Tranexamic Acid Reduces Total Blood Loss and Inflammatory Response in Computer-Assisted Navigation Total Knee Arthroplasty

Traumatic bleeding and mortality in mice are intensified by iron deficiency anemia and can be rescued with tranexamic acid

Background

Clinical evidence suggests that anemia exacerbates traumatic bleeding and worsens outcomes.

Objectives

To study the influence of iron deficiency anemia on traumatic bleeding, coagulopathy, and mortality.

Methods

C57BL/6J mice received an iron-deficient diet (8 weeks; ±1 mg intraperitoneal iron dextran 2 weeks before trauma). Control mice received a normal diet. Iron deficiency anemia was confirmed by hematocrit, red cell indices, and liver iron. Mice received saline or tranexamic acid (TXA; 10 mg/kg) just before liver laceration. Blood loss, coagulopathy (activated partial thromboplastin time, factor [F]II, FV, FVIII, FX, and fibrinogen), D-dimer, thrombin-antithrombin complexes, and plasmin-alpha-2-antiplasmin complexes were analyzed at 15 and 60 minutes, and a cytokine panel was performed at 60 minutes and 6 hours after trauma. Survival was monitored for 7 days.

Results

Compared with nonanemic mice, anemic mice had lower hematocrit and hepatic iron content. Anemic mice experienced higher blood loss compared with nonanemic mice, which was reduced by TXA. Both groups developed traumatic coagulopathy characterized by activated partial thromboplastin time prolongation, thrombin-antithrombin complex formation, and depletion of FV, FVIII, and fibrinogen. TXA corrected the coagulopathy. However, plasmin-alpha-2-antiplasmin complex formation and D-dimers, markers of fibrinolysis, were higher in anemic mice and were not corrected by TXA. Seven-day survival was low in anemic mice, and rescued by TXA, but high in nonanemic mice without additional improvement by TXA. Among cytokines, only interleukin-6 increased, which was prevented by TXA most notably in anemic mice.

Conclusion

These observations provide first and critical proof-of-principle evidence that anemia accelerates traumatic bleeding and increases mortality, which could be rescued by anemia correction (parenteral iron) or periprocedural TXA.

Evaluation of efficacy and safety of perioperative tranexamic acid during Primary Total Knee Arthroplasty: A randomized, Clinical trial

Background

Primary total knee arthroplasty (TKA) is the gold standard treatment for degenerative joint disease, but it carries a significant risk of blood loss that may require transfusion. Various techniques are implemented to reduce the possibility of the need for allogeneic blood transfusion (ABT). To this end, this study aims to assess the effectiveness of tranexamic acid (TXA) in decreasing blood loss following primary TKA.

Materials and methods

This study is a randomized controlled study of 100 cases of primary total knee arthroplasty conducted in Damascus from July 2021 to September 2022, followed up with every patient for six months. The patients were randomized into two groups. We compared intraoperative, postoperative, total, and hidden blood loss and perioperative complications.

Results

We observed a statistically significant difference between the two groups in total calculated, hidden, and postoperative blood loss. However, this difference does not seem clinically significant, as we didn't find a significant difference in allogeneic blood transfusion between the groups. Regarding complications, the TXA group had five cases of superficial wound infection and six cases of deep venous thrombosis. In contrast, the control group had eight cases of superficial wound infection and five cases of deep venous thrombosis.

Conclusion

Our study suggests that the role of TXA in primary unilateral total knee arthroplasty in the hands of an experienced surgeon might be overrated. The reduced blood loss did not seem to have clinical importance and didn't affect the transfusion rates.

Tranexamic acid administration for the prevention of periprosthetic joint infection and surgical site infection: a systematic review and meta-analysis

INTRODUCTION

Tranexamic acid (TXA) has been widely utilized to reduce blood loss and allogeneic transfusions in patients who undergo lower limb arthroplasty. In recent years, there have been several articles reporting the incidence of periprosthetic joint infection (PJI) as a primary outcome of TXA administration, but no meta-analysis has been conducted to date. The present systematic review and meta-analysis evaluated the efficacy of TXA administration in preventing PJI and surgical site infection (SSI).

MATERIALS AND METHODS

Pubmed, CINAHL, and the Cochrane Library bibliographic databases were searched for studies published by May 24, 2022, that evaluated the effects of TXA on PJI and SSI. Two researchers screened the identified studies based on the PRISMA flow diagram. The quality of each randomized clinical trial was assessed using Version 2 of the Cochrane risk-of-bias tool for randomized trials (ROB2.0), and the quality of cohort and case-control studies was assessed by risk of bias for nonrandomized studies (ROBANS-I).

RESULTS

Of the 2259 articles identified from the database search, 31 were screened and selected. Treatment with TXA significantly reduced the incidence of overall infection, including PJI, SSI, and other infections (OR 0.55; 95% CI 0.49-0.62) (P < 0.00001), and that of PJI alone (OR 0.53; 95% CI 0.47-0.59) (P < 0.00001). TXA reduced the incidence of overall infection in patients who underwent total hip arthroplasty (THA; OR 0.51; 95% CI: 0.35-0.75) (P = 0.0005) and total knee arthroplasty (TKA; OR 0.55; 95% CI: 0.43-0.71) (P < 0.00001). Intravenous administration of TXA reduced the incidence of overall infection (OR 0.59; 95% CI 0.47-0.75) (P < 0.0001), whereas topical administration did not.

CONCLUSIONS

Intravenous administration of TXA reduces the incidence of overall infection in patients undergoing both THA and TKA.

LEVEL OF EVIDENCE

Level III.

The Clinical Effect of Topical Application of Tranexamic Acid in Arthroscopic Synovectomy of Pigmented Villonodular Synovitis of the Knee

This study investigated the clinical effect of topical application of tranexamic acid (TXA) in arthroscopic synovectomy of pigmented villonodular synovitis (PVNS) of the knee. Eighty patients who were diagnosed with unilateral knee PVNS underwent arthroscopic synovectomies from January 2017 to January 2021 and were retrospectively investigated in this study. Patients were divided into two groups: group A was the control group, whereas patients in group B received an intra-articular injection of 50 mL of TXA (1 g:100 mL) immediately after the synovectomies. The primary outcome measurement was the drainage volume of the affected knee in each postoperative stage, as well as the hematological parameters. Secondary outcomes included visual analog scale score, knee range of motion, and Lysholm score. Postoperative complications were also recorded. A lower volume of drainage was found in group B than in group A on postoperative day (POD) 1, on POD 2, and in total (POD 1, P=.000; POD 2, P=.000; total, P=.000). A lower visual analog scale pain score in group B was noticed on POD 1 (P=.000) and POD 2 (P=.005). Range of motion (P=.019) and Lysholm score (P=.001) were significantly superior in group B compared with group A on POD 14. Regarding complications, 3 patients in group A and 1 patient in group B developed deep venous thrombosis after surgery. Hematomas were found intra-articularly in 5 patients in group A during follow-up. Intraarticular topical application of TXA was effective in reducing postoperative bleeding and early postoperative pain for patients who underwent arthroscopic synovectomy of PVNS. [Orthopedics. 20XX;XX(X):xx-xx.].

Variable Response to Antifibrinolytics Correlates with Blood-loss and Transfusion in Posterior Spinal Fusion

PURPOSE

Posterior spinal fusion (PSF) activates the fibrinolytic protease plasmin, which is implicated in blood loss and transfusion. While antifibrinolytic drugs have improved blood loss and reduced transfusion, variable blood loss has been observed in similar PSF procedures treated with the same dose of antifibrinolytics. However, both the cause of this and the appropriate measures to determine antifibrinolytic efficacy during high-blood-loss spine surgery are unknown, making clinical trials to optimize antifibrinolytic dosing in PSF difficult. We hypothesized that patients undergoing PSF respond differently to antifibrinolytic dosing, resulting in variable blood loss, and that specific diagnostic markers of plasmin activity will accurately measure the efficacy of antifibrinolytics in PSF.

METHODS

A prospective study of 17 patients undergoing elective PSF with the same dosing regimen of TXA was conducted. Surgery-induced plasmin activity was exhaustively analyzed in perioperative blood samples and correlated to measures of inflammation, bleeding, and transfusion.

RESULTS

While markers of in vivo plasmin activation (PAP and D-dimer) suggested significant breakthrough plasmin activation and fibrinolysis (P < 0.01), in vitro plasmin assays, including TEG, did not detect plasmin activation. In vivo measures of breakthrough plasmin activation correlated with blood loss (R2 = 0.400, 0.264; P < 0.01), transfusions (R2 = 0.388; P < 0.01), and complement activation (R2 = 0.346, P < 0.05).

CONCLUSIONS

Despite all patients receiving a high dose of TXA, its efficacy among patients was variable, indicated by notable intra-operative plasmin activity. Markers of in vivo plasmin activation best correlated with clinical outcomes. These findings suggest that the efficacy of antifibrinolytic therapy to inhibit plasmin in PSF surgery should be determined by markers of in vivo plasmin activation in future studies.

LEVEL OF EVIDENCE

Level II-diagnostic.

Safety and Efficacy of Local Tranexamic Acid for the Prevention of Surgical Bleeding in Soft-Tissue Surgery: A Review of the Literature and Recommendations for Plastic Surgery

BACKGROUND

Although high-bleed surgery routinely utilizes the antifibrinolytic drug tranexamic acid, most plastic surgical procedures are conducted in soft tissue with low-volume bleeding. Unease regarding possible systemic adverse effects prevents widespread systemic use, but local use of tranexamic acid is gaining popularity among plastic surgeons. Randomized controlled trials on topical use of tranexamic acid are mainly from high-bleed surgeries, and few studies address the effect in soft tissue. This article reviews the scientific evidence regarding local use of tranexamic acid in soft-tissue surgery, discusses pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery.

METHODS

A systematic search of databases for studies on local use of tranexamic acid in soft-tissue surgery was performed. Randomized controlled trials were included for a systematic review on effect; a narrative review regarding other clinically relevant aspects is based on extensive literature searches combined with the authors' own research.

RESULTS

Fourteen randomized controlled trials, including 1923 patients, were included in the systematic review on local use of tranexamic acid in soft-tissue surgery.

CONCLUSIONS

Local use of tranexamic acid may reduce blood loss comparably to intravenous prophylactic use with negligible risk of systemic adverse effects, but high-quality randomized controlled trials are few. Prolonged exposure to high local concentrations is discouraged, and direct contact with the central nervous system may cause seizures. No single superior means of administration or dosage is supported in the literature, and lowest effective dose is unknown. There may not be one single ideal dosing regimen, but rather many possibilities adaptable for different surgical situations.

Impact of Tranexamic Acid on Chondrocytes and Osteogenically Differentiated Human Mesenchymal Stromal Cells (hMSCs) In Vitro

The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations of TXA on proliferation rates, gene expression and differentiation capacity of chondrocytes and human mesenchymal stromal cells (hMSCs), which underwent osteogenic differentiation. Chondrocytes and hMSCs were isolated and multiplied in monolayer cell cultures. Osteogenic differentiation of hMSCs was induced for 21 days using a differentiation medium containing specific growth factors. Cell proliferation was analyzed using ATP assays. Effects of TXA on cell morphology were examined via light microscopy and histological staining, while expression levels of tissue-specific genes were measured using semiquantitative RT-PCR. After treatment with 50 mg/mL of TXA, a decrease in cell proliferation rates was observed. Furthermore, treatment with concentrations of 20 mg/mL of TXA for at least 48 h led to a visible detachment of chondrocytes. TXA treatment with 50 mg/mL for at least 24 h led to a decrease in the expression of specific marker genes in chondrocytes and osteogenically differentiated hMSCs. No significant effects were observed for concentrations beyond 20 mg/mL of TXA combined with exposure times of less than 24 h. This might therefore represent a safe limit for topical application in vivo. Further research regarding in vivo conditions and effects on hMSC functionality are necessary to fully determine the effects of TXA on articular and periarticular tissues.

Hemostatic effect of tourniquet combined with tranexamic acid in total knee arthroplasty: a network meta-analysis

BACKGROUND

There are various techniques to reduce blood loss in total knee arthroplasty (TKA), including the use of a tourniquet and tranexamic acid (TXA). In this study, we studied the combined effect of TXA with a tourniquet on blood loss in the setting of primary TKA.

METHODS

Randomized controlled trials (RCTs) of nine treatment methods were included (placebo, intravenous [i.v.] TXA, topical TXA, i.v.-combined topical TXA, oral TXA, placebo + tourniquet, i.v. TXA +tourniquet, topical TXA + tourniquet, and i.v.-combined topical TXA + tourniquet). The patients were divided into eight groups according to the different treatment strategies, with 30 cases per group. The differences in the total blood volume, the number of patients transfused, the hemoglobin before and after the operation, and complications after the operation were compared.

RESULTS

Totally 15 RCTs meeting our inclusion criteria were collected in this study. Compared with the placebo + tourniquet group, the i.v. TXA + tourniquet group displayed lower hemoglobin reduction value, pulmonary embolism (PE) incidence, total blood loss, and blood transfusion risk; the topical TXA + tourniquet group showed reduced PE incidence, total blood loss, and blood transfusion risk, and the i.v.-combined topical TXA and i.v.-combined topical TXA + tourniquet groups showed decreased total blood loss and lower blood transfusion risk. Retrospective clinical study results also demonstrated that the efficacy of i.v.-combined topical TXA was the best.

CONCLUSIONS

Our meta-analysis indicates that i.v.-combined topical TXA provides a low total blood loss without increasing the blood transfusion risk in patients undergoing total knee replacement surgery.

Tranexamic Acid Combined with Compression Bandage Following Total Knee Arthroplasty Promotes Blood Coagulation: A Retrospective Analysis

Objective

This paper included a retrospective review of the effect of tranexamic acid (TXA) combined with pressure bandaging on hemostasis of patients who received a unilateral total knee arthroplasty (TKA) from 2017 to 2019.

Methods

A total of 197 patients undergoing TKA were chosen to be classified into 2 groups, the compression bandage control group and compression bandage combined with TXA observation group. The patients received blood routine examination when they were in the 1st, 3rd, and 6th days of before and postoperation. Some parameters, such as hemoglobin (Hb), C-reactive protein (CRP), D-dimer value, fibrinogen, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), international normalized ratio (INR), and erythrocyte sedimentation rate (ESR), were also investigated.

Results

In our research, the mean age was 66.54 ± 7.95 years. No difference was found in patient sex (P = 0.876) and age (P = 0.749) between groups. No differences were found in the levels of Hb, fibrinogen, TT, and INR between the 2 groups at each period (P > 0.05). The difference of PT was significantly different on the 1st day (P = 0.011), 3rd day (P = 0.010), and 6th day (P = 0.004) after surgery. Besides, the changes in APTT in observation group were clearly higher compared with the control group on the 3rd day (P = 0.001) and 6th day (P = 0.001). On the 3rd and 6th days after operation, the CRP level of the two groups increased continuously, and the CRP level was significantly higher in the observation group in comparison with the control group (P = 0.008, P = 0.010). On 1st and 3rd days after surgery, compared to the control group, the D-dimer level of patients in the observation group was distinctly fewer (P = 0.001, P = 0.027).

Conclusion

TXA combined with compression bandage is a potential option for the reduction of bleeding after TKA.