Reduction of Blood Loss by Tranexamic Acid Following Total Hip and Knee Arthroplasty: A Meta-Analysis

Tranexamic Acid for Rotator Cuff Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Several randomized controlled trials (RCTs) have been conducted to assess the use of tranexamic acid (TXA) in the setting of arthroscopic rotator cuff repair (ARCR). However, these studies have shown mixed results, with some showing improved intraoperative visualization, subsequent operative times, and pain levels, and others finding no difference.

PURPOSE

To perform a systematic review of the RCTs in the literature to evaluate the use of TXA on ARCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing TXA with a control in ARCR were included. Visualization, postoperative pain, operative time, pump pressures, and shoulder swelling were evaluated. A P value < .05 was deemed statistically significant.

RESULTS

Six RCTs with 450 patients were included in this review. Overall, 5 studies evaluated intraoperative visualization, with 3 studies finding a significant difference in favor of TXA. With TXA, patients had a lower mean postoperative visual analog scale (VAS) score of 3.3, and with the control, patients had a mean VAS score of 4.1, which was statistically significant (P = .001). With TXA, the mean weighted operation time was 79.3 minutes, and with the control, the mean operation time was 88.8 minutes, which was statistically significant (P = .001). No study found any difference in intraoperative pump pressures or swelling.

CONCLUSION

TXA improved visualization, operative time, and subsequent postoperative pain levels in patients undergoing ARCR.

Does tranexamic acid reduce elbow swelling and improve early function following arthroscopic arthrolysis? A double-blind randomized controlled trial

BACKGROUND

Tranexamic acid (TXA) reduces bleeding and hematoma rates in open elbow arthrolysis. However, its effects on arthroscopic elbow arthrolysis remain unclear. This study aims to evaluate the effect of TXA on elbow arthroscopic procedures and compare bleeding volume, hemarthrosis, visual analog scale (VAS) for pain, range of motion (ROM), and Mayo Elbow Performance Score (MEPS) in the early postoperative period between patients who received intra-articular TXA and those who did not.

METHODS

A prospective, double-blind, randomized controlled trial enrolling 80 patients with stiff elbows who underwent arthroscopic arthrolysis was performed from January 2021 to December 2022. Intra-articularly, 1 g of TXA in 100 ml of saline or placebo (control group) was administered after the arthroscopic operation according to randomization. Parameters were recorded and compared between the groups, including bleeding volume of drainage, hemoglobin (Hgb) level, ratio of arm and forearm circumference of the surgical side to the contralateral side, grading of hematoma, VAS, ROM, and MEPS within 1 week postoperatively. And during 1 year follow-up, ROM and MEPS were recorded.

RESULTS

All patients enrolled in this study demonstrated significant improvements in ROM (flexion-extension) and MEPS 1 week postoperatively, with no significant differences observed between the 2 groups. Compared to the control group, the TXA group exhibited significant differences in the bleeding volume of drainage (61.45 ± 47.7 ml vs. 89.8 ± 47.0 ml, P = .030) and a higher Hgb level 24 hours postoperatively (13.5 ± 1.5 g/dL vs. 12.6 ± 1.8 g/dL P = .049). While the ratio of arm and forearm circumferences significantly increased 24 hours postoperatively compared to preoperative values in TXA group (1.05 ± 0.06 vs. 1.02 ± 0.04 and 1.02 ± 0.06 vs. 0.98 ± 0.04, with P = .019 and P = .005, respectively), this difference vanished 1 week postoperatively for the ratio of arm circumference. However, it persisted for the ratio of forearm circumference (1.02 ± 0.07 vs. 0.98 ± 0.04, P = .003). Furthermore, there was no significant difference in MEPS, VAS, or ROM between the 2 groups 1 week postoperatively.

CONCLUSION

Patients with stiff elbows who underwent arthroscopic arthrolysis achieved satisfactory clinical outcomes very early postoperatively. Compared to the control group, patients who underwent arthroscopic elbow arthrolysis with intra-articular administration of TXA exhibited significantly less bleeding volume of drainage and slightly higher Hgb levels postoperatively. One week postoperatively, slightly more swelling in the upper arm region was noted in the control group compared to the TXA group. These findings suggest that the intra-articular injection of TXA after arthroscopic release for elbow stiffness may statistically reduce complications related to postoperative bleeding. However, it's clinical relevance needs further investigation.

Tranexamic acid use in arthroscopic rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials

Background

Rotator cuff disease, a prevalent cause of shoulder disability and pain among middle-aged and older adults, has seen an uptick in arthroscopic repairs in the last 2 decades. These repairs necessitate optimal visualization and controlled hemostasis to prevent complications. This study aimed to assess the efficacy of tranexamic acid (TXA) in arthroscopic rotator cuff repairs by evaluating all available randomized controlled trials (RCTs) in the literature.

Methods

A systematic search was conducted in PubMed, Cochrane Library, Embase, Science Direct, Web of Science, Google Scholar, and CINAHL databases from inception through November 2022 for RCTs investigating the use of TXA in arthroscopic rotator cuff repair. The studies selected reported on the primary outcomes, which include visual clarity during surgery, postoperative pain, and operative time. The quality of the studies was evaluated using the RoB 2 (Risk of Bias) tool.

Results

A total of 7 studies, with level I and II of evidence, comprising 510 randomized patients (253 females, 257 males) were included, with mean ages of 59 and 58 years for the TXA and control groups, respectively. Bias was graded "Low" in 2 RCTs and "Some concerns" in 5 RCTs. Visual analog scale for pain was significantly different with TXA use at postoperative day 1 (weighted mean difference (WMD) = -0.55; 95% confidence interval (CI): -1.07 to -0.04, P = .04). Operative time was significantly higher for the control group with a mean difference of 7.97 minutes (WMD = -7.97; 95% CI: -15.19 to -0.74, P = .04). The impact of TXA on visual clarity during shoulder arthroscopy remains uncertain. However, postoperative shoulder swelling results were comparable in both groups (WMD = -1.71; 95% CI: -3.72 to 0.29, I2 = 99% (where I2 = heterogeneity statistic), P = .69). Considerable heterogeneity was seen in some results.

Conclusion

Pooled data suggest that the use of TXA in shoulder arthroscopy does reduce postoperative shoulder pain and has a positive effect on decreasing operative time. However, the reduction in pain may not be clinically significant, and there is no effect on reducing shoulder swelling. The impact of TXA on visual clarity remains inconclusive, and further research is needed using methodologically rigorous articles that incorporate objective measures and controlled factors to eliminate subjective bias.

Comparative effectiveness of combined peri-articular and intra-articular injection versus intravenous and intra-articular injection of tranexamic acid in total knee arthroplasty: a randomized controlled trial study

INTRODUCTION

Tranexamic acid (TXA) administration is supported by numerous evidence in reducing blood loss after total knee arthroplasty (TKA). The combination of intravenous (IV) and intra-articular (IA) TXA administration revealed good result in blood loss reduction with less evidence of venous thromboembolism event (VTE). Several literature reviews portray that peri-articular (PA) administration yields similar hemostasis in comparison to IV route. However, there is no report on the clinical effect of combining PA + IA TXA in blood loss reduction and its complications, compared to combining IV + IA TXA after TKA.

MATERIALS AND METHODS

We conducted a double-blind, randomized controlled trial comparing the use of PA + IA TXA administration and IV + IA TXA administration in 70 patients who were scheduled for unilateral primary TKA. Thirty-five patients were assigned for PA + IA injection (Group 1) and anoter 35 patients were assigned for IV + IA injection (Group 2). Primary outcomes included total blood loss at 48 h, and the need for blood transfusion. Secondary outcomes included thigh and leg circumference, degree of knee flexion, and postoperative complications.

RESULTS

The calculated blood loss at 48 h showed no difference between Groups 1 and 2 (617 ml vs. 632 ml, p = 0.425). The total hemoglobin and hematocrit changes were not different (1.89 g/dL vs. 1.97 g/dL, p = 0.371 and 5.66% vs. 5.87%, p = 0.391). There was no need for blood transfusion in either group. However, lower thigh swelling was significant in Group 1 (2.15 cm vs. 2.79 cm, p = 0.04). Leg circumferences at 48 h was also lower in Group 1 (42.12 cm vs. 42.77 cm, p = 0.04). There was no significant difference in knee flexion decrease between the two groups (38° vs. 37°, p = 0.425). There were no VTE complications or infections found in either group.

CONCLUSIONS

Combined PA + IA TXA administration had similar efficacy in blood loss reduction and blood transfusion when compared to combined IV + IA TXA. The first group displayed less soft tissue swelling. The combination of PA + IA TXA administration can be used as an alternative regimen to avoid IV TXA administration.

Impact of intra- and extramedullary alignment on blood loss in total knee arthroplasty: a retrospective study

BACKGROUND

There is a scarcity of scientific data regarding the correlation between alignment techniques during total knee arthroplasty (TKA) and blood loss as well as transfusion rates. This study's hypothesis posited that intramedullary-aligned (IM) TKA exhibits higher blood loss and transfusion rates when contrasted with extramedullary-aligned (EM) TKA.

METHODS

We conducted a retrospective examination of 883 patients who underwent total knee arthroplasty (TKA) in 2021 at a solitary orthopedic center in Germany. These patients were divided into two groups based on their tibial alignment technique: extramedullary alignment and intramedullary tibial alignment.

RESULTS

In the intramedullary tibial alignment (IM) group, we observed a blood loss of 0.91 L, while in the extramedullary tibial alignment (EM) group, the blood loss was 0.89 L. These values did not demonstrate a significant difference (p = 0.69). Transfusion rates were 0.99% in the IM group and 0.21% in the EM group, and there was no significant distinction between them (Chi-squared test: p > 0.05).

CONCLUSION

We observed no statistically significant variance in blood loss between the IM and EM groups. Likewise, there was no substantial disparity in transfusion rates between these groups. It can be concluded that the selection of a knee arthroplasty system incorporating either intramedullary tibial alignment or extramedullary alignment does not significantly impact blood loss.

Tranexamic acid administered intraarticularly to the knee is safer for the articular cartilage and anterior cruciate ligament compared to intravenous administration: Histological analysis of an experimental rat model

In this study, the effects of tranexamic acid (TXA) on the knee's articular cartilage, anterior cruciate ligament (ACL), and joint capsule were assessed histologically. There were 15 rats in each of the 3 groups, totaling 45 rats. Intraarticular (IA) saline injections were applied for the first group, IA TXA injections for the second group, and intravenous (IV) TXA injections for the third group. Using samples taken from the knee joint 3 weeks later, the medial/lateral femoral condyle and medial/lateral tibial plateau articular cartilages were evaluated with Osteoarthritis Research Society International (OARSI) scoring, while ACL diameter and joint capsule thickness were analyzed histologically. In comparisons of OARSI scores for the medial/lateral femoral condyle and medial/lateral tibial plateau cartilage regions, the scores obtained for the IV TXA group were significantly higher than those of the IA saline group (P < 0.001, P = 0.001, P = 0.003, P = 0.011). In comparisons of medial/lateral femoral condyle and medial/lateral tibial plateau OARSI scores, the scores obtained for the IV TXA group were again significantly higher than those of the IA TXA group (P < 0.001, P < 0.001, P < 0.001, P = 0.002). When ACL diameters were compared, a significant decrease was observed in the ACL diameters of the IV TXA group compared to the IA saline and IA TXA groups (P < 0.001, P = 0.039). Histologically, IV TXA damages the articular cartilage and ACL more than IA TXA. IA administration of TXA is more protective when the articular cartilage and ACL are preserved.

The Efficacy and Safety of Tranexamic Acid in Total Hip and Knee Arthroplasty: A Literature Review

Historically, total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been associated with significant perioperative blood loss and a relatively high rate of allogeneic blood transfusions. However, in recent years, tranexamic acid (TXA), a competitive inhibitor of tissue plasminogen activator, inhibiting fibrinolysis of existing thrombi, has substantially decreased the need for blood transfusion in THA and TKA. Various administration strategies have been studied, but there remains a lack of consensus on an optimal route and dosing regimen, with intravenous and topical regimens being widely used. A growing body of literature has demonstrated the safety and efficacy of TXA in primary and revision THA and TKA to reduce blood loss, allogeneic transfusions, and complications; it is associated with lowered lengths of stay, costs, and readmission rates.

Day-case hip and knee arthroplasty: stages of care and the development of an institutional pathway

Day-case, or outpatient, arthroplasty is growing and has been adopted in healthcare systems because of its cost-effectiveness. A number of studies that reported on day-case total hip arthroplasty, total knee arthroplasty and unicompartmental knee arthroplasty have shown that they can be performed successfully in a select group of patients. However, safety remains a concern, as a clear pathway, including discharge criteria, is not well described in the literature. This article outlines the stages of care involved in day-case hip and knee arthroplasty and gives insights from University College London Hospital's own evidence-based day-case arthroplasty pathway.

Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial

BACKGROUND

The use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients.

METHODS

In this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction.

RESULTS

No statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.).

CONCLUSION

TXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.

A neck-sparing short stem shows significantly lower blood loss in total hip arthroplasty compared to a neck-resecting short stem

Short stems are associated with a significantly lower blood loss (BL) compared to straight stems in total hip arthroplasty (THA). Different types of stems differ in design, fixation and level of femoral neck osteotomy. Therefore, we sought to evaluate the difference regarding the perioperative BL between two short stems with different designs in direct anterior approach (DAA). A total of 187 THA performed by a single surgeon were analysed. 107 patients received a neck-resecting (Group A) and 80 patients a neck-sparing short stem (Group B). Blood counts of the day before surgery and of two days after surgery were evaluated. Total blood volume and BL were calculated. Additionally, duration of surgery was analysed. The perioperative BL was significantly lower in Group B (451.4 ± 188.4 ml) compared to Group A (546.6 ± 232.7 ml; p = 0.002). The postoperative haematocrit (31.6 ± 3.7% vs. 30.4 ± 4.4%; p = 0.049) and haemoglobin-level (11.0 ± 1.3 g/dL vs. 10.4 ± 1.5 g/dL; p = 0.002) were significantly higher in Group B. Duration of surgery was significantly shorter in Group B (62.0 ± 11.4 min vs. 72.6 ± 21.8 min; p < 0.001). The use of a neck-sparing short stem leads to a significantly decreased BL compared to a neck-resecting short stem in DAA THA. A less extensively conducted capsular release necessary for optimal femoral exposition might lead to a lower perioperative BL and shorter durations of surgery.

Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement

With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.

Tranexamic Acid Treatment Reduces Blood Loss After Elective and Semi-Urgent Reverse Total Shoulder Arthroplasty

Introduction

Post operative blood loss after reverse shoulder arthroplasty (RSA) is associated with the need for blood transfusion and prolonged hospital stay, among other complications. Tranexamic acid (TXA) reduces perioperative blood loss and is effective when delivered systemically or locally. We compared the effects of TXA on perioperative blood loss between elective and semi-urgent RSA.

Methods

We retrospectively reviewed patients who underwent either elective or semi-urgent RSA for fracture repair, with and without TXA treatment. Demographics, clinical records, and laboratory results were collected and analyzed to compare peripheral blood hemoglobin concentrations before and after surgery, the need for blood transfusion, and length of hospital stay between the 2 groups.

Results

In a cohort of 158 patients, 91 (58%) underwent elective RSA. TXA was administered in 91 (58%) patients from the entire group. TXA administration was associated with a significant decrease in post operative hemoglobin concentration reduction in both the elective and fracture groups (P = .026 and P = .018, respectively), a significant decrease in post operative blood transfusion rates (P = .004 and P = .003, respectively), and a decrease in the need for prolonged hospitalization (P = .038 and P = .009, respectively).

Discussion

The local application of TXA during RSA yielded a significant reduction in perioperative blood loss. We showed a significant positive effect of local TXA administration during RSA that is comparable for both elective and semi-urgent patients. Due to the baseline characteristics of fracture patients, their clinical benefits may be more notable.

Conclusions

The positive outcomes for surgical patients with the use of TXA during RSA can possibly cause future consideration in clinical practice.

Topical use of tranexamic acid can reduce opioid consumption compared with intravenous use for patients undergoing primary total hip arthroplasty: a prospective randomized controlled trial

BACKGROUND

The problem of opioid addiction after total hip arthroplasty (THA) has been widely concerned. Tranexamic acid (TXA) has been shown to be effective in reducing blood loss for patients undergoing THA, but few studies focus on its alleviation of postoperative local pain symptoms. The purpose of this study was to investigate whether topical TXA could reduce early postoperative hip pain for primary THA patients, thereby reducing the use of opioids, and whether local pain is related to inflammatory response.

METHODS

In this prospective randomized controlled study, we randomly divided 161 patients into a topical group (n = 79) and an intravenous group (n = 82). Hip pain was assessed using the visual analogue scale (VAS) score within three days after surgery and tramadol was used for pain relief when necessary. Inflammatory markers such as high-sensitivity C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-6 (IL-6), total blood loss and hemoglobin drop were assessed by hematologic tests. The primary outcomes included the VAS score and dose of tramadol from the first to the third day after surgery. The secondary outcomes included the inflammatory markers level, total blood loss and complications.

RESULTS

The pain score and inflammation markers level on the first day in the topical TXA group were significantly lower than those in the intravenous TXA group (P < 0.05). The correlation analysis showed that the VAS score on the first day after surgery was positively correlated with the inflammation markers level (P < 0.05). The tramadol dose for topical group was lower than intravenous group on the first and second day after surgery. There were no differences in total blood loss between the two groups (640.60 ± 188.12 ml vs. 634.20 ± 187.85 ml, P = 0.06). There was no difference in the incidence of complications.

CONCLUSION

Topical use of TXA could relieve the local pain symptoms and reduce opioid consumption compared with intravenous use for patients undergoing primary THA by reduce the early postoperative inflammatory response.

TRIAL REGISTRATION

The trial was registered at the China Clinical Trial Registry (ChiCTR2100052396) on 10/24/2021.

Suction drainage in total knee replacement does not influence early functional outcomes or blood loss: a randomized control trial

INTRODUCTION

The use of wound drainage following total knee arthroplasty (TKA) remains controversial. The purpose of this study was to evaluate the impact of suction drainage on early postoperative outcomes in patients who underwent TKA with concomitant administration of intravenous tranexamic acid (TXA).

METHOD

One hundred forty-six patients undergoing primary TKA with systematic intravenous TXA were prospectively selected and randomly divided into two groups. The first "Study group" (n = 67) received no suction drain and the second "Control" group (n = 79) had a suction drain. Perioperative hemoglobin levels, blood loss, complications, and length of hospital stay were assessed in both groups. Preoperative and postoperative range of motion and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were also compared at a 6-week follow-up.

RESULTS

The study group was found to have higher hemoglobin levels preoperatively and during the first two days following surgery, and no difference was found between the groups on the third day. No significant discrepancies at any time were found between groups in terms of blood loss, length of hospitalization, knee range of motion, and KOOS score. Complications requiring further treatment were observed in one patient from the study group and ten patients from the control group.

CONCLUSION

The use of suction drains after TKA with TXA did not alter early postoperative outcomes.

Transfusion Rates in the Operative Treatment of Prosthetic Hip and Knee Infection

Surgery for prosthetic joint infection (PJI) can often lead to significant blood loss, necessitating allogeneic blood transfusion (ABT). The use of ABT is associated with higher rates of morbidity and death in revision total joint arthroplasty, particularly in the treatment of PJI. We compared ABT rates by procedure type among patients treated for PJI. We retrospectively reviewed 143 operative cases of hip and knee PJI performed at our institution between 2016 and 2018. Procedures were categorized as irrigation and debridement (I&D) with modular component exchange (modular component exchange), explantation with I&D and placement of an antibiotic spacer (explantation), I&D with antibiotic spacer exchange (spacer exchange), or antibiotic spacer removal and prosthetic reimplantation (reimplantation). Rates of ABT and the number of units transfused were assessed. Factors associated with ABT were assessed with a multilevel mixed-effects regression model. Of the cases, 77 (54%) required ABT. The highest rates of ABT occurred during explantation (74%) and spacer exchange (72%), followed by reimplantation (36%) and modular component exchange (33%). A lower preoperative hemoglobin level was associated with higher odds of ABT. Explantation, reimplantation, and spacer exchange were associated with greater odds of ABT. Antibiotic spacer exchange and explantation were associated with greater odds of multiple-unit transfusion. Rates of ABT remain high in the surgical treatment of PJI. Antibiotic spacer exchange and explantation procedures had high rates of multiple-unit transfusions, and additional units of blood should be made available. Preoperative anemia should be treated when possible, and further refinement of blood management protocols for prosthetic joint infection is necessary. [Orthopedics. 2022;45(6):353-359.].

Blood Management in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018

Both advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA (n = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT <35.5% for females and <38.5% for males), platelet count, thrombocytopenia (platelet count < 150,000/µL), international normalized ration (INR), INR > 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, (p < 0.001), as well as in preoperative anemia from a high of 13.3% in 2011 to a low of 9.5% in 2016 to 2017 (p < 0.001). There were statistically significant, but clinically irrelevant changes in the other variables examined. There was a HCT high of 41.2 in 2016 and a low of 40.4 in 2011 to 2012 (p < 0.001). There was platelet count high of 247,400 in 2018 and a low of 242,700 in 201 (p < 0.001). There was a high incidence of thrombocytopenia of 5.2% in 2017 and a low of low of 4.4% in 2018 (p < 0.001). There was a high INR of 1.037 in 2011 and a low of 1.021 in 2013 (p < 0.001). There was a high incidence of INR >2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 (p = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 (p < 0.001). There was a high incidence of preoperative transfusions of 0.1% in 2011 to 2014 and a low of <0.1% in 2015 to 2018 (p = 0.021). From 2011 to 2018, there has been substantial decreases in patients receiving postoperative transfusions after primary TKA. Similarly, although a decrease in patients with anemia was seen, there remains 1 out 10 patients with preoperative anemia, highlighting the opportunity to further improve and address this potentially modifiable risk factor before surgery. These findings may reflect changes during TKA patient selection, optimization, or management, and emphasizes the need to further advance multimodal approaches for perioperative blood management of TKA patients. This is a Level III study.

Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials

AIM

The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA.

METHODS

PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA.

RESULTS

Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01).

CONCLUSION

In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty.

LEVEL OF EVIDENCE

Level 1. PROSPERO Registration CRD42021271355.

German surgeons' technical preferences for performing total hip arthroplasties: a survey from the National Endoprosthesis Society

PURPOSE

The goal of our study was to conduct an online survey that highlights patterns of practice during total hip arthroplasty (THA).

METHODS

The survey was conducted in June and August 2020. Three hundred thirteen members of the German Society for Endoprosthesis participated in the survey.

RESULTS

The anterolateral approach is by far the most popular approach used for primary total hip arthroplasty, followed by the anterior approach during minimally invasive (55% for the anterolateral and 29% for the anterior) and regular surgery (52% for the anterolateral and 20% for the anterior). Two-thirds of the orthopaedic surgeons do not use drainages during THA. Moreover, 80% of the survey participants routinely apply tranexamic acid during surgery. Surgeons who perform minimally invasive surgery for THA use more frequently fast-track-concepts for post-operative rehabilitation. According to the interviewees, the application of fast-track-concepts leads to reduced periods of hospital stay after THA.

CONCLUSION

Our data demonstrate that patterns of practice during THA in Germany are in line with the evidence provided by current literature. This study can be seen as a stimulus to conduct similar surveys in other countries in order to promote minimally invasive surgery for THA.

Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study.

PURPOSE

To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis.

RESULTS

Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, -95.51 to -27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (-1.96 points; 95% CI, -2.19 to -1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups.

CONCLUSION

The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.

Transfusion in orthopaedic surgery : a retrospective multicentre cohort study

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

Methods

We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma.

Results

Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon.

Conclusion

Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies.

Cite this article: Bone Jt Open 2021;2(10):850–857.

A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial

BACKGROUND

Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty.

MATERIALS AND METHODS

We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications.

RESULTS

Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion.

CONCLUSION

A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.

Local Infiltration of Tranexamic Acid (TXA) in Liposuction: A Single-Surgeon Outcomes Analysis and Considerations for Minimizing Postoperative Donor Site Ecchymosis

BACKGROUND

Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.

OBJECTIVES

The authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.

METHODS

A single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.

RESULTS

Overall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.

CONCLUSIONS

Patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.

LEVEL OF EVIDENCE: 4

Tranexamic Acid Has No Effect on Postoperative Hemarthrosis or Pain Control After Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft: A Double-Blind, Randomized, Controlled Trial

PURPOSE

The purpose of this double-blind, randomized, controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone-patellar tendon-bone (BPTB) anterior cruciate ligament reconstruction (ACLR) regarding postoperative hemarthrosis, pain, opioid consumption, and quadriceps atrophy and activation.

METHODS

A controlled, randomized, double-blind trial was conducted in 110 patients who underwent ACLR with BPTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-g boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated and the volume of blood (in milliliters) was recorded. Additionally, we recorded perioperative blood loss (in milliliters); visual analog scale scores on postoperative days 1, 4, and 7 and at postoperative weeks 1, 6, and 12; postoperative opioid consumption on postoperative days 1, 4, and 7; range of motion (ROM) and ability to perform a straight leg raise at postoperative weeks 1, 6, and 12; and preoperative and postoperative thigh circumference ratio.

RESULTS

There was no significant difference in perioperative blood loss between the TXA and control groups (32.5 mL vs 35.6 mL, P = .47). In the TXA group, 23 knees were aspirated; in the control group, 26 knees were aspirated (P = .56). No significant difference in postoperative hemarthrosis volume was seen in patients who received IV TXA versus those who did not (26.7 mL vs 37.3 mL, P = .12). There was no significant difference in visual analog scale scores between the 2 groups (P = .15); in addition, there was no difference in postoperative opioid consumption (P = .33). No significant difference in ROM, ability to perform a straight leg raise, or postoperative thigh circumference ratio was observed (P > .05 for all).

CONCLUSIONS

IV TXA in patients who undergo ACLR with BPTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early postoperative recovery regarding ROM or quadriceps reactivation.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery

PURPOSE

In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery.

PRINCIPAL FINDINGS

Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations.

CONCLUSIONS

Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.

Prolonged antibiotic prophylaxis use in elective orthopaedic surgery - a cross-sectional analysis

Purpose

Surgical antibiotic prophylaxis (SAP) prevents surgical site infections (SSI). In orthopaedic surgery, the use of prolonged SAP (PSAP) has been reported in daily routine, despite guidelines advising against it. Therefore, we asked: What is the proportion of PSAP use, defined as administration of SAP ≥24 h after elective orthopaedic surgery? Are there patient- and surgery-related predictors of PSAP use?

Methods

This cross-sectional analysis investigated 1292 patients who underwent elective orthopaedic surgery including total joint arthroplasties at one Swiss centre between 2015 and 2017. Patient comorbidities, surgical characteristics and occurrence of SSI at 90 days in PSAP group were compared to the SAP group (< 24 h post-operative).

Results

PSAP use was 12% (155 of 1292). Patient-related factors associated with PSAP compared to the SAP group included older age (63 vs. 58y; p < 0.001), higher BMI (29 vs. 27 kg/m²; p < 0.001), ASA classification ≥3 (31% vs. 17%; p < 0.001) and lung disease (17% vs. 9%; p = 0.002). Surgery-related factors associated with PSAP were use of prosthetics (62% vs. 45%; p < 0.001), surgery of the knee (65% vs. 25%; p < 0.001), longer surgery duration (87 vs. 68 min; p < 0.001) and presence of drains (90% vs. 65%; p < 0.001). All four SSI occurred in the SAP group (0 vs. 4; p = 1.0). Surgeons administered PSAP with varying frequencies; proportions ranged from 0 to 33%.

Conclusion

PSAP use and SSI proportions were lower than reported in the literature. Several patient- and surgery-related factors associated with PSAP use were identified and some were potentially modifiable. Also, experienced surgeons seemed to implement differing approaches regarding the duration of SAP administration.

Topical, intravenous tranexamic acid and their combined use are equivalent in reducing blood loss after primary total hip arthroplasty

OBJECTIVE

To determine the equivalence of tranexamic acid (TXA) administration topically, intravenously or the combination of both routes are equivalent in reducing blood loss after primary total hip arthroplasty.

MATERIAL AND METHODS

In this prospective study, we divided 285 total hip arthroplasty into 4 groups. Group A received 2,5g of intraarticular topical TXA, Group B did not receive TXA, Group C received 1g intravenous TXA and group D a combination of topical and intravenous TXA. The main outcome was blood loss according to Nadler's formula and total hemoglobin.

RESULTS

Blood loss was significantly greater in Group B (Group A. 797.13ml; Group B: 1,308.24; Group C: 986.30 and Group D: 859.09ml; P<.01) with no differences between the other groups. Hemoglobin loss was greater in Group B (11.81, 19.46, 14.52 and 12.78 respectively, P<.001). Two patients (3,1%) were transfused in Group A, 4 (5,3%) in Group B, 3 (3,4%) in Group C, and 1 (1,8%) in Group D (P=.75). The mean reduction in hemoglobin at 48hours was less in the topical Group (P<.05). In comparison with Group B the mean reduction in hemoglobin after 48hours was greater (P<.001) and we can also see a longer hospital stay (P<.001). One patient in Group A presented pulmonary thromboembolism 72hours after surgery, which was resolved without complications.

CONCLUSIONS

The administration of TXA topically, intravenously or in combination in primary total hip arthroplasty, is a simple and safe procedure that provides equivalent reductions in hemoglobin and blood loss.

Intravenous tranexamic acid is associated with safe reduced blood loss and transfusion rate in one-stage exchange for infected hip arthroplasty

Objectives

This study aims to investigate if the use of intravenous (IV) tranexamic acid (TXA) during one-stage exchange for periprosthetic joint infection (PJI) of the hip that necessitates an extensive debridement is associated with decreased blood loss, if the rate of blood transfusion that may lead to side effects can be lowered with IV TXA, and if there is any difference regarding the occurrence of postoperative venous thromboembolism (VTE).

Patients and methods

We retrospectively reviewed patients who underwent one-stage exchange for PJI of the hip with perioperative IV administration of TXA (n=163; 90 males, 73 females; mean age 68±10.3; range, 25 to 90 years) between January 2015 and December 2016 and compared them to another group (n=190; 106 males, 84 females; mean age 71±10.1; range, 39 to 92 years) who underwent one-stage exchange for PJI of the hip without perioperative IV administration of TXA between January 2006 and December 2012. Blood loss, transfusion rates, amount of transfused blood, and occurrence of VTE complications were observed.

Results

Mean blood loss of the TXA group was significantly lower than that of the non-TXA group (2.4 L and 4.5 L, respectively; p<0.001). Patients in non-TXA group experienced significantly higher rate of blood transfusion (71.1% and 58.3%, respectively; p=0.014) and higher quantity of transfused packed red blood cells (3.2 and 1.9 units, respectively; p<0.001). There was one patient with VTE complication in each group.

Conclusion

Even in the presence of infection, usage of IV TXA during one-stage exchange for PJI of the hip is associated with significantly lower blood loss and transfusion rates showing no higher risk of VTE events.

Intra-articular vs. intravenous administration: a meta-analysis of tranexamic acid in primary total knee arthroplasty

BACKGROUND

The optimal dosage and administration approach of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains controversial. In light of recently published 14 randomized controlled trials (RCTs), the study aims to incorporate the newly found evidence and compare the efficacy and safety of intra-articular (IA) vs. intravenous (IV) application of TXA in primary TKA.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for RCTs comparing IA with IV TXA for primary TKA. Primary outcomes included total blood loss (TBL) and drain output. Secondary outcomes included hidden blood loss (HBL), hemoglobin (Hb) fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time.

RESULT

In all, 34 RCTs involving 3867 patients were included in our meta-analysis. Significant advantages of IA were shown on TBL (MD = 33.38, 95% CI = 19.24 to 47.51, P < 0.001), drain output (MD = 28.44, 95% CI = 2.61 to 54.27, P = 0.03), and postoperative day (POD) 3+ Hb fall (MD = 0.24, 95% CI = 0.09 to 0.39, P = 0.001) compared with IV. There existed no significant difference on HBL, POD1 and POD2 Hb fall, blood transfusion rate, perioperative complications, length of hospital stay, and tourniquet time between IA and IV.

CONCLUSION

Intra-articular administration of TXA is superior to intravenous in primary TKA patients regarding the performance on TBL, drain output, and POD3+ Hb fall, without increased risk of perioperative complications. Therefore, intra-articular administration is the recommended approach in clinical practice for primary TKA.

Intravenous tranexamic acid reduces blood loss and transfusion requirements after periacetabular osteotomy

AIMS

Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing orthopaedic surgery. There remains a lack of prospective evidence for the use of TXA in patients undergoing periacetabular osteotomy (PAO). The purpose of this study was to determine if intravenous (IV) TXA is effective in reducing calculated blood loss and transfusions after PAO.

METHODS

This was a single-centre prospective double-blind placebo-controlled randomized trial of 81 patients aged 12 to 45 years undergoing elective PAO by a single surgeon. The intervention group (n = 40) received two doses of IV TXA of a maximum 1 g in each dose; the control group (n = 41) received two doses of 50 ml 0.9% saline IV. The primary outcome was perioperative calculated blood loss. Secondary outcomes included allogenic transfusions and six-week postoperative complications.

RESULTS

There were no differences in demographics or intraoperative variables between study groups. The TXA group demonstrated lower mean calculated blood loss (1,265 ml, (SD 321) vs 1,515 ml, (SD 394); p = 0.002) and lower frequency of allogenic transfusion (10%/n = 4 vs 37%/n = 15; p = 0.008). Regression analyses associated TXA use with significant reductions in calculated blood loss (p < 0.001) and transfusion (p = 0.007) after adjusting for age, sex, body mass index, preoperative haemoglobin, cell-saver volume, intraoperative mean arterial blood pressure, and operating time. No patients suffered venous thromboembolic complications.

CONCLUSION

In this trial, IV TXA decreased postoperative calculated blood loss by 293 ml and reduced the frequency of allogenic transfusions by 73% (37% vs 10%) following PAO. TXA may be safe and effective for reducing blood loss in patients undergoing PAO. Cite this article: Bone Joint J 2020;102-B(9):1151-1157.

Tranexamic Acid Does Not Reduce the Risk of Transfusion in Rheumatoid Arthritis Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Patients with rheumatoid arthritis (RA) receive transfusions more often than patients with osteoarthritis following lower extremity total joint arthroplasty (TJA), but mitigating factors are not described. Tranexamic acid (TXA) is widely used to reduce blood loss in patients undergoing TJA, but its effect on transfusion rates in patients with RA has not been studied.

METHODS

We retrospectively reviewed data from a prospectively collected cohort of patients with RA undergoing TJA. Disease activity measured by Clinical Disease Activity Index, patient-reported outcome measures, and serologies was obtained. Baseline characteristics were summarized and compared. Transfusion requirements and TXA usage were obtained from chart review. Logistic regression was used to determine factors associated with transfusion in RA patients undergoing TJA.

RESULTS

The cohort included 252 patients, mostly women with longstanding RA and end-stage arthritis requiring TJA. In multivariate analysis, 1 g/dL decrease in baseline hemoglobin (odds ratio [OR] = 0.394, 95% confidence interval [CI] [0.232, 0.669], P = .001), 1-minute increase in surgical duration (OR = 1.022, 95% CI [1.008, 1.037], P = .003), and 1-point increase in Clinical Disease Activity Index (OR = 1.079, 95% CI [1.001, 1.162]) were associated with increased risk of transfusion. TXA use was not associated with decreased risk of postoperative transfusion.

CONCLUSIONS

Preoperative health optimization should include assessment and treatment of anemia in RA patients before TJA, as preoperative hemoglobin level is the main risk factor for postoperative transfusion. Increased disease activity and increased surgical time were independent risk factors for postoperative transfusion but are less modifiable. While TXA did not decrease transfusion risk in this population, a prospective trial is needed to confirm this.

LEVEL OF EVIDENCE

IV.

Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty

BACKGROUND

Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events.

METHODS

A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon.

RESULTS

TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77).

CONCLUSION

Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA.

LEVEL OF EVIDENCE

Level III, Observational Cohort Study.

Tranexamic acid for the Latarjet procedure: a randomized controlled trial

BACKGROUND

Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce perioperative bleeding and the need for transfusion. The purpose of the study was to assess whether TXA could reduce the incidence of postoperative swelling and hematoma formation and pain and opioid use in the early postoperative period following the Latarjet procedure.

METHODS

A randomized controlled trial was conducted in 100 patients undergoing open Latarjet surgery for anterior shoulder instability by a single surgeon. Patients were randomized to receive either 1 g TXA or a placebo intravenously preoperatively. Outcomes measured during the perioperative period were (1) intraoperative blood loss, (2) postoperative blood loss (via drain output), (3) postoperative swelling/hematoma formation, (4) visual analog scale (VAS) score, and (5) postoperative opioid use (in morphine milligram equivalents).

RESULTS

There was no significant difference in intraoperative blood loss (60.9 vs. 68.9 mL, P = .18). However, there was significantly lower postoperative blood loss with TXA (29.6 vs. 64.9 mL, P < .01). There was a significantly lower rate of painful postoperative swelling (4% vs. 32%, P < .01). Additionally, we found a significantly lower VAS score for pain (1.7 vs. 3.0, P < .01) and significantly less postoperative opioid use (9.4 vs. 22 mg, P < .01) in the TXA group. Postoperative swelling was shown to correlate with increased pain and opioid use (P < .01).

CONCLUSION

Our study found that TXA significantly reduced postoperative blood loss, painful postoperative swelling, and hematoma formation and subsequently reduced postoperative pain and opioid use following the Latarjet procedure.

Trends in Total Knee Arthroplasty in a Developing Region: A Survey of Latin American Orthopaedic Surgeons

INTRODUCTION

A number of different total knee arthroplasty techniques are available. There is also a degree of surgeon preference for these, and the variation across orthopaedic surgeons in Latin America is currently unknown.

METHODS

A survey on members of Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte was performed, with questions based on categories within worldwide national joint registries. In total, 315 Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte members received the survey via e-mail, and the return answers were compared with the latest worldwide national joint registry annual reports.

RESULTS

The survey was completed in full by 262 surgeons (83%). It was answered that 19% of surgeons perform less than 10 total knee arthroplasties per year, 54% perform less than 30, and only 9% perform more than 100. Seventy-three percent of surgeons use a posterior stabilized total knee replacement, 18% use a cruciate retaining total knee replacement, and 9% use a medial pivot design. Forty-nine percent of surgeons resurface the patella, 27% never resurface it, and 24% choose to resurface it based on an individual case scenario. Ninety-eight percent of surgeons use cemented fixation in the femur and tibia, with the remaining 2% choosing hybrid fixation and 1% using fully noncemented fixation.

CONCLUSION

This survey among Latin American surgeons has demonstrated important differences in surgical technique and implants choice compared with worldwide national registries.

Outpatient total knee arthroplasty: is it worth considering?

Some authors have reported that outpatient total knee arthroplasty (TKA) is a successful, safe and cost-effective treatment in the management of advanced osteoarthritis.The success obtained has been attributed to the coordination of the multidisciplinary team, standardized perioperative protocols, optimal hospital discharge planning and careful selection of patients.One study has demonstrated a higher risk of perioperative surgical and medical outcomes in outpatient TKA than inpatient TKA, including component failure, surgical site infection, knee stiffness and deep vein thrombosis.There remains a lack of universal criteria for patient selection. Outpatient TKA has thus far been performed in relatively young patients with few comorbidities.It is not yet clear whether outpatient TKA is worth considering, except in very exceptional cases (young patients without associated comorbidities).Outpatient TKA should not be generally recommended at the present time. Cite this article: EFORT Open Rev 2020;5:172-179. DOI: 10.1302/2058-5241.5.180101.

Total Joint Arthroplasty in Patients With Cerebral Palsy

INTRODUCTION

Cerebral palsy (CP) is a neurodevelopmental condition with a wide range of presentations that usually lead to muscle imbalance culminating with precocious knee and hip arthrosis, often leading to total hip (THA) and knee arthroplasty (TKA). This study sought to determine the following: (1) the inherent differences of in-hospital characteristics and comorbidities between CP and non-CP patients undergoing total joint arthroplasty (TJA) and (2) do patients with CP have an increased risk of perioperative complications after TJA?

METHODS

The Nationwide Inpatient Sample database from 2005 to 2014 was queried in this retrospective cohort study to compare patient demographics and comorbidities, hospital characteristics, perioperative complications, and length of stay in patients with CP undergoing TJA compared with their non-CP counterparts. Statistical analyses were performed using the Rao-Scott chi-square test and analysis of variance. All analyses took into account the sampling procedure and weighting.

RESULTS

A total of 2,062 and 2,193 patients with CP underwent THA and TKA, respectively, during the study period. Both CP groups were younger (P < 0.0001), were more likely to have Medicaid insurance (P < 0.0001), and had longer lengths of hospital stay (P < 0.0001) compared with their non-CP counterparts. Non-CP patients had significantly higher rates of obesity, coronary artery disease, diabetes, and peripheral vascular disease (P < 0.05). However, patients with CP undergoing THA had a lower Charlson Comorbidity Index (P = 0.0002), whereas those undergoing TKA had similar comorbidity profile as the non-CP group (P = 0.097). Both THA and TKA CP patients had a higher risk of overall postoperative complications (P < 0.05) and surgical complications (P < 0.05), in particular acute postoperative anemia (P < 0.05).

CONCLUSION

Despite being younger with fewer comorbidities, patients with CP are at an increased risk of immediate perioperative complications after TJA compared with the general osteoarthritis population. Given that these patients have satisfactory long-term outcomes after TJA, these procedures can be performed successfully for patients with CP with careful medical management and surgical planning.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Comparison of efficacy and safety between oral and intravenous administration of tranexamic acid for primary total knee/hip replacement: a meta-analysis of randomized controlled trial

Background

Tranexamic acid (TXA) has been demonstrated to reduce blood loss following primary total knee and hip arthroplasty. This study aimed to compare the efficacy and safety of oral and intravenous tranexamic acid for primary total knee and hip arthroplasty.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies published before June 20, 2019. Studies clearly reporting a comparison of oral and intravenous TXA were selected, and total blood loss (TBL), the decline in hemoglobin (DHB), deep vein thrombosis (DVT), intramuscular venous thrombosis (IVT), the length of hospital stay, and the transfusion rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed-effects or random-effects model.

Results

Ten studies involving 1140 (oral 557; intravenous 583) patients were included in this meta-analysis. There was no significant difference in terms of total blood loss, the decline in hemoglobin, the length of hospital stay, the incidence of DVT or IVT, or the transfusion rate between the oral and intravenous groups, and five studies reported that oral TXA was associated with a lower cost.

Conclusion

Our research suggests that compared with intravenous use of TXA, the oral approach has similar clinical outcomes and is less expensive for total joint replacement patients.

[Research progress on tranexamic acid in traumatic orthopedic surgery]

OBJECTIVE

To summarize the research progress on the application of tranexamic acid (TXA) in traumatic orthopedic surgery in recent years.

METHODS

The domestic and foreign literature in recent years was reviewed, and the efficacy and safety of TXA in traumatic orthopedic surgeries with different regimen, dose and route of administration were comprehensively summarized and compared.

RESULTS

The application of TXA in traumatic orthopedic surgeries increased gradually in recent years. Intravenous or topical administration of TXA efficaciously reduced blood loss and transfusion requirements during hip fracture surgery without significantly increasing the risk of thromboembolic events. However, the efficacy was not clear in other traumatic orthopedic surgeries such as pelvic and acetabular fractures.

CONCLUSION

More studies are needed to confirm the efficacy and safety of TXA in traumatic orthopedic surgeries.

Preoperative Patient Factors Affecting Length of Stay following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty (TKA) yields substantial improvements in quality of life for patients with severe osteoarthritis. Previous research has shown that TKA outcomes are inferior in patients with certain demographic and clinical factors. Length of stay (LOS) following TKA is a major component of costs incurred by healthcare providers. It is hypothesized that patient-related factors may influence LOS following TKA. The purpose of this systematic review and meta-analysis is to investigate these factors.

METHODS

Three databases (PubMed, Embase, and OVID Medline) were searched using variants of the terms "total knee arthroplasty" and "length of stay". Studies were screened and data abstracted in duplicate. The primary outcome was the effect of prognostic variables on LOS following TKA. Meta-analysis was performed using the Review Manager (RevMan) software (version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014).

RESULTS

A total of 68 studies met all inclusion criteria for this review. These studies comprised 21,494,459 patients undergoing TKA with mean age 66.82 years (range, 15-95 years) and 63.8% (12,165,160 of 19,060,572 reported) females. The mean MINORS score was 7, suggesting that studies had a low quality of evidence. Mean LOS following TKA has steadily decreased over the past 4 decades, partially because of the implementation of fast-track programs. Demographic factors associated with increased LOS were age >70 years (mean difference [MD] = 0.81; 95% confidence interval [CI] = 0.38-1.24), female gender (MD = 0.32; 95% CI = 0.29-0.48), body mass index >30 (MD = 0.09; 95% CI = 0.01-0.16), and non-White race (MD = 0.20; 95% CI = 0.10-0.29). Clinical factors associated with increased LOS were American Society of Anesthesiologists score 3-4 vs 1-2 (MD = 1.12; 95% CI = 0.58 to 1.66), Charlson Comorbidity Index > 0 vs 0 (MD = 0.77; 95% CI = 0.32 to 1.22), and preoperative hemoglobin < 130 g/L (MD = 0.66; 95% CI = 0.34 to 0.98).

CONCLUSION

This systematic review and meta-analysis showed that increased age, female gender, body mass index ≥ 30, non-White race, American Society of Anesthesiologists > 2, Charlson Comorbidity Index > 0, and preoperative hemoglobin < 130 g/L were predictors of increased LOS. Mean LOS has steadily decreased over the past decades with the implementation of perioperative "fast-track" programs. Future research should investigate the benefits of preoperative risk factor modification on LOS, in addition to novel surgical approaches, anesthetic adjuvants, and physiotherapy modifications.

LEVEL OF EVIDENCE

IV, systematic review, and meta-analysis of level III and IV evidence.

Effects of tranexamic acid on the recovery of osteochondral defects treated by microfracture and acellular matrix scaffold: an experimental study

Background

Microfracture and scaffold application in the treatment of osteochondral defects is still one of the most frequently used methods in the clinic. The most important step in this treatment method is the stabilization of fibrin clot. Tranexamic acid (TA) is an antifibrinolytic agent commonly used in orthopedic surgery in recent years. This study evaluated the effect of local TA application on healing of experimentally induced osteochondral defects on rabbits.

Methods

This paper contains an animal in vivo data and histological outcomes on the effect of TA. Eighteen New Zealand white rabbits were treated unilaterally and cylindrical defects having a width of 4 mm and depth of 5 mm were created in the weight-bearing surfaces of the medial and lateral condyles of the right femur. They were divided into two groups, as group 1 study and group 2 control groups, respectively. One milliliter (ml) of TA was injected into the knee joints of the subjects in group 1. All animals were sacrificed for the extraction of the femur condyles for histologic study at the fourth and eighth weeks after surgery. Histological evaluations were performed by Brittberg and O’Driscoll scores to all samples. Data were organized in a Standard Statistical Package System v.22 software package (SPSS/PC Inc., Chicago, IL.) and reported as mean and median (min-max). Repeated measures ANOVA test was used to compare groups and condyle effects together for each week. p values below 0.05 were considered as statistically significant.

Results

Samples were taken in the fourth and eighth weeks. The regularity of the surface in group 1 was smoother, and the tissue stability was more robust. Mean Brittberg scores in both weeks were statistically higher in group 1 when compared with group 2. In the microscopic evaluation, it was observed that the regeneration of subchondral and cartilage tissues were more rapid and organized in group 1, and the mean O’ Driscoll scores in both weeks were statistically higher in group 1.

Conclusions

Application of TA improves the healing time and tissue stability in osteochondral defects which are implanted a-cellular scaffold after microfracture and should be applicable to humans for the treatment of osteochondral defects.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1144-7) contains supplementary material, which is available to authorized users.

Tranexamic Acid in the Treatment of Hip Fractures: A Clinical Review

INTRODUCTION

Although regularly used as a method to reduce blood loss in elective orthopedic procedures (e.g., total hip and knee arthroplasty), there currently is little evidence concerning the optimal dosage, timing and route for the use of tranexamic acid to reduce postoperative blood loss in hip fracture repair.

SUMMARY OF THE EVIDENCE

The current literature suggests that tranexamic acid may be used to reduce postoperative blood loss in addition to reducing the risk of requiring blood transfusions following the surgical repair of hip fractures. Furthermore, it may have the potential to improve patient outcomes and decrease the overall costs of caring for this patient population.

CONCLUSIONS

Further studies are needed to truly gauge the effect of tranexamic acid on long-term patient outcomes and hospital costs.

Reducing Blood Loss in Revision Total Hip and Knee Arthroplasty: Tranexamic Acid Is Effective in Aseptic Revisions and in Second-Stage Reimplantations for Periprosthetic Infection

Introduction

The aim of the study was to determine the usefulness of tranexamic acid (TXA) in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA). We analyzed the perioperative blood loss with and without TXA in aseptic rTHA and rTKA as well as in second-stage reimplantation for hip and knee periprosthetic infection.

Materials and Methods

In this prospective cohort study, 147 patients receiving TXA (96 rTHA, 51 rTKA) were compared to a retrospective cohort of 155 patients without TXA (103 rTHA, 52 rTKA). The TXA regimen consisted of a preoperative bolus of 10 mg/kg bodyweight (BW) TXA plus 1 mg/kgBW/h perioperatively. Given blood products were documented and the perioperative blood loss was calculated. Thromboembolic events were registered until three months postoperatively. In subgroups, the effects of TXA were separately analyzed in 215 aseptic revisions as well as in 87 reimplantations in two-stage revisions for periprosthetic infection.

Results

Both TXA groups showed a significantly reduced mean blood loss compared to the respective control groups. The TXA group of rTHA patients had a mean blood loss of 2916 ml ± 1226 ml versus 3611 ml ± 1474 ml in the control group (p<.001). For the TXA group of rTKA patients, mean calculated blood loss was 2756 ml ± 975 ml compared to 3441 ml ± 1100 ml in the control group (p=.0012). A significantly reduced blood loss was also found in the TXA subgroups for aseptic and septic revision procedures. No thromboembolic events were recorded among the TXA groups.

Conclusions

There is a significant reduction of perioperative blood loss under TXA influence without an increased incidence of adverse events. The standard use of TXA can be recommended in aseptic hip and knee revision arthroplasties as well as in second-stage reimplantations for periprosthetic infection.

Comparative effectiveness and safety of tranexamic acid plus diluted epinephrine to control blood loss during total hip arthroplasty: a meta-analysis

BACKGROUND

The standard protocol to achieve haemostasis during total hip arthroplasty (THA) is uncertain. Tranexamic acid plus diluted epinephrine (DEP) and tranexamic acid (TXA) alone are the two most common alternatives. The purpose of this study was to compare the efficacy and safety of TXA plus DEP to treat blood loss in THA patients.

METHODS

Published randomized controlled trials (RCTs) were identified from the following electronic databases: PubMed, Embase, Web of Science, Cochrane Library and Google from inception to July 10, 2018. Studies comparing TXA plus DEP with TXA alone to treat blood loss were included. Either a random-effects model or a fixed-effects model was used for meta-analysis depending on the heterogeneity. We used the need for transfusion as the primary outcome. Stata 12.0 was used for meta-analysis.

RESULTS

Six studies involving 703 patients were included in the present meta-analysis. The pooled results demonstrated that TXA plus DEP was associated with a lower transfusion rate than TXA alone (RR = 0.57, 95% CI 0.38-0.86, P = 0.006). Furthermore, TXA plus DEP was associated with less total blood loss and hidden blood loss by approximately 209.79 ml and 297.74 ml, respectively, than TXA alone. There was no significant difference in terms of intraoperative blood loss or the occurrence of deep venous thrombosis or haematoma between the TXA plus DEP and TXA alone groups (P > 0.05).

CONCLUSIONS

Our meta-analysis suggested that TXA plus DEP significantly decreased the need for transfusion, total blood loss and hidden blood loss among THA patients. Furthermore, TXA plus DEP did not increase the occurrence of DVT or haemostasis. Additional long-term follow-up RCTs are needed to identify the optimal doses of TXA and DEP.