Blood loss of total knee arthroplasty in osteoarthritis: an analysis of influential factors

Risk factor analysis and establishment of a nomogram model to predict blood loss during total knee arthroplasty

PURPOSE

The risk factors for excessive blood loss and transfusion during total knee arthroplasty (TKA) remain unclear. The present study aimed to determine the risk factors for excessive blood loss and establish a predictive model for postoperative blood transfusion.

METHODS

This retrospective study included 329 patients received TKA, who were randomly assigned to a training set (n = 229) or a test set (n = 100). Univariate and multivariate linear regression analyses were used to determine risk factors for excessive blood loss. Univariate and multivariate logistic regression analyses were used to determine risk factors for blood transfusion. R software was used to establish the prediction model. The accuracy and stability of the models were evaluated using calibration curves, consistency indices, and receiver operating characteristic (ROC) curve analysis.

RESULTS

Risk factors for excessive blood loss included timing of using a tourniquet, the use of drainage, preoperative ESR, fibrinogen, HCT, ALB, and free fatty acid levels. Predictors in the nomogram included timing of using a tourniquet, the use of drainage, the use of TXA, preoperative ESR, HCT, and albumin levels. The area under the ROC curve was 0.855 (95% CI, 0.800 to 0.910) for the training set and 0.824 (95% CI, 0.740 to 0.909) for the test set. The consistency index values for the training and test sets were 0.855 and 0.824, respectively.

CONCLUSIONS

Risk factors for excessive blood loss during and after TKA were determined, and a satisfactory and reliable nomogram model was designed to predict the risk for postoperative blood transfusion.

Topical Use of Low-dose Tranexamic Acid Has no Effect on Drainage Volume after Medial Open Wedge High Tibial Osteotomy: A Case Control Study

OBJECTIVE

Many studies reported that tranexamic acid (TXA) was effective in reducing surgical blood loss in the perioperative period of medial open wedge high tibial osteotomy (MOWHTO). However, few studies focused on the simple topical use of TXA in MOWHTO, and the modality and dosage of topical use of TXA varied. The purpose of this study was to observe the effect of topical use of low-dose TXA on drainage volume after MOWHTO, and to analyze the related influencing factors.

METHODS

Data of patients who underwent MOWHTO combined with arthroscopic knee surgery in our department from January 2019 to September 2021 were retrospectively analyzed. A total of 105 patients (38 males and 67 females, aged 57.7 ± 7.5 years) were included in this study who received topical TXA or no TXA. The patients were divided into three groups: control group (39 cases), 0.5 g TXA group (40 cases), 1 g TXA group (26 cases). Postoperative drainage volume, wound healing, incidence of hematoma and deep venous thrombosis (DVT) were observed and analyzed in the three groups. The effects of gender, hypertension and diabetes on postoperative drainage volume were analyzed using a t-test. The correlation between age, body mass index (BMI), osteotomy gap and postoperative drainage volume were analyzed using the Pearson correlation coefficient.

RESULTS

The average postoperative drainage volume of the control group was 259.54 ± 226.33 mL, that of the 0.5 g TXA group was 277.18 ± 177.68 mL, and that of the 1 g TXA group was 229.15 ± 219.93 mL. There was no statistically significant difference in postoperative drainage volume among the three groups (F = 0.423, p = 0.656). There was no local hematoma and wound infection in the three groups. The wound fat liquefaction was found in one patient of the control group. The incidence of DVT was 38.9% (7/18) and 57.1% (8/14) in the control group and 0.5 TXA group, respectively. There was no significant difference in the incidence of DVT between the above two groups (p = 0.476). The average postoperative drainage volume of male patients in the three groups was higher than that of female patients, and the differences were statistically significant (p < 0.05). There was no correlation between age, BMI, osteotomy gap and postoperative drainage volume in the three groups (p > 0.05).

CONCLUSION

Topical use of low-dose TXA has no significant effect on drainage volume after MOWHTO. The drainage volume after MOWHTO in male patients was more than that in female patients. Topical administration of low-dose TXA does not increase postoperative complications, such as DVT and hematoma.

Intra-articular injection of tranexamic acid in patients with haemophilia arthritis: retrospective controlled study in total knee arthroplasty

PURPOSE

Total knee arthroplasty is the main method for the treatment of advanced haemophilic knee arthritis. Due to the particularity of hemophilia, the blood management plan is the focus of the perioperative period for haemophilia patients. This study aimed to investigate the clinical effect and safety of intra-articular injection of tranexamic acid in patients with haemophilia.

METHODS

This is a retrospective study. According to whether tranexamic acid is used or not, patients are divided into tranexamic acid group (n=30) and non-tranexamic acid group (n=29). Total blood loss, intraoperative blood loss, complete blood count, total amount of coagulation factor VIII (FVIII) usage, coagulation biomarkers, inflammatory biomarkers, knee range of motion, knee joint function, pain status, complication rate, and patient satisfaction were assessed and compared at a mean follow-up of 16 months.

RESULTS

Injecting tranexamic acid into the knee joint cavity can effectively reduce the hidden blood loss and total blood loss (P<0.001), and reduce the patient's early postoperative inflammation biomarkers, pain status, and limb swelling. Therefore, the patient can obtain a better range of motion following total knee arthroplasty. In the long run, in terms of joint function and surgical satisfaction, there are no statistically significant differences. In addition, there are no statistically significant differences between the two groups of patients in terms of the total amount of FVIII usage, length of stay, and hospitalization expenses.

CONCLUSION

In patients with haemophilia, intra-articular injection of tranexamic acid during total knee arthroplasty can effectively reduce postoperative blood loss, early postoperative inflammation levels, pain and limb swelling, and enable patients to receive higher-quality rehabilitation exercises to get better joint function. Previous studies on TKA in haemophilic patients have already demonstrated the efficacy of intra-articular injections of TXA in reducing postoperative blood loss. Our study confirms this efficacy.

The Association between Bleeding Disorders and Postoperative Complications Following Operative Treatment of Distal Radius Fracture

Background  While previous studies have investigated the association between bleeding disorders and outcomes with hip or knee surgeries, no studies have investigated the association between bleeding disorders and outcomes in upper extremity surgery. Questions/Purposes  The purpose of this study was to investigate if a past history of bleeding disorders is associated with which, if any postoperative complications for patients receiving distal radius fracture open reduction internal fixation. Patients and Methods  Patients undergoing operative treatment for distal radius fracture from 2007 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into two cohorts: patients with a bleeding disorder and patients without a bleeding disorder. In this analysis, 30-day postoperative complications were assessed, as well as mortality, extended length of stay, reoperation, and readmission. Bivariate and multivariate analyses were performed. Results  Of the 16,489 total patients undergoing operative treatment for distal radius fracture, 16,047 patients (97.3%) did not have a bleeding disorder, whereas 442 (2.7%) had a bleeding disorder. Following adjustment on multivariate analyses, an increased risk of postoperative transfusion requirement (odds ratio [OR] 17.437; p  = 0.001), extended length of hospital stay more than 3 days (OR 1.564; p  = 0.038), and readmission (OR 2.515; p  < 0.001) were seen in patients with a bleeding disorder compared to those without a bleeding disorder. Conclusion  History of bleeding disorders is an independent risk factor for transfusions, extended length of stay, and readmission. We recommend a multidisciplinary team approach to addressing bleeding disorders before patients receive distal radius fracture open reduction internal fixation. Level of Evidence  Level III, retrospective study.

Effects of Thrombin-Based Hemostatic Agent in Total Knee Arthroplasty: Meta-Analysis

The effectiveness of Floseal, a thrombin-based hemostatic matrix, in total knee arthroplasty (TKA) in minimizing blood loss and transfusion requirements remains a topic of debate. This meta-analysis aims to evaluate the up-to-date randomized controlled trials (RCTs) on the efficacy and safety of Floseal in TKA. A comprehensive search was conducted in electronic databases to identify relevant RCTs. The methodological quality of the included studies was assessed, and data extraction was performed. The pooled effect sizes were calculated using standardized mean difference (SMD) or odds ratios (OR) with 95% confidence intervals (CIs). Eight studies involving 904 patients were included in the meta-analysis. The use of a thrombin-based hemostatic agent significantly reduced hemoglobin decline (SMD = -0.49, 95% CI: -0.92 to -0.07) and the risk of allogenic transfusion (OR = 0.45, 95% CI: 0.25 to 0.81) but showed no significant difference in the volume of drainage or total blood loss. Funnel plots showed no evidence of publication bias. This meta-analysis provides robust evidence supporting the effectiveness of Floseal in reducing hemoglobin decline and transfusion in TKA. Further well-designed RCTs with longer follow-up periods are warranted to assess long-term efficacy and safety.

No Blood Loss Increase in Cementless vs. Cemented Fixation Following Bilateral Total Knee Arthroplasty: A Propensity Score Matching Study

Background and Objectives: Recent advancements in three-dimensional printing technology have enhanced the biologic fixation of cementless total knee arthroplasty (TKA), therefore increasing the utilization of newer-generation cementless implants. However, the lack of sealing and tamponade effect of cement on the resected bone surface after cementless TKA raises concerns regarding the potential for greater blood loss compared to cemented TKA. The aim of this study was to (1) compare blood loss and transfusion rates between cementless and cemented TKAs and (2) identify the risk factor for higher blood loss in patients who underwent 1-week-interval staggered bilateral (SB) TKA. Materials and Methods: This retrospective, propensity-matched study included 54 cementless and 53 cemented SB TKAs performed by a single surgeon from 2019 to 2023 with a single implant that has similar design features in both cementless and cemented implants. All patients underwent 1-week-interval SB TKA and received the same patient blood management (PBM) and rehabilitation protocol. The estimated total blood loss (TBL), transfusion rate, and total hemoglobin drop were assessed. Patients were categorized according to TBL into average TBL and higher TBL groups. Univariate and multiple logistic regression analyses were performed to identify risk factors for higher blood loss. Results: There was no difference in TBL between cementless and cemented TKA groups (1233 ± 299 and 1282 ± 309 mL, respectively; p > 0.05). In addition, no between-group differences in the transfusion rate and mean total hemoglobin drop were observed. The logistic regression analyses revealed that whether TKA was cementless or cemented was not associated with higher blood loss; rather, the only identified risk factor was the pre-TKA patient blood volume (odd ratio 1.001, 95% confidence interval 1.000-1002, p = 0.026). Conclusions: Contemporary cementless fixation does not increase blood loss or transfusion rates compared to cemented fixation in patients undergoing 1-week-interval staggered bilateral TKA.

Indicators and medical tests to identify lower limb swelling causes after total knee arthroplasty: a Delphi study with multidisciplinary experts

BACKGROUND

Lower limb swelling after total knee arthroplasty (TKA) hinders surgical effectiveness. The poor results of studies on swelling interventions are due to the lack of a classification of swelling causes through appropriate medical tests. A gold standard is missing. This study aimed to clarify the causes of TKA postoperative swelling and how to identify them through indicators and medical tests by consulting a wide range of experts from multiple disciplines.

METHOD

The Delphi method was used. A first draft of the index was prepared based on a systematic search of the literature. A total of 11 experts from several disciplines were invited to evaluate the rationality of the indicators and suggest modifications. After two rounds of consultation, the experts reached a consensus, and the consultation was stopped.

RESULTS

The response rate of the 11 experts was 100%, and the authoritative Cr was 0.896. Kendall's W values for opinion coordination of the two rounds of consultation were 0.262 and 0.226, respectively (P < 0.001). Among the final indicators, there were 4 primary indicators for swelling cause classification (inflammatory response, poor venous return, joint hematoma, muscle damage, and healing), 19 secondary and 19 tertiary indicators.

CONCLUSION

The indications obtained by systematic literature review and multidisciplinary expert consultation are reliable and scientific. Multiple causes of lower extremity swelling after TKA were identified. Blood test indicators can reflect an inflammatory response, suggest poor venous return, and reflect muscle damage and healing progress. Ultrasound scans are needed to identify underlying thrombotic or valvular problems, joint hematomas, and muscle damage. These tests help clinicians and researchers determine the cause of swelling after TKA and take appropriate management.

Effect of bone cement sealing of the intramedullary femoral canal on coagulation status after total knee arthroplasty: a retrospective thromboelastography study

BACKGROUND

The main objective of this study was to investigate whether the use of bone cement in total knee arthroplasty (TKA) has an effect on postoperative coagulation status and bleeding.

METHODS

153 patients who underwent unilateral TKA between September 2019 and February 2023 were collected and divided into Bone and Cement&Bone groups according to whether bone cement was used to seal the bone medullary canal intraoperatively. Routine blood and thromboelastography (TEG) examinations were performed on the day before, the first day and the seventh day after surgery; postoperative bleeding, drainage, transfusion rate and the number of people suffering from deep venous thrombosis (DVT) were recorded.

RESULTS

There were no significant differences between the two groups in terms of baseline clinical characteristics before surgery (P > 0.05). In terms of TEG indicators, the coagulation index (CI) of the Bone&Cement group was lower than that of the Bone group on the first postoperative day and on the seventh postoperative day (P < 0.05). The CI of patients in the Bone group on the first postoperative day was lower than that of the preoperative day (P < 0.05); in terms of blood loss, the total blood loss and occult blood loss were lower in the Bone&Cement group than in the Bone group (P < 0.05). In addition, there was no significant difference in postoperative drainage,transfusion rate and the incidence of DVT between the two groups.

CONCLUSION

Blocking the intramedullary canal of the femur with bone cement during TKA improves relative postoperative hypocoagulation and reduces postoperative blood loss, although there is no significant effect on transfusion rates, drainage and DVT.

Effectiveness of Robotic Arm-Assisted Total Knee Arthroplasty on Transfusion Rate in Staged Bilateral Surgery

The transfusion rate in staged bilateral total knee arthroplasty (TKA) remains high despite the application of blood management techniques. The potential of robotic arm-assisted TKA (R-TKA) in reducing the transfusion rate in staged bilateral surgery has not yet been investigated. Therefore, we aimed to evaluate the effectiveness of R-TKA on transfusion reduction compared with conventional TKA (C-TKA) in staged bilateral surgery. This retrospective study involved two groups of patients who underwent 1-week interval staged bilateral TKA-the C-TKA group and the R-TKA group-using MAKO SmartRobotics (Stryker, Kalamazoo, MI, USA). Each group comprised 53 patients after propensity score matching and was compared in terms of nadir hemoglobin (Hb) level and transfusion rate after each stage of surgery. Both groups showed no significant differences in the propensity-matched variables of age, sex, body mass index, American Society of Anesthesiologists physical status score, and preoperative Hb level. The R-TKA group showed a significantly higher nadir Hb level than the C-TKA group after the second TKA (p = 0.002). The transfusion rate was not significantly different between the two groups after the first TKA (p = 0.558). However, the R-TKA group showed a significantly lower transfusion rate in the TKA (p = 0.030) and overall period (p = 0.023) than the C-TKA group. Patients who undergo staged bilateral R-TKA have lower transfusion rate than those who undergo C-TKA. R-TKA may be effective in minimizing unnecessary allogeneic transfusions in staged bilateral surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Predictive and protective factors for allogenic blood transfusion in total knee arthroplasty. A retrospective cohort study

Background

This study aimed to identify the predictive and protective factors of blood transfusion in patients undergoing total knee arthroplasty (TKA) and therefore determine the profile of patients with low and high risk of blood transfusion after arthroplasty.

Methods

We conducted a retrospective study with all patients who underwent primary TKA between January 2017 and December 2019 (n = 1.028 patients) in our institution. Information about allogenic transfusion was collected from medical records to determine the incidence, the predictive and protective factors of blood transfusion. All cases of blood transfusions were documented as well the number of units and the moment of each transfusion. We performed univariate and multivariate logistic regression analyses to identify the independent risk and protective factors.

Results

The total transfusion rate was 11%, 1.1% at intraoperative and 9,9% at postoperative period. The independent risk factors for transfusion were female gender (OR 1.64), older age (>55yo, OR > 2) higher surgical risk (ASA III, OR 3.07), lower preoperative hemoglobin levels (p = 0.024), post-traumatic arthritis (OR 4.11) and use of postoperative drains (OR 1.81) The protective factors for transfusion were male gender (OR 0.60), obesity (IMC >30, OR 0.60) and use of intravenous tranexamic acid intraoperatively (OR 0.40).

Conclusions

We conclude that in addition to the well-established risk factors for blood transfusion such as advanced age, low hemoglobin levels and high surgical risk, we can add post-fracture arthroplasty, non-use of tranexamic acid and the use of postoperative joint drain.

The natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty

We retrospectively investigated the natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty. All patients were treated according to the same clinical pathway, and blood tests were performed on the same day. All blood tests were done on pre-op, immediate post-op, midnight of op day, 1st, 2nd, 3rd, 5th, 7th, and 11th day after surgery. Of the total 593 cases, a total of 197 cases (33.2%) were performed within 3 days of surgery. Hemoglobin level was significantly lowest on the 3rd day after surgery and tended to increase afterwards in the non-transfusion group. In the case of blood transfusion on the day of surgery, the hemoglobin level showed an increase on the next day and then showed a minimum value on the fifth day of surgery and then increased. The same pattern was identified when blood transfusion was done on the 1st and 2nd day of surgery. However, when blood transfusion was done on the 3rd day, the hemoglobin level showed a steady increase afterwards. The hemoglobin level of total knee arthroplasty patients with no blood transfusion was the lowest on the 3rd day after surgery and increased afterwards. If blood transfusion was done within 2 days after surgery, the hemoglobin level was the lowest on the 5th day after surgery and increased afterwards. If blood transfusion was done on the 3rd day after surgery, the hemoglobin level increased afterwards.

The limited use of a tourniquet during total knee arthroplasty under a contemporary enhanced recovery protocol has no meaningful benefit: a prospective randomized controlled trial

PURPOSE

This prospective randomized controlled trial aimed to determine whether the limited use of tourniquets during total knee arthroplasty (TKA) would be more beneficial under the contemporary enhanced recovery after surgery (ERAS) protocol than the conventional use of tourniquets.

METHODS

One hundred patients with knee osteoarthritis who underwent primary TKA were randomly assigned to the limited tourniquet (LT, n = 51) and conventional tourniquet (CT, n = 49) groups. Operation time, serial hemoglobin drops, calculated blood loss, transfusion rate, D-dimer levels, and the presence of deep vein thrombosis (DVT) were assessed. In addition, visual analog scale (VAS) scores for pain around the knee and thigh were measured while resting during the day, at night, and during ambulation. Opioid consumption, range of motion, knee circumference, and postoperative complications were also analyzed. Isokinetic muscle strength, knee injury and osteoarthritis outcome scores, and Euro-QoL-5D scores were also assessed before and 3 months after TKA. For statistical analysis, Chi-square and Fisher's exact tests were performed to compare the differences in categorical variables. Continuous variables were compared using an independent t test or Mann‒Whitney U test.

RESULTS

The average tourniquet time was 46.7 min in the CT group and 5.4 min in the LT group. Knee pain on the first night after surgery was significantly higher in the CT group (3.2 vs. 4.6, p = 0.033). However, daytime pain in the thigh at 2 weeks and in the knee at 3 months after TKA were higher in the LT group than in the CT group (p = 0.048 and p = 0.036, respectively). The D-dimer level 3 months after TKA was also higher in the LT group than in the CT group (p = 0.028), but there was no difference in DVT incidence between the two groups (n.s.). Additionally, there were no significant differences in the other variables between the groups.

CONCLUSIONS

Although the limited use of tourniquets did not increase the operation time, blood loss, or transfusion rate, this study found that the limited use of tourniquets would not provide additional meaningful benefit in reducing pain and early functional restoration after TKA when applying the ERAS protocol.

LEVEL OF EVIDENCE

I.

CONTEMPORARY RECOMMENDATIONS ON PATIENT BLOOD MANAGEMENT IN JOINT ARTHROPLASTY

Hip and knee replacement surgery are a common and effective procedure for the relief of pain and loss of function. The number of procedures is increasing and great interest is given how to improve outcome following hip and knee replacement surgery. Last two decades have been characterized by many innovations in hip and knee replacement surgery including minimally invasive technique but also by improvements in anesthetic technique and blood management. The patients undergoing hip and knee replacement surgery are commonly elderly and have cos-existing organ dysfunctions. These procedures are characterized by great perioperative disturbances including cardiovascular complications, high incidence of thromboembolic complications, possible significant perioperative blood loss, possible bone cement effect and high level of postoperative pain. Anesthetic assessment of patients include preoperative preparations, intraoperative and postoperative care. In this article, all problems of perioperative blood management are discussed. The recent data of advantages of blood management for every patient are outlined. Blood management include preoperative preparation, use of autologous blood in perioperative period and administration of drugs for minimizing intraoperative blood loss. The final result of improvements in blood management is reducing in blood loss and need for allogeneic blood and significant reduction in perioperative morbidity.

Acute Postoperative Anemia After Unilateral Primary Total Joint Arthroplasty: Restrictive Transfusion Thresholds are Safe for Discharge Regardless of Delta Hemoglobin

BACKGROUND

Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions.

METHODS

A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission.

RESULTS

Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787).

CONCLUSION

The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.

Comparison of three methods for sealing of the intramedullary femoral canal during total knee arthroplasty; a randomized controlled trial

PURPOSE

The purpose of this randomized controlled study was to examine the effect of sealing the intramedullary canal with a bone or cement plug or leaving it empty on postoperative bleeding and pain MATERIALS AND METHODS: A total of 120 patients with knee osteoarthritis who underwent unilateral TKA participated in the trial and were assigned to one of three groups. The femoral canal was sealed with an autogenous bone plug (Group I) or cement plug (Group II), or it was left open (Group III). Estimated blood loss, Hemoglobin decline, bleeding into the drain, and postoperative pain w compared between groups.

RESULTS

Six patients were excluded due to various reasons, and the remaining 114 patients were included in the final analysis. There were no significant variations in baseline clinical characteristics between the three groups (p > 0.05). Hemoglobin reduction between preoperative and 72 h after the surgery (p: 0.034) and estimated blood loss (p: 0.003) were significantly different between groups. The cement plug group showed the least bleeding. Although there was a significant difference between the cement and empty canal groups (p: 0.03 and p: 0.002, respectively), the difference between the cement and bone groups was similar regarding both hemoglobin reduction and estimated blood loss. The blood volume in the suction drain (p: 0.598) and transfusion rate (p: 0.087) were similar between the groups. VAS at the 12 h after the surgery was similarly high in each group (p: 0.676). It declined at 36 h after surgery, but no significant difference was determined between groups (p: 0.815).

CONCLUSIONS

This study showed that estimated blood loss and hemoglobin reduction were significantly lower in the cement plug group than in the empty canal group. But bone plug group did not show any difference with both empty canal and cement plug groups. Sealing the IM canal or leaving it open did not change the bleeding into the drain, transfusion rate, and postoperative pain between groups. Based on these findings, sealing the IM canal with a cement plug might be recommended to diminish bleeding during TKA despite similar transfusion rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Effect of Tranexamic Acid on Blood Management during a High Tibial Osteotomy: A Systematic Review and Meta-analysis

This study aimed to evaluate the efficiency and safety of tranexamic acid for blood management during high tibial osteotomy (HTO). A systematic search was conducted in Medline, Embase, and the Cochrane library database. Six studies and 208 patients were included in this meta‐analysis using Review Manager V.5.3 and Stata 15.1 software. For primary outcomes, tranexamic acid lowered the total blood loss (WMD = –219.47, 95% CI [−355.61, −83.33], P = 0.002). For secondary outcomes, a significant reduction was found for decreased hemoglobin (POD1: WMD = –9.86, 95% CI [−13.45, −6.28], P < 0.05; POD2: WMD = –8.41, 95% CI [−11.50, −5.32], P < 0.05; POD5: WMD = –11.48, 95% CI [−14.56, −8.39], P < 0.05) and drainage (total: WMD = –105.93, 95% CI [−187.08, −24.78], P < 0.05; POD1: WMD = –122.195, 95% CI [−168.902, −75.488], P < 0.05). The sex difference (male/female ratio) was determined (total blood loss: P = 0.025; total drainage amount: p = 0.018) using meta‐regression analysis. Females benefited more from tranexamic acid in terms of total blood loss (M/F > 40%: WMD = –53.11, 95% CI [−100.16, −6.05], P = 0.03; 40% ≥ M/F ≥ 20%: WMD = –362.20, 95% CI [−423.96, −300.45], P < 0.05; M/F < 20%: WMD = –263.00, 95% CI [−277.17, −248.83], P < 0.05) and total drainage (M/F > 40%: WMD = –7.11, 95% CI [−10.75, −3.47], P < 0.05; 40% ≥ M/F ≥ 20%: WMD = –104.72, 95% CI [−155.36, −54.08], P < 0.05; M/F < 20%: WMD = –222.00, 95% CI [−297.42, −146.58], P < 0.05). No significant differences were found for drainage on POD2 and POD3, wound complications, orthromboembolic events. In conclusion, tranexamic acid is effective and safe for blood management during HTO. Females appeared to benefit more from it, and an additional postoperative dose is suggested fora better effect.

Evaluation of Blood Loss in Conventional vs MAKOplasty Total Knee Arthroplasty

Background

Methods

Results

Conclusions

Perioperative blood loss during joint replacement: comparison between patients with and without hemophilia

Background

Although arthroplasty provides satisfactory pain relief, functional improvement, and reduced flexion contracture in patients with hemophilia arthropathy, bleeding remains the primary problem associated with hemophilic arthropathy joint replacement. We aimed to explore the differences in perioperative blood loss (PBL) associated with joint replacement surgery in patients with and without hemophilia.

Methods

This study retrospectively analyzed 61 cases of PBL in patients undergoing joint replacement surgery, including 37 patients with hemophilia and 24 patients without hemophilia. All patients demonstrated severe joint flexion contractures that seriously affected their daily lives and required surgical intervention. PBL was compared between the two groups.

Results

In univariate analysis, the overall (p < 0.001) and hidden (p < 0.001) blood losses were significantly higher for patients with hemophilia than those for patients without hemophilia. However, after adjustment for multiple factors, there was no significant difference in overall blood loss between the two groups (p = 0.731). In addition, sex, age group, and surgical site did not affect blood loss in patients with hemophilia.

Conclusion

Overt bleeding did not increase significantly in patients with hemophilia, compared with that in patients without hemophilia. In terms of blood loss, joint replacement surgery for patients with hemophilia is relatively safe. The results of this study must be verified by a prospective follow-up study with larger sample size.

Trial registration Retrospectively registered.

Intravenous Ferric Carboxymaltose Improves Response to Postoperative Anemia Following Total Knee Arthroplasty: A Prospective Randomized Controlled Trial in Asian Cohort

Background: Ferric carboxymaltose (FCM) is an intravenous (IV) high-dose iron that is effective in the treatment of iron deficiency anemia. This study was performed to determine whether postoperative FCM infusion is effective at improving hemoglobin (Hb) responders, Hb and iron profiles, and the patient’s quality of life (QOL). Methods: A total of 110 patients with postoperative anemia, defined by a Hb < 10 g/dL within 3 days of unilateral primary TKA, between June 2018 and February 2020 were randomized into either the FCM or Control group. On postoperative day 3, the FCM group (55 patients) received IV FCM while the Control group (55 patients) did not. The Hb responders (Hb increase ≥ 2 g/dL compared to baseline), Hb level, iron profiles (ferritin, total iron-binding capacity (TIBC), transferrin saturation (TSAT)), and EQ-5D scores were compared at weeks 2, 4, and 8. Results: The FCM group demonstrated a significantly greater number of Hb responders (p < 0.001) and a higher Hb level (p = 0.008) at 2 weeks postoperative than did the Control group. The FCM group recovered its preoperative Hb level between 4 and 8 weeks. In contrast, the Control group did not recover its preoperative level until 8 weeks. The FCM infusion group also had higher serum ferritin, iron and TSAT, and lower TIBC levels than those of the Control group between 2 and 8 weeks (all p < 0.001). However, there was no significant difference in the postoperative transfusion rate (p = 0.741) or EQ-5D score between the two groups (all p > 0.05). Discussion: In postoperative anemia following TKA, IV FCM increases the Hb response and improves Hb and iron metabolism variables, however, it does not affect the transfusion rate or QOL.

Are Risk Factors for Postoperative Significant Hemorrhage following Total Knee Arthroplasty Potentially Modifiable? A Retrospective Cohort Study

Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis (OA) of the knee, because it alleviates pain and restores function of the knee. However, TKA-associated hemorrhage and subsequent anemia remain a concern. Most previous studies have defined meaningful postoperative bleeding as blood loss > 500 mL or hemoglobin (Hb) drop > 20 g/L. Therefore, we defined significant hemorrhage as a postoperative Hb drop more than 20 g/L in this study, and we investigated possible risk factors related to significant hemorrhage in TKA and whether these risk factors are modifiable. This retrospective study was conducted through a comprehensive review of the perioperative records of patients with OA of the knee who underwent TKA between January 2009 and December 2015 at our hospital. Patients were allocated into two groups: patients in Group A had their Hb drop ≤ 20 g/L; patients in Group B had their Hb drop > 20 g/L. Factors analyzed included sex, age, body mass index (BMI), the American Society of Anesthesiologists (ASA) classification, comorbidities, preoperative platelet count, use of tranexamic acid (TXA), operation time, and type of anesthesia. A total of 3350 patients met the criteria for analysis, with 1782 patients allocated to Group A and 1568 patients to Group B. Five independent risk factors for significant hemorrhage were identified: male sex (odds ratio(OR), 1.29; 95% confidence interval(CI), 1.08−1.53; p = 0.005), age (OR, 1.02; 95% CI, 1.01−1.03; p = 0.001), use of TXA (OR, 0.39; 95% CI, 0.34−0.45; p < 0.001), spinal anesthesia versus general anesthesia (OR, 0.71; 95% CI, 0.56−0.90; p = 0.004), and preoperative platelet count (OR, 0.96; 95% CI, 0.93−0.98; p = 0.001). Of these identified risk factors, preoperative platelet count, use of TXA, and spinal anesthesia are modifiable. These potentially modifiable risk factors need to be taken into consideration when making both the perioperative care and anesthesia plan by surgeons and anesthesiologists, especially in patients at risk of significant hemorrhage.

Gender-specific differences in haemostatic parameters and their influence on blood loss in bimaxillary surgery

Objective

The objectives of this prospective cohort study were to establish gender-related differences in blood loss and haemostatic profiles associated with bimaxillary surgery. In addition, we aimed to identify if any gender differences could be established which might help predict blood loss volume.

Materials and methods

Fifty-four patients (22 males; 32 females) undergoing bimaxillary surgery for skeletal dentofacial deformities were eligible for inclusion. Blood samples were taken 1 day preoperatively and 48 h postoperatively for detailed gender-specific coagulation analysis incorporating global coagulation assays (endogenous thrombin potential) and specific coagulation parameters. Blood loss was measured at two different time points: (1) the end of surgery, visible intraoperative blood loss (IOB) using ‘subtraction method’; and (2) 48 h postoperatively perioperative bleeding volume (CBL-48 h) using ‘haemoglobin-balance method’ and Nadler’s formula. Correlation and regression analyses were performed to identify relevant parameters affecting the amount of blood loss.

Results

Significant differences in IOB and CBL-48 h were observed (p < 0.001). Men had higher IOB versus women, lacking statistical significance (p = 0.056). In contrast, men had significantly higher CLB-48 h (p = 0.019). Reduced CBL-48 h was shown to be most closely associated with the level of Antithrombin-III being decreased in females.

Conclusions

Male gender is associated with higher IOB and CBL-48 compared with females. Gender does not affect IOB regarding haemostatic profile but does correlate strongly with procedure length. Conversely, CBL-48 is closely associated with gender-specific imbalances in the anticoagulant system.

Clinical relevance

Knowledge of gender-related differences will help clinicians establish predictive factors regarding excessive blood loss in orthognathic surgery and identify at-risk patients.

Characteristics of hidden blood loss following hybrid total knee arthroplasty

BACKGROUND

Hidden blood loss (HBL) unrecognized by the usual practice of assessing intraoperative loss and postoperative drainage comprises a considerable proportion of total blood loss (TBL) during primary total knee arthroplasty (TKA). However, HBL has not been adequately investigated in hybrid TKA (uncemented femur, cemented tibia). The purpose of this study was to clarify the amount and influential factors of HBL in hybrid TKA.

METHODS

A consecutive series of 151 knees in 137 patients with knee osteoarthritis who underwent hybrid TKA were retrospectively evaluated. We examined the correlations between HBL and various factors of concern for their effects on TBL, including age, sex, body weight (BW), body height, body mass index, operation time, tourniquet time, and visible blood loss (VBL) in three periods (intraoperative: VBL₁; until 3 h postoperatively: VBL₂; from 3 h to 1 day postoperatively: VBL₃).

RESULTS

Median (interquartile range) HBL and TBL were 528 (388, 711) mL and 725 (582, 926) mL, respectively. HBL relative to TBL (H/T) was 73%. There were weak correlations between HBL and BW (r = 0.249, p = 0.002) and between HBL and VBL₃ (r = -0.261, p = 0.001). Multivariate analyses confirmed a positive correlation between HBL and BW (β = 0.296, p < 0.001) and a negative correlation between HBL and VBL₃ (β = -0.270, p < 0.001).

CONCLUSIONS

Hybrid TKA showed comparable values of HBL and H/T to those reported for cemented TKA. Therefore, management strategies for HBL in hybrid TKA can follow the same protocols used for cemented TKA. High BW and low VBL₃ may be predictors of postoperative HBL in hybrid TKA.

Tranexamic acid use in simultaneous bilateral total knee arthroplasty : a comparison of intravenous and intra-articular applications, which is more effective?

Patients applied with simultaneous bilateral total knee arthroplasty (SBTKA) with the administration of intravenous or intra-articular tranexamic acid (TXA) were compared in respect of blood loss and the need for allogenic blood transfusion. Of a total 53 patients applied with SBTKA, 32(60%) were administered intravenous TXA and 21(40%) intra-articular TXA. The patients were evaluated in respect of age, gender, height, weight, body mass index (BMI), body blood volume, preoperative and 1,2,3 and 4 days postoperative levels of hemoglobin (Hb) and hematocrit (Htc) and the change in Hb levels, estimated blood loss, mean actual blood loss, the need for allogenic blood transfusion (ABT) and the use or not of a drain. No difference was determined between the intravenous and intra-articular groups in respect of mean age, gender, height, weight, and body blood volume. No difference was determined between the groups in preoperative and postoperative mean Hb and Hct values, the reduction in mean Hb postoperatively, estimated blood loss, or the need for ABT. No deep vein thrombosis or pulmonary embolism was determined in any patient. In the application of SBTKA, TXA can be safely administered by the intravenous or intra-articular route to reduce the need for ABT. The results of this study determined no difference in efficacy between the routes of application. For patients with a risk of intravenous use, intra-articular application can be preferred.

The association between bone mineral density and postoperative drainage volume following cruciate-substituting primary total knee arthroplasty: a cross-sectional study

Background

The prevalence of osteoporosis in patients who undergo a primary total knee arthroplasty (TKA) is increasing. Low bone mineral density (BMD) is related to unfavorable outcomes following TKA such as migration of uncemented tibial components. Postoperative blood loss in TKA is an important complication. Non-modifying predicting factors for postoperative blood loss in patients undergoing primary TKA need further elucidation. Studies on the association between BMD and blood loss after TKA are limited. We aimed to demonstrate the relationship between BMD and postoperative drainage volume following primary TKA.

Methods

A cross-sectional study was conducted between January 2014 and August 2020. A total of 119 primary varus osteoarthritis knees with BMD results were included in the study. Patients with secondary causes of osteoporosis were excluded.

Results

The median postoperative drainage volume of participants in the normal total hip BMD group and the normal trochanter BMD group was higher than that of patients in the low total hip BMD group and the low trochanter BMD group (285.0 ml vs 230.0 ml, P = 0.003; 282.5 ml vs 240.0 ml, P = 0.013, respectively). Multivariate regression analyses showed that operative time, spinal anesthesia, and normal total hip BMD status were significant predictive factors associated with increased postoperative drainage volume (P = 0.014, 0.022, and 0.013, respectively). No association was identified between the lumbar spine BMD status and postoperative drainage volume.

Conclusions

The relationship between BMD and postoperative blood loss in primary TKA was identified in this study. Normal total hip BMD was found to be associated with an increased postoperative drainage volume after primary TKA compared with low BMD.

Blood loss and transfusion risk in robotic-assisted knee arthroplasty: A retrospective analysis

BACKGROUND

The purpose of this study was to compare total blood loss and the risk of receiving a blood transfusion in robotic-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) against conventional jig-based techniques.

METHODS

Robotic TKA (n = 50) and UKA (n = 50) patients were matched to contemporary controls for TKA (n = 50) and UKA (n = 50) and retrospectively analysed.

RESULTS

Robotic TKA patients experienced 23.7% less blood loss compared to conventional TKA patients (911.0 ml vs 1193.7 ml, p < 0.01), and were associated with an 83% relative risk reduction of receiving a transfusion (2% of patients vs 12%, p = 0.02). Robotic UKA patients did not demonstrate less blood loss compared to corresponding controls (821.7 ml vs 854.7 ml, p = 0.69). Both UKA groups received no transfusions.

CONCLUSIONS

Robotic surgical systems in TKA reduces blood loss and lowers the risk of requiring a blood transfusion. In UKA, robotic-assisted arthroplasty did not reduce blood loss compared to conventional arthroplasty.

Closed suction drainages in Lower Limb Joint Arthroplasty: A level I evidence based meta-analysis

INTRODUCTION

The role of closed suction drainage during elective total joint arthroplasty is still unclear. The present study compared the use of closed suction drains to no drainage for elective total knee arthroplasty (TKA) and in total hip arthroplasty (THA) through a meta-analysis of randomized clinical trials (RCTs).

METHODS

Following the PRISMA guidelines, a meta-analysis of randomized controlled trials identified in December 2021. All randomized clinical trials comparing the use of closed suction drains to no drainage for elective THA or TKA were considered.

RESULTS

Twenty-five RCTs were included in the final analysis. 49% (1722 of 3505) of patients received no-drainage, and 51% (1783 of 3505) received closed suction drainage. There was no evidence of a statistically significant evidence between the two groups in occurrence of postoperative infections (P = 0.4), mean total postoperative hemoglobin (P = 0.2) or length of hospital stay (P = 0.1). The no-drainage group showed a lower rate of blood transfusion (P < 0.0001).

CONCLUSION

There is no evidence to support the routine use of closed suction drainage in THA or TKA patients.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized clinical trials.

Perioperative Hidden Blood Loss in Elderly Cervical Spondylosis Patients With Anterior Cervical Discectomy Fusion and Influencing Factors

Introduction:

To analyze the perioperative hidden blood loss (HBL) and its influencing factors in elderly cervical spondylosis patients treated with anterior cervical discectomy fusion (ACDF).

Materials and Methods:

From January 2017 to December 2018, 128 elderly cervical spondylosis patients (age > 65 y) treated with ACDF were selected. The patients’ height, weight, duration of symptoms, previous medical history and other basic information were routinely recorded. The hemoglobin (Hb), hematocrit (Hct) and blood coagulation function preoperative and the next day postoperative were recorded. The operation time, surgical bleeding, ASA classification, fixation method, total drainage and the time for extraction of drainage tube were recorded. The total blood loss (TBL) was calculated according to the Gross’s formula, and HBL was calculated based on TBL, total drainage and surgical bleeding. The statistical analysis of HBL was performed, and then influential factors were further analyzed by multivariate linear regression analysis and t test.

Results:

The mean surgical bleeding was 102.70 ± 46.78 mL and HBL was 487.98 ± 255.96 mL. HBL accounted for 67.61 ± 5.20% of TBL. According to the multiple linear regression analysis, the gender (P = 0.047), operation time (P = 0.000), fixation method (P = 0.014) and international normalized ratio (INR) (P = 0.003) influenced the amount of HBL. Body mass index (BMI) (P = 0.624), hypertension (P = 0.977), diabetes (P = 0.528), blood type (P = 0.577), ASA classification (P = 0.711), duration of symptoms (P = 0.661), preoperative cobb angle (P = 0.152), number of surgical level (P = 0.709), intramedullary hyperintensity (P = 0.967), drainage time (P = 0.294), postoperative drainage volume (P = 0.599), prothrombin time (PT) (P = 0.674), activated partial thromboplastin time (APTT) (P = 0.544) and thrombin time (TT) (P = 0.680) had no correlation with the amount of HBL.

Conclusions:

There was obvious HBL during the perioperative period of ACDF in elderly cervical spondylosis patients. The male patients, longer operation time, fusion with titanium plate and cage and high INR were independent risk factors for HBL.

Perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty

Knee osteoarthritis is a common arthritic disease which mainly affects the elderly (≥65 years old) population. As a result of the cartilage degeneration, it can cause a significant amount of pain and functional limitation. In patients who are refractory to conservative management, total knee arthroplasty is being utilised as the last resort in management. In this review, we discuss the perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty.

Is tranexamic acid effective on hidden blood loss in patients during total knee arthroplasty?

OBJECTIVES

This study aims to investigate if tranexamic acid (TXA) reduces both visible and hidden blood loss in patients undergoing total knee arthroplasty (TKA).

PATIENTS AND METHODS

A total of 128 female patients (mean age 68.9±5.8 years; range, 55 to 80 years) who underwent TKA and were admitted between January 2010 and January 2020 were included in this retrospective study. Only patients who had primary unilateral knee arthroplasty with a cemented posterior cruciate ligament substituting implant were included. Patients were divided into two groups according to TXA administration in the perioperative period. Group 1 consisted of patients who did not receive TXA (n=69), while Group 2 consisted of patients who received TXA (n=59). The effect of TXA on visible and hidden blood loss, amount of erythrocyte suspension transfusions, postoperative early wound complications, and the relationship between the volume of hidden blood loss and drainage volume were detected.

RESULTS

There was no statistically significant difference between the groups in terms of age, body mass index, operation side, preoperative hematocrit (HCT) values, and total blood volume. Postoperative HCT values were statistically higher in Group 2. Fifty-four units of erythrocyte suspension transfusion were required in Group 1, while six units were required in Group 2 (p<0.001). Early wound complication was determined in 10 patients in Group 1 and only in one patient in Group 2 (p=0.011). Intraoperative blood loss, postoperative drainage volume, hidden blood loss, and total blood loss values were significantly lower in Group 2 (p=0.001). In all patients, there was a significant positive correlation between the postoperative drainage volume and the hidden blood loss volume (r=0.532, p=0.001).

CONCLUSION

The use of TXA in patients undergoing TKA reduces postoperative bleeding (visible and hidden blood loss), blood transfusion needs, and early wound complications. In addition, drainage volume in postoperative 24 hours can be used to estimate the amount of hidden blood loss in early postoperative period.

Role of arthroplasty in the Jehovah's Witness population

BACKGROUND

Total joint arthroplasties aim to improve quality of life from joint-related pain. Jehovah's Witnesses refuse blood products due to their religious beliefs. Surgeons may be reluctant to perform arthroplasty procedures on these patients for fear of uncontrolled bleeding. However, we hypothesize that through preoperative optimization, arthroplasty can be performed safely.

METHODS

We retrospectively reviewed 184 total joint arthroplasties in Jehovah's Witnesses between 2011 and 2019. Each patient was enrolled in the institutions' Bloodless Medicine program. Hemoglobin levels were recorded through standard laboratory testing while in the hospital. Primary outcomes were changes in preoperative and postoperative hemoglobin measures, short-term outcomes measures, and complications.

RESULTS

A total of 103 total knee arthroplasties (8 revisions) and 81 total hip arthroplasties (5 revisions) were performed. Hemoglobin drift was 2.5 ± 1.0 for primary TKA and 2.6 ± 1.3 for primary THA (p = 0.570). Hemoglobin drift was 1.9 ± 0.9 for revision TKA and 1.9 ± 0.2 for revision THA (p = 0.990). Only 2.7% of patients met the transfusion requirement of 7 g/dL. The major complication rate for the cohort was 1.6% systemic and 4.9% local, respectively, with no mortalities. The overall readmission rate was 2.7%.

CONCLUSION

To our knowledge, this is the largest reported sample of Jehovah's Witness patients undergoing total joint arthroplasty. Postoperative hemoglobin values did not prompt additional intervention in the overwhelming majority of patients, and complication rates were acceptable. Our data suggest that primary arthroplasty is safe in the Jehovah's Witness population. Additionally, we show preliminary evidence that revision arthroplasty is safe in Jehovah's Witness patients.

Is Intra-Articular Administration of Fibrinogen Effective in Postoperative Total Knee Arthroplasty Blood Loss? A Randomized Clinical Trial

Objectives

The purpose of this study was to evaluate the effect of intra-articular injection of fibrinogen on postoperative bleeding following total knee arthroplasty.

Methods

A double-blind randomized clinical trial was conducted on 40 patients aged 40 - 70 years under spinal anesthesia candidate for total knee arthroplasty in Golestan hospital, Ahwaz, Iran, in 2017-2018. Patients were divided into fibrinogen intra-articular injection (n = 20) and control (n = 20) groups. The amounts of blood loss and blood transfusion requirement were recorded. Hemoglobin (Hb), hematocrit (HCT), international normalized ratio (INR), platelet (PLT), prothrombin time (PT), and partial thromboplastin time (PTT) were recorded before and after the surgery.

Results

There was no significant difference in the average amount of intraoperative blood loss between the groups (P > 0.05). The average amount of blood loss 24 hours after the surgery was significantly lower in the fibrinogen group than in the control group (fibrinogen group 350.61 ± 120.32 cc; control group 540.00 ± 170.21 cc; P = 0.0002). There were significant differences in transfusion between the groups (fibrinogen group 250 ± 20 cc; control group 350 ± 50 cc; P < 0.0001). There was a significant difference between the two groups in 24 h postoperative Hb and HCT (P < 0.001).

Conclusions

Intra-articular fibrinogen administration may reduce acute bleeding and can be used as an effective intervention to prevent further bleeding and the need for transfusion in patients undergoing total knee arthroplasty.

Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial

BACKGROUND

Tranexamic acid (TXA) is efficacious for reducing blood loss and transfusion use in patients who undergo bilateral TKA, and it is administered intravenously alone, intraarticularly alone, or as a combination of these. However, it is unclear whether combined intravenous (IV) and intraarticular TXA offers any additional benefit over intraarticular use alone in patients undergoing bilateral TKA.

QUESTIONS/PURPOSES

The purposes of our study was to determine (1) whether combined IV and intraarticular TXA reduces blood loss and blood transfusion use compared with intraarticular use alone and (2) whether the frequency of adverse events is different between these routes of administration in patients who undergo simultaneous or staged bilateral TKA.

METHODS

Between April 2015 and May 2017, one surgeon performed 316 same-day bilateral TKAs and 314 staged bilateral TKAs. Of those, 98% of patients in each same-day TKA (310) and staged bilateral TKA (309) groups were eligible for this randomized trial and all of those patients agreed to participate and were randomized. The study included four groups: simultaneous TKA with intraarticular TXA only (n = 157), simultaneous TKA with IV and intraarticular TXA (n = 153), staged TKA with intraarticular TXA only (n = 156), and staged TKA with IV and intraarticular TXA (n = 155). There were no differences in demographic data among the intraarticular alone and IV plus intraarticular TXA groups of patients who underwent simultaneous or staged bilateral TKA in terms of age, proportion of female patients, BMI, or preoperative hematologic values. The primary outcome variables were total blood loss calculated based on patient blood volume and a drop in the hemoglobin level and administration of blood transfusion. The secondary outcomes of this study were a decrease in the postoperative hemoglobin level; the proportion of patients with a hemoglobin level lower than 7.0, 8.0, or 9.0 g/dL; and the frequencies of symptomatic deep vein thrombosis, symptomatic pulmonary embolism, wound complications, and periprosthetic joint infection.

RESULTS

Total blood loss with intraarticular TXA alone in patients undergoing simultaneous bilateral TKA and those undergoing staged procedures was not different from the total blood loss with the combined IV plus intraarticular TXA regimen (1063 mL ± 303 mL versus 1004 mL ± 287 mL, mean difference 59 mL [95% CI -7 to 125]; p = 0.08 and 909 ml ± 283 ml versus 845 ml ± 278 ml; mean difference 64 mL [95% CI 1 to 127]; p = 0.046, respectively). The use of blood transfusions between intraarticular alone and combined IV and intraarticular TXA was also not different among patients undergoing simultaneous (0% [0 of 152] versus 1%; p = 0.149) and staged TKA (1% [1 of 155] versus 0% [0 of 153]; p = 0.98). Furthermore, the frequency of symptomatic thromboembolic events, wound complications, and periprosthetic joint infections was low, without any differences among the groups with the numbers available.

CONCLUSION

Because there was no difference between intraarticular alone and combined intraarticular plus IV regimen of TXA administration, we recommend that IV and intraarticular TXA should not be used in combination. Moreover, other studies have found no differences between intraarticular and IV TXA used alone, and hence to avoid potential complications associated with systemic administration, we recommend that intraarticular alone is sufficient for routine TKA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

[Effect of pneumatic tourniquet on perioperative blood loss in total knee arthroplasty]

Objective

To evaluate the effect of pneumatic tourniquet on perioperative period of total knee arthroplasty (TKA).

Methods

The perioperative period data of 116 patients over 60 years old with severe knee osteoarthritis treated with TKA between January 2018 and January 2019 were retrospectively analyzed. According to whether pneumatic tourniquet was used during operation, the patients were divided into trial group (49 cases, pneumatic tourniquet was not used during operation) and control group (67 cases, pneumatic tourniquet was used during operation). There was no significant difference in gender, age, body mass index, lesion side, disease duration, and preoperative hemoglobin between the two groups ( P>0.05). The operation time, actual total blood loss, overt blood loss, hidden blood loss, and percentage of hidden blood loss, knee swelling at 3 days after operation, and range of motion of knee at 2 weeks after operation were recorded and compared between the two groups.

Results

The operation time of the trial group was significantly longer than that of the control group ( t=14.013, P=0.000). The actual total blood loss, hidden blood loss, and percentage of hidden blood loss in the trial group were significantly lower than those in the control group ( P<0.05); there was no significant difference in the overt blood loss between the two groups ( t=-1.293, P=0.200). The knee swelling degree in the trial group was significantly slighter than that in the control group at 3 days after operation, and the range of motion of knee in the trial group was significantly better than that in the control group at 2 weeks after operation ( P<0.05).

Conclusion

Pneumatic tourniquet can reduce the operation time of TKA significantly. However, it may increase the hidden blood loss and knee swelling, and negatively impact the recovery of knee function in the early postoperative stage of TKA.