hb) level at 12 hours postoperatively and the number of patients requiring blood transfusion were recorded and compared.

Results

The mean postoperative volumes of drained blood and the amount of blood transfusion in the three study groups (group B, C and D) were significantly lower than those in the control group (p < 0.05), which group D had the lowest values. Furthermore, group B and D could maintain the Hb level better than group A and C (p < 0.001). In terms of blood transfusions rate, although the patients in group D required transfusion less than group A and C (p < 0.05), there was no significant difference between group D and B. The relative risks for transfusion requirement were 4.4 for group A, 1.4 for group B and 3.0 for group C when compared to group D.

Conclusions

The clamping of drain combined with tranexamic acid administration could reduce postoperative blood loss and blood transfusion after TKA, significantly greater than using tranexamic acid or drain clamping alone.

Trial registration

ClinicalTrials.gov NCT01449552

Fibrin tissue adhesive reduces postoperative blood loss in total knee arthroplasty

Background

Blood transfusion is often required in total knee replacement; various methods of blood preservation have been studied. The best solution is to reduce the loss of blood during and after surgery.

Materials and methods

We designed this study to evaluate the hemostatic efficacy and safety of fibrin tissue adhesive (Quixil) in patients receiving total knee arthroplasty [low contact stress (LCS, DePuy, Warsaw, IN, US) cementless total knee replacement (TKR)] with a prospective, randomized, standard treatment controlled study. Thirty-five patients were randomized to receive treatment with fibrin tissue adhesive (treatment group), and 35 were randomized to be managed with postoperative blood recovery and reinfusion (control group). Blood loss in suction drain, decrease in hemoglobin values, and transfusions were recorded.

Results

A significant reduction in apparent total blood loss was detected in the treatment group compared with the control group. There was also a lower decrease in hemoglobin level, although this difference was not significant. When fibrin tissue adhesive was administered, the need for transfusions was lower. No major adverse events were recorded in our series.

Conclusions

Fibrin tissue adhesive reduced blood loss in TKR and seemed to significantly reduce the need for blood transfusion. Fibrin tissue adhesive can be an appropriate solution to enhance hemostasis and vessel sealing at the operative site in TKR, in order to reduce blood loss after surgery and the risk of complications.

Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial

BACKGROUND

TKA may be associated with considerable blood loss, and transfusion carries substantial risk of immunologic reaction and disease transmission. Blood transfusion also involves additional cost, therefore a reduction in its use is important. Several methods reportedly reduce postoperative blood loss and avoid homologous blood transfusion with traditional TKA approaches, but it is unclear these reductions apply to a minimally invasive technique.

QUESTIONS/PURPOSES

We asked whether tranexamic acid administration could reduce blood loss and blood transfusion requirements after TKA.

PATIENTS AND METHODS

Between March 2008 and May 2008, we enrolled 100 patients with primary osteoarthritis undergoing a unilateral cemented TKA in a prospective, randomized, double-blind study. Patients were randomized into one of two groups: the control group received a placebo and the study group received tranexamic acid intravenously (10 mg/kg) 10 minutes before inflation of the tourniquet and 3 hours postoperatively and orally (250 mg/capsule; two capsules three times daily) for 5 days. We measured volume of drained blood 48 hours postoperatively, decrease in hemoglobin levels 12 hours postoperatively, amount of blood transfused, and number of patients requiring allogenic blood transfusion. The minimum followup was 6 months (mean, 10.4 months; range, 6-12 months).

RESULTS

Mean (± SD) postoperative volume of drained blood was lower in the group receiving tranexamic acid (727.50 ± 234 mL) than in control subjects (1208.77 ± 421 mL). The mean hemoglobin decrease 12 hours postoperatively was lower in patients receiving tranexamic acid (2.12 ± 0.64 g/dL) than in control subjects (3.33 ± 0.88 g/dL). The amount of blood transfused and number of patients requiring blood transfusion were lower in patients receiving tranexamic acid than in control subjects.

CONCLUSIONS

Tranexamic acid reduced postoperative blood loss after TKA, as reflected in reduction in the number of blood transfusions. We did not observe any change in symptomatic thromboembolic phenomenon.

LEVEL OF EVIDENCE

Level 1, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial

BACKGROUND

Topical application of tranexamic acid to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of the present trial was to assess the efficacy and safety of the topical application of tranexamic acid on postoperative blood loss in patients undergoing primary unilateral total knee arthroplasty with cement.

METHODS

In a prospective, double-blind, placebo-controlled trial, 124 patients were randomized to receive 1.5 or 3.0 g of tranexamic acid in 100 mL of normal saline solution or an equivalent volume of placebo (normal saline solution) applied into the joint for five minutes at the end of surgery. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. The safety outcomes included Doppler ultrasound in all patients and measurement of plasma levels of tranexamic acid one hour after release of the tourniquet.

RESULTS

Twenty-five patients were withdrawn for various reasons; therefore, ninety-nine patients were included in the intention-to-treat analysis. The postoperative blood loss was reduced in the 1.5 and 3-g tranexamic acid groups (1295 mL [95% confidence interval, 1167 to 1422 mL] and 1208 mL [95% confidence interval, 1078 to 1339 mL], respectively) in comparison with the placebo group (1610 mL [95% confidence interval, 1480 to 1738 mL]) (p < 0.017). The postoperative hemoglobin levels were higher in the 1.5 and 3.0-g tranexamic acid groups (10.0 g/dL [95% confidence interval, 9.5 to 10.4 g/dL] and 10.1 g/dL [95% confidence interval, 9.8 to 10.5 g/dL], respectively) in comparison with the placebo group (8.6 g/dL [95% confidence interval, 8.2 to 9 g/dL]) (p < 0.017). With the numbers studied, there was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the three groups. Minimal systemic absorption of tranexamic acid was observed.

CONCLUSIONS

At the conclusion of a total knee arthroplasty with cement, topical application of tranexamic acid directly into the surgical wound reduced postoperative bleeding by 20% to 25%, or 300 to 400 mL, resulting in 16% to 17% higher postoperative hemoglobin levels compared with placebo, with no clinically important increase in complications being identified in the treatment groups.

The use of fibrin glue in surgery of the knee

Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.

Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review

Proponents of tourniquets postulate that they optimise intra-operative visibility and reduce blood loss. This study compared the outcomes of tourniquet assisted to non-tourniquet assisted total knee replacement (TKR). A systematic review was undertaken of the electronic databases Medline, CINAHL, AMED and EMBASE, in addition to a review of unpublished material and a hand search of pertinent orthopaedic journals. The evidence-base was critically appraised using a tool from the Cochrane Bone, Joint and Muscle Trauma Group. Fifteen studies were identified evaluating 16 outcome measures and parameters of 1040 TKRs in 991 patients. There was a significantly greater intra-operative blood loss in non-tourniquet compared to tourniquet assisted surgery (p=0.004). There was no significant difference between the groups for total blood loss or transfusion rate (p=0.22; p=0.48). There was a trend for greater complications in tourniquet compared to non-tourniquet patients. There was no difference between the groups for any other outcome measure assessed. In conclusion, this systematic review has found that there is no advantage to using a tourniquet in knee replacement surgery for reduction of transfusion requirements.

The Medial Rotation total knee replacement: a clinical and radiological review at a mean follow-up of six years

We describe the survivorship of the Medial Rotation total knee replacement (TKR) at ten years in 228 cemented primary replacements implanted between October 1994 and October 2006, with their clinical and radiological outcome. This implant has a highly congruent medial compartment, with the femoral component represented by a portion of a sphere which articulates with a matched concave surface on the medial side of the tibial insert. There were 78 men (17 bilateral TKRs) and 111 women (22 bilateral TKRs) with a mean age of 67.9 years (28 to 90). All the patients were assessed clinically and radiologically using the American Knee Society scoring systems. The mean follow-up was for six years (1 to 13) with only two patients lost to follow-up and 34 dying during the period of study, one of whom had required revision for infection. There were 11 revisions performed in total, three for aseptic loosening, six for infection, one for a periprosthetic fracture and one for a painful but well-fixed replacement performed at another centre. With revision for any cause as the endpoint, the survival at ten years was 94.5% (95% CI 85.1 to 100), and with aseptic loosening as the endpoint 98.4% (95% CI 93 to 100). The mean American Knee Society score improved from 47.6 (0 to 88) to 72.2 (26 to 100) and for function from 45.1 (0 to 100) to 93.1 (45 to 100). Radiological review failed to detect migration in any of the surviving knees. The clinical and radiological results of the Medial Rotation TKR are satisfactory at ten years. The increased congruence of the medial compartment has not led to an increased rate of loosening and continued use can be supported.

Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials

BACKGROUND

Minimizing bleeding and transfusion is desirable given its cost, complexity and potential for adverse events. Concerns have been heightened by recent data demonstrating that bleeding events may predict worse outcomes and by warnings about the safety of erythropoietic stimulating agents. Prior small studies suggest that antifibrinolytic agents may reduce bleeding and transfusion need in patients undergoing total hip replacement (THR) or total knee arthroplasty (TKA). However, no single study has been large enough to definitively determine if these agents are safe and effective. To address this issue we performed a systematic review of randomized trials describing the use of tranexamic acid, epsilon aminocaproic acid, or aprotinin administration in the perioperative setting.

METHODS

MEDLINE, EMBASE, CINAHL and the Cochrane databases were searched for relevant trials. Two independent reviewers abstracted total blood loss, transfusion requirements, and venous thromboembolism (VTE) rates. Data were combined using the Mantel-Haenszel method and dichotomous data expressed as relative risk (RR) with 95% confidence intervals (CI).

RESULTS

Patients receiving antifibrinolytic agents had reduced transfusion need (RR 0.52; 95% CI, 0.42 to 0.64; P<0.00001), reduced blood loss and no increase in the risk of VTE (RR 0.95% CI, 0.80 to 1.10, I(2)=0%, P=0.531).

CONCLUSIONS

We conclude that antifibrinolytic agents may reduce bleeding and transfusion in patients undergoing THR or TKA who receive appropriate antithrombotic prophylaxis. There is a need for a large, adequately powered prospective study to carefully examine the safety and efficacy of these agents.

Release of ischaemia prior to wound closure in total knee arthroplasty: a better method?

We included 46 total knee arthroplasties (43 patients) in a prospective, randomised study, dividing them into two groups: group A (23 knees, 21 patients) in which the ischaemia was released prior to wound closure allowing control of bleeding and group B (23 knees, 22 patients) releasing the tourniquet after suturing and bandaging. We compared the haemoglobin before surgery and at 24 and 48 h postoperatively, the total blood loss and the transfusions that were needed. Student's t-test was used to analyse the data. The results we obtained were as follows: preoperative haemoglobin in group A was 14.21 g/dl and group B 14.28 g/dl; haemoglobin at 24/48 h for group A was 10.04/10.1 g/dl and group B 10.28/10.3 g/dl; total blood loss was 743.2 cc for group A and 692.5 cc for group B; the mean number of blood units transfused were 2 in group A and 1.8 in group B. No statistical differences were found in the data analysed, but one of the complications in group B was major blood loss right after surgery that needed reintervention. We assume that this could have been avoided if the tourniquet had been released beforehand. We conclude that releasing ischaemia prior to wound closure does not demonstrate a statistical difference, but like other authors, we found clinical advantages suggesting the need of further study of this situation.

Tranexamic acid for hemostasis in the surgical treatment of metastatic tumors of the spine

STUDY DESIGN

This is a retrospective study of sequential cohorts.

OBJECTIVE

To assess the efficacy of tranexamic acid in decreasing operative blood loss and the need for intraoperative transfusion in metastatic spine surgery.

SUMMARY OF BACKGROUND DATA

Significant published data have established the efficacy of antifibrinolytic drugs in limiting surgical bleeding during heart surgery and total joint replacement. One study in scoliosis suggested benefit in spine surgery as well.

METHODS

During a 6-month trial period, 14 patients with spine cancer undergoing palliative intralesional tumor excision and concomitant instrumentation to stabilize the spine in the hands of a single surgeon were administered tranexamic acid intraoperatively in the attempt to minimize operative blood loss. They were then compared to the immediately preceding 14 patients.

RESULTS

Estimated operative blood loss was 1385 mL in the study group treated with tranexamic acid and 1815 mL in controls not receiving the drug, and was not found to be significantly decreased in this study.

CONCLUSIONS

Control of operative bleeding in metastatic spine surgery can be problematical. Optimum protocol might include routine preoperative angiographic tumor embolization to decrease lesion vascularity in all cases, but angiography is not without risk. Noninvasive prophylaxis of tumor bleeding would have obvious desirable advantages but was, unfortunately, not achieved in this study.

Tranexamic acid reduces early post-operative blood loss after total knee arthroplasty: a prospective randomised controlled trial of 29 patients

INTRODUCTION

Extensive blood loss related to knee arthroplasty is quite normal and many patients require blood transfusions. Surgery and the use of pneumatic tourniquets lead to an increase in the activity of the fibrinolytic system, which in turn may accentuate the blood loss. Drugs that inhibit the fibrinolytic system may thus be used to reduce blood loss. Tranexamic acid (TA) acts by binding to one of the enzymes at the start of the coagulation cascade, so inhibiting the fibrinolytic system. A concern is that this inhibition may have the side effect of increasing thromboembolic disease, a common complication of joint replacement surgery. We aimed to confirm the reductions in blood loss and to assess the impact of TA usage on clinical and sub-clinical DVT.

METHOD

We performed a prospective, randomised, double blind, controlled trial, using patients due to undergo primary unilateral total knee arthroplasty. Patients were randomised to receive either 15 mg/kg of tranexamic acid or a similar volume of normal saline at the time of cementing of the prosthesis. Perioperative blood loss was recorded and patients were screened for DVT with duplex ultrasound assessment of both legs on the fifth post-operative day.

RESULTS

A statistically significant (p=0.006) decrease in blood loss in the early post-operative period was noted in the group receiving tranexamic acid. This was not associated with a significant difference in total blood loss (p=0.55) or in transfusion requirements. There was no of evidence in DVT in either group on duplex ultrasound screening of the lower limbs.

INTERPRETATION

One injection of 15 mg/kg of tranexamic given at the time of cementing the prosthesis in total knee arthroplasty, before deflation of the tourniquet, significantly decreases the amount of blood loss in the early post-operative period. The treatment was not associated with an increase in thromboembolic complications.

Current trends in blood conservation in total knee arthroplasty

There is a lack of consensus with regard to ways to minimize blood transfusions after total knee arthroplasty. We surveyed 434 members of the American Association of Hip and Knee Surgeons, each of whom averaged 18 years in practice and performed an average of between 100 and 150 knee replacements a year, about their preferences and practices regarding blood conservation during total knee arthroplasty. Of those surveyed, only 24% reported that there was a blood conservation program in place at their institutions. Fifty-nine percent of those surveyed routinely asked their patients to donate blood before unilateral and bilateral knee replacements. The amount of blood collected averaged 1.32 units (range, 1-4 units) and 2.04 units (range, 1-4 units) before unilateral and bilateral knee arthroplasty, respectively. Nearly half (47.5%) reported they rarely ever prescribed epoetin alfa because of a combination of cost, time, and labor issues. Furthermore, the majority (84%) has not had any experience with the use of antifibrinolytics. Overall, the mean transfusion rate after unilateral knee replacement was estimated to be less than 5% (range, 0%-20%) whereas the rate after bilateral knee replacement was estimated to be between 10% and 20% (range, 5%-20%).

Tranexamic acid for major spinal surgery

Patients who undergo major spinal surgery often require multiple blood transfusions. The antifibrinolytics are medications that can reduce blood-transfusion requirements in cardiac surgery and total knee arthroplasty. The present role of synthetic antifibrinolytics, especially tranexamic acid, in reducing peri-operative blood-transfusion requirements in spine surgery is still unclear. The majority of studies exploring the role of these drugs in spine surgery have limited patient enrollment and report mixed results. The goal of the present review is to discuss the pharmacology of tranexamic acid briefly. A brief synopsis of the studies using the synthetic antifibrinolytics for spine surgery is presented. Finally, the potential risks and the benefits of antifibrinolytics are discussed.

An overview of blood-sparing techniques used in spine surgery during the perioperative period

The problems linked to blood loss and blood-sparing techniques in spine surgery have been less studied than in other fields of orthopedics, such as joint-replacement procedures. Decreasing bleeding is not only important for keeping the patient's hemodynamic equilibrium but also for allowing a better view of the surgical field. In spine surgery the latter aspect is especially important because of the vicinity of major and highly fragile neurologic structures. The techniques and agents used for hemostasis and blood sparing in spinal procedures are mostly similar to those used elsewhere in surgery. Their use is modulated by the specific aspects of spinal approach and its relation to the contents of the spinal canal. Blood-sparing techniques can be divided into two categories based on their goals: either they are aimed at decreasing the bleeding itself, or they are aimed at decreasing the need for homologous transfusion. Various hemodynamic techniques, as well as systemic and local drugs and agents, can be used separately or in combination, and their use in the field of spine surgery is reported. The level of evidence for the efficacy of many of those methods in surgery as a whole is limited, and there is a lack of evidence for most of them in spine surgery. However, several blood-saving procedures and drugs, as well as promising new agents, appear to be efficient, although their efficacy has yet to be assessed by proper randomized controlled trials.