Effect of peroperative local tranexamic acid admistration on bleeding in total knee arthroplasty performed with general or spinal anesthesia

Year 2025, Volume: 18 Issue: 2, 3 - 3

Bahadır Balkanlı , İsmail Tüter , Enver İpek

https://doi.org/10.31362/patd.1500706

Abstract

Purpose: This retrospective study focused on a comparative examination of the effect of local tranexamic use on postoperative bleeding in TKA surgery performed with general or spinal anaesthesia.
Materials and methods: This study analysed the postoperative bleeding amounts in 95 knees with primary osteoarthritis that underwent TKA between January 2017 and 2023. Patients undergoing TKA under general or spinal anaesthesia were separated into four groups based on whether or not local tranexamic acid was given perioperatively. Patients who underwent total knee arthroplasty under general anaesthesia were divided into two groups: group 1 if local tranexamic acid was applied, and group 2 if tranexamic acid was not applied. Patients who underwent total knee arthroplasty under spinal anaesthesia were divided into two groups: group 3 if local tranexamic acid was applied, and group 4 if tranexamic acid was not applied. Tranexamic acid administration was performed locally as 1 g injection into the surrounding soft tissues after knee arthroplasty. The postoperative hemogram alterations, drainage volume, and transfusion needs of these patients were assessed.
Results: Group 4 saw a significantly higher decline in haemoglobin levels within the first twenty-four hours following surgery, distinct from groups 1-3 (p1:0.001; p2:0.000; p3:0.001, p<0.05). There was no notable variance in third-day haemoglobin control values (HG3) between groups 1-4 (p>0.05). Postoperative haemoglobin values in Group 3 were statistically significantly higher than in Groups 1, 2, and 4 (p1:0.019; p2:0.003; p<0.05). Group 4 showed considerably higher drainage values compared to groups 1­3 (p=0.000; p<0.05). The drainage values in group 1 were statistically substantially lower than those in groups 2, 3, and 4 (p1: 0.001; p2: 0.032; p<0.05). When evaluating a replacement threshold of 2 units (6.1%), group 3 had considerably lower blood replacement rates than group 1 (26.7%), group 2 (45.5%), and group 4 (25%) (p1:0.002; p2:0.000; p<0.05).
Discussion: Our study found that administering local tranexamic acid during TKA surgery, whether under general or spinal anaesthesia, has a substantial impact on postoperative bleeding and transfusion requirements. Overall, these findings suggest that local use of TXA during TKA surgery can effectively reduce postoperative bleeding, maintain haemoglobin levels, reduce drainage amounts, and reduce transfusion rates, thus potentially reducing bleeding-related complications and contributing to cost savings.

Keywords

Tranexamic acid, knee arthroplasty, blood transfusion, anesthesia, surgical drain

Ethical Statement

Permission was received for the study from the Health Sciences University Şişli Hamidiye Etfal Training and Research Hospital SUAM Clinical Research Ethics Committee (13/06/2023 (Permission number 3971).

Genel veya spinal anestezi ile yapılan total diz artroplastisinde peroperatif lokal traneksamik asit uygulamasının kanamaya etkisi

Abstract

Amaç: Bu retrospektif çalışma, genel veya spinal anestezi ile yapılan Total diz artroplastisi cerrahisinde lokal traneksamik kullanımının postoperatif kanamaya etkisinin karşılaştırmalı olarak incelenmesine odaklanmıştır.
Gereç ve yöntem: Bu çalışmada Ocak 2017-2023 tarihleri arasında TDA uygulanan primer osteoartritli 95 dizdeki postoperatif kanama miktarları analiz edildi. Genel veya spinal anestezi altında TDA uygulanan hastalar perioperatif olarak lokal traneksamik asit verilip verilmediğine göre dört gruba ayrıldı. Genel anestezi altında total diz artroplastisi yapılan hastalarda lokal traneksamik asit uygulandıysa grup 1, traneksamik asit uygulanmadıysa grup 2 olarak gruplara ayrılmıştır. Spinal anestezi altında total diz artroplastisi yapılan hastalarda lokal traneksamik asit uygulandı ise grup 3, traneksamik asit uygulanmadıysa grup 4 olarak gruplara ayrılmıştırr. Traneksamik asit uygulaması diz artroplastisi uygulandıktan sonra çevre yumuşak dokulara enjeksiyon şeklinde 1 g lokal olarak yapılmıştır. Bu hastaların postoperatif hemogram değişiklikleri, dren miktarı ve transfüzyon miktarları değerlendirildi.
Bulgular: Grup 4'te, grup 1-3'ten farklı olarak ameliyattan sonraki ilk yirmi dört saat içinde hemoglobin düzeylerinde anlamlı düzeyde daha yüksek bir düşüş görüldü (p1:0,001; p2:0,000; p3:0,001, p<0,05). Üçüncü gün hemoglobin kontrol değerlerinde (HG3) grup 1-4 arasında kayda değer bir farklılık yoktu (p>0,05). Grup 3'te ameliyat sonrası hemoglobin değerleri Grup 1,2 ve 4'e göre istatistiksel olarak anlamlı derecede yüksekti (p1:0,019; p2:0,003; p<0,05). Grup 4'te grup 1-3'e göre anlamlı derecede yüksek dren hacimleri görüldü (p=0,000; p<0,05). Grup 1'deki drenden gelen miktarları grup 2-4'e göre istatistiksel olarak anlamlı derecede düşüktü (p1:0,001; p2:0,032; p<0,05). 2 ünite (%6,1) replasman miktarı değerlendirildiğinde, grup 3'te kan replasman oranları grup 1 (%26,7), grup 2 (%45,5) ve grup 4'e (%25) göre oldukça düşüktü (p1:0,002; p2: 0,000; p<0,05).
Tartışma: Çalışma, ister genel ister spinal anestezi altında olsun, TDA ameliyatı sırasında lokal traneksamik asit uygulamasının postoperatif kanama ve transfüzyon gereksinimleri üzerinde önemli bir etkiye sahip olduğunu buldu. Genel olarak bu bulgular, TDA ameliyatı sırasında traneksamik asitin lokal kullanımının postoperatif kanamayı etkili bir şekilde azaltabileceğini, hemoglobin düzeylerini koruyabileceğini, dren miktarlarını azaltabileceğini ve transfüzyon oranlarını azaltabileceğini, dolayısıyla potansiyel olarak kanamayla ilişkili komplikasyonları azaltabileceğini ve maliyetlerin azalmasına katkıda bulunabileceğini göstermektedir.

Keywords

Traneksamik asit, diz artroplastisi, kan transfüzyonu, anestezi, cerrahi dren

Ethical Statement

Araştırma için Sağlık Bilimleri Üniversitesi Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi SUAM Klinik Araştırmalar Etik Kurulu'ndan 13/06/2023 (İzin numarası 3971) izin alındı.

References

• 1. 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;96:1945-1951. https://doi.org/10.2106/JBJS.N.00077
• 2. Kato H, Nakayama T, Uruma M, et al. A retrospective observational study to assess adverse transfusion reactions of patients with and without prior transfusion history. Vox Sang 2015;108:243-250. https://doi.org/10.1111/vox.12208
• 3. Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 2009;208:931-937. https://doi.org/10.1016/j.jamcollsurg.2008.11.019
• 4. Browne JA, Adib F, Brown TE, Novicoff WM. Transfusion rates are increasing following total hip arthroplasty: risk factors and outcomes. J Arthroplasty 2013;28:34-37. https://doi.org/10.1016/j.arth.2013.03.035
• 5. Banerjee S, Issa K, Kapadia BH, et al. Intraoperative nonpharmacotherapeutic blood management strategies in total knee arthroplasty. J Knee Surg 2013;26:387-393. https://doi.org/10.1055/s-0033-1353993
• 6. Chareancholvanich K, Siriwattanasakul P, Narkbunnam R, Pornrattanamaneewong C. Temporary clamping of drain combined with tranexamic acid reduce blood loss after total knee arthroplasty: a prospective randomized controlled trial. BMC Musculoskelet Disord 2012;13:124. https://doi.org/10.1186/1471-2474-13-124
• 7. Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The efficacy of tranexamic acid in total knee arthroplasty: a network meta-analysis. J Arthroplasty 2018;33:3090-3098.e1. https://doi.org/10.1016/j.arth.2018.04.043
• 8. Cam N, Balkanlı B, Altuntaş Y, Kanar M, Özdemir HM. The effect of local tranexamic acid administration on blood loss and transfusion in total knee arthroplasty: a retrospective study. Sisli Etfal Hastan tip Bul 2023;57:245-249. https://doi.org/10.14744/SEMB.2023.42800
• 9. Heckmann ND, De A, Porter KR, Stambough JB. Spinal versus general anesthesia in total knee arthroplasty: are there differences in complication and readmission rates? J Arthroplasty 2023;38:673-679.e1. https://doi.org/10.1016/j.arth.2022.10.036
• 10. Good L, Peterson E, Lisander B. Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth 2003;90:596-599. https://doi.org/10.1093/bja/aeg111
• 11. Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly. The framingham osteoarthritis study. Arthritis Rheum 1987;30:914-918. https://doi.org/10.1002/art.1780300811
• 12. Driban JB, Bannuru RR, Eaton CB, et al. The incidence and characteristics of accelerated knee osteoarthritis among women: the Chingford cohort. BMC Musculoskelet Disord 2020;21:60. https://doi.org/10.1186/s12891-020-3073-3
• 13. Hong JW, Noh JH, Kim DJ. The prevalence of and demographic factors associated with radiographic knee osteoarthritis in Korean adults aged ≥ 50 years: The 2010-2013 Korea National Health and Nutrition Examination Survey. PLoS One 2020;15:e0230613. https://doi.org/10.1371/journal.pone.0230613
• 14. Pierson JL, Hannon TJ, Earles DR. A blood-conservation algorithm to reduce blood transfusions after total hip and knee arthroplasty. J Bone Joint Surg Am 2004;86:1512-1518. https://doi.org/10.2106/00004623-200407000-00022
• 15. Kwon JB, Choi JH, Che SH, Choi WK. The natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty. Medicine (Baltimore) 2023;102:E33387. https://doi.org/10.1097/MD.0000000000033387
• 16. Cho MR, Jun CM, Song SK, Choi WK. Natural course of hemoglobin level after total knee arthroplasty and the benefit of tranexamic acid injection in the joint. Medicine (Baltimore) 2021;100:e27097. https://doi.org/10.1097/MD.0000000000027097
• 17. Hartmann B, Junger A, Klasen J, et al. The incidence and risk factors for hypotension after spinal anesthesia induction: an analysis with automated data collection. Anesth Analg 2002;94:1521-1529. https://doi.org/10.1097/00000539-200206000-00027
• 18. Collins VJ (Vincent J. Principles of anesthesiology : general and regional anesthesia. Lea & Ferbiger, Philadelpia. Lea & Febiger; 1993:1445-1497, 1498-1512. Available from: https://search.worldcat.org/title/23355228. Accessed Mar 12, 2024
• 19. Schatz C, Plötz W, Beckmann J, Bredow K, Leidl R, Buschner P. Associations of preoperative anemia and postoperative hemoglobin values with hospital costs in total knee arthroplasty (TKA). Arch Orthop Trauma Surg 2023;143:6741-6751. https://doi.org/10.1007/s00402-023-04929-4
• 20. Zhang Y, Zhang JW, Wang BH. Efficacy of tranexamic acid plus drain-clamping to reduce blood loss in total knee arthroplasty: a meta-analysis. Medicine (Baltimore) [Internet]. 2017;96:73-63. https://doi.org/10.1097/MD.0000000000007363
• 21. Bemelmans Y, Haaren E Van, Boonen B, Hendrickx R, Schotanus M. Low blood transfusion rate after implementation of tranexamic acid for fast- track hip- and knee arthroplasty. An observational study of 5205 patients. Acta Orthop Belg 2021;87:9-16.
• 22. Franchini M, Mengoli C, Marietta M, et al. Safety of intravenous tranexamic acid in patients undergoing majororthopaedic surgery: a meta-analysis of randomised controlled trials. Blood Transfus 2018;16:36-43. https://doi.org/10.2450//2017.0219-17
• 23. Poeran J, Rasul R, Suzuki S, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014;349:g4829. https://doi.org/10.1136/bmj.g4829
• 24. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ;321:1493-1497. https://doi.org/10.1136/bmj.321.7275.1493
• 25. Yue C, Pei F, Yang P, Xie J, Kang P. Effect of topical tranexamic acid in reducing bleeding and transfusions in TKA. Orthopedics 2015;38:315-324. https://doi.org/10.3928/01477447-20150504-06
• 26. Wei C, Muthiah A, Gu A, et al. Association of anesthesia type with postoperative outcome and complications in patients undergoing revision total knee arthroplasty. J Knee Surg 2022;35:345-354. https://doi.org/10.1055/s-0040-1713776
• 27. Lee SY, Kim MK, Ahn EJ, Jung YH. Comparison of general and regional anesthesia on short-term complications in patients undergoing total knee arthroplasty: A retrospective study using national health insurance service-national sample cohort. Medicine (Baltimore) 2023;102:e33032. https://doi.org/10.1097/MD.0000000000033032