Decreased blood loss with systemic and intraarticular tranexamic acid administration after total knee arthroplasty

Abstract

Objective: Perioperative bleeding during total knee arthroplasty (TKA) is a lasting problem for surgeons. Intravenous or intra-articular administration of tranexamic acid (TXA) can effectively stop bleeding, but there is still no uniform standard for the best administration and dosing.

Method: Between October 2017 and September 2019, ninety patients with unilateral primary knee osteoarthritis requiring knee replacement were retrospectively evaluated and investigated in three groups according to the route of TXA administration: Group 1 (n=30) intravenous (IV) injection, Group 2 (n=30) intra-articular injection (IAI), and Group 3 (n = 30) combined IV and IAI. Demographic characteristics, hematological indices, and the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) were studied.

Results: Of the patients included in the study, 86% were female (n=78), and 14% were male (n=12). The gender distribution of the groups was homogeneous (p=0.749). The mean hemoglobin values of Group 2 were significantly lower than those of Group 1 and Group 3 (p=0.002 and p=0.045, respectively). Less postoperative blood loss was observed in the group receiving combined IV and IA TXA. The mean blood loss from the drain in Group 3 was significantly lower than that in Group 1 and Group 2 (p=0.001). Postoperative infection, DVT, and PE were not seen in any group.

Conclusion: This study demonstrated that the use of intraarticular and intravenous tranexamic acid in primary unilateral TKA significantly reduced postoperative blood loss and consequently decreased the need for blood transfusion without an increase in adverse events, particularly thromboembolic complications.

Keywords

• Total knee arthroplasty,Tranexamic acid,Efficacy,Bleeding

References

1. 1. Tille E, Mysliwietz J, Beyer F, Postler A, Lützner J. Intraarticular use of tranexamic acid reduces blood loss and transfusion rate after primary total knee arthroplasty. BMC Musculoskelet Disord 2019;27;20(1):341. doi:10.1186/s12891-019-2715-9.
2. 2. Kalairajah Y, Simpson D, Cossey AJ, Verrall GM, Spriggins AJ. Blood loss after total knee replacement: effects of computer-assisted surgery. J Bone Joint Surg Br 2005;87(11):1480-2.
3. 3. Bidolegui F, Arce G, Lugones A, Pereira S, Vindver G. Tranexamic Acid Reduces Blood Loss and Transfusion in Patients Undergoing Total Knee Arthroplasty without Tourniquet: A Prospective Randomized Controlled Trial. Open Orthop J 2014;8:250–254. doi:10.2174/1874325001408010250.
4. 4. Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J. Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. J Bone Joint Surg Am 2014;3;96(23):1945-51. doi:10.2106/JBJS.N.00077.
5. 5. Xiong H, Liu Y, Zeng Y, Wu Y, Shen B. The efficacy and safety of combined administration of intravenous and topical tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2018;7;19(1):321. doi: 10.1186/s12891-018-2181-9.
6. 6. Georgiev GP, Tanchev PP, Zheleva Z, Kinov P. Comparison of topical and intravenous administration of tranexamic acid for blood loss control during total joint replacement: Review of literature. J Orthop Translat 2018;20;13:7-12. doi: 10.1016/j.jot.2017.12.006.
7. 7. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs 1999;57(6):1005-32.
8. 8. Hamlin BR, DiGioia AM, Plakseychuk AY, Levison TJ. Topical versus intravenous tranexamic acid in total knee arthroplasty. J Arthroplasty 2015;30(3):384-6. doi: 10.1016/j.arth.2014.10.007.

9. 9. Chen TP, Chen YM, Jiao JB, Wang YF, Qian LG, Guo Z, Ma Z, Han CY, Shi TH.Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2017;19;12(1):11. doi:10.1186/s13018-017-0512-4.
10. 10. Aguilera X, Martínez-Zapata MJ, Hinarejos P, Jordán M, Leal J, González JC, Monllau JC, Celaya F, Rodríguez-Arias A, Fernández JA, Pelfort X, Puig-Verdie Ll. Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial. Arch Orthop Trauma Surg 2015;135(7):1017-25. doi:10.1007/s00402-015-2232-8.
11. 11. Risberg B: The response of the fibrinolytic system in trauma. Acta Chir Scand Suppl 1985, 522:245–271.
12. 12. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs 1999;57(6):1005-32.
13. 13. Ng W, Jerath A, Wąsowicz M. Tranexamic acid: a clinical review. Anaesthesiol Intensive Ther 2015;47(4):339-50. doi: 10.5603/AIT.a2015.0011.
14. 14. Benoni G, Fredin H: Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: a prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg Br 1996;78:434–440.
15. 15. Astedt B, Liedholm P, Wingerup L: The effect of tranexamic acid on the fibrinolytic activity of vein walls. Ann Chir Gynaecol 1978;67:203–205.
16. 16. Mutsuzaki H, Ikeda K. Intra-articular injection of tranexamic acid via a drain plus drain-clamping to reduce blood loss in cementless total knee arthroplasty. J Orthop Surg Res 2012;29;7:32. doi: 10.1186/1749-799X-7-32.
17. 17. Fiebig E. Safety of the blood supply. Clin Orthop Relat Res 1998;357:6–18.
18. 18. Ishida K, Tsumura N, Kitagawa A, Hamamura S, Fukuda K, Dogaki Y, Kubo S, Matsumoto T, Matsushita T, Chin T, Iguchi T, Kurosaka M, Kuroda R. Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. Int Orthop 2011;35(11):1639-45. doi: 10.1007/s00264-010-1205-3.
19. 19. Han YH, Huang HT, Pan JK, Zeng LF, Liang GH, Liang HD, Yang WY, Guo D, Liu J. Is the combined application of both drain-clamping and tranexamic acid superior to the single use of either application in patients with total-knee arthroplasty?: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018;97(36):e11573. doi: 10.1097/MD.0000000000011573.
20. 20. Slover J, Lavery JA, Schwarzkopf R, Iorio R, Bosco J, Gold HT. Incidence and Risk Factors for Blood Transfusion in Total Joint Arthroplasty: Analysis of aStatewide Database. J Arthroplasty 2017;32(9):2684–2687.e1. doi:https://doi.org/10.1016/j.arth.2017.04.048.
21. 21. Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2010;50(4):753–65. https://doi.org/10.1111/j.1537-2995.2009.02518.x.
22. 22. Stanworth SJ, Cockburn HAC, Boralessa H, Contreras M. Which groups of patients are transfused? A study of red cell usage in London and SoutheastEngland. Vox Sang 2002;83(4):352–7.
23. 23. Legnani C, Oriani G, Parente F, Ventura A. Reducing transfusion requirements following total knee arthroplasty: effectiveness of a double infusion oftranexamic acid. Eur Rev Med Pharmacol Sci 2019;23(5):2253-2256. doi:10.26355/eurrev_201903_17273.
24. 24. Zekcer A, Priori RD, Tieppo C, Silva RSD, Severino NR. Comparative study of topical vs. intravenous tranexamic acid regarding blood loss in total knee arthroplasty. Rev Bras Ortop 2017;52(5):589–595. doi:10.1016/j.rboe.2017.08.005
25. 25. Zhang S, Wang C, Shi L, Xue Q. Multi-route applications of tranexamic acid to reduce blood loss after total knee arthroplasty: a randomized controlled trial.Medicine (Baltimore) 2019;98(30):e16570. doi: 10.1097/MD.0000000000016570.
26. 26. Huang Z, Ma J, Pei F, et al. Meta-analysis of temporary versus no clamping in TKA. Orthopedics 2013;36:543–50.
27. 27. Mi B, Liu G, Lv H, Liu Y, Zha K, Wu Q, Liu J. Is combined use of intravenous and intraarticular tranexamic acid superior to intravenous or intraarticular tranexamic acid alone in total knee arthroplasty? A meta-analysis of randomized controlled trials. J Orthop Surg Res 2017;18;12(1):61. doi:10.1186/s13018-017-0559-2.
28. 28. Tai TW, Yang CY, Jou IM, et al. Temporary drainage clamping after total knee arthroplasty: ameta-analysis of randomized controlled trials. J Arthroplasty 2010;25:1240–5.
29. 29. Shen PC, Jou IM, Lin YT, et al. Comparison between 4-hour clamping drainage and nonclamping drainage after total knee arthroplasty. J Arthroplasty 2005;20:909–13.
30. 30. Liao L, Chen Y, Tang Q, et al. Tranexamic acid plus drain-clamping can reduce blood loss in total knee arthroplasty: a systematic review and meta-analysis. Int J Surg 2018;52:334–41.
31. 31. Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Risk factors for clinically relevant pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or knee arthroplasty. Anesthesiology 2003;99:552–60. doi: 10.1097/00000542-200309000-00009.
32. 32. Kim YH, Park JW, Kim JS, Seo DH. Does tranexamic acid increase the risk of thromboembolism after bilateral simultaneous total knee arthroplasties in Asian Population? Arch Orthop Trauma Surg 2018;138(1):83-89. doi:10.1007/s00402-017-2791-y.
33. 33. Lin SY, Chen CH, Fu YC, Huang PJ, Chang JK, Huang HT. The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty. J Arthroplasty 2015;30:776–80. doi:10.1016/j.arth.2014.12.001.